1. Perinatal Substance Abuse Program
Dept of Alcohol and Drug Services (DADS)
Presented by Lara Windett
M.A., MFT, LPPC Certified Addiction Specialist (CAS)
Please hold questions until after the presentation: I most likely will answer all questions you have as I go along…

2. The Department of Alcohol & Drug Services
exists within the overall
Santa Clara Valley Health & Hospital System
Dedicated to the health of the whole community
regardless of ability to pay

3. Background PSAP was Brainchild of Anthony Puentes, MD, MPH, 1987
Funding stream
Goal of PSAP Program
The Perinatal Substance Abuse Program of SCC was introduced in 1987 to address the growing need for appropriate and effective chemical dependency treatment for pregnant women.
Funding streams include:, Medical, Drug Medical, Medicare and other insurances (VHP, Valley Care), Calif State Department of Alcohol and Drug Programs, Perinatal Block Grant Funding – SAPT (Substance Abuse Prevention and Treatment) which is federal allocations for DOA Tx, Prop 36, Self Pay, State general funds.
The goal of the program is to promote healthy mothers and healthy babies by providing the tools of recovery from alcohol, tobacco, and other drug addiction to mothers through treatment and education.

4. PSAP Keeps babies out of the NICU
NICU costs ~$2,100 – 5000 per day
babies exposed, 30 in NICU
Avg Length of Stay: 15 days
Do the math (avg 3,550 per day) $1,597,500.

5. PSAP Treatment Works! 92% drug/alcohol free - neg tox screens
PSAP provides treatment for $67.15 per client per day. This diverted babies who otherwise may have been admitted to VMC’s NICU.

6. Perinatal Drug Exposure Overview
1992 Study
Estimated 15-18% of pregnant women use alcohol or drugs.
PSAP Admission Statistics
SCC 1992 Perinatal Substance Exposure Study in California 2 hospitals participated – 9.8 % of babies born had alcohol or drugs in their systems (8 babies born per day).
Women who drink alcohol/tobacco illicit drugs increase their risks for obstetrical complication and for premature labor and delivery (fetal loss, spontaneous abortion, miscarriages and stillbirths)
Their addiction may result in other medical, social, legal, and family problems as they progress further in the disease of chemical dependency.
On admission: 30-50% pregnant, 82% Methamphetamine users, 84% nicotine, 65% have between 1 and 3 children under 5 years of age.

7. PSAP = Empowerment Model
Comprehensive Intensive Outpatient Treatment
Medically Monitored
Multidisciplinary Approach
Day Care for clients’ children
Transportation
Comprehensive Intensive Outpatient Treatment services to heroin/opiate addicted women and to women addicted to all other drugs or alcohol on and outpatient basis.
Medically Monitored and supervised program.
Multidisciplinary Approach to tx of chemically dependency and provide DOA as well as pregnancy, childbirth, parenting, relationship, trauma, and life skills education using SAMSHA and other guidelines
Day Care for clients’ children
Transportation

8. PSAP Client Eligibility
Resident of Santa Clara County
Pregnant or Early Parenting Women
18 years or older
On Methadone (MMT) or opiate dependent
Hx or DOA abuse or currently using
Family Wellness Court Referrals
Medi-cal, Valley Care II, sliding scale fee, or other insurance (Kaiser)
65 Maximum clients. Pregnant women and methadone and FWC are 1st priority (holding pen to get in is discovery group).

9. Length of PSAP Stay Assigned a Licensed Therapist, PSW Case Management
Individualized Tx Plan
Typical Treatment Episode: months
The client is assigned a counselor who will individualize her treatment plan and corroborate with the client, our PSAP Team the legal system, and or the MD regarding the length of time required to complete the program.

