Substance Use

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Substance Use Abusein Pregnancy

• Janet L. Mitchell, M.D., M.P.H., F.A.C.O.G.
• Consultant on Womens Health
• Addiction Research Treatment Corporation
• Brooklyn, NY

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"THE ALCOHOL OF GREAT BRITAIN AND TENNESSEE AND
THE TOBACCO OF KENTUCKY UNDOUBTEDLY CREATE
GREATER RATES OF MORBIDITY AND DEATH THAN THE
POPPY SEED OF TURKEY AND MEXICO

• BLINICK, ET AL., DRUG ADDICTION IN PREGNANCY AND
  THE NEONATEAMERICAN JOURNAL OF OBSTETRICS AND
  GYNECOLOGYVOL. 125, NO. 2, 1976

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Harlem Hospitals Special Prenatal Program for
Chemically Dependent Women

• 1200 Pregnancies between 1988 - 1996
• 20 were HIV infected, 50 for those with a hx of
  IDU
• 4 ? 21 years of age - primary drug of use
  marijuana
• 80 listed crack and/or cocaine as their primary
  drug of choice
• Avg of drugs used 3.5
• Higher rates of HCV then HBV

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ADDICTION

• Polydrug Abuse
• Poor Nutritional Status
• STD's
• Hepatitis
• HIV Infection
• Other Medical Problems

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ADDICTION and PREGNANCY

• Poor Dates
• Late Registration
• Inadequate Follow-up

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ADDICTION and PREGNANCYMATERNAL CONCERNS

• Poor Pregnancy Self-image
• Low Tolerance For Pain
• Poor Bonding
• Poor Parenting Skills

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ADDICTIONFETAL/NEONATAL CONCERNS

• Low Birth Weight
• Teratogenicity (Congenital Anomalies)
• SIDS
• Spontaneous Abortions
• Abstinence Syndromes
• Future Development

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ADDICTIONIS ACHRONIC RELAPSING, MEDICAL
DISEASE !!
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ALCOHOL

• CNS Depressant
• Known Teratogen
• Psychological and Physiological Dependence

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OTHER CNS DEPRESSANTS

• Barbiturates
• Benzodiazepines
• Methaqualone

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COCAINE

• CNS Stimulant
• Psychological Dependence
• ? Physiological Dependence
• ? Neonatal Abstinence Syndrome

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OTHER CNS STIMULANTS

• Amphetamines
• Ice
• Diet Pills
• Nicotine
• Caffeine

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COCAINEMATERNAL COMPLICATION

• Abruptio Placenta
• Preterm and/or Precipitous Labor
• Pre-eclamptic Like Syndrome
• Cardio-pulmonary problems
• Seizures

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COCAINEFETAL/NEONATAL COMPLICATION

• Low Birth Weight
• Seizures
• Intracranial Hemorrhage
• ? Neonatal Abstinence Syndrome
• Not a Teratogen

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OPIOIDS

• CNS Euphoria
• Not a Teratogen
• Psychological and Physiological Dependence
• Well Documented Neonatal Abstinence

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METHADONE MAINTENANCEIS THETREATMENT OF
CHOICEDURING PREGNANCY!!
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METHADONE and PREGNANCYMATERNAL CONCERNS

• Inappropriate Medical Withdrawal
• Inadequate Dosage
• Chronic Constipation
• Pain Management

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METHADONE and PREGNANCYFETAL/NEONATAL CONCERNS

• Altered Antepartum Testing
• Neonatal Abstinence Syndrome

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METHADONE MAINTENANCEIS THETREATMENT OF
CHOICEDURING PREGNANCY!!
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ADDICTIONIS ACHRONIC RELAPSING, MEDICAL
DISEASE !!
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CONCEPTS

• TREATMENT READINESS
• MOTIVATION TO TREATMENT

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DRUG DEPENDENCY AS DESCRIBED BY THE WORLD HEALTH
ORGANIZATION (WHO)

• A BEHAVIORAL PATTERN IN WHICH THE USE OF A GIVEN
  PSYCHOACTIVE DRUG IS GIVEN A SHARPLY HIGHER
  PRIORITY OVER OTHER BEHAVIORS WHICH ONCE HAD A
  SIGNIFICANTLY HIGHER VALUE
• WHO, 1982

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STAGES TO SUCCESSFUL TREATMENT

• DENIAL
• NEGOTIATION
• ACCEPTANCE

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PRENATAL INTAKE PROTOCOL

• Complete history, especially psychosocial drug
  use
• Complete physical examination focusing on the
  multiple medical programs
• Routine prenatal bloods hepatitis screen for B
  C
• Tuberculin test
• Counseling for HIV with strong recommendation for
  testing
• Social service referral
• Referral to therapeutic drug program
• Methadone maintenance for opiod addiction
• Establish rules, requirements and goals with
  patient and significant others

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PRENATAL FOLLOW-UP PROTOCOL

• More frequent visits to identify medical and
  psychosocial problems early
• Random urine toxicologies
• Order and repeat appropriate tests as necessary
• Establish an ongoing relationship with the
  patients therapeutic drug program
• Establish an ongoing relationship with patients
  significant other(s)
• Began to discuss contraceptive methods

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LABOR AND DELIVERY PROTOCOLS

• Complete history and physical, especially recent
  drug history
• Repeat hepatitis screens and serological test for
  syphilis
• Urine toxicology
• Alert pediatric and nursing staff
• Alert social service
• Pain management as appropriate
• Method of delivery dependent on obstetrical
  indications only

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POST PARTUM PROTOCOL

• Encourage continuation in a therapeutic drug
  program
• Encourage use of an appropriate contraceptive
  method
• Breastfeeding not contraindicated in methadone
  maintained women

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ADDICTIONIS ACHRONIC RELAPSING, MEDICAL
DISEASE !!
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TREATMENT IMPROVEMENT PROTOCALS
(TIPS)FORPREGNANT, SUBSTANCE-USING
WOMENChair Janet L Mitchell, MD, MPH,
FACOGThe Centers for Substance Abuse
Treatment (CSAT)Division for State
ProgramsSubstance Abuse and Mental Health
Services AdministrationSAMSA