Pregnancy-Related Issues in the Management of Addictions

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Pregnancy-Related Issues in the Management of
Addictions
Train the Trainer Workshop Problematic Substance
Use in Pregnancy (PSUP) www.addictionpregnancy.ca
Last modified March 2008
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Conflict of Interest Disclosure

• Financial support for this workshop was provided
  by Health Canada
• Funding for the PRIMA Pocket Reference was
  provided by the Lawson Foundation
• No commercial sponsorship has been received to
  support this program

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Pregnancy-Related Issues in the Management of
Addictions

• Overview of Addictions

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Key Concepts
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Addiction (dependence)

• Women using addictive substances find the effects
  of the drug so pleasurable and reinforcing that
  they have difficulty controlling their use of the
  drug
• Reinforcement may be small and multiple, e.g.,
  nicotine, or large, e.g., heroin

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Many Substance Users are Survivors of Childhood
Trauma

• Women in substance abuse treatment report
• A lifetime history of trauma, most commonly
  physical or sexual abuse
• This ranges from 55 to 99 compared to women in
  community samples (36-51)
• Najavits et al, 1997

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Addictive Potential of Drugs

• Correlates with
• Rapid onset of action
• Potency at receptor site (euphoric effect)
• Short duration of action (contrast between
  intoxication and sober state)
• Tolerance (forces woman to escalate dose to
  achieve same effect)
• Withdrawal (forces woman to use drugs to avoid
  withdrawal)

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Reward Pathway

• All drugs of abuse
• Increased dopamine receptor stimulation in
  nucleus accumbens and medial forebrain bundle
• Cocaine stimulates it directly
• Opioids, alcohol, nicotine stimulate it via
  effects on other neurotransmitters

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Opiate Use is a Very Powerful self-medication for

• Blocking out intrusive thoughts, flashbacks and
  nightmares
• Numbing and avoiding feelings, thoughts, people
• Achieving sleep

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Tolerance

• Repeated administration alters
• Receptor numbers and sensitivity
• Levels of neurotransmitters
• Result decreased effect with same dose
• CNS develops resistance to drug effect
• Adaptive mechanism can function almost normally
  despite very high doses

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Tolerance (2)

• Rate of development of tolerance depends on the
  effects
• For example, with opioids
• Analgesia - slow tolerance (months)
• Sedation rapid tolerance (days)

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Withdrawal

• On sudden cessation of drug, alterations in
  receptors take days or weeks to normalize
• Receptors that resist the drug are now
  unopposed, leading to drug-opposite effects
• Sedating drugs withdrawal -gt autonomic
  hyperactivity
• Symptoms appear when drug use decreases, forcing
  woman to resume drug use

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Genetic Influences on Drug Dependence

• Positive family history increases risk of alcohol
  dependence
• Fewer adverse effects
• Greater tolerance
• More positive effects

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Sex and Gender Differences

• The Formative Years report from CASA demonstrates
  that
• Girls and young women use cigarettes, alcohol and
  drugs for reasons different than boys
• The signals and situations of high risk are
  different
• Girls are more vulnerable to substance use and
  abuse and its consequences
• Girls have incorrect knowledge and beliefs about
  substances
• Parents are often inattentive contd
• CASA. The Formative Years Pathways to Substance
  Abuse Among Girls and Young Women Ages 8-22.
  2003. www.casacolumbia.org

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Sex and Gender Differences (2)

• The Formative Years report indicates that girls
  are influenced by
• Substance-using friends
• Schools and communities that turn a blind eye
• Physicians who are not vigilant to early warning
  signs
• Exposure to entertainment media and alcohol and
  cigarette advertising, which bombard girls and
  young women with unhealthy and unrealistic
  messages about smoking, drinking and weight loss

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Substance Use by Women

• Substance use by women has been viewed by health
  professionals as more problematic
• This has led to disparities in screening and
  access to care and treatment
• Poor women, aboriginal women and women of colour
  are more frequently screened for substance use
  when accessing prenatal care than middle class
  and Caucasian women

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Risks for Addiction

• Psychiatric Risk
• Mood disorders
• Anxiety disorders, esp. post-traumatic stress
  disorder
• Personality disorders that effect impulse control
• Social, Cultural
• Lack of meaningful work/school/relationships
• Lack of social support
• Cultural attitudes towards alcohol, drugs
• Poverty