10. Staff HCPM II 3 Therapists (MFT) MD Health Ed Specialist
1 Health Services Representative
3 day care aides (1/2 codes)
1 Community Worker (van) (1/2 codes)
Volunteers

11. Current PSAP Client Demographics
~Capacity for 65+
Women ages 19 to 43 years
23% pregnant
10 clients on Methadone (3 pregnant)
30% Caucasian
33% Latina,
9 % Asian/Pacific Islander
18% Mixed Race
2% African American
8 % Declined to State
30% in THU’s
CPS Cases ~70%
Prop 36 ~40%
FWC 30%
Probation Only - 20%
DEJ – 10%,
PSAP was nominated for the 2007 National Exemplary Award for Innovative Prevention Programs, Practices and Policies by the National Association of State Alcohol/Drug Abuse Directors (NASADAD)

12. Out Patient Drug Treatment in Santa Clara County – Including Methadone
On the VMC campus
Readily accessible - pregnant OPIOID DEPENDENT patients (Methadone candidates) are scheduled for admission the next business day
All Patients can call Gateway
Providers can call Central Valley Clinic
Front Desk
PSAP Clerical

13. Items to Remember if a Patient is in PSAP Treatment
We ask for a verification of OB Care/complete the referral to VMC if no care is scheduled for pregnant people.
We obtain a release to speak with the OB and all MDs in the patient's life.
We obtain a release to Public Health.
We obtain a release to the Pedi and we alert the Pedi (and OB) if the patient drops out of treatment.

14. Overview of AOD Treatment/Concerns
Red flags
When interviewing/observing the patient
When considering the history
Risks associated with various drugs
To the pregnancy
To the baby

15. Substances to Be Discussed
Opioids
Cigarettes
Alcohol
Marijuana
Methamphetamine

16. Amber 32 y.o. Woman and the mother of an 8 y.o. Unplanned pregnancy
Using daily
Heroin by injection 2 grams/day
Cocaine
Cigarettes 2 PPD
Seeking admission to methadone program

17. Amber Stealing to obtain drugs
Isolated – only living relative is maternal grandmother
8 y.o. son is being raised by patient’s grandmother
Father of baby is using and at risk of deportation

18. Amber Medically indigent History of depression and anxiety
History of domestic violence (prior relationship)

19. Amber Frustrated – requested tubal ligation at 23
Frightened – concerned about damage already done to baby
Motivated
Requests residential treatment
Resolves to leave boyfriend if he will not get into treatment

20. Red Flags: Multiple & Obvious
Patient volunteering history of substance abuse
Physical exam remarkable for multiple tracks and physical withdrawal
Life in disarray
Chaotic and disrupted family relationships

21. Why Share this Story? Opioid dependence requires medical intervention
Pregnant patients need treatment to prevent adverse outcomes
Women caring for infants need treatment to be functional mothers

22. Pregnancy can be a Huge Motivation for Change: Amber
Stabilized on methadone maintenance
Completed residential treatment
Permanently left the boyfriend who continued to use
Delivered drug free

23. A Sense of Hope: 12 Years Later Amber is…
Abstinent and still in treatment
Raising her daughter
Working

24. Prevalence of AOD Abuse in Pregnancy
2008 and 2009 data from the National Survey on Drug Use and Health found that among pregnant women ages 15 to 44, the youngest ones generally reported the greatest substance use. Also, pregnant women ages 15 to 17 had similar rates of illicit drug use (15.8 percent or 14,000 women) as women of the same age who were not pregnant (13.0 percent or 832,000 women).

