Download Substance abuse in pregnancy

Melanie M. Watkins, MD
Staff Psychiatrist
Contra Costa Regional Medical Center
December 15, 2010
Melanie Watkins, MD
DISCLOSURE OF CONFLICT OF
INTEREST
Speaker has nothing to disclose
Melanie Watkins, MD
Participants will be able to:
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Take a substance abuse history and learn more
about screening tools used specifically for the
pregnant population
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Discuss co-occurring medical diagnoses and
psychosocial concerns
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Understand consequences of substance
dependence (medical, legal, social).
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Discuss perinatal and neonatal outcomes
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Discuss management and treatment
Melanie Watkins, MD
At least 50 percent of women in the U.S. who use
illicit drugs are within childbearing ages of 15 to
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 Best way to decrease the numbers of women who
have substance use concerns in pregnancy is to
talk with them about family planning to reduce
the numbers of pregnancies.
 Women who have substance use concerns are less
likely to use contraception and are more
vulnerable. They may also have underlying mental
health concerns.
 However, pregnancy can be a great time to
intervene—patients tend to be highly motivated.
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Melanie Watkins, MD
Use-sporadic consumption of alcohol or drugs
with no apparent consequences
 Abuse-some consequences of use are experienced
 Physiological Dependence-state of adaptation that
is manifested by a drug class-specific withdrawal
syndrome that can be produced by abrupt
cessation or rapid dose reduction of a drug, or by
administration of an antagonist
 Psychological Dependence-subjective need for a
specific psychoactive substance for its positive
effects or to avoid negative effects a/w abstinence
 Addiction-chronic, neurobiologic disease with
genetic, psychosocial, and environmental factors.
Characterized by impaired control, compulsive
use, continued use despite consequences
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Melanie Watkins, MD
 Approximately
5% of pregnant women use
illicit substances*
 Larger proportion use cigarettes and alcohol
 Many use more than one substance
 Among women aged 15 to 17 who were
pregnant had a higher rate of use than those
who were not pregnant (21.6 v 12.9)
*National Survey on Drug Use and Health: National
Findings. Department of Health and Human Services.
(http://oas.samhsa.gov/NSDUH)
Melanie Watkins, MD
 Late
initiation of prenatal care
 Multiple missed prenatal visits
 Impaired school or work performance
 Past OB history of: miscarriage, growth
restriction, prematurity, placental abruption,
stillbirth, precipitous delivery
 Offspring with neurodevelopmental or
behavioral pblms
 Offspring not living with mother or involved
with CPS
Melanie Watkins, MD
 H/o
drug or alcohol related problems (e.g.
pancreatitis, skin abscesses, SBE)
 Family history of substance use (genetic and
environmental factors)
 Frequent encounters with law enforcement
agencies
 Having a partner who abuses substances**
(particularly important for women who may
have been introduced to and supplied with
drugs from partner)
Melanie Watkins, MD
 Who?
 What?
 When?
 Where?
 Why?
 How?
Melanie Watkins, MD
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What to ask? (History of use, frequency of use,
route of administration)
Previous treatment (self help groups,
residential, etc)
Previous consequences of use (children taken
away, jail, )
Factors: denial, stigma, shame
Urine drug screen/urine toxicology
Melanie Watkins, MD
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The T-ACE questions are:
How many drinks does it take for you to feel high (TOLERANCE)?
Do you feel ANNOYED by people complaining about your drinking?
Have you ever felt the need to CUT down on your drinking?
Have you ever had a drink first thing in the morning (EYE-OPENER)?
TWEAK is another screening instrument used in pregnant women:
T = TOLERANCE for alcohol
W = WORRY or concern by family or friends about drinking behavior
E = EYE OPENER, the need to have a drink in the morning
A = "blackouts" or AMNESIA while drinking
K = the self-perception of the need to CUT DOWN on alcohol
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4P’s Plus Screen for Perinatal Substance Use
“Parents, Partner, Past, and Pregnancy”
Melanie Watkins, MD
Mood changes
 Appetite changes (weight loss/decreased appetite)
 Sleep disturbances
 Infections (endocarditis, hepatitis, HIV)
 Skin (tracks, absecesses, perforation of nasal
septum)
 STDs
 Bizarre behavior
 Physical changes such as tachycardia, pupillary
size, sweating, conjunctival injection, arousal
(agitation or sedation)
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Melanie Watkins, MD
 Previous
treatment (self help, residential, etc)
 Longest periods of sobriety/abstinence.
