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SUBSTANCE ABUSE SCREENING IN PREGNANCY

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Maternal alcohol abuse during pregnancy is associated with: Fetal Alcohol Syndrome (FAS) ... MG, Burd L. 'Fetal alcohol syndrome prevention: annual and ... – PowerPoint PPT presentation

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Title: SUBSTANCE ABUSE SCREENING IN PREGNANCY


1
SUBSTANCE ABUSE SCREENING IN PREGNANCY
  • Presented by-
  • Debby Carapezza, RN, MSN
  • Nurse Consultant
  • Utah Department of Health
  • Reproductive Health Program
  • January 2004

2
The Problem
  • While many providers know substance abuse during
    pregnancy is a problem, many assume
  • -it only exists among the poor and
  • -it couldnt possibly be a problem in their
    practice!
  • DATA BEG TO DIFFER!!

3
Maternal alcohol abuse during pregnancy is
associated with
  • Fetal Alcohol Syndrome (FAS)
  • Increased risk of spontaneous abortion
  • Alcohol-related neurodevelopmental disorder
    (ARND)
  • Alcohol-related birth defects (ARBD)

4
How Prevalent is FAS?
  • Prevalence varies by population studied methods
    used
  • According to the CDC, rates vary from 0.2 to 1.5
    cases per 1,000 live births in various areas of
    the US
  • FAS is one of the leading causes of preventable
    mental retardation

5
What about ARND ARBD?
  • These conditions are believed to occur 3 times
    more often than FAS.

6
What about the ?
  • A North Dakota study found that if a prevention
    program prevents one new case of FAS/year, it
    would save that state
  • 2,342 in the first year
  • 128,810 after 10 years
  • 491,820 after 20 years1
  • 1. Klug, MG, Burd L. Fetal alcohol syndrome
    prevention annual and cumulative cost savings.
    Neurotoxicology Teratology. (Nov-Dec. 2003).
    25(6) 763-765.

7
But Isnt Utah Different?
  • According to birth certificate data from 2002-
  • 1 of women, or 514 women, experiencing a live
    birth in that year reported using alcohol while
    pregnant.

8
ILLICIT DRUGS The National Survey on Drug Use
Health
  • During 2002, data were collected from 1,104
    pregnant women aged 18-44 years of age2
  • 2. Substance Abuse and Mental Health Services
    Administration. The National Survey on Drug Use
    and Health, Pregnancy and Substance Use. (Jan
    2, 2004). Available at http//oas.samhsa.gov/2k3/
    pregnancy/pregnancy.htm

9
Results
  • 9 of nonpregnant women ages 15 to 44 years
    reported use of illicit drugs in the month
    previous to the survey
  • 3 of pregnant women reported use of illicit
    drugs in the month previous to the survey
  • Pregnant women aged 15 to 25 were more likely to
    use illicit drugs in the past month than pregnant
    women aged 26 to 44

10
Results continued
  • Among pregnant women aged 15 to 44, approximately
    6 of blacks, 4 of whites and 2 of Hispanics
    used illicit drugs in the past month
  • Pregnant white Hispanic women had lower rates
    of illicit drug use than nonpregnant women of the
    same age
  • Among pregnant, black women, the rate of past
    month illicit drug use was not statistically
    different from nonpregnant black women
  • Marijuana was the most widely used illicit drug
    among both pregnant and nonpregnant women

11
But Isnt Utah Different?
  • During 2000, 13 well baby nurseries during
    2000-2001, 6 NICUs collected anonymous meconium
    samples on newborns3
  • Data were compared to results of a maternal
    substance abuse prevalence study conducted in the
    same geographic area in 1991.4
  • Buchi KF, Zone S, Langheinrich K, Varner MW.
    Changing prevalence of prenatal substance abuse
    in Utah. Obstetrics Gynecology. (2003) Jul
    102(1) 27-30.
  • Buchi KF, Varner MW, Chase RA. The prevalence of
    substance abuse among pregnant women in Utah.
    Obstetrics Gynecology. (1993) Feb 81(2)239-42.

