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1A Slide Lecture Presentation Illicit Drug Abuseand Dependence in WomenA Slide Lecture Presentation409 12th Street, SWWashington DC202/
2Illicit Drug Abuse and Dependence in Women Ronald A. Chez, MD, FACOGUniversity of South Florida, College of MedicineRobert L. Andres, MD, FACOGUniversity of Texas Medical School, HoustonCynthia Chazotte, MD, FACOGAlbert Einstein College of MedicineFrank W. Ling, MD, FACOGUniversity of Tennessee, College of Medicine
3This educational program was funded by the Physician Leadership on National Drug Policy at Brown University, Providence, Rhode Island. (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.
4Overview Addiction to illegal drugs: a major national problem causes impaired health, harmful behaviorscreates major economic and social burdensTreatment of drug addiction:efficacy equivalent to other chronic conditions:hypertensionasthmadiabetes mellitusAddiction begins with a voluntary decision conditioned by heredity and environment.Addiction to illegal drugs is a chronic, relapsing disease. It results in long lasting anatomic and functional changes that put the patient at risk for health problems.There are effective acute and maintenance therapeutic interventions which will reduce the harmful use of illicit drugs. As such, the efficacy of treatment is equivalent to that of other chronic conditions.The components of treatment include continuity of care, encompassing acute and follow up care strategies, management of any relapses and the use of satisfactory outcome measures.
5Prevalence and Incidence Substance use varies among and withindifferent cultural groups:Present among all socioeconomic, culturaland ethnic groupsDescriptive categories of abusers do notrepresent distinct, homogenous groupsSubstance use is culturally constructed, socially conditioned and value-laden.In various studies, some ethnic populations do have higher rates of use than others. However, the preconception that only certain socioeconomic or ethnic groups abuse is invalid. Also, a clinician’s suspicions are of limited value: selective screening based on clinical suspicion leads to a diagnosis in only 3% of patients, whereas screening of all patients leads to a diagnosis in 16%.
6Prevalence and Incidence 30 million Americans have used illegal substances:40% of year oldsAdult monthly cocaine users:1.5 million abusers67% are employed full time53% of their fathers went to collegeAge of first use is declining:23% high school seniors regularly use marijuana10% of all students have used an illicit drugA significant proportion of the drug dependence problem occurs in a relatively young population. The age of first exposure continues to decrease. Of note, patients who would not be suspect based on traditional criteria (employed, relatively well educated persons), can have drug dependence problems.Of women who use illicit drugs, about half are in the childbearing age group of 15 to 44 years.Reference: National Household Survey on Drug Abuse. Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, 1998.
7Prevalence and Incidence 3.6 million Americans dependent on illicit drugs:50% have a co-morbid medical condition19,000 drug addiction deaths annually$4.5 billion in health expenditures:only 10% used for treatment of addiction$44 billion productivity lossThe large number of drug abusers/addicted persons in the U.S. may be surprising to some. Over half of the patients have a co-morbid medical condition for which they may present to the physician.References:Drug Dependence, A Chronic Medical Illness. Implications for treatment, insurance, and outcomes evaluation. McLellan AT, Lewis DC, O’Brien, CP, Kleber HD. JAMA 2000;284:Position Paper on Drug Policy published by the Physician Leadership on National Drug Policy January, Data source: Center for Substance Abuse Treatment, Federal Bureau of Prisons National Treatment Improvement Evaluation Study.
8Physician Barriers Lack of training: only 1/3 primary care physicians carefullyscreen for substance abuseonly 1/6 believe they are very prepared tospot illegal drug useMost misunderstand:chronic, relapsing nature of dependenceintensity of the urge to usepreoccupation with the substanceAmong the factors preventing physicians from recognizing this diagnosis are the low proportion of physicians who carefully screen and the lower percentage of physicians who feel they are prepared to assess for the diagnosis.The lack of identified, formal education and training in this subject results in a reluctance to screen patients, or recognize clinical clues. In addition, physicians unfamiliar with the topic don’t understand the relapsing nature of the condition, and underestimate the urge to use and the preoccupation with the drug that overwhelms the patient.Reference: National Survey of Primary Care Physicians and Patients on Substance Abuse. The National Center on Addiction and Substance Abuse at Columbia University. April 2000.
9Physician Barriers Lack of awareness: pervasiveness throughout society treatment optionscommunity resourcesSkepticism:treatment for illegal drug abuse is not effectivepatients lie about their substance abuseDiscomfort:difficulty discussing potential of prescriptiondrug abuseAdditional challenges face the busy clinician. Even if screening results in identification, the practitioner may lack awareness of appropriate treatment options, community resources, or even the behaviors contributing to the underlying problem.When resources are available, they may be scarce, inadequately coordinated, or difficult to access. As an extension, there may be skepticism that treatment is effective (it can be), or that patients lie about their abuse (they might).Finally, many physicians have a difficult time discussing the potential abuse of indicated prescription medications with their patients.Reference: National Survey of Primary Care Physicians and Patients on Substance Abuse. The National Center on Addiction and Substance Abuse at Columbia University. April 2000.
10Physician Barriers Time constraints: impediment to full discussion with patientsFear of losing patients by asking:resulting in patient fear, angerInsurance coverage:lack of reimbursement for time to screenlack of reimbursement parity for treatmentdenial of coverage for referralsBecause of the nature of contemporary medical practice, the time to fully discuss these issues in the office is rarely available. The physician may be concerned that addressing these sensitive issues might alienate the patient. Because these issues require significant time and counseling efforts, it is critical that the practitioner have the flexibility to create the right atmosphere to work with the patient in a non-threatening and sensitive manner.The physician should be cognizant of reimbursement guidelines which may allow for a higher level of coding for an office visit. To do so, the amount of face-to-face time must be documented and there must be evidence that over 50% of the time was spent in counseling related to medical risks, benefits of therapy, coping strategies and other aspects of comprehensive care.Reference: National Survey of Primary Care Physicians and Patients on Substance Abuse. The National Center on Addiction and Substance Abuse at Columbia University. April 2000.