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Clinical Features

• Drug use becomes major focus of life and the
• addicted woman
• Neglects major responsibilities
• Continues to use despite knowledge of
  consequences
• Repeatedly tries to quit but relapses
• Develops tolerance and can go into withdrawal
• Experiences powerful urges to use (cravings)

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The 4 Cs of Addiction

• Continued use despite Consequences
• Unable to Cut down
• Cravings
• Compulsive drug use

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Classification of Drugs of Abuse

• Alcohol
• Benzodiazepines and other sedatives
• Opioids
• Stimulants cocaine, amphetamines
• Nicotine
• Cannabis
• Hallucinogens

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Psychological Treatment

• Natural Recovery
• Mutual Help Groups
• Outpatient Counseling
• Residential Treatment
• Minnesota model (28 or 21 day)
• Therapeutic community (months to years)

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Treatment of Substance Dependence Prognosis

• Approx. 30 abstinent one year post-treatment
• Prognosis worse if
• Older
• Longer drinking history
• Other substance use
• Untreated psychiatric disorder(s)
• Social instability
• Physicians warning associated with better
  prognosis at 2 years
• Treatment is cost-effective

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Success Rates of Formal Treatment (6 month
follow-up)Addiction Severity Index (ASI)
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Treatment for Women and Mothers

• When mothers and babies stay together in
  treatment, women indicate that maintaining close
  contact with their children was integral to their
  recovery efforts.
• Besinger, B.A. 2003. Mothers in addiction
  treatment The role of onsite childcare.
  University of Cincinnati, Cincinnati)
• Women stayed in treatment longer, had less
  depression and higher measures of self-esteem
  than women separated from their infants.
• Wobbie, K., Eyler F.D., 1997. Women and
  Children in Residential Treatment Outcomes for
  Mothers and their Infants. Journal of Drug
  Issues, 27 (3), 585-607

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Cost-effectiveness of Treatment Matched
Case-control Study

• 300 reduction in health care costs in treated
  group vs. waiting list controls
• Holder HD, Blose JO. J Stud Alcohol 1992 53
  293-302

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Role of the Health Care Providers

• Most substance users do not go to formal
  treatment
• BUT they make frequent use of health care
  provider (HCP) services
• Women often have considerable trust in their
  nurse/midwife/physician
• Health Care Providers should see women over long
  periods of time and build therapeutic
  relationships in order to effect long-term change
• contd

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Role of Health Care Providers (2)

• Smoking cessation counselling one of the most
  cost-effective interventions we can do
• At-risk drinking often brief advice (5-15
  minutes) is enough to get women to reduce
  drinking to low-risk levels
• Alcohol and drug dependence many women will
  accept HCP advice to attend treatment program
• contd

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Role of Health Care Providers (3)

• Treatment of withdrawal is first step to recovery
• Pharmacotherapy (methadone, bupropion, NRT, etc.)
  greatly increases success rates of counselling

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Failure to Understand and Address Trauma Can Lead
to

• Retraumatization of the woman
• Increase in symptoms
• Increase in management problems
• Increase in relapse
• Withdrawal from service relationship
• (Finkelstein, 2006)

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Approach to the Woman who is Addicted to
Substance(s)

• Dos Like any other disease
• Express concern
• Review diagnosis and health effects
• Present range of treatment options
• Acknowledge womans efforts and successes
• Arrange follow-up

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Approach for Provider/Counselor and Woman

• Meet basic needs
• Build positive social network
• Advise group and individual support
• Teach techniques to avoid drugs and triggers for
  substance use
• Encourage to have a structured day, keep busy

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Pregnancy-Related Issues in the Management of
AddictionsSlide presentation developed by
members of the National PRIMA group

• Ron Abrahams
• Talar Boyajian
• Jennifer Boyd
• Wendy Burgoyne
• Katherine Cardinal
• Rosa Dragonetti
• Lisa Graves
• Phil Hall

• Samuel Harper
• Georgia Hunt
• Meldon Kahan
• Theresa Kim
• Lisa Lefebvre
• Nick Leyland
• Margaret Leslie
• Deana Midmer

• Stephanie Minorgan
• Pat Mousmanis
• Alice Ordean
• Sarah Payne
• Peter Selby
• Melanie Smith
• Ron Wilson
• Suzanne Wong

Principal Authors
Prima.medicine_at_utoronto.ca