12
Results THE GOOD!
  • No significant differences in the rates of
    positivity for methamphetamines and marijuana
    were noted between the 2 studies
  • Cocaine use had declined from 1.1 in 1991 to
    0.3 in 2000/2001

13
Results THE BAD UGLY!
  • Positivity for methamphetamines, marijuana
    cocaine was 4.7 among infants in NICUs
  • Positivity for those 3 drugs was 1.9 for infants
    in well baby nurseries

14
What is the Impact of Substance Use on the
Fetus/Infant?
  • ALCOHOL USE

15
The Impact of Alcohol on the Infant
16
How much alcohol does it take to produce FAS?
  • The exact levels are unknown. However the
    following is known5
  • With intake of 4 drinks/day, the risk for FAS may
    be 20
  • With the intake of 5 drinks/day, the risk for FAS
    increases to 30
  • With the intake of 6 drinks/day, the risk for FAS
    increases to 40
  • Maternal binge drinking may also produce
    substantial risk to the fetus
  • 5. The American College of Obstetrics
    Gynecologists. Precis V An Update in Obstetrics
    Gynecology.(1994). Washington DC. p. 140.

17
What is the Impact of Substance Use on the
Fetus/Infant?
  • COCAINE

18
What about Cocaine?
  • A meta-analysis reviewed 33 studies of pregnancy
    outcomes among cocaine consuming women.6
  • Women were categorized into 4 groups by type of
    exposure
  • Mainly cocaine
  • Cocaine plus polydrug use
  • Polydrug use but no cocaine
  • No drug use
  • 6. Addis A, Moretti ME, Syed FA, Einarson TR,
    Koren G. Fetal effects of cocaine an updated
    meta-analysis. Reproductive Toxicology. (2001).
    Jul-Aug 15(4)341-369.

19
Results
  • When cocaine exposed children were compared to
    those with no exposure, the cocaine exposed
    children had higher risks of
  • -Major malformations
  • -Low birth weights
  • -Prematurity
  • -Placental abruption
  • -Premature rupture of membranes
  • -Decreased length head circumference

20
But
  • Comparison of cocaine exposed children to
    children exposed to polydrug used without cocaine
    revealed-
  • -That only the risk of placental abruption and
    PROM were statistically associated with cocaine
    use
  • -That many adverse perinatal effects attributed
    to cocaine may be caused by multiple confounders

21
Recommendation by ACOG
  • Substance abuse is one of the most important
    risks encountered in contemporary obstetrics.
    Therefore, all patients should be questioned
    thoroughly about substance abuse (including
    alcohol and tobacco) at the time of their first
    prenatal visit. (ACOG, 1994)

22
Not to worry! We all ask about drug alcohol
use dont we???
  • PRAMS asks new moms,
  • During your prenatal visits, did a doctor,
    nurse, or other health care worker talk with you
    about any of the things listed below?
  • How drinking during pregnancy could affect your
    baby?
  • How using illegal drugs could affect your baby?
  • PRAMS is an ongoing, population-based risk
    factor surveillance system designed to identify
    and monitor selected maternal experiences that
    occur before and during pregnancy and experiences
    of the childs early infancy.

23
And the results were7
  • Only 55.4 of women reported discussion of the
    affects of alcohol on a baby
  • Only 47.6 of women reported discussion of how
    using illegal drugs affects a baby
  • Women receiving prenatal care through a private
    provider had the lowest rates of counseling
  • 7. Utah Department of Health, Reproductive Health
    Program. Prenatal Education in Utah. PRAMS
    Perspectives A Pregnancy Risk Assessment
    Monitoring System Quarterly Report. V.3 No. 1. p.
    2-4.

24
SCREENING!
  • WHEN?

25
In a perfect world-
  • Preconceptionally during routine primary care
    visits
  • Preconceptionally during family planning visits

26
During pregnancy-
  • At the first prenatal visit
  • During each trimester
  • At the postpartum visit
  • More frequently if risk factors are present

27
I dont screen all of my prenatal clients because
  • I dont want to offend anyone!

28
To avoid problems, before you start screening
  • Train involved staff in interviewing techniques
  • Train involved staff in use of the screening tool
  • Assure a non-judgmental supportive attitude
  • Assure confidentiality to the extent permitted by
    law
  • Involved staff should have an on-going
    relationship with the client
  • Screen all clients to decrease subjectivity
    bias
  • Screen in a language understood by the client

29
Remember
  • Screening provides the opportunity to begin an
    open discussion of substance abuse!
  • During the screening whether the screening is
    positive or negative for substance abuse, the
    health implications of use and the benefits of
    reduction/abstinence should be stressed!