11Physician Barriers Physician as an enabler: giving tacit approval of the abuse by notaddressing the problemproviding patient excuses for work or schoolproviding prescriptions for inappropriatedrugs and in excess quantity including refillsPhysician may be a drug abuserUnfortunately, the physician may become an enabler in the ways listed on this slide.
12Patient Barriers Reasons for lying to physician: ashamed, afraid, do not want to stopnon-sympathetic, non-confidential settingphysician not knowledgeable, acting busyAbusers’ attitudes toward physicians:do not know how to detect addictionsprescribe potentially dangerous drugsnever diagnosed the abuseknew about abuse but did nothing about itOn average, patients have abused drugs for 10 years before they receive therapy. Often the patient, and not the physician makes the decision to seek treatment. Patients may lie to a physician to avoid the shame, or because they do not wish to stop the drug abuse.In addition, there may be the perception that the physician is not sympathetic or might divulge the problem to others. Some patients believe that most physicians are ill-prepared to diagnose and treat, concerns that may be justified. In summary, the atmosphere for full disclosure is far from reassuring to the patient with a substance abuse problem.Reference: National Survey of Primary Care Physicians and Patients on Substance Abuse. The National Center on Addiction and Substance Abuse at Columbia University. April 2000.
13Patient Barriers Fear of government agencies Loss of family role with legal and child-custodyimplicationsSocietal stigmataDenial:may be subconscious and unawarea psychological defense against acknowledgingthe personal painThere are also pragmatic reasons why patients do not fully disclose their problems. There can be fear of interacting with government agencies and resulting punishment including incarceration, reprisal from their significant other, loss of child custody, and the inability to care for children and family while in treatment. Even among drug addicts, users who are pregnant are looked down upon by others because of the acknowledged additional fetal risks that are incurred.The resultant underreporting of drug abuse by the patient, and the resistance to seek care make for an even greater challenge for the clinician.
14Patient Barriers Enabling by others reinforces patient denial: covering at work or schoolhiding the problem from superiors at work orschoolminimizing or ignoring the substance abuseproblemproviding drugs to avoid confrontation orunpleasantnessCodependency with others may also be present. In order to maintain any semblance of balance in the relationship, other people around the substance abuser can be drawn into circumstances that further inhibit the disclosure process. Sometimes this person is the physician.
15Diagnostic Criteria: Substance Abuse A maladaptive pattern of substance use leading toclinically significant impairment or distressmanifested by 1 or more of the following occurringwithin a 12 month period:use results in failure to fulfill major role obligations:work: absences, poor performanceschool: absences, suspensions, expulsionshome: neglect of children or householdrecurrent use in physically hazardous situationsrecurrent substance-related legal problemscontinued use despite resulting persistent orrecurrent social or interpersonal problemsThe diagnostic criteria described in this and the next two slides derive from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, also known as DSM-IV published in 1994 by the American Psychiatric Association.The diagnosis of substance abuse and substance dependence differ. The diagnostic criteria for substance abuse are listed on this slide. The criteria for substance dependence are on the next two slides.
16Diagnostic Criteria: Substance Dependence A maladaptive pattern of substance use leading toclinically significant impairment or distressmanifested by 3 or more of the following occurringat anytime within the same 12-month period:tolerance of the substance: need for markedlyincreased amounts to achieve intoxication orthe desired effect, or markedly diminishedeffect with continued use of the same amountwithdrawal: the characteristic withdrawalsyndrome, or substance taken to relieve oravoid withdrawal symptomsThe diagnostic criteria for substance dependence which distinguish it from abuse are noted on this and the next slide.
17Substance Dependence (continued) larger amounts of substance taken or over a longerperiod than was intendedpersistent desire or unsuccessful efforts to cutdown or control usegreat deal of time spent in activities to obtain, useor recover from the substance’s effectsimportant social, occupational and recreationalactivities given up or reduced because of usecontinued use despite knowledge of a persistent orrecurrent psychological or physical problemlikely to have been caused or exacerbated by use
18Role of Ob/Gyn Physician Screening, identifying and counseling womenregarding substance useRoutine screening in history taking:no physical symptoms in majority of abusersscreen everyone since no predictorsKnow local community resourcesTriage to community resourcesThe obstetrician-gynecologist has an important role in the prevention and the identification of women with substance use problems. Screening for substance use will identify patients who should be assessed for substance abuse or dependence. The ob/gyn then can work with the patient to accept referral and treatment while providing encouragement and support to reduce or eliminate use.Opportunities for screening and education exist at routine gynecologic and obstetric visits as well as emergency visits. Illicit drug use may be asked about in the context of routine history taking about prescription drugs, over-the-counter-drugs, and tobacco and alcohol use.
19Screening Questions First, use ubiquity statements: “Substance use is so common in our societythat I now ask all my patients what, if any,substances they are using?”Then, 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?”Asking about substance use communicates to the patient a level of caring and comfort with the issue. By screening for substance use, the physician emphasizes the importance of this problem, and may prevent initial use in patients who are precontemplators.It is important to frame questions in a nonthreatening way. If a patient is using, determine the context of use, the potential for change and the motivational factors for change.