 History of IVDU/shared needles (even if not
currently using this route)
 Patterns of use (time of day, social, when
stressed, etc)
 What has been helpful in the past and what
hasn’t worked? Why?
Melanie Watkins, MD
More specifically:
 Quantity
 Amount spent
 Time spent
 Time of last use
 Frequency
 Consequences of use (arrests, loss of custody,
accidents, DUIs, etc)
Melanie Watkins, MD
According to Guttmacher institute (as of
December 1, 2010):
 15 states consider substance abuse during
pregnancy child abuse and 3 consider it
grounds for civil commitment
 14 states require health care professionals to
report suspected prenatal drug abuse and 4
states require testing for exposure if suspect
abuse
Melanie Watkins, MD
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APA opposes the criminal prosecution and incarceration of pregnant
and/or newly delivered women on child abuse charges based solely on the
use of substances during pregnancy. (Child abuse charges may be
appropriate if positive evidence of abuse or neglect is found following the
birth of a child.) The best way to prevent abuse and neglect in this
situation is adequate treatment for the mother and family.
APA advocates that adequate prenatal care be available to all pregnant
women, including pregnant addicts, irrespective of ability to pay and
without fear of punitive consequences.
APA urges that societal resources be directed not to punitive actions but to
adequate preventive and treatment services for these women and children.
APA strongly advocates the development and funding of the necessary
inpatient, outpatient, and residential programs for mothers with their
children. Services should address and foster the parental functions, as well
as the care of individual mother and child.
APA opposes involuntary commitment laws that are applied only to
pregnant women in ways that do not apply to men or women who are not
pregnant.
Melanie Watkins, MD
 Urine,
blood, hair, saliva and sweat.
 Implications and ethical considerations
 States requirements vary for testing and
reporting drug test results*
*Guttmatcher institute handout
Melanie Watkins, MD
 Usually
urinalysis
 May detect only recent maternal use
 May test meconium (begins to form at 12
weeks gestation and the presence and
concentration of drug in meconium is thought
to be related to the amount, timing and
duration of drug exposure during intrauterine
life). Can test meconium up to three days after
delivery
 Neonatal hair can be tested for narcotics,
marijuana and cocaine use
Melanie Watkins, MD
 Medical
(HIV/Hepatitis)
 Homeless
 Unemployment
 Mental illness
 Abuse (physical, sexual, emotional)
 Lack of transportation
Melanie Watkins, MD
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Counseling regarding risks of substances
Multidisciplinary team (nurses, social worker, case
manager, etc)
Testing for STDs
Increased frequency of prenatal visits to monitor
mother and fetus and to provide additional support
Early ultrasound to confirm GA and accurate baseline
to follow fetal growth
Begin antepartum surveillance if evidence of
complications (IUGR, 3rd trimester bleeding maternal
withdrawal)
Informing pediatrician of mother’s substance use
history
Discouraging breastfeeding if continuing to abuse
illicit drugs
Melanie Watkins, MD
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Most commonly used illicit substance taken during
pregnancy
Prevalence varies based on age, ethnicity, SES
Impact of prenatal marijuana use unclear
Some studies indicate that heavy users may have
offspring with smaller head circumference. There may
be a trend towards decrease in birthweight.
As with other substances, there are likely confounding
variables. Pregnant persons who use marijuana are
also more likely to drink alcohol and smoke cigarettes.
Emerging data indicate there may be effects on later
functioning and even an increased of some cancers.
Cannabinoids relax uterine muscle (no a/w PTL)
Melanie Watkins, MD
Diagnosis is becoming more common in
hospitalized pregnant women
 The drug most often produced by clandestine
laboratories in the U.S.
 Speed, meth, chalk (or as ice, crystal, and glass
when smoked)
 Known neurotoxic agent-damages endings of
brain cells containing dopamine
 Studies have shown neonates to be 3.5x likely to
be SGA and there is an association with poor
neurobehavioral outcomes (decreased arousal,
increased stress, poor quality of movement) first
five days of life.
