Substance Use and Addiction in Pregnancy - PowerPoint PPT Presentation

Loading...

PPT – Substance Use and Addiction in Pregnancy PowerPoint presentation | free to view - id: 15ef5-NDFjN



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Substance Use and Addiction in Pregnancy

Description:

Disguised Veins (tattoos, self-scarring) ... Ability to stop or cut back as desired ... there, since the fetal pH is lower than the maternal pH, it accumulates ... – PowerPoint PPT presentation

Number of Views:1561
Avg rating:3.0/5.0
Slides: 125
Provided by: MMil2
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Substance Use and Addiction in Pregnancy


1
Substance Use and Addiction in Pregnancy
  • Michael M. Miller, MD, FASAM, FAPA
  • OB GYN Grand Rounds
  • March 9, 2006

2
Addiction Medicine
  • The specialty of medicine devoted to diagnosis,
    treatment, prevention, education, epidemiology,
    research, and public policy advocacy regarding
    addiction and other substance-related health
    conditions

3
Addiction Medicine
  • Its not just for addiction specialists
  • There can never be enough addiction specialists
    to address such prevalent/common conditions
  • Every physicianincluding OB/GYNs
  • encounters patients or family members affected by
    substance-related conditions
  • Every physician needs to know some basics about
    recognition and referral

4
The American Society of Addiction Medicine
ASAM
For Attendings, Residents, Students
5
Addiction is only one of the Substance-Related
Disorders
  • Addiction (Substance Dependence)
  • Problem Use (Substance Abuse)
  • Intoxication States
  • Withdrawal States
  • Substance-Induced Medical Problems
  • Substance-Induced Psychiatric Problems
  • Health Problems linked to Secondary Use
  • Codependency and ACOA Syndromes

6
Each of these can affect pregnancy
  • Addiction (Substance Dependence)
  • Problem Use (Substance Abuse)
  • Intoxication States
  • Withdrawal States
  • Substance-Induced Medical Problems
  • Substance-Induced Psychiatric Problems
  • Health Problems linked to Secondary Use
  • Codependency and ACOA Syndromes

7
Addiction in Women
  • Increasing (equality of the sexes)
  • 19th Century 2/3 of Americas opiate addicts
    and large age of MJ, sed, coc
  • Down to 20 of illegal drug addicts during
    1914-1954
  • Possibly 1/3 of current addicts (excluding
    alcohol and prescription drugs!)

8
Substance Use in Women
  • In early 1990s,
  • DSM IV alcohol dependence
  • 2 million women,
  • alcohol abuse 2 million women, compared to
  • alcohol abuse and dependence 12 million men
  • 1-month prevalence of illicit drug use
  • 4 of women ages 12 above,
  • but in childbearing ages,
  • 8 of women ages 18-25 and 6 of women ages
    26-34.
  • Regular use (once or more per week)see table

9
Why Relevant
  • Since many alcohol/tobacco/other drug-using women
    are of childbearing age,
  • Use of substances by women means that there will
    be a significant prevalence of intrauterine drug
    exposure
  • Adverse biological effects on development
  • Adverse effects during labor of intoxication of
    the fetus
  • Adverse effects postpartum from neonatal
    abstinence syndromes
  • Adverse long-term effects of exposure

10
But….!
  • This doesnt mean a large prevalence / incidence
    of addicted babiesfetuses and infants do not
    have the capacity to manifest the chronic
    behavioral disorder of addiction
  • And any intrauterine biological effect of drug
    exposure may be trumped by biological effects of
    the psychsocial aspects of the life of the
    pregnant alcohol/tobacco/drug addicted woman
  • And, any post-partum effects on children are more
    likely due to parenting deficits associated with
    ongoing substance use/addiction than with
    long-lasting biological effects of intrauterine
    drug exposure

11
Exposure Rates
  • not called use rates since the fetus isnt a
    user and the mother is not a supplier or
    dealer
  • 2.5 of babies (80 k/yr USA) opiate exposed
  • 5 of babies (160 k/yr USA) cocaine exposed
  • 20 of babies (640 k/yr USA) MJ exposed
  • 75 of babies (2.4 m/yr USA) EtOH exposed
  • The above were 1980s data in 1990s some
    suggest that use rates were only 1/3 of the
    1980s rates.