20History: Red Flags Maternal chaotic lifestyle: psychosocial stresses spouse/partner of an alcoholic or drug abuserdomestic violence, physical and sexualPsychiatric diagnosis:depressions, psychosis, anxiety, PTSDlack of functional coping skillsunexplained mood swings, personality changesLate or no prenatal care:missed appointments and compliance problemsSTDs, sexual promiscuityAlthough drug users may reveal nothing on history to suggest use, there are some “red flags” that raise the physician’s suspicion. These include a chaotic lifestyle, a peer group involved in drug use, easy access to a drug supply and domestic violence.Other “red flags” include patients who suffer from post-traumatic stress disorder (PTSD), have intellectual changes, memory loss, unexplained mood swings and personality changes, frequent missed appointments and problems with health-related compliance.
21Physical ExaminationNothing unusual is the most frequent finding in users of illicit drugs.Traditionally, the image of a chronic drug abuser includes overt signs such as:self neglect or poor hygiene nervous mechanisms: licking lips, jitters, foot-tapping slurred speech tremors sniffles, chronic rhinorrhea bloody nose with inflammation of mucosa pinpoint or dilated pupils tachycardia and bradycardia hypertension cheilosis and other evidence of malnutrition skin with evidence of injecting drug use:multiple scarssoft tissue abscesses and injuriestrack marksImportantly, most drug users have no signs on physical examination.
22Toxicology Testing: Principles Random checks without clinical suspicion:many consider this unethicalmay be illegal in some localesNonemergency and competent patient:verbally inform prior to testingdocument permission in medical recordTest if necessary to direct immediate medicalinterventionsA careful history by a trusted clinician remains the most sensitive means of detecting drug use and abuse. However, many women conceal the use of illicit drugs since it may provide grounds for action by child welfare agencies. Because of the possible implications of a positive drug screen, the rights of patients to autonomy and privacy should be respected in asymptomatic patients. Patients should give informed consent prior to testing.Toxicologic screening may be useful in situations when the patient is symptomatic, when the nature of the presenting illness suggests drug use as a cause, and when the information will direct medical interventions. In these instances, tests for hepatitis and sexually transmitted diseases should also be considered.
23Toxicology Testing: Screening Panel Usually urine:major route of excretion and concentrationinexpensive and quickTests include:enzyme multiplied immunoassay techniquesthin layer chromatographyConfirmatory tests:gas chromatography, mass spectrometryPanels of screening tests usually include most commonly used illicit drugs. They tend to be rapid and sensitive, but may not be specific (i.e. false-positives can occur). Confirmatory tests are highly specific, but more expensive. These procedures do not completely eliminate the possibility of false-positive results due to contamination or mislabeled specimens.There is an emerging role of the use of newborn meconium, and newborn and maternal hair to identify illicit drug in the mother. These analyses are reported to have 3 times the sensitivity of urine testing and 4 times the sensitivity of a patient interview. Again, because positive results have implications beyond heath care, informed consent is important. Further, use of this testing may be subject to state law.
24Toxicology Drug Screen: Urine Time frame for drug or metabolite to be present:marijuana, acute use 3 daysmarijuana, chronic use 30 dayscocaine –3 daysheroin daymethadone daysDrug screening panels can differ in what substances are detected, what threshold of sensitivity is selected and what assay is used.The sensitivity of urine toxicology screening for detecting drug use also depends on the timing of drug use and the urinary excretion of metabolites. Drug users who try to avoid detection may use various techniques to reduce the sensitivity of urine testing. These can include water loading, diuretic use, or adulterating urine samples.Toxicologic testing does not distinguish between the occasional user and user who is dependent on or impaired by drug use. Nor will testing identify a patient who has not recently used.
25Treatment: Principles Drug addiction is a treatable diseaseNo single treatment is appropriate for all individualsRecovery from drug addiction is a long-term process:multiple treatment episodes with relapsesEffectiveness is dependent on remaining in treatmentfor a dedicated period of timeMatching multiple needs is critical:medical, psychological, social, legal, vocationalRecovery from drug abuse and drug addiction is a long-term process. Treatment is comparable to that of other chronic conditions such as diabetes, hypertension and asthma. That is, the interventions most frequently are long-term, and cures are not likely. Interspersed with the treatment are periods of relapse and remissions.Although it is true that no single treatment is appropriate for all individuals, all treatment needs to be readily available, flexible in design and be associated with ongoing assessment of its efficacy.The patient requires comprehensive care. The physician who treats her addiction may also have to treat pulmonary, cardiac and hepatic complications of addiction as well as the woman’s psychosocial needs.
26Treatment: Cost Considerations Year in prison$53 -$71/day$25,900Annual treatment costs for a drug addict:Outpatient$15/day x 120 days$1,800Intensive outpatient9 hours/wk + 6 months maintenance$2,500Methadone maintenance$13/day x 300 days$3,900Short termresidential treatment$130/day x 30 days + $400 x 25 weeks$4,400Long term$49/day x 140 days$6,800Medical treatment is a cost-effective means to reduce drug use and related crime. It is cheaper than interdiction, law enforcement and prosecution. $1 spent on treatment saves $7 in crime-related spending.The most effective methods of reducing harmful use of illegal drugs is through enhanced medical and community-based public health approaches integrated into multidisciplinary and collaborative approaches.Reference: Position Paper on Drug Policy published by the Physician Leadership on National Drug Policy January, Data source: Center for Substance Abuse Treatment, Federal Bureau of Prisons National Treatment Improvement Evaluation Study.
27Plan of Care Establish a supportive relationship Educate the patient: ask the patient to describe her understanding ofthe situation and correct misunderstandingslink substance use to patient’s signs & symptomsdescribe the importance of stopping or cutting downexplain consequences of continued useRefer to specialists for assessment and initiation of atreatment planCaring for a patient who is a substance user or abuser is a long term process which requires multiple office visits, the need for multiple interventions, and intermittent crisis intervention. The ability to provide all of this is usually outside the scope of practice for most obstetrician-gynecologists.However, the obstetrician-gynecologist can initiate the first phase of a treatment plan by informing the patient that treatment is available, emphasizing the benefits of quitting (particularly the importance of quitting if the patient is pregnant), and discussion of what the treatment will be composed of and the importance of follow ups and referrals.