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Melanie Watkins, MD
 More
pregnant women smoke cigarettes,
drink alcohol, or smoke marijuana than use
cocaine
 5.3 million Americans ages 12 and older had
abused cocaine (in any form) according to
National Survey on Drug Use and Health in
2008.
Melanie Watkins, MD
VASOCONTRICTION is the major mechanism
for fetal and placental damage.
Effects on fetus:
 SAB
 Prematurity
 Placental Abruption
 Fetal death
 LBW, shorter length and smaller head
circumference
*Teratogenic effects have not been definitely
established
Melanie Watkins, MD
Preschoolers who were exposed to cocaine:
 Have verbal and performance IQ scores
similar to unexposed children
 Visual spatial skills, general knowledge and
arithmetic skills are lower
 Lower likelihood of IQ score above the mean
for the general population
*Quality of home environment is most
important predictor of outcome
Melanie Watkins, MD
Melanie Watkins, MD
 Current
alcohol usage: 10.6%
 Binge drinking: 4.5%
 Heavy drinking: 0.8%
Melanie Watkins, MD
Alcohol freely crosses the placenta and is
known to be teratogenic. Infants whose
mothers consume alcohol during pregnancy
can have acute withdrawal presenting several
hours after birth, have chronic non-reversible
sequelae defined as the fetal alcohol spectrum
disorder (FASD), or they may be normal
Melanie Watkins, MD
How much is too much?
*Risk drinking during pregnancy has been
defined as an average of more than 1 drink
(e.g. 5 ounce glass of wine) per day or binges of
> 5 drinks per episode.
*Recent research documents deleterious
outcomes for children prenatally exposed to
small amounts of alcohol (e.g. one drink of wine
per day)
* No proven safe amount of alcohol use during
pregnancy.
Melanie Watkins, MD
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Older maternal age, high parity, and being AfricanAmerican or Native American appear to increase the risk of
FAS for unknown reasons.
Maternal polymorphisms of the alcohol dehydrogenase gene
(ADH) that encodes an enzyme responsible for alcohol
metabolism could explain variations in the extent of
neonatal damage among individuals ingesting the same
amount of ethanol . The presence of the ADH1B*3 allele in
the mother appears to protect the fetus from the effects of
prenatal exposure of alcohol. This allele results in an
isoenzyme that is associated with more rapid metabolism of
alcohol.
Binge drinking during pregnancy exerts a potentially greater
negative effect than comparable consumption of low
amounts of alcohol that results in the same volume of
consumption (eg, four drinks in one sitting versus one drink
a day for four days) .
Melanie Watkins, MD
FASD is an umbrella term describing the range of effects
that can occur in an individual whose mother drank
alcohol during pregnancy. These effects may include
physical, mental, behavioral, and/or learning
disabilities with possible lifelong implications.
FASD includes the following conditions:
 – Fetal alcohol syndrome (FAS), including partial FAS
 – Fetal alcohol effects (FAE)
 – Alcohol-related birth defects (ARBD)
 – Alcohol-related neurodevelopmentaldisorder
(ARND)
www.fasdpn.org
Melanie Watkins, MD
Evidence of intrauterine and postnatal growth
retardation (height or weight ≤10th percentile ,
failure to thrive not caused by inadequate intake,
disproportionate growth e.g. low weight to height)
 Evidence of deficient brain growth or brain
malformation (structural brain abnormalities ,
head circumference ≤10th percentile , abnormal
neurologic examination )
 Evidence of a characteristic pattern of minor facial
anomalies (short palpebral fissures (≤10th
percentile), thin vermilion border of the upper lip,
smooth philtrum, flattened midface)
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Adapted from American Academcy of Pediatrics. Pediatrics 2005; 115:39.