12
Prenatal Exposure Rate Data from National Survey
on Drug Use and Health (NSDUH), Office of
Applied Studies, SAMHSA, US DHHS
  • In 2002 and 2003, 4.3 percent of pregnant women
    aged 15 to 44 used illicit drugs during the past
    month,
  • 4.1 percent reported binge alcohol use, and
  • 18.0 percent reported smoking cigarettes
  • Pregnant women aged 15 to 25 were more likely to
    use illicit drugs and smoke cigarettes during the
    past month than pregnant women aged 26 to 44
  • Among pregnant women aged 15 to 44, whites were
    more likely to have smoked cigarettes during the
    past month than blacks or Hispanics

13
  • Percentages of Past Month Illicit Drug Use among
    Women Aged 15 to 44, by Pregnancy Status, Age,
    and Race/Ethnicity 2002 and 2003

14
Percentages of Past Month Alcohol Use among Women
Aged 15 to 44, by Pregnancy Status 2002 and
2003 (Data from National Survey on Drug Use and
Health, Office of Applied Studies, SAMHSA, US
DHHS)
15
What to make of any data?
  • …Because of the high incidence of polysubstance
    use, it is essential to remember the inherent
    difficulties involved in ascribing a specific
    perinatal effect to one specific substance.
  • --Finnegan and Kandall, 1997

16
Substance Use and Addiction are Public Health
Problems
  • Use direct exposure to toxic effects
  • Use exposure to health risks associated with
    route of administration
  • Use placing oneself in contexts with health
    consequences (unwanted pregnancy, STDs,
    violence, vehicular crashes)
  • Passive exposure poses health risks
  • tobacco smoke vehicle passenger gang violence

17
Take-Home Messages Re Substance Use and
Addiction in Pregnancy
  • Substance use is widespread.
  • Addiction is not uncommon.
  • Not all heavy/frequent
  • substance users are addicts.
  • Not all addicts are daily users
  • or users of large quantities of
  • substances.

18
Take-Home Messages Re Substance Use and
Addiction in Pregnancy
  • Addiction is a stigmatized condition.
  • Patients with addiction feel ashamed, and will
    hide the truth (from themselves and others)
    because of shamepregnancy amplifies this.
  • Criminalization intensifies shame and
    withholding of information (arrest/ CPS) .
  • Addiction is not a desired state.

19
What are the clinical features of addiction?
  • Substance use
  • Use behaviors and procurement behaviors persist
    despite problems due to use
  • Return to use after periods of abstinence,
    despite previous problems
  • Inability to consistently control use
  • Preoccupation with use/procurement salience of
    use-related behaviors
  • Cognitive changes (over-valuation, de-valuation,
    minimization/denial)
  • Enhanced cue responsiveness via conditioning and
    generalization

20
What is the natural history of addiction?
  • some variants are more malignant in course than
    others
  • some variants are pediatric diseases (onset
    before adulthood)
  • chronic disease pattern waxing and waning of
    signs/symptoms
  • usually progressive
  • insidious atrophy of judgment, coping skills,
    relationships, values
  • sometimes fatal

21
What is the main clinical feature of addiction?
  • Inconsistent control of use

22
DSM IV Criteria for Substance Dependence Disorder
  • A maladaptive pattern of substance use, leading
    to clinically significant impairment or distress,
    as manifested by three (or more) of the
    following, occurring at any time in the same
    12-month period
  • 1. Tolerance, as defined by either of the
    following
  • a need for markedly increased amounts of the
    substance to achieve intoxication or the desired
    effect, or
  • b) markedly diminished effect with continued use
    of the same amount of the substance

23
DSM IV Substance Dependence
  • 2. Withdrawal
  • 3. The substance is often taken in larger
    amounts or over a longer period than was intended
  • 4. There is a persistent desire or there are
    unsuccessful efforts to cut down or control
    substance use
  • 5. A great deal of time is spent in activities
    necessary to obtain the substance, use the
    substance, or recover from its effects

24
DSM IV Substance Dependence
  • 6. Important social, occupational, or
    recreational activities are given up or reduced
    because of substance use
  • 7. The substance use is continued despite
    knowledge of having a persistent or recurrent
    physical or psychological problem that is likely
    to have been caused or exacerbated by the
    substance

25
Addiction is not Abuse
  • Odd words physical abuse, sexual abuse,
    substance abuse
  • Substance Abuse -- overarching term
  • Substance Abuse -- DSM-IV meaning

26
Addiction is not Dependence
  • Physical vs. Psychological Dependence
  • Physiological Dependence
  • Tolerance
  • Withdrawal
  • DSM-IV terms

27
Addiction occurs as a result of interactions
among
  • Agent factors (substances)
  • Host factors (genetics, vulnerabilities,
    comorbidities)
  • Environmental factors (culture, neighborhood,
    household)