28Treatment: Critical Components DetoxificationMedications combined with counselingBehavioral therapies: skill-building, problem-solvingto prevent relapseAssess for and treat coexisting conditions:mental disordersinfectious diseasesfamily planningThese are the generic components that patients being treated for substance abuse can expect.The first phase of treatment for many addicts is medical detoxification and the relief of acute physical symptoms. However, this approach does not change the patient’s long-term substance use. Behavioral therapies and medications effective in ameliorating the symptoms of drug craving are then required.Because of the increased incidence of infectious diseases in the these patients, it is appropriate to screen or test for hepatitis B and C, tuberculosis and sexually transmitted diseases including HIV.Treatment can be effective even when it is not received voluntarily by the patient.
29Treatment: Behavioral Change Prochaska’s stages of readiness:assess the patient’s readiness for change and toaccept treatmentmatch intervention strategies and goals to thepatient’s stageStage = precontemplationpatient does not believe a problem existsneeds evidence of problem and its consequencesChanging the patient’s behavior is crucial to successful treatment. Dr. Prochaska is a behavioral scientist who has published research on his principles of behavioral learning and change. These intervention strategies have been found to be effective in changing patients’ behaviors related to primary care issues such as weight management and smoking cessation.He has defined a series of stages which assess the patient’s readiness for change and her motivation for treatment. The physician matches his or her interactions with the patient relative to her stage and with a focus to help the patient move from that stage towards an action stage.When the patient is in the precontemplation stage, the physician’s advice and concern may go unheeded. In this instance, the physician can describe the adverse consequences and impact of continued substance abuse.Reference: Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: Applications to addictive behavior. Am Psychol 1992; 47:
30Treatment: Behavorial Change Stage = contemplationpatient recognizes a problem exists:is considering treatmentpatient needs:support/encouragement to initiate treatmentinformation on treatment optionsreferral to a specific treatment programWhen the patient is in the contemplation stage, she is prepared to understand the benefits of treatment. At this point, it is appropriate for the physician to provide information on treatment options and support and encourage the patient to accept a referral in order to initiate treatment.
31Treatment: Behavioral Change Stage = actionpatient begins treatment:needs ongoing supportneeds follow up to ensure successSteps to break the cycle of recurrent binges ordaily use:weekly contactpeer support groupsfamily or group therapyurine monitoringThe action stage occurs in the treatment center. The patient will receive ongoing support to break any cycle of recurrent binges or daily use. The variables that are associated with the success of this action step include the severity of the addiction, the availability and utilization of referral and community resources, and the patient’s culture.The motivational factors for change also play an important role. Pregnancy is a well-known motivation factor. Social, legal, or child welfare issues can be pertinent as are the influences of life stresses such as job related difficulties and medical illnesses.
32Treatment: Behavioral Change Intervention with family, close friends and co-workers:group meets with patienteach group member states the effects of thepatient’s substance useconsequences of not accepting treatment are stated:loss of job; loss of familylegal consequencespotential of danger from drug access & presenceexpressions of concern, support and loveThe treating physician or center may suggest a group meeting to reinforce the patient’s treatment. Those non-drug abusing people who are associated with the patient on a daily basis and support her accepting treatment can include family members, close friends and co-workers. Although it can be associated with great stress, many patients will derive benefit from meeting with these people in a group setting. The purpose of the meeting is for each member to state with friendship and love their awareness of the adverse effects of the patient’s substance use and the consequences they see that derive from it. This experience can markedly support the patient’s desire for treatment and control drug use. It also sets the stage for education and job rehabilitation.
33Treatment: Behavioral Change Stage = relapseexpected, not a failureprevention is essential:alter life style to reduce their influencedevelop drug free socializationidentify social pressures that may predict use:rehearse avoidance strategieslearn ways to deal with negative feelings:identify ways to manage distorted thinkingLapses and relapse are normal, expected steps in the treatment and recovery of addiction. They can be considered a “slip” and not a failure. There are a number of reasons that relapse occurs. They may include stress associated with psychosocial issues (divorce, job loss, arrest, domestic violence), and crisis associated illness secondary to overdosing or severe intoxication.The patient needs immediate treatment focusing on treating the pain associated with the etiology of the crisis. Then, when stable, she can be helped to identify the linkages between the crisis and substance use problem. The follow up focuses on prevention by identifying the social pressures that have and may predict use. Social pressures predictive of a relapse can benefit from the creation of a more balanced lifestyle with a network of support persons. The patient will benefit from rehearsing strategies to avoid use.Many drug abusers have strong, negative feelings about themselves and their self-worth. As a result, distorted thinking can occur. Two ways to manage the latter are to develop a plan to interrupt the relapse when this does occur and to harden memories of the negative consequences and pain associated with a relapse.
34Prevention: Stages Primary prevention = use has not begun, or use is not problematicSecondary prevention =treatment of problematic usersTertiary prevention =preventing and treating complications ofsubstance abuseThere are three stages of prevention. Patient education that focuses on the adverse effects of substance abuse on reproductive health is itself a prevention tool. The act of verbal screening and history taking also is a primary prevention method.In considering intervention programs, collaboration and cooperation from the private and public sectors are essential. This includes input from clergy and the religious community, the criminal justice system, the schools, the business community, local politicians in their own neighborhoods, and positive reporting by the media.