25. Brenda Referred to treatment for history of methamphetamine abuse
Worked as a medical assistant until about two years ago
Served as caretaker for mother who died of breast cancer
After mother died, dad was diagnosed with lung cancer; patient served as caretaker
Reported having a prescription for vicodin

26. Brenda
Reported taking prescribed vicodin for chronic back pain (occasionally)
Denied history of prescription opioid abuse
Weekly u tox screens consistently positive
For a variety of prescription opioids
Not just for vicodin
Easy access to unlimited supply of prescription opioids
Transferred to methadone maintenance

27. Prescription Opioid Abuse May Not Be Obvious
Consider the history
Unusual number of painful conditions for a young healthy patient
Multiple opioid prescriptions during pregnancy
Multiple ER visits for complaints of pain
Multiple care providers/no regular provider
Opioids for unusual indications

28. Patient’s Appearance on Opioids
Normal
Sedated with small pupils
Symptoms of withdrawal
Sweats/chills/gooseflesh
Lacrimation/rhinorrhea
Yawning/sneezing
Irritable/anxious/fidgety
Vomiting

29. Ask About Behaviors: Have you ever?…
Taken more than prescribed?
Taken medication after the pain was gone?
Gotten pills from a friend or relative?
Bought pills on the street?
Written or called in a prescription for yourself?
Tried to stop and found you couldn’t?

30. Ask about Reasons for Use
Manage emotions?
Deal with stress?
Feel high?
Numb everything or go to sleep?

31. Opioids: Three to Seven Times Higher Rates of…
Still birth
Fetal growth retardation
Low birth weight
Small head circumference
Prematurity
Neonatal mortality

32. Heroin: Medical Risks Associated With Injection
Cellulitis
Abscesses
Endocarditis
Hepatitis
HIV infection
Wound Botulism

33. Opioid Dependence in Pregnancy: Treatment
Currently, methadone maintenance is the gold standard
Buprenorphine maintenance looks promising and may be more available in the future (not FDA approved)
A comfortable, stable mother increases the likelihood of a healthy, term delivery

34. Impact of Methadone Treatment
Reduced deaths
Reduced IVDU
Reduced HIV seroconversion
Reduced crime days
Reduced relapse
Improved health
Improved relationships
Improved productivity
Improved social functioning
8-10 fold reduction in death rate
The rule of fours
Demonstrated to improve pregnancy outcome
Benefits society as well as the individual drug addict

35. Additional Benefits During Pregnancy
Increased participation in prenatal care
Reduced obstetrical complications
Improved maternal nutrition
Daily observation in clinic while dosing

36. Therapeutic Dosing With Methadone
Suppresses opioid withdrawal symptoms
Reduces opioid cravings
Provides a stable opioid blood level
Allows a patient to concentrate on counseling/program to support recovery
Minimizes side effects; patient should not be sedated

37. Methadone Withdrawal: Not Recommended During Pregnancy
The relapse rate is high (80%)
Risk of intrauterine demise
Risk of premature labor/miscarriage
What can you say to a patient wanting to Withdraw from MMT?
Send them to their primary CSLR/the addiction MD to discuss

38. Methadone Withdrawal: Not Recommended After Delivery?
Like insulin, methadone stabilizes a chronic illness
The normal brain has an endogenous opioid system that may never function properly in an opioid dependent patient
Very high relapse rate when methadone treatment is discontinued

39. Methadone: Effects on the Baby
No known birth defects
More likely to be born at term
Lower birth weight/smaller head circumference at birth
May experience developmental delay during the first year of life
Not associated with learning difficulties
Increased SIDS with opioid exposure

40. Methadone and Breastfeeding
Negligible amounts of methadone are passed in breast milk
The American Academy of Pediatrics considers methadone compatible with breastfeeding at any dose

41. Methadone: Neonatal Withdrawal
Safer than heroin withdrawal in utero
Experienced by 60-80% of exposed babies
Usually occurs within the first 2-3 days of life; may occur within the first month
Usually treated with an opiate agonist
Duration of treatment is days to months
Can be life threatening without treatment

42. Opiates: The Neonatal Abstinence Syndrome
High-pitched cry, irritability
Poor feeding, vomiting, diarrhea
Hyper tonicity (stiff muscles)
Tremors
Sneezing
Sweating
Occasionally seizures