Melanie Watkins, MD
Cigarette smoking during pregnancy has been
associated with complications and adverse
effects at delivery including:
 placental abruption,
 premature rupture of membranes
 placenta previa
 preterm labor and delivery, and low birth
weight (LBW)
*These complications contribute to an increase
in neonatal mortality of infants prenatally
exposed to tobacco compared to unexposed
infants
Melanie Watkins, MD
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Sudden infant death syndrome (SIDS) — Several
prospective case controlled studies from different countries
have shown that maternal smoking during pregnancy
increases the risk of SIDS two to four-fold . Smoking also
increases other known risk factors for SIDS such as preterm
birth and low birth weight.
Increased risk of developing asthma.
Diabetes mellitus — Cigarette smoking by the individual has
been associated with an increased risk of type 2 diabetes.
Cognitive ability — Several cohort studies have reported an
inverse association between maternal smoking during
pregnancy and offspring cognitive ability. However, in many
of these studies, confounding variables (particularly
maternal characteristics such as socioeconomic status, use
of other drugs of abuse, and maternal cognitive ability) were
not well controlled.
Melanie Watkins, MD
 Growing
problem in U.S.
 Long term prescription use in young women
and pregnant women warrants assessment for
addiction.
Melanie Watkins, MD
 25
percent of women of reproductive age who
abuse substances use heroin.
 (Short term) Maternal concerns are: infection,
psychosocial stress, violence.
 Prescription opiates are a more and more of a
concern
Melanie Watkins, MD
 Preeclampsia
 3rd
Trimester bleeding
 Malpresentation
 NRFHT
 Passage of meconium
 LBW
 Perinatal mortality
 Perinatal morbidity
Melanie Watkins, MD
 Prematurity
 Opiate
withdrawal
 Post natal growth deficiency
 Microcephaly
 Neurobehavioral deficits
 SIDS
***Sometimes difficult to determine if prblms
are due to opiates or due to coexistent
medical, nutritional, psychological and
socioeconomic concerns.
Melanie Watkins, MD
 Methadone
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Used for over 30 years
Oral adminstration (liquid or pills)
Not associated w/ birth defects, but a/w fetal
and neonatal effects
Several maternal, obstetrical, and neonatal
benefits
Barriers to treatment
Melanie Watkins, MD
Broad topic!
Important to know:
 Avoid detox in the first or third trimester
 Dosing is usually BID or TID
 Women are more likely to receive PNC
 Pregnant women usually require higher doses
 Patients are screened weekly for drug use (one third to
two-thirds of women enrolled in methadone
maintenance programs continue to use alcohol and
other drugs)
 Dose is usually decreased immediately postpartum
 Pain control and anesthesia are challenging and
complex
 American academy of pediatrics lists methadone as
compatible with breastfeeding (any dose).
Melanie Watkins, MD
Buprenorphine
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Can “continue” buprenorphine, but need more
data.
No “new starts”, but may be alternative to
methadone
Administered by specially certified physicians
Lower, but still substantial, risk of NAS
(neonatal abstinence syndrome)
Not a standard treatment at this point
Melanie Watkins, MD
Factual and non-judgmental information
Discussion about maternal and fetal risk
Testing (UDS)
Assessing motivation
Discussing factors that may influence treatment
Melanie Watkins, MD
AA and NA (self help)
 Residential treatment
 Substance dependence treatment programs
(outpatient, PHP, IOP)
 Smoking cessation programs 1-800-NO BUTTS
 Medication (e.g. methadone, buproprion, nicotine
patch)
 Treating underlying disorder
 Social support (social services)
 Collaborative care (ob/gyn, psychiatrist, case
management/social services, etc)
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Melanie Watkins, MD
 Born
Free Program 925-431-2440 (east
county) or 510-231-1390 (west county)
 Perinatal Outpatient Substance Abuse (New
Connections 925-363-5000
 Ujima East 925-427-9100 (east county)
 Ujima Family Recovery Services 925-2290230 (central county)
Melanie Watkins, MD
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UptoDate.com (recent journal articles)
Guttmatcher institute
American Psychiatric Association (APA)
American College of Obstetrics and
Gynecology(ACOG)
Pubmed
NIH and NIMH
US Department of Health and Human Services
NIDA (National Institute on Drug Abuse)
Maternal, Child and Adolescent Health Program,
California Department of Public Health (Publication
on Perinatal Substance Use Screening in California).
Melanie Watkins, MD
Melanie Watkins, MD