28
Its not only the agents (self-reinforcing
euphoriants)
29
Its not only the hosts (susceptible individuals)
30
Its not only the environments (cultures,
neighborhoods, homes, settings)
31
Substances
  • DRUGS vs. ALCOHOL
  • ILLEGAL vs. LEGAL
  • HARD vs. SOFT
  • STREET vs. PRESCRIPTION
  • CLUB DRUGS vs. THERAPEUTIC RXs

32
Its TOBACCO !
  • The Killer Drug
  • The Gateway Drug
  • The Commonest Drug

33
Mortality from Drug Use (direct toxic effects of
intoxication) (medical complications of chronic
use)
  • Tobacco 500,000 deaths / year
  • Alcohol 125,000 deaths/year
  • Drugs

34
Epidemiology
  • 10 of adults have a lifetime prevalence of
    addiction to alcohol/drugs, excluding nicotine
  • 20 of primary care outpatients have a lifetime
    prevalence of SUD (excl. nicotine)
  • 30 of hospitalized inpatients have a lifetime
    prevalence of SUD (excl. nicotine)

35
Epidemiology
  • Alcohol abuse dependence lifetime prevalence
    14 (males 24, females 5)
  • Drug abuse dependence lifetime prevalence 6
  • Combined is about 10

36
Substance Dependence or Abuse among Persons Aged
12 or Older 2002 and 2003
Numbers in Millions
22.0
21.6
3.2
3.1
NHSUD
37
Substances
  • Sedatives
  • Stimulants
  • Opioids
  • Hallucinogens
  • Inhalants

38
Sedatives
  • Alcoholic beverages
  • Barbiturates
  • Benzodiazepines
  • Sedative-Hypnotics
  • GHB (GBL, 1,4 BD)
  • Propofol

39
Stimulants
  • Speed
  • Cocaine
  • Psychostimulants
  • Appetite Suppressants
  • Designer Drugs (Ecstasy, et al.)
  • Nicotine

40
Opioids
  • Natural (codeine, morphine, opium, heroin)
  • Semi-synthetic
  • Synthetic
  • Partial Agonists
  • --novel delivery systems patches, lollipops,
    nasal sprays

41
Hallucinogens
  • LSD
  • Mescaline (Peyote)
  • Psilocybin (mushrooms)
  • Cannabinoids
  • NMDA-antagonists
  • (PCP, ketamine, dextromethorphan)

42
Inhalants
  • Nitrous Oxide
  • Nitrates
  • Hydrocarbons

43
Routes of Administration
  • Oral
  • Nasal
  • Inhaled/Smoked
  • IV
  • IM
  • Sub-cutaneous
  • Transdermal
  • Sublingual

44
Range of Conditions
  • Use
  • Misuse
  • Risky Use
  • Problem Use
  • Addiction
  • Disability
  • Death

45
Relationship Between Alcohol Use and Alcohol
Problems
Alcohol Use
None
Light
Moderate
Heavy
At Risk
Problem
Dependent
Low Risk
Severe
Moderate
Small
Alcohol Problems
None
46
A bit more on WORDS
  • SUBSTANCE ABUSE
  • DEPENDENCE
  • CRACK BABY
  • METH BABY
  • ADDICTED BABY
  • TOXICOLOGY SCREEN
  • DIAGNOSED BY PHYSICAL EXAM AND LAB TESTS
  • ASSESSMENT SOCIAL HISTORY

47
Substance Use and Addiction
  • …in pregnancy
  • ... in women who could become pregnant
  • For substance using and addicted women, it may be
    several months before she knows shes pregnant
    (irregular menses associated with alcohol or
    other drug use may not prevent the ability to
    conceive!)

48
Substance Use and Addiction
  • …in pregnancy
  • ... in women who could become pregnant
  • Surveys suggest that 67 of pregnant women drink,
    and over 10 of pregnant women use illegal drugs
  • Tobacco use in young women is about 1/3.
  • Black / White, rich / poor, public / private

49
Initial Presentation
  • When drug-addicted women present to health care
    facilities for services, some are presenting for
    prenatal care, but others are presenting only to
    deliver their baby
  • Access to prenatal care is affected by insurance
    status, lifestyle issues, and also fear of
    referral to legal or child protective services
    authorities
  • Access is also affected by delivery system
    issues services unfriendly to women/moms
    (child care, transportation)

50
? Index of Suspicion
  • Positive history of addiction in biological
    family
  • Positive history of addiction in partner
  • Psychiatric co-morbidity
  • Personality Disorders
  • Affective Disorders (20 of females with
    addiction cf. 1 in 20 males with addiction)
  • Frequent legal encounters
  • Other substance use