35Prevention: Prescribing Guidelines Potentially addictive drugs:assess option of alternative treatments:nonpharmacological treatmentsnonaddicting medicationsdetermine risk of developing abuse or dependenceorder an initial dose sufficient to provideanalgesia, then taper to smallest effective doseThe practice of medicine includes the prescribing of potentially addictive drugs. When this must occur for appropriate indications, the physician should be alert to the risk potential for a patient to develop substance abuse or dependence.The treatment of pain with a narcotic should start with an initial dose potent enough to be effective so the patient has confidence that the drug is going to work. Then as the pain subsides over time, it is appropriate to taper to the smallest effective dose.It can be helpful for patients to read educational materials related to the risks of addiction, and that differentiate the use of addicting drugs for specific medical purposes as opposed to use for recreational purposes.
36Prevention: Prescribing Guidelines Analgesics for acute pain symptoms:short period of time for treatmentavoid more than one refillavoid telephone refillsreassess at frequent intervalsprescribe on a fixed schedule vs. prntaper, rather than discontinue if used long termWrite both number and word to minimize alterationThe physician can decrease the likelihood of inappropriate prescribing and the prevention of diversion into the illicit market by considering the guidelines on this slide.The recommendation for prescribing on a fixed schedule instead of an as necessary schedule is to minimize reinforcement of the patient’s symptoms and medication seeking behavior by improving the control of symptoms on a regular basis. This results in the patient avoiding taking a drug only for short-term relief as opposed to continually taking the medication to maintain therapeutic levels.The emerging prescription drugs of abuse in 1999 were clonazepam, hydrocodone, hydromorphone, and oxycodone.
37Prevention: Drug Seeking Clues Patient may be abusing psychoactive medication:exaggerates or feigns symptomsloses prescriptions or medicationsruns out of medications ahead of timeobtains same prescription from multiple doctorsclaims refill need but original doctor not availableinsists that only one drug will workdemands an immediate prescription for achronic illnessthreatens when physician does not complyClues that the patient is abusing psychoactive medication are listed on this slide. Other clues include a patient who describes symptoms in dramatic fashion, changes the descriptions when repeating the symptoms and gives every evidence of lying to the physician.An effective response by the physician is to stick to the principle of requiring a formal physician-patient relationship before prescribing medication. The components of this relationship can include a complete history, obtaining confirmatory medical records from other practitioners and hospitals, a thorough physical examination and the obtaining of indicated diagnostic tests.
38Fertility Generic factors related to substance abuse: men: impotence decreased semen qualitywomen:alterations in ovulationmenstrual irregularitylibido:variable effectThere is very little published research in this area. It would appear that many of the illicit drugs (and certainly abuse of alcohol and tobacco) can be associated with both menstrual irregularities and impaired male and female fertility.
39Pregnancy Prevalence and incidence: no difference: indigent/nonindigent patientspublic and private clinicsethnic groups4 million women who gave birth:757,000 drank alcohol products820,000 smoked cigarettes221,000 used illegal drugsDuring pregnancy, marijuana and cocaine are the most prevalent illegal drugs used, 2.9% and 1.1% of patients respectively.There is a strong link between alcohol, cigarette and illegal drug use. One third of pregnant women who report use of one drug also smoked cigarettes and drank alcohol. Conversely, women who use tobacco and alcohol are much more likely to report use of marijuana and cocaine.Reference: National Pregnancy and Health Survey, National Institute on Drug Abuse, U.S. Department of Health and Human Services, 1997.
40Pregnancy: Generic Issues Educate patient about adverse outcome effectsScreen for domestic violenceScreen for STDs, hepatitis B and C, TBCo-manager or refer to multispecialty clinicRefer to drug counseling programMonitor with urine toxicologySequential antepartum assessment of growthRefer newborn to pediatricsClose postpartum follow upIt is very difficult to establish a clear cause and effect relationship between illicit drug use and many of these complications. However, it is clear that a “chaotic” lifestyle can result in an increased risk of adverse perinatal outcome. The management of the obstetric patient who uses illicit drugs is very similar to the care of any “high-risk” pregnancy. This includes possible referral for a diagnostic assessment, co-management of care or referral, sequential surveillance for preterm birth and the use of antepartum testing where appropriate.Referrals to drug counseling programs and/or multispecialty programs are ideal, but complicated by the paucity of such programs for pregnant women. The involvement of pediatrics and close postpartum follow up are important to address the issues of child custody, breast feeding, developmental examinations, prevention of SIDS and the continuation of any involvement with drug treatment centers.Reference: Andres RL. Social and illicit drug use in pregnancy. In: Creasy and Resnik. Maternal-Fetal Medicine 4th Edition. Saunders, 1999.
41Cocaine Alkaloid from leaves of Erythroxylon coca bush: marketed as crystals, granules, white powderroutes:intranasal, parenteral, oral, vaginal, rectaldecomposes with heating, melts at 195oCwater solubleCrack cocaine alkaloid is free base:soluble in alcohol, oils, acetone, ethercolorless, odorless, transparent crystalmelts at 98oCnot destroyed at higher temperatures“Crack” cocaine is a heat stable preparation. It is smoked and the drug is absorbed through the alveolar membranes. This results in a rapid effect that is similar to that with either intravenous or intranasal use.Cocaine is metabolized by the action of plasma and hepatic cholinesterases. Cholinesterase activity has been reported to be diminished during a normal pregnancy and may contribute to the accentuation of the drug’s effect observed in the pregnant patient.
