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Illicit Drug Abuse and Dependence in Women A Slide Lecture Presentation 409 12 th Street, SW Washington DC 20024 202/638-5577 www.acog.org.

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Presentation on theme: "Illicit Drug Abuse and Dependence in Women A Slide Lecture Presentation 409 12 th Street, SW Washington DC 20024 202/638-5577 www.acog.org."— Presentation transcript:

1 Illicit Drug Abuse and Dependence in Women A Slide Lecture Presentation th Street, SW Washington DC /

2 Illicit Drug Abuse and Dependence in Women Ronald A. Chez, MD, FACOG University of South Florida, College of Medicine Robert L. Andres, MD, FACOG University of Texas Medical School, Houston Cynthia Chazotte, MD, FACOG Albert Einstein College of Medicine Frank W. Ling, MD, FACOG University of Tennessee, College of Medicine

3 This educational program was funded by the Physician Leadership on National Drug Policy at Brown University, Providence, Rhode Island. (www.plndp.org)www.plndp.org The Physician Leadership on National Drug Policy project is supported through generous contributions from individuals and foundations, primarily the Robert Wood Johnson Foundation and the John D. and Catherine T. MacArthur Foundation.

4 Overview ãAddiction to illegal drugs:  a major national problem  causes impaired health, harmful behaviors  creates major economic and social burdens ãTreatment of drug addiction:  efficacy equivalent to other chronic conditions:  hypertension  asthma  diabetes mellitus

5 Prevalence and Incidence ãSubstance use varies among and within different cultural groups: ãPresent among all socioeconomic, cultural and ethnic groups ãDescriptive categories of abusers do not represent distinct, homogenous groups

6 Prevalence and Incidence ã30 million Americans have used illegal substances:  40% of year olds ãAdult monthly cocaine users:  1.5 million abusers  67% are employed full time  53% of their fathers went to college ãAge of first use is declining:  23% high school seniors regularly use marijuana  10% of all students have used an illicit drug

7 Prevalence and Incidence ã3.6 million Americans dependent on illicit drugs:  50% have a co-morbid medical condition  19,000 drug addiction deaths annually ã$4.5 billion in health expenditures:  only 10% used for treatment of addiction ã$44 billion productivity loss

8 Physician Barriers ãLack of training:  only 1/3 primary care physicians carefully screen for substance abuse  only 1/6 believe they are very prepared to spot illegal drug use ãMost misunderstand:  chronic, relapsing nature of dependence  intensity of the urge to use  preoccupation with the substance

9 Physician Barriers ãLack of awareness:  pervasiveness throughout society  treatment options  community resources ãSkepticism:  treatment for illegal drug abuse is not effective  patients lie about their substance abuse ãDiscomfort:  difficulty discussing potential of prescription drug abuse

10 Physician Barriers ãTime constraints:  impediment to full discussion with patients ãFear of losing patients by asking:  resulting in patient fear, anger ãInsurance coverage:  lack of reimbursement for time to screen  lack of reimbursement parity for treatment  denial of coverage for referrals

11 Physician Barriers ãPhysician as an enabler:  giving tacit approval of the abuse by not addressing the problem  providing patient excuses for work or school  providing prescriptions for inappropriate drugs and in excess quantity including refills ãPhysician may be a drug abuser

12 Patient Barriers ãReasons for lying to physician:  ashamed, afraid, do not want to stop  non-sympathetic, non-confidential setting  physician not knowledgeable, acting busy ãAbusers’ attitudes toward physicians:  do not know how to detect addictions  prescribe potentially dangerous drugs  never diagnosed the abuse  knew about abuse but did nothing about it

13 Patient Barriers ãFear of government agencies ãLoss of family role with legal and child-custody implications ãSocietal stigmata ãDenial:  may be subconscious and unaware  a psychological defense against acknowledging the personal pain

14 Patient Barriers ãEnabling by others reinforces patient denial:  covering at work or school  hiding the problem from superiors at work or school  minimizing or ignoring the substance abuse problem  providing drugs to avoid confrontation or unpleasantness

15 Diagnostic Criteria: Substance Abuse ãA maladaptive pattern of substance use leading to clinically significant impairment or distress manifested by 1 or more of the following occurring within a 12 month period: 1. use results in failure to fulfill major role obligations:  work: absences, poor performance  school: absences, suspensions, expulsions  home: neglect of children or household 2. recurrent use in physically hazardous situations 3. recurrent substance-related legal problems 4. continued use despite resulting persistent or recurrent social or interpersonal problems

16 Diagnostic Criteria: Substance Dependence ãA maladaptive pattern of substance use leading to clinically significant impairment or distress manifested by 3 or more of the following occurring at anytime within the same 12-month period: 1. tolerance of the substance: need for markedly increased amounts to achieve intoxication or the desired effect, or markedly diminished effect with continued use of the same amount 2. withdrawal: the characteristic withdrawal syndrome, or substance taken to relieve or avoid withdrawal symptoms