51
Injection Drug Use
  • Needle Marks
  • Track Marks
  • Sclerosed Veins
  • Disguised Veins (tattoos, self-scarring)
  • Hidden Veins (under breasts, under tongue,
    between fingers/toes)
  • Acute cellulitis or endocarditis

52
? Index of Suspicion
  • Physical, sexual, verbal abuse in Soc. Hx.
  • Hepatitis, cellulitis in P.M.Hx.
  • Nosebleeds, cough in R.O.S.
  • Nasal septal irritation on P.E.
  • Lymphadenopathy, fevers …..
  • Labs ? MCV, GGTP
  • BUT NOTHING IS AS GOOD AS SCREENING QUESTIONNAIRES

53
Screening Tools
  • C A G E
  • Control Annoyed Guilt Eye-opener
  • T A C E
  • Tolerance Annoyed Control Eye-opener
  • (How many drinks does it take to
  • make you feel high?)

54
Addressing Nicotine Dependence
  • The Five As
  • Ask
  • Advise
  • Assess Motivation to Change
  • Assist
  • Arrange Follow-Up

55
Ask !
  • Screening patients in a prenatal clinic with
    specific questions about substance use is an
    effective means of reducing substance use in this
    population

56
(No Transcript)
57
Assessing Quantity Backwards
  • 6 pack -- 12 pack -- 18 pack -- 24 pack
  • 1/2 pt -- pint ---1/5 gal (27 oz or 18 drinks)
  • 4/5 quart of wine -- 1/2 gal of wine --
  • 1.75 liters 57 oz ( 12 drinks of wine, 38
    drinks of 80-proof, 48 drinks of 100-proof)
  • HOW MANY DO YOU BUY PER WEEK?

58
Assessment Taking a History
  • Age at First Use
  • Age at First Regular Use
  • Age of First Problem Use
  • Physical symptoms from use
  • Alcohol Blackouts
  • First O.W.I.
  • First complaints from family/friends/employer
  • Period of Heaviest Use

59
Assessing for Detox Needs
  • Maximum Use in 24 Hours
  • Tolerance noted (larger dose required to produce
    given effect)
  • First withdrawal symptoms
  • Worst withdrawal symptoms

60
Assessing for Rehab Needs
  • Days of use per month
  • Longest span without use in last one, three,
    twelve months
  • Days of intoxication per month
  • Ability to stop or cut back as desired
  • Salience of use it takes over, becomes 1
    thing of importance
  • Assess denialsymptom attribution

61
Remember where this came from….
  • Because of preexisting conditions and ongoing
    active drug use, the drug-dependent woman
    frequently suffers from chronic anxiety and
    depression. Lacking self-confidence and hope for
    the future, these women often have interpersonal
    heterosexual difficulties and become victims of
    abuse and battering.

62
  • …Poverty, homelessness, and the need to engage
    in prostitution or other crimes to support a drug
    habit may overwhelm coping mechanisms….The
    pregnant drug-dependent woman must often indulge
    in…the sale of drugs, prostitution, robbery, or
    forgery. Because most of her day is consumed by
    the two activities of either obtaining drugs or
    using drugs, she spends most of her time unable
    to function in the usual activities of daily
    living.

63
Remember where this came from….
  • The opiate addict will have intermittent periods
    of normal alertness and well-being, but for most
    of the day will either be high or sick.
    Because of her lifestyle and because she may fear
    calling attention to her drug habit, the pregnant
    addict often does not seek prenatal care.
  • --Finnegan and Kandall, 1997

64
Daily fluctuations in functional state, heroin
user.
65
Methadone Simulated 24 Hr. Dose/Response At
steady-state in tolerant patient
Loaded High
Methadone Maintained Pt
Normal Range Comfort Zone
Dose Response
Bup Maintained
Subjective w/d
Heroin- Using Pt.
Sick
Objective w/d
Time
0 hrs.
24 hrs.
Opioid Agonist Treatment of Addiction - Payte -
1998
66
  • Alcohol Use
  • and Addiction
  • in Pregnancy

67
EtOH Pharmacology
  • Water solublegoes to total body water
  • Readily crosses placenta present in amniotic
    fluid after moderate maternal dose
  • Elimination from amniotic fluid is at only ½ the
    rate of elimination from maternal blood, so when
    moms BAC is zero, baby may still be under the
    influence
  • Around 3 in 4 pregnant moms exposes her baby to
    ethanol in utero
  • Alcohol is a prominent part of many if not most
    drug users lives (Finnegan and Kandall)