42Cocaine Produces a dose dependent increase in: heart rate and blood pressurearousal, enhanced vigilance and alertnesssense of self confidence and well-beingChronic, heavy use associated with:pronounced irritabilityparanoid ideationsincreased risk of violencereduced libidoCocaine exerts its effect by interfering with the reuptake of neurotransmitters, such as dopamine and norepinephrine, at the presynaptic nerve terminals. This leads to an increase in circulating catecholamines with resultant hypertension and tachycardia.Binge use is common and may last up to several days. Although there is no physiologic “withdrawal” from cocaine (as seen with opiate cessation), there are typical findings associated with abrupt discontinuation of the drug. This may include extreme exhaustion with prolonged hypersomnolence, apathy, hyperphagia, and anhedonia.Reference: Gawin FM, Ellinwood, EM Jr. Cocaine and other stimulants: actions and treatment. N. Engl J. Med 1988;318:
43Cocaine: Adverse Maternal Effects Possible systemic complications:cardiovascular:tachycardia and cardiac arrhythmiasvasoconstriction and hypertensioncentral nervous system:hyperthermiaCVAseizuresThe prominent effect of cocaine on the cardiovascular system can be further accentuated during normal pregnancy. This may be due to the effect of progesterone which has been shown to increase the metabolism of cocaine to norcocaine, a biologically active metabolite, or an increased sensitivity of alpha-anergic receptors.Reference: Andres RL. Social and illicit drug use in pregnancy. In: Creasy and Resnik. Maternal-Fetal Medicine 4th Edition. Saunders, 1999.
44Cocaine: Adverse Fetal Effects Questionable Congenital anomalies:published data are equivocalreported anomalies include:limb reduction defectsgenitourinary tract malformationscongenital heart diseasecentral nervous systemThe association between cocaine exposure and congenital anomalies is controversial. The difficulty is distinguishing the effects of poly-substance use and negative environmental factors.Several authors have suggested that the mechanism of these anomalies is profound vasoconstriction and hypoperfusion leading to the deformation or destruction of normally formed embryonic structures, but this theory has not been validated.References:Andres RL. Social and illicit drug use in pregnancy. In: Creasy and Resnik. Maternal-Fetal Medicine 4th Edition. Saunders, 1999.Lutiger B. Graham K, Einarson TR, Koren G. Relationship between gestational cocaine use and pregnancy outcome: A meta-analysis. Teratology 1991; 44:MMWR Atlanta Urogenital anomalies in the offspring of women using cocaine during early pregnancy ;38:
45Cocaine: Adverse Fetal Effects Impaired fetal growth:decrease in mean birthweightincrease in low birthweight infantsincrease in intrauterine growth restrictionsignificant correlation between cocainemetabolites in meconium and decreases inbirth weight, birth length and headcircumference.Published data support the association between maternal cocaine use and impaired fetal growth. Numerous studies (controlling for gestational age and other confounders such as race, alcohol, prenatal care and tobacco use) demonstrate a reduction in mean birthweight of 300 – 500 grams; this is similar to that seen with patients using tobacco. The most compelling evidence is that showing a significant correlation between cocaine exposure (manifest as cocaine metabolites in neonatal meconium) and a decrease in birth weight.References:Andres RL. Social and illicit drug use in pregnancy. In: Creasy and Resnik. Maternal-Fetal Medicine 4th Edition. Saunders, 1999.Sprauve ME, Lindsay MK, Herbert S, Graves W. Adverse Perinatal Outcome in Patients Who Use Crack Cocaine. Obstet Gynecol 1997,89:674-8.
46Cocaine: Adverse Prenatal Effects Preterm labor and delivery:no consensus among clinical studies:Premature separation of the placenta:most studies confirmPremature rupture of the membranes:controversial associationAlthough there are data from several animal models (and from in vitro human myometrium) linking cocaine to an increase in myometrial contractility, the clinical data remain inconclusive. Conclusions from many of the studies from the late 1980’s and the 1990’s are limited by both sample size and lack of attention to controlling for confounding risk factors (tobacco use, previous preterm birth, inadequate prenatal care, etc.). The two largest studies, both of which controlled for these risk factors, are in disagreement about the association of cocaine use and preterm birth.A recent study by Sprauve and colleagues which controlled for confounding risk factors found no association between abruptio and cocaine in 483 users. Shortcomings of other studies include inconsistent clinical diagnosis of abruptio, inconsistent pathologic exam of placenta and poor control for confounders such as tobacco and hypertension.References:Andres RL. Social and illicit drug use in pregnancy. In: Creasy and Resnik. Maternal-Fetal Medicine 4th Edition. Saunders, 1999.Sprauve ME, Lindsay MK, Herbert S, Graves W. Adverse Perinatal Outcome in Patients Who Use Crack Cocaine. Obstet Gynecol 1997,89:674-8.
47Cocaine: Adverse Neonatal Effects Initial neurologic findings:coarse tremorhypertoniaextensor leg postureIncreased risk of SIDS (4x)Long-term consequences:no consistent negative associationsdevelopmental outcome similar to drug-freenewbornsIn contrast to opiate exposure, there is no overt physiologic withdrawal from cocaine in newborns. Related to the adverse impact of cocaine exposure to the growth and development of these infants, it is necessary to control for confounding variables. These include prenatal exposure to tobacco, marijuana and alcohol and the subsequent quality of the parenting skills and overall “chaotic” environment in which many of these children live. In children younger than 7 years, there is no convincing evidence of negative associations related to prenatal cocaine exposure and physical growth, developmental test scores, or receptive or expressive language.Early identification of the drug-exposed newborn that results in early intervention is important. The child’s eventual outcome can be positively influenced by the impact of family protection and support in the home, and more formal intervention strategies available through community services.References:Frank DA, Augustyn M, Knight WG, Pell T, Zuckerman B. Growth, development and behaviors in early childhood following prenatal cocaine exposure. A systematic review. JAMA 2001:285:Chiriboga CA, Brust JC, Bateman D, Hauser WA. Dose-response effect of fetal cocaine exposure on newborn neurologic function. Ped 1999; 103:79-85.