17 Substance Dependence (continued) 3.larger amounts of substance taken or over a longer period than was intended 4.persistent desire or unsuccessful efforts to cut down or control use 5.great deal of time spent in activities to obtain, use or recover from the substance’s effects 6.important social, occupational and recreational activities given up or reduced because of use 7.continued use despite knowledge of a persistent or recurrent psychological or physical problem likely to have been caused or exacerbated by use

18 Role of Ob/Gyn Physician ãScreening, identifying and counseling women regarding substance use ãRoutine screening in history taking:  no physical symptoms in majority of abusers  screen everyone since no predictors ãKnow local community resources ãTriage to community resources

19 Screening Questions ãFirst, use ubiquity statements:  “Substance use is so common in our society that I now ask all my patients what, if any, substances they are using?” ãThen, ask direct questions:  “Have you ever tried...?”  “How old were you when you first used...?”  “How often; what route; how much?”  “How much does your drug habit cost you?”

20 History: Red Flags ãMaternal chaotic lifestyle:  psychosocial stresses  spouse/partner of an alcoholic or drug abuser  domestic violence, physical and sexual ãPsychiatric diagnosis:  depressions, psychosis, anxiety, PTSD  lack of functional coping skills  unexplained mood swings, personality changes ãLate or no prenatal care:  missed appointments and compliance problems  STDs, sexual promiscuity

21 Physical Examination Nothing unusual is the most frequent finding in users of illicit drugs.

22 Toxicology Testing: Principles ãRandom checks without clinical suspicion:  many consider this unethical  may be illegal in some locales ãNonemergency and competent patient:  verbally inform prior to testing  document permission in medical record ãTest if necessary to direct immediate medical interventions

23 Toxicology Testing: Screening Panel ãUsually urine:  major route of excretion and concentration  inexpensive and quick ãTests include:  enzyme multiplied immunoassay techniques  thin layer chromatography ãConfirmatory tests:  gas chromatography, mass spectrometry

24 Toxicology Drug Screen: Urine ãTime frame for drug or metabolite to be present:  marijuana, acute use 3 days  marijuana, chronic use30 days  cocaine 1–3 days  heroin 1 day  methadone 3 days

25 Treatment: Principles ãDrug addiction is a treatable disease ãNo single treatment is appropriate for all individuals ãRecovery from drug addiction is a long-term process:  multiple treatment episodes with relapses ãEffectiveness is dependent on remaining in treatment for a dedicated period of time ãMatching multiple needs is critical:  medical, psychological, social, legal, vocational

26 Treatment: Cost Considerations Outpatient$15/day x 120 days$1,800 Intensive outpatient9 hours/wk + 6 months maintenance $2,500 Methadone maintenance$13/day x 300 days$3,900 Short term residential treatment $130/day x 30 days + $400 x 25 weeks $4,400 Long term residential treatment $49/day x 140 days$6,800 Annual treatment costs for a drug addict: Year in prison$53 -$71/day$25,900

27 Plan of Care ãEstablish a supportive relationship ãEducate the patient:  ask the patient to describe her understanding of the situation and correct misunderstandings  link substance use to patient’s signs & symptoms  describe the importance of stopping or cutting down  explain consequences of continued use ãRefer to specialists for assessment and initiation of a treatment plan

28 Treatment: Critical Components ãDetoxification ãMedications combined with counseling ã Behavioral therapies: skill-building, problem-solving to prevent relapse ãAssess for and treat coexisting conditions:  mental disorders  infectious diseases  family planning

29 Treatment: Behavioral Change ãProchaska’s stages of readiness:  assess the patient’s readiness for change and to accept treatment  match intervention strategies and goals to the patient’s stage ãStage = precontemplation  patient does not believe a problem exists  needs evidence of problem and its consequences

30 Treatment: Behavorial Change ãStage = contemplation  patient recognizes a problem exists:  is considering treatment  patient needs:  support/encouragement to initiate treatment  information on treatment options  referral to a specific treatment program

31 Treatment: Behavioral Change ãStage = action  patient begins treatment:  needs ongoing support  needs follow up to ensure success ãSteps to break the cycle of recurrent binges or daily use:  weekly contact  peer support groups  family or group therapy  urine monitoring

32 Treatment: Behavioral Change ãIntervention with family, close friends and co-workers:  group meets with patient  each group member states the effects of the patient’s substance use  consequences of not accepting treatment are stated:  loss of job; loss of family  legal consequences  potential of danger from drug access & presence  expressions of concern, support and love

33 Treatment: Behavioral Change ãStage = relapse  expected, not a failure  prevention is essential:  alter life style to reduce their influence  develop drug free socialization  identify social pressures that may predict use:  rehearse avoidance strategies  learn ways to deal with negative feelings:  identify ways to manage distorted thinking