68
F A S D Fetal Alcohol Spectrum Disorders
  • FAS
  • Fetal growth retardation (head circumference,
    height, or weight
  • Facial dysmorphism
  • CNS dysfunction (neurodevelopmental delay, IQ
    averages 68 microcephalycircumference impulsivity/judgment, irritability, memory, motor
    skills, etc.)
  • 85 of FAS kids have mental retardation
  • FAS is the Leading Cause of Preventable MR

69
FAS Facial Features
70
Fetal Alcohol Syndrome (FAS)
  • Prevalence (1997)
  • 0.3/1,000 live births
  • 7-10 alcohol dependent women who drink during
    pregnancy will have an FASD baby
  • Dose Effects
  • special risk when 5 drinks or more per day (3 oz
    100 EtOH 5 drinks of 0.6 oz EtOH)
  • Risk factors
  • Parity, age
  • Race, culture

71
Fetal Alcohol Effects (FAE)
  • Incidence 1 in 100 live births
  • Abnormalities seen depend on when woman drinks
    during pregnancy
  • Defects occur before most women know they are
    pregnant
  • There is no known safe level of drinking for
    pregnant women
  • Binges may be worse than daily drinking
  • The higher the blood level of alcohol, the
    greater the chance of damage.

72
FAS is not treatable.
  • Effects persist long after pregnancy
  • …more realistic expectations for performance
    during childhood and adolescence may result in
    the availability of more appropriate services,
    less frustration, and improved behavioral outcome
    in later adolescence and adulthood Letter to
    the Editor, JAACAP

73
Effect of Pregnancy on Use
  • Alcohol Using Women
  • Abstinence in 1st Trimester 46
  • Abstinence in 2nd Trimester 79
  • Abstinence in 3rd Trimester 69
  • Abstinence Post Pregnancy 16

74
  • Nicotine Use
  • and Addiction
  • in Pregnancy

75
Effect of Pregnancy on Use
  • Tobacco Using Women
  • Abstinence in 1st Trimester 28
  • Abstinence in 2nd Trimester 36
  • Abstinence in 3rd Trimester 47
  • Abstinence Post Pregnancy 16

76
Nicotine Use and Pregnancy
  • A clear inverse relationship between birth weight
    and of cigarettes smoked per day
  • Birth weight averages 200 g lower.
  • LBW/SGA resolves itself by 1 year of life
  • LBW/SGA are avoided when moms stop smoking during
    first trimester
  • But when mom doesnt stop smoking, full-term
    births show increased placenta previa, abruptio
    placentae, and fetal loss

77
Smoking and Pregnancy
  • Effects persist long after pregnancy
  • SIDS rates are 4.4 times higher for infants born
    to mothers who smoked through pregnancy
  • IQ scores are 4 points lower in offspring of
    mothers who smoked through pregnancy
  • Stopping Smoking Helps!

78
Nicotine Replacement Therapy
  • Serum levels are ½ of those in smokers
  • Nicotine gum use enhances success rates for
    smoking cessation in pregnancy
  • Fetal/maternal hemodynamics are measurably better
    in the oral NRT patients than in the patients
    continuing to smoke
  • 1 mg per cigarette (21 mg patch 1 PPD) 2 mg
    per piece10 Nicorette/day 1 PPD

79
  • Sedative Use
  • and Addiction
  • in Pregnancy

80
Patterns of Sedative Use
  • It is unusual to see patients who are abusing
    only prescription medications. Most women who
    abuse sedative-hypnotics take one or more
    benzodiazepines in combination with alcohol,
    along with barbiturates and other sleeping pills.

81
Sedative Withdrawal
  • The risk to both mother and fetus from untreated
    sedative-hypnotic withdrawal usually is greater
    than the potential risk to the fetus from
    exposure to either benzodiazepines or
    barbiturates given in a controlled setting.

82
  • Illicit Drug Use
  • and Addiction
  • in Pregnancy

83
  • Experimental studies to evaluate the long-term
    effects of intrauterine exposure to drugs are
    limited, so it is difficult to differentiate the
    effects of the actual drug exposure from the
    effects of being raised in an environment of
    ongoing parental drug use.
  • Infants born to women who are addicted to alcohol
    or other drugs are at high risk for sequelae such
    as attachment difficulties, behavioral problems
    (disorganization, unpredictability, and
    distractibility), and child neglect or abuse.
    Weaver

84
General Epidemiology
  • Data from the 1996 and 1998 National Household
    Survey on Drug Use (now NSDUH)
  • 6.4 of non pregnant women of childbearing age
    used illicit drugs
  • 2.8 of pregnant women used illicit drugs
  • MJ ¾ of illicit drug use, Coc 1/10 of illicit
    use
  • Of illicit drug users, 2/3 of non-pregnant women
    of childbearing age also used alcohol and
    tobacco, and ½ of pregnant women used alcohol and
    tobacco