48Cocaine: Treatment Goal = help patient resist the urge to restart compulsive cocaine useOptions according to personal characteristics:group and individual drug counselingcognitive behavioral therapy to prevent relapse:ways to act and think in response to cuesavoid environmental/social pressurespractice drug refusal skillsmedicationsMedications are of modest help. There is no FDA approved medication that can be used reliably in the treatment of cocaine addiction. Those being used in investigational protocols include desipramine (tricyclic antidepressant), amantadine (dopaminergic agent), fluoxetine (selective serotonin reuptake antagonist), buprenorphine (partial opioid agonist), disulfiram (alcohol oxidase inhibitor) and selegiline (MAO inhibitor).The safety in using any of these prescription drugs in pregnancy has to be weighted in a benefit – risk ratio and discussed with the patient.
49Opiates and Opioids Opiates (naturally occurring): derived from the Paper somniferum poppyexamples: morphine, codeineOpioids (synthetic):examples: fentanyl, heroin, hydrocodone,hydromorphone, meperidine, methadone,and oxycodoneOpiates and opioids share common features. Specifically, they activate the same receptors, reduce the perception of pain and produce a state of well being and euphoria
50Heroin Routes: inhaled, intranasal, IV, IM, SQ lipid soluble, rapidly crosses the blood-brain barrierConstant oscillation between feeling:initial warmth, intense pleasure or rushduration of high between 3-5 hoursfollowed by sedation and tranquility (on the nod)symptoms of early withdrawalHeroin was initially thought to be the “preferred” alternative to morphine in the treatment of various conditions including chronic pain, chronic cough and alcohol dependence.It is now known that heroin is a highly addictive drug that exerts its effects very rapidly and creates a paralyzing cyclic pattern of feeling the “high” of the drug and then feeling the symptoms of opiate withdrawal. This results in a situation of escalating, destructive drug seeking behavior which effectively monopolizes the daily activities of the user. A typical heroin abuse may inject up to four times a day.
51Heroin: Maternal Adverse Effects Short-term adverse effects:somnolencealtered mentationcardiorespiratory arrest (overdose)Long-term adverse effects:physiologic withdrawalhepatitis B and CSTD’s, HIVendocarditisabscessespneumonia and tuberculosisThe medical complications of heroin use are profound. The preponderance of intravenous use with its attendant risks (e.g., hepatitis, HIV, endocarditis), the potential for contamination of the drug with various toxins (e.g., strychnine) and the variability of the dose obtained “on the street” (with the risk of overdose) all contribute to the medical and obstetric risks of heroin use.
52Heroin: Withdrawal Syndrome Symptoms:drug cravinganorexia, nausea, abdominal crampingincreased sensitivity to painSigns:hypertension, hyperventilation, tachycardialacrimation, mydriasis, rhinorrheayawning, sweatingvomiting, diarrheachills, flushing, muscle spasmsrestlessness, tremors, and irritabilitypiloerectionThe physiologic dependence of heroin and the resultant “withdrawal syndrome” fuels the drug-seeking behavior that profoundly effects the lives of these patients. The withdrawal syndrome is extremely unpleasant, but not life threatening. It begins several hours after last drug use and peaks at hours.The abrupt withdrawal of heroin (opiates and opioids in general) during pregnancy is associated with an increase in the risk of pregnancy loss.Reference: Hoegerman G, Schnoll S. Narcotic use in pregnancy. Clin Perinatal 1991;18:58-9.
53Heroin: Adverse Pregnancy Effects Intrauterine growth restrictionNeonatal abstinence syndrome:central nervous system:hypertonia, hyperreflexia, tremors, convulsionsgastrointestinal system:fist sucking, poor feeding, vomiting, diarrhearespiratory system:tachypnea, sneezing, yawning, hiccupsautonomic nervous system:fever, vasomotor instability, sweating, tearingThe majority of the published investigations evaluating the perinatal outcome in patients using heroin during their pregnancy are poorly controlled for confounding variables known to affect pregnancy outcome. Overall, it would seem that the issues of growth restriction and neonatal abstinence syndrome (withdrawal) are the most well supported perinatal complications of heroin use.The neonatal abstinence syndrome is well described and effects 50-95% of “exposed” infants. It begins on the first several days of life and may be subacute for 3-6 months. Many investigators have suggested that it is more common in the offspring of women exposed to methadone than those exposed to heroin.Treatment consists of supportive therapy (calm, warm and quiet environment). The pharmacological treatment can include diazepam, phenobarbital, paregoric and chlorpromazine.References:Andres RL. Social and illicit drug use in pregnancy. In: Creasy and Resnik. Maternal-Fetal Medicine 4th Edition. Saunders, 1999.Stimmel B, Jerez E. Alcohol and substance use during pregnancy. In: Cherry SH, Berkowitz RL, Kase NG (eds): Medical, Surgical and Gynecologic Complication of Pregnancy. Baltimore, Williams and Wilkens, 1985.
54Heroin: Treatment Principle = change from a short acting IV to long acting oral opioid to relieve drug craving andwithdrawalMethadone:synthetic opioid blocks effect of heroinlong half life allows daily dosingno euphoria, no interference with daily activitiesNew agents:levomethadyl-acetate (LAAM)buprenorphine (combined with naloxone)The recommended treatment for pregnant women who are physically dependent upon heroin is to replace the heroin with long acting oral methadone. Introduced 30 years ago, it is the pharmacological treatment for patients who can abstain from opiates and require maintenance therapy. Its daily oral dosing schedule and lack of sedating or intoxicating properties make it an ideal agent for interrupting the cycle of heroin craving, heroin use and withdrawal symptoms and allowing neuroendocrine rhythms to be restored.Although still investigational, there are two new agents of note. LAAM is also a synthetic opioid that blocks the effects of heroin for as long as 72 hours. The half-life of this drug allows it to be taken orally three times a week. Buprenorphine is a partial opioid agonist that is thought to cause less physical dependence and therefore less profound withdrawal symptoms upon its discontinuation. Combined with the antagonist naloxone, it will probably become the primary formulation for the detoxifying opiate-dependent patients.