43. Symptoms of Opioid Withdrawal
W = wakefulness
I = irritability
T = tremulousness, temperature variation,
tachypnea
H = hyperactivity, high-pitched persistent cry,
hyperacusia, hyperreflexia, hypertonus
D = diarrhea, diaphoresis, disorganized suck
R = rub marks, respiratory distress, rhinorrhea
A = apneic attacks, autonomic dysfunction
W = weight loss or failure to gain weight
A = alkalosis (respiratory)
L = lacrimation

44. Clarissa 23 y.o. Pregnant with first child
Smoking 1½ - 2 PPD since late teens
“I will only quit if the doctor tells me my baby will die if I do not quit now”
“My whole family smokes; I grew up with it; I’ve been around it my whole life”

45. United States ( )
National Household Survey on Drug Abuse (NHSDA)
Survey of pregnant women
Cigarettes
Alcohol
Any Illicit Drug
% using # fetuses/yr
20.3% million
14.8% million
2.8% million
Ebrahim, SH, Gfroerer, J. Pregnancy-related substance use in the United States during Obstet Gynecol 2003; 101:374.

46. Cigarette Smoking
Smoking during pregnancy is the most modifiable risk factor for poor birth outcome
It is associated with 5% of infant deaths, 10% of preterm births, and 30% of small for gestational age infants
There are a plethora of medical risks for pregnant and non-pregnant patients
Patients who smoke are more likely to relapse to other drugs of abuse
Cigarettes stimulate the same brain pathway as heroin and cocaine
Trends in smoking before, during, and after pregnancy - Pregnancy Risk Assessment Monitoring System (PRAMS), MMWR Surveill Summ May 29;58(4):1-29.

47. Cigarettes in Pregnancy: Obstetric Complications
Adverse Event
Relative Risk
Placental Abruption
dose dependent
Placenta Previa
Stillbirth
dose dependent
Pre-term PROM
Preterm Birth
Low Birth Weight
dose dependent

48. Clinical Outcomes in Pregnant Women who Quit Smoking
20% reduction in low birth weight babies
17% decrease in pre-term births
Average increase in birth weight of 280g.
Quitting before 30 weeks can still positively affect birth weight

49. Cigarette Smoking in Pregnancy & Other Drug Use
10 times higher use of marijuana
22 times higher use of cocaine
21 times higher use of amphetamine
Vega, WA, Kolody, B, Hwang, J, Noble, A. Prevalence and magnitude of perinatal substance exposures in California. N Engl J Med 1993; 329:850

50. In Utero Cigarette Exposure: Congenital Malformations
May contribute to anomalies associated with focal vascular disruption
Cleft lip with or without cleft palate
Gastroschisis
Anal atresia
Transverse limb reduction defects
Risk may be modified by genetic factors

51. In Utero Cigarette Exposure: Effects on the Newborn
There is a dose-response relationship between maternal cigarette use and infant…
Stress
Hypertonicity
Excitability and irritability
May be due to neurotoxicity or withdrawal
With second hand smoke exposure there is an increased risk of low birth weight

52. In Utero Cigarette Exposure: Postnatal Morbidities
Morbidity
Neonatal death RR
SIDS
RR 2.0 – 7.2
Prenatal exposure a higher risk than postnatal 2nd hand exposure
Respiratory infections, asthma, otitis media, infantile colic, bronchiolitis, short stature, childhood obesity, type 2 diabetes in adulthood
Heart disease and lung cancer in never smokers
Second-hand smoke increases risk by 20-30%

53. In Utero Cigarette Exposure: Behavioral Problems
Toddlers (12-24 mo.s) showed a high and escalating pattern of disruptive behavior
Children developed Oppositional Defiant Disorder at double the rate of controls
ODD is a precursor of Conduct Disorder
Seen in older children and adolescents
Characterized by persistent antisocial behaviors (lying truancy, vandalism, aggression)
NIDA Notes 2008: Vol.21 No. 6