85
Effect of Pregnancy on Use
  • Illicit Drug Using Women
  • Abstinence in 1st Trimester 28
  • Abstinence in 2nd Trimester 76
  • Abstinence in 3rd Trimester 93
  • Abstinence Post Pregnancy 24

86
  • Cocaine Use
  • and Addiction
  • in Pregnancy

87
Cocaine
  • Erythroxylon coca pasteextraction from the
    plant involves solvents such as benzene
  • Cocaine HClfurther extraction from the paste
    involves hydrochloric acid
  • Cocaine base (crack)extraction from the HCl
    salt involves ether
  • The salt is used per nasum or IV it does not
    volatile at the temperatures of a cigarette
  • The base is smoked both snorting and smoking
    bypass first-pass metabolism in the liver

88
Cocaine
  • Even the HCl salt is an alkaloid
  • Cocaine is low MW and water-soluble and crosses
    the placenta readily cocaine base crosses even
    more efficiently. Once there, since the fetal pH
    is lower than the maternal pH, it accumulates on
    the fetal side of the placenta
  • In asphyxial episodes, fetal pH drops even more
  • And metabolism by the fetus is less than maternal
    metabolism
  • So the babys levels are higher than the moms
    serum levels!

89
Cocaine
  • It is metabolized to water-soluble products such
    as benzoyl ecgonine while cocaine disappears
    from serum and urine in 12 hours, benzoylecgonine
    is detected in urine drug tests for 2-7 day (or
    even weeks in very heavy daily users)
  • EMIT or radio immumo diffusion finds it readily
  • Analysis of meconium can find benzoylecgonine in
    an additional 1/3 of cases cf. neonatal urine
    anaylsis

90
The Crack Epidemic
  • Up to 5 of babies in 1980s were exposed to
    cocaine in utero
  • NYC cocaine-exposed babies rose from 7
  • to 21 per 1000 live births from 1983 to 87
    similar 3x increases 85 to 88 elsewhere
  • In NYC, it was back to 0.7/100 by 1990, whereas
    crack arrived in Madison (as ready rock) in
    1990.
  • Highly over-represented in moms on M.A.(4x
    privately insured moms)
  • In 1990s, 8 of black babies were exposed

91
The Crack Epidemic
  • The typical cocaine user abuses cocaine
    repeatedly before conception, continues to use
    the drug repeatedly throughout the pregnancy, and
    often combines it with other drugs. (Graham
    textbook, ASAM)

92
The Crack Epidemic
  • Assessment of the organic impact of cocaine on
    the human pregnancy must consider confounding
    drug use-associated variables such as poverty,
    homelessness, inadequate prenatal and postnatal
    care, deficient nutrition, varying types of
    cocaine use, multiple drug use, sexually
    transmitted diseases, and the possible presence
    of toxic adulterants that are mixed with or used
    to process cocaine. (Lowinson textbook
    Finnegan Kandall)

93
Cocaine Physiology
  • It constricts vesselsin the uterus, cord, and
    placenta
  • Deleterious effects on fetal oxygen and nutrient
    exchange outweigh effects on decreased efficiency
    of cocaine delivery to the fetus
  • Uterine blood flow and maternal BP vary in
    dose-response relationships to cocaine-induced
    catecholamine serum levels

94
Cocaine Physiology
  • It increases uterine contractility
  • It precipiates premature labor
  • It is associated with increased abruption
  • Greater rates of fetal demise
  • Even non-tobacco using moms who use cocaine have
    LBW and premature babies
  • Lower birth weight and SGA, maybe due to
    utero-placental vasoconstriction, but may be due
    to contextual factors

95
Neonatal Cocaine Intoxication and Withdrawal
  • CNS excitation, irritability, insomnia, poor
    feeding in babies born under the influence
    acutely
  • CNS depression, irritability, hypersomnia,
    insomnia, poor feeding in babies born with
    exposure just pre-partumthis sluggishness is the
    babys crash

96
Cocaine Pathology
  • Maternal strokes
  • Fetal strokes (some attribute to context)
  • Fetal seizures (some attribute to context)
  • No definite teratogenicity
  • No definitive persistent behavioral change/ADHD
    that can be linked to direct drug effects vs.
    contextual effects (maternal nutrition/infection
    maternal functioning during infancy/toddler ages)