34 Prevention: Stages ãPrimary prevention = use has not begun, or use is not problematic ãSecondary prevention = treatment of problematic users ãTertiary prevention = preventing and treating complications of substance abuse

35 Prevention: Prescribing Guidelines ãPotentially addictive drugs:  assess option of alternative treatments:  nonpharmacological treatments  nonaddicting medications  determine risk of developing abuse or dependence  order an initial dose sufficient to provide analgesia, then taper to smallest effective dose

36 Prevention: Prescribing Guidelines ãAnalgesics for acute pain symptoms:  short period of time for treatment  avoid more than one refill  avoid telephone refills  reassess at frequent intervals  prescribe on a fixed schedule vs. prn  taper, rather than discontinue if used long term ãWrite both number and word to minimize alteration

37 Prevention: Drug Seeking Clues ãPatient may be abusing psychoactive medication:  exaggerates or feigns symptoms  loses prescriptions or medications  runs out of medications ahead of time  obtains same prescription from multiple doctors  claims refill need but original doctor not available  insists that only one drug will work  demands an immediate prescription for a chronic illness  threatens when physician does not comply

38 Fertility ãGeneric factors related to substance abuse:  men:  impotence  decreased semen quality  women:  alterations in ovulation  menstrual irregularity  libido:  variable effect

39 Pregnancy ãPrevalence and incidence:  no difference:  indigent/nonindigent patients  public and private clinics  ethnic groups ã4 million women who gave birth:  757,000 drank alcohol products  820,000 smoked cigarettes  221,000 used illegal drugs

40 Pregnancy: Generic Issues ãEducate patient about adverse outcome effects ãScreen for domestic violence ãScreen for STDs, hepatitis B and C, TB ãCo-manager or refer to multispecialty clinic ãRefer to drug counseling program ãMonitor with urine toxicology ãSequential antepartum assessment of growth ãRefer newborn to pediatrics ãClose postpartum follow up

41 Cocaine ãAlkaloid from leaves of Erythroxylon coca bush:  marketed as crystals, granules, white powder  routes:  intranasal, parenteral, oral, vaginal, rectal  decomposes with heating, melts at 195 o C  water soluble ãCrack cocaine alkaloid is free base:  soluble in alcohol, oils, acetone, ether  colorless, odorless, transparent crystal  melts at 98 o C  not destroyed at higher temperatures

42 Cocaine ãProduces a dose dependent increase in:  heart rate and blood pressure  arousal, enhanced vigilance and alertness  sense of self confidence and well-being ãChronic, heavy use associated with:  pronounced irritability  paranoid ideations  increased risk of violence  reduced libido

43 Cocaine: Adverse Maternal Effects ãPossible systemic complications:  cardiovascular:  tachycardia and cardiac arrhythmias  vasoconstriction and hypertension  central nervous system:  hyperthermia  CVA  seizures

44 Cocaine: Adverse Fetal Effects ãQuestionable Congenital anomalies:  published data are equivocal  reported anomalies include:  limb reduction defects  genitourinary tract malformations  congenital heart disease  central nervous system

45 Cocaine: Adverse Fetal Effects ãImpaired fetal growth:  decrease in mean birthweight  increase in low birthweight infants  increase in intrauterine growth restriction  significant correlation between cocaine metabolites in meconium and decreases in birth weight, birth length and head circumference.

46 Cocaine: Adverse Prenatal Effects ãPreterm labor and delivery:  no consensus among clinical studies: ãPremature separation of the placenta:  most studies confirm ãPremature rupture of the membranes:  controversial association

47 Cocaine: Adverse Neonatal Effects ãInitial neurologic findings:  coarse tremor  hypertonia  extensor leg posture ãIncreased risk of SIDS (4x) ãLong-term consequences:  no consistent negative associations  developmental outcome similar to drug-free newborns

48 Cocaine: Treatment ãGoal = help patient resist the urge to restart compulsive cocaine use ãOptions according to personal characteristics:  group and individual drug counseling  cognitive behavioral therapy to prevent relapse:  ways to act and think in response to cues  avoid environmental/social pressures  practice drug refusal skills  medications

49 Opiates and Opioids ãOpiates (naturally occurring):  derived from the Paper somniferum poppy  examples: morphine, codeine ãOpioids (synthetic):  examples: fentanyl, heroin, hydrocodone, hydromorphone, meperidine, methadone, and oxycodone

50 Heroin ãRoutes:  inhaled, intranasal, IV, IM, SQ  lipid soluble, rapidly crosses the blood-brain barrier ãConstant oscillation between feeling:  initial warmth, intense pleasure or rush  duration of high between 3-5 hours  followed by sedation and tranquility (on the nod)  symptoms of early withdrawal