30
I dont screen because
  • in my busy office, I just dont have time!

31
Most screening can be accomplished in a short
time.
  • For the majority of clients, screening can take
    30 seconds
  • For women with a problem, screening can often be
    accomplished in 5 to 10 minutes

32
Try these strategies for women with a positive
screen
  • Review for the client the information she has
    just reported to you
  • State your concern for both her her babys
    health
  • State your belief that you know she want to have
    a healthy baby and that abstinence from alcohol
    drugs will improve her babys health

33
Try these strategies for women with a positive
screen
  • State the need for her to stop using alcohol
    drugs during pregnancy
  • Assure the client you will work with her to
    achieve a substance free pregnancy
  • Know your referral sources

34
Try these strategies for women with a positive
screen
  • Discuss possible strategies for her to stop
  • Individual counseling
  • 12-step programs
  • Addiction treatment programs

35
Try these strategies for women with a positive
screen
  • Suggest referral source(s) for a more in-depth
    assessment by a specialist
  • If possible, make an appointment for her while in
    your office
  • Make a follow-up appointment to see the client
    after her assessment
  • Keep an on-going interest in her progress
  • Praise any reported reduction in use
  • Maintain communication with the treatment
    provider to monitor progress

36
Emphasize to the client struggling with substance
abuse
  • The benefits will begin as soon as she reduces or
    stops her substance use the earlier the better
    but it is never too late!

37
The 4 Ps Screening Tool
38
A word (or 2) about the tool
  • This tool has been chosen to screen for alcohol
    drug use during pregnancy due to its brevity,
    validity, specificity and sensitivity.
  • It has been used with populations of pregnant
    women
  • It is public domain and may be copied without
    permission

39
And a few more words about the tool
  • It has been recommended for use by the National
    Center for Education in Maternal Child Health
  • Its screening questions can be included in other
    areas of the visit, i.e., in the family history
    review or when discussing the home environment
  • However, providers should select a tool with
    which they are comfortable and that fits their
    interview style

40
General Instructions on Use of the Tools
  • Substance abuse screening should ideally occur
    face-to-face
  • Screening can be accomplished via a client
    completed questionnaire administered prior to the
    visit reviewed with the woman during her intake
    history

41
4Ps
  • Have you ever used drugs or alcohol during the
    Pregnancy?
  • Have you had a problem with drugs or alcohol in
    the Past?
  • Does your Partner have a problem with drugs or
    alcohol?
  • Do you consider one of your Parents to be an
    addict or alcoholic?
  • Any woman who answers yes to 1 or more questions
    should be referred for further assessment

42
Other screening tools are available.
  • You may also wish to consider the following
  • T-ACE
  • Tweak
  • TQDH
  • AUDIT

43
Resources
  • For substance abuse
  • Utah Department of Human Services
  • Division of Substance Abuse Mental Health
  • 120 N 200 W
  • Salt Lake City, UT 84103
  • 801-58-4379
  • www.utahdsa.com

44
Substance Abuse Resources, continued
  • Substance Abuse Mental Health Services
    Administration
  • Local treatment centers can be found by city,
    address or zip code at the following website
  • http//findtreatment.samhsa.gov/facilitylocatordoc
    .htm

45
Mental Health Resources-
  • Mental Health Association in Utah
  • 1800 S W Temple, Suite 501
  • Salt Lake City, UT 84115
  • 801-569-3705
  • http//www.xmission.com/mhaut/index.htm

46
Mental Health Resources, continued-
  • National Alliance for the Mentally Ill Utah
  • 309 E 100 S
  • Salt Lake City, UT 84111
  • 801-323-9900
  • Bridges Program, Kim Haws, Program Director
  • Family to Family (provides support to individuals
    coping with mentally ill family members)

47
Substance Abuse Resources, continued-
  • Medicaid
  • Utah Department of Health
  • Division of Health Care Financing
  • PO Box 143106
  • Salt Lake City, UT 84114-3106
  • 801-538-6155
  • Toll-free 800-662-9651

48
In Summary
  • All pregnant women should be screened for
    substance abuse at the first prenatal visit,
    every trimester thereafter and at the postpartum
    visit
  • Women with positive screens should be referred
    for more detailed assessment / treatment
  • Screening provides the opportunity to begin an
    open discussion of substance abuse!
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