97
The Reality of the Cocaine Baby
  • The most critical aspect of the childs
    development is what happens postpartum.
  • Infants with intrauterine drug exposure may be
    difficult to nurture due to behavioral changes,
    which cause problems with bonding between mother
    and infant.
  • Mothers who continue to abuse stimulants after
    delivery put their children at risk if they
    breastfeed, because stimulants pass into breast
    milk.
  • Maternal drug abuse can have adverse consequences
    for children, such as child neglect and abuse or
    loss of family structure. (Weaver)

98
  • Opiate/Opioid Use
  • and Addiction
  • in Pregnancy

99
A Few Words about Urine Drug Testing
  • Not toxicology
  • Not screening
  • Know whats being tested for
  • Know the method (TLC, RIA, GC/MS)
  • Opiates vs. Opioids
  • Confirmatory testing / Adulterant testing
  • A POSITIVE TEST ONLY PROVIDES INFORMATION ABOUT
    RECENT USE, NOT ABOUT DIAGNOSIS OF ADDICTION

100
Heroin Addicted Women
  • Heroin causes fetal growth retardationin animal
    lab research, and in humans addicted to heroin
  • 35 years ago, researchers found that initiation
    of methadone maintenance eliminated maternal
    deaths, fetal demise, and reduced several
    complications of pregnancyfirst trimester MMT
    dosing is directly linked to birth weight
  • Meconium staining is vastly less on MMT patients
    vs. active heroin addicted mothers birth weight
    approaches normal

101
Continue Opioids During Pregnancy
  • Medical withdrawal of the pregnant
    opioid-dependent woman is not recommended because
    of high rates of relapse to heroin use and the
    increased risk to the fetus of intrauterine
    death. Methadone maintenance is the treatment of
    choice (CSAT, 1993).

102
Use of Methadone General
  • Recall, methadone can be prescribed
  • for treatment of narcotic addiction
  • for treatment of narcotic withdrawal
  • for treatment of pain, whenever indicated
  • for treatment of pain, even in addicts ! !
  • Methadone, when used for pain, can be prescribed
    by any physician with DEA registration for C-IIs
  • Methadone, when used for pain, can be tapered by
    any physician with DEA registration for C-IIs

103
Use of Methadone Pregnancy
  • Must be ordered and dispensed through
    licensed/accredited methadone clinic (OTPopioid
    treatment program)
  • If admitted to general hospital / OB unit already
    on MMT, can be continued
  • If pregnant, an OP or IP facility can start MMT
    themselves if a hand-off to a licensed OTP is
    pending within 72 hours

104
Rationale for Methadone Maintenance
  • Methadone maintenance reduces use of illicit
    opioids by blocking withdrawal symptoms and
    cravings. Use of a stable methadone dose reduces
    fluctuations in maternal opioid level, which
    reduces stress on the fetus (fluctuations between
    intoxication and withdrawal result in adverse
    fetal effects, such as premature labor and
    spontaneous abortion).

105
Daily fluctuations in functional state, heroin
user.
106
Methadone Simulated 24 Hr. Dose/Response At
steady-state in tolerant patient
Loaded High
Methadone Maintained Pt
Normal Range Comfort Zone
Dose Response
Bup Maintained
Subjective w/d
Heroin- Using Pt.
Sick
Objective w/d
Time
0 hrs.
24 hrs.
Opioid Agonist Treatment of Addiction - Payte -
1998
107
Dosing of Methadone
  • Low Dose strategies are ineffective
  • Pregnant women especially should be dosed at over
    60 mg, probably over 120 mg daily.
  • Dosage requirements rise in the third trimester
  • larger plasma volume / total body water
  • decreased plasma protein binding
  • increased methadone metabolism
  • increased clearance by the mother

108
Late Pregnancy Dosing
  • Methadone half-life is shortened
  • Watch for breakthrough withdrawal sx in mom as
    methadone levels drop need to adjust dose upward
  • Splitting dosage (BID) may be required, if
    possible

109
Advantages of Methadone Maintenance
  • Methadone maintenance enhances the ability of the
    woman to participate in prenatal care and in
    addiction treatment, thus allowing her to better
    prepare for the arrival of the infant.
  • There are measurable reductions in criminal
    activity.
  • The pregnant mom is more functional overall
    there are decreased disruption of the
    maternal-child unit, especially if shes avoiding
    incarceration.
  • Elimination of heroin use with adequate doses of
    methadone prevents harm to the fetus from
    exposure to adulterant compounds in street
    heroin.
  • Improved maternal health and nutrition reduce
    obstetrical complications and improve the health
    of the infant at delivery.