51 Heroin: Maternal Adverse Effects ãShort-term adverse effects:  somnolence  altered mentation  cardiorespiratory arrest (overdose) ãLong-term adverse effects:  physiologic withdrawal  hepatitis B and C  STD’s, HIV  endocarditis  abscesses  pneumonia and tuberculosis

52 Heroin: Withdrawal Syndrome ãSymptoms:  drug craving  anorexia, nausea, abdominal cramping  increased sensitivity to pain ãSigns:  hypertension, hyperventilation, tachycardia  lacrimation, mydriasis, rhinorrhea  yawning, sweating  vomiting, diarrhea  chills, flushing, muscle spasms  restlessness, tremors, and irritability  piloerection

53 Heroin: Adverse Pregnancy Effects ãIntrauterine growth restriction ãNeonatal abstinence syndrome:  central nervous system:  hypertonia, hyperreflexia, tremors, convulsions  gastrointestinal system:  fist sucking, poor feeding, vomiting, diarrhea  respiratory system:  tachypnea, sneezing, yawning, hiccups  autonomic nervous system:  fever, vasomotor instability, sweating, tearing

54 Heroin: Treatment ãPrinciple = change from a short acting IV to long acting oral opioid to relieve drug craving and withdrawal ãMethadone:  synthetic opioid blocks effect of heroin  long half life allows daily dosing  no euphoria, no interference with daily activities ãNew agents:  levomethadyl-acetate (LAAM)  buprenorphine (combined with naloxone)

55 Methadone: Perinatal Effects ãPregnancy:  continuation of normal daily activities  decrease in associated maternal morbidity ãNeonatal abstinence syndrome:  occurs on day 2-3 up to a week  similar to heroin withdrawal syndrome  Naloxone (Narcan  ) contraindicated; severe withdrawal

56 Methadone: Treatment Protocol ãInitiation of treatment:  mg initial dose  next 24 hours: 5-10 mg every 6 hours per signs and symptoms of opiate withdrawal  daily maintenance dose mg, qd or bid ãDetoxification during pregnancy, controversial:  only if 30 mg/day is realistic goal  inpatient: 2 mg/day decrease in dose  outpatient: mg/week decrease in dose

57 Methadone: Maintenance Programs ãState and federal regulations restrict prescribing:  who enters the program  daily dosing schedule  location of clinic sites  specially licensed physicians

58 Marijuana ãActive ingredient = tetrahydrocannabinol (THC):  derived from Cannabis sativa  lipophilic with accumulation in fatty tissues  metabolized by liver and eliminated in feces  effects:  onset within minutes  3-5 hour duration

59 Marijuana: Adverse Maternal Effects ãCNS depression ãMay act as a cardiovascular stimulant:  tachycardia, hypotension ãRespiratory problems similar to tobacco smokers:  bronchitis, sinusitis, pharyngitis ãLearning & social behavior:  changes in attention, memory, information processing

60 Marijuana: Adverse Perinatal Effects ãControversial or no clear association:  no evidence of congenital anomalies  doubt decrease in birth weight  doubt increase in preterm birth  no evidence of long term infant-child neurodevelopmental sequela ãTHC is present in breast milk

61 Pregnancy: Ethical Issues ãMaternal autonomy:  the pregnant woman’s right to choose or refuse recommended therapy  fetal interests do not have to be abandoned ãIf conflict between maternal and fetal interests:  urge the woman to seek consultation  refer to institution’s ethics committee  document in detail in medical chart ãCourt orders for treatment can be destructive to:  the woman’s autonomy  the physician-patient relationship

62 Summary 1.Drug dependence is a chronic, relapsing medical illness. 2.The etiology and course of the disease is influenced by genetic heritability, personal choice and environmental factors. 3.Drug dependence produces lasting change in brain chemistry and function. 4.Effective medications are available to treat opiate dependence and achieve abstinence. 5.Long-term care strategies produce lasting benefits for the patient who can live normal, productive lives.

63 Sources of Learning Materials ãAmerican College of Obstetricians and Gynecologists  ãAmerican Society of Addiction Medicine  ãMarch of Dimes Birth Defects Foundation  ãNational Clearinghouse for Alcohol & Drug Information  or ãNational Institute on Drug Abuse  ãPhysician Leadership on National Drug Policy 

64 Internet Resources ãAssociation for Medical Education & Research in Substance Abuse  ãCenter for Alcohol & Addiction Studies, Brown University  ãCenter for Substance Abuse Treatment (DHHS)  ãNarcotics Anonymous 

65 Internet Resources (continued) ãNational Advisory Council on Drug Abuse, National Institute on Drug Abuse (NIDA)  ãNational Clearinghouse for Alcohol & Drug Information  ãPhysician Leadership on National Drug Policy  ãUS Department of Justice, Drug Enforcement Admin. 


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