54. In Utero Cigarette Exposure: Cognitive Outcomes in 9-12 yr olds
IQ impacted (dose response effect)
Poorer impulse control
Many individual WISC tests w/ significant dose response effects
Poorer performance on tests requiring visuoperceptual skills.
Auditory memory particularly impacted
WISC = Wechsler Intelligence Scale for Children

55. Medical Issues for the Children of Smokers
Increased incidence of smoking initiation
20% higher if mom smoked up to 1PPD
60% higher if mom smoked 1PPD or more
Diabetes mellitus
Four times higher with more than 10 cigs/day
Increased asthma in adult offspring
Decreased sperm volume/count in adult male offspring
Neonatal withdrawals are similar to opiate withdrawals less severe
SIDS risk is significant…dose response curve
Increased risk of asthma

56. Alcohol
“Of all the substances of abuse (including cocaine, heroin, and marijuana), alcohol produces by far the most serious neurobehavioral effects in the fetus.” IOM Report to Congress, 1996

57. A look at Denial/Pre-Contemplation: Denise
28 y.o. pregnant woman and the mother of 7 and 3 y.o. boys
Pregnant for the 5th time
History of two 2nd trimester miscarriages
Started drinking at 23 (not pregnant)

58. Denise
Drinking 1-2 shots of peppermint schnapps daily until about 1 yr ago
Quit drinking when learned was pregnant with second child, now age 3
GA ~ 9wks when quit
Growth and development of this child appear normal

59. Denise Drinking 5 shots of peppermint schnapps daily for the past year
Drinking this pregnancy until GA ~33 wks
Not worried about the baby because
Last baby was okay
U/S during this pregnancy looks normal

60. Alcohol Use During Pregnancy: Obstetrical Complications
Increased risk of second-trimester abortion
50% increase in fetal mortality
Infant withdrawal (3-12 hrs after delivery)
Fetal Alcohol Spectrum Disorders

61. Alcohol is a Teratogen that Freely Passes the Placenta
Teratogen: a substance that causes abnormal physical development
Behavior teratogen: a substance that causes impaired cognitive, affective, social, reproductive, and/or sensorimotor behavior, even in the absence of obvious physical problems

62. Prenatal Alcohol Exposure Can Cause:
Death
Malformation
Growth deficiency
Functional deficits

63. Teratogenic Effects Depend On:
Dose of alcohol
Pattern of exposure (binge vs. chronic)
Developmental timing of exposure
Susceptibility (genotype of mother and fetus)
Synergistic reactions with other drugs
Interaction with nutritional variables

64. Dose-Response Effects
Higher maximum blood alcohol levels result in more severe neurotoxicity
Binge drinking is particularly dangerous
Males appear to be more susceptible than females

65. SOME CREDIBLE INCREDIBLE WEBSITES! (Thanks Mark Stanford, PhD)
Addiction Technology Transfer Center
Brookhaven Addiction Research. Center for Translational Neuroimaging
National Institute of Drug Abuse (NIDA). Medical and Health Professionals
Moyers On Addiction: Addiction As A Disease
The Institute of Medicine. Marijuana and Medicine: Assessing the Science Base
NIDA Science & Practice Perspectives
National Institute of Mental Health (NIMH). Medications
UCLA Addiction Clinic
University of Utah. Genetic Science Learning Center
Counselor Magazine for Addiction Professionals
Society of Neuroscience. Advancing the Understanding of the Brain and Nervous System
DADS:
Sccdads.org
Please ask me for more – or me!!!

66. Content Provided by:
Deborah Stephenson, MD, MPH Dept of Alcohol & Drug Services Santa Clara Valley Health & Hospital System
Mark Stanford, PhD Dept of Alcohol & Drug Services Santa Clara Valley Health & Hospital System
Margaret Williams, M.S., RD, H.E.S. Dept of Alcohol & Drug Services Santa Clara Valley Health & Hospital System

67. Thank you!