110
Methadone Maintenance
  • …reducing illegal drug use, removing the woman
    from a drug-seeking environment, preventing
    fluctuations of drug levels throughout the day,
    improving maternal nutrition, increasing the
    likelihood of prenatal care, enhancing the
    womans ability to prepare for the birth of her
    baby, reducing obstetrical complications, and
    offering the pregnant heroin addict an
    opportunity restructure her life…. Finnegan and
    Kandall

111
Management of Labor
  • Generally, the same as for any L D
  • May choose to start conduction anesthesia
    earlier to minimize need for narcotic therapy
  • Tolerance will be higher, so higher opioid doses
    will be needed when those agents are chosen
  • If mom is in some degree of acute withdrawal,
    give more methadone before delivery
  • Dont give Narcan ! !

112
Opioid Overdosage in Pregnancy
  • Naloxone should not be given to a pregnant woman
    except as a last resort for severe opioid
    overdose, because withdrawal precipitated by an
    opioid antagonist can result in spontaneous
    abortion, premature labor, or stillbirth.

113
Opioid Withdrawal
  • Abrupt withdrawal in the non-pregnant individual
    usually causes physical effects no worse than a
    bad case of influenza.
  • However, opioid withdrawal during pregnancy can
    lead to fetal distress and premature labor
    because of increased oxygen consumption by both
    mother and fetus.
  • Even minimal symptoms in the mother may indicate
    fetal distress, since the fetus may be more
    susceptible to withdrawal symptoms than the
    mother. Weaver

114
Neonatal Opioid Withdrawal
  • Neonatal opioid withdrawal syndrome occurs in 60
    to 80 of infants with intrauterine exposure to
    heroin or methadone
  • But its easy to manage!

115
Breastfeeding
  • Breastfeeding should be encouraged to promote
    mother-infant bonding and to provide optimal
    nutrition and passive immunization to the child.
  • Women can breastfeed while on methadone
    maintenance as long as they are not abusing any
    drugs and are not HIV-positive.
  • Weaver (2003)

116
Other issues
  • Research has been unable to link either illicit
    heroin or prescribed methadone to any genetic
    damage in offspring
  • There do seem to be tendencies toward multiple
    births in women exposed to opioids regularly
    around the time of conception
  • The risk of SIDS is greater in births from
    heroin-dependent moms, and possibly greater in
    births from MMT-treated moms

117
Intravenous Drug Use and Pregnancy
  • It may not be the substance (heroin, cocaine,
    speed, downers) those poses the health risk
  • Maybe its the route of administration
  • Maybe its the associated behaviors (trading
    sex for drugs, prostitution)
  • And maybe its nutrition (intake, absorption, or
    hepatitis effects)

118
Medical Complications in Pregnant IV Drug Users
(IVDUs)
  • Anemia
  • Cellulitis
  • Dental decay
  • Edema
  • Endocarditis
  • HBVacute / chronic
  • HCVacute / chronic
  • HIV
  • Hypertension
  • Phlebitis
  • Pneumonia
  • STDs
  • Septicemia
  • TB
  • UTIscystitis, pyelonephritis

119
  • Inhalant Use
  • and Addiction
  • in Pregnancy

120
Anne Marie Pagliaro, Ph.D., R.N. Louis A.
Pagliaro, Ph.D.
  • Toluene embryopathy
  • Case reports of FAS-like syndrome with growth
    retardation, developmental delays, and
    craniofacial anomalies.

121
From Zebras Back to Horses Addressing Drug
Dependence
  • The Five As
  • Ask
  • Advise
  • Assess Motivation to Change
  • Assist
  • Arrange Follow-Up

122
Arrange Follow-Up
  • Its a CHRONIC disease
  • If its addiction, it wont go away with brief
    advice only
  • It must be addressed again and again over the
    course of the condition, whether its getting
    worse or better
  • If you give an assignment, you must follow up or
    else the patient will know that this isnt really
    important

123
To wrap it all up….
  • Appropriate support should be available to
    addicted women after delivery to help them meet
    the challenge of dealing with their newborn,
    especially if older children are present and
    require care. Support can come from the womans
    family, a Twelve Step self-help group, or health
    care practitioners with appropriate advice. Lack
    of support can lead to relapse, which may result
    in neglect of the infant. Weaver

124
Weaver (ASAM Textbook, 2003)
  • Continuation of addiction treatment postpartum,
    coupled with appropriate social support for new
    mothers, is essential to prevent relapse after
    delivery. Basic knowledge of perinatal addiction
    allows health care providers to improve the
    health and welfare of mothers and their children.
About PowerShow.com