55Methadone: Perinatal Effects Pregnancy:continuation of normal daily activitiesdecrease in associated maternal morbidityNeonatal abstinence syndrome:occurs on day 2-3 up to a weeksimilar to heroin withdrawal syndromeNaloxone (Narcan) contraindicated; severe withdrawalThe institution of methadone maintenance (treatment for heroin dependence) is associated with a decrease in maternal morbidity and perinatal complications.Abrupt cessation of heroin or methadone (or any opiate/opioid) is contraindicated because of the reported risk of pregnancy loss and fetal compromise.
56Methadone: Treatment Protocol Initiation of treatment:10-20 mg initial dosenext 24 hours: mg every 6 hours per signsand symptoms of opiate withdrawaldaily maintenance dose mg, qd or bidDetoxification during pregnancy, controversial:only if 30 mg/day is realistic goalinpatient: 2 mg/day decrease in doseoutpatient: mg/week decrease in doseIn general, patients should be maintained on a dose of methadone that is sufficient to eliminate the “cravings” for heroin. Adjustments in the methadone dose are based upon the signs and symptoms of opiate withdrawal near the time of the next expected dose. Some investigators have suggested that dividing the dose (12 hour regimen) is beneficial for pregnant patients.Many patients will express a desire to “wean” from their methadone so that they will be “drug free” at the time of delivery. This should be considered only if the patient can realistically be taking less than 30 mg daily at term. This dose of methadone has been associated with a decrease in the incidence and severity of the neonatal abstinence syndrome.Withdrawal of methadone maintenance should be supervised by those with experience in this area. Women who are taking low doses of methadone should not be discouraged from breast feeding their newborns.Reference: Andres RL. Social and illicit drug use in pregnancy. In: Creasy and Resnik. Maternal-Fetal Medicine 4th Edition. Saunders, 1999.
57Methadone: Maintenance Programs State and federal regulations restrict prescribing:who enters the programdaily dosing schedulelocation of clinic sitesspecially licensed physiciansOffice-based methadone maintenance therapy is not available at the present time.Proposed federal regulations (The Children's Health Act of 2000; Public Law ) will allow physicians associated with approved addiction treatment programs to develop individualized treatment plans. This will include prescribing several days of methadone dosing or LAAM. The goal is to increase the number of heroin addicts receiving treatment by increasing access to care. (see
58Marijuana Active ingredient = tetrahydrocannabinol (THC): derived from Cannabis sativalipophilic with accumulation in fatty tissuesmetabolized by liver and eliminated in feceseffects:onset within minutes3-5 hour durationMarijuana is the most commonly used illicit drug in the United States. In 1998, an estimated 2.1 million people started using it and 18.7 million people were estimated to have used marijuana in the past year.Marijuana meets the criteria for an addicting drug. Over 120,000 people annually enter treatment for primary marijuana addiction. The use of this drug increases the likelihood of subsequent addiction to cocaine and opiates.The use of marijuana by pregnant women has been estimated to be as high as 35% in some populations. The concurrent use of alcohol, tobacco and illicit drugs is commonplace.Reference: National Household Survey on Drug Abuse. Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, 1998.
59Marijuana: Adverse Maternal Effects CNS depressionMay act as a cardiovascular stimulant:tachycardia, hypotensionRespiratory problems similar to tobacco smokers:bronchitis, sinusitis, pharyngitisLearning & social behavior:changes in attention, memory, informationprocessingMarijuana does not pose as many overt health problems as other illicit drugs or even alcohol and tobacco. However, the more frequent current use of alcohol and cigarette smoking can serve as additional health concerns.There are concerns over the contribution of contaminants in marijuana (including cocaine, heroin, strychnine) that may have significant adverse effects.
60Marijuana: Adverse Perinatal Effects Controversial or no clear association:no evidence of congenital anomaliesdoubt decrease in birth weightdoubt increase in preterm birthno evidence of long term infant-childneurodevelopmental sequelaTHC is present in breast milkThere is little evidence that marijuana use is associated with an increase in the risk of adverse perinatal outcome. The concurrent use of alcohol, tobacco or illicit drugs and/or the presence of contaminants pose the greatest risk to the pregnancy.
61Pregnancy: Ethical Issues Maternal autonomy:the pregnant woman’s right to choose orrefuse recommended therapyfetal interests do not have to be abandonedIf conflict between maternal and fetal interests:urge the woman to seek consultationrefer to institution’s ethics committeedocument in detail in medical chartCourt orders for treatment can be destructive to:the woman’s autonomythe physician-patient relationshipThe issues surrounding maternal autonomy and rights of the fetus are complex. Involvement of institutional legal consultants and ethics committees are crucial in caring for these patients and in achieving acceptable compromises that maintain the integrity of the patient-physician relationship.
62Summary Drug dependence is a chronic, relapsing medical illness. The etiology and course of the disease isinfluenced by genetic heritability, personalchoice and environmental factors.Drug dependence produces lasting change inbrain chemistry and function.Effective medications are available to treatopiate dependence and achieve abstinence.Long-term care strategies produce lastingbenefits for the patient who can live normal,productive lives.Hypertension, asthma and type 2 diabetes mellitus are examples of chronic medical illness. Drug dependence shares similar characteristics to these diseases in its genetic and environmental etiology, pathophysiology, and response to treatment. Medical adherence and relapse rates also are similar across these illnesses.Drug dependence is more than an acute illness. Rather, long-term medical management and continued monitoring are required. They will produce lasting benefits for the patient.As with other chronic health problems, the evaluation and treatment of drug abuse and drug dependence should achieve parity in health insurance coverage and reimbursement.Reference: Drug Dependence, A Chronic Medical Illness. Implications for treatment, insurance, and outcomes evaluation. McLellan AT, Lewis DC, O’Brien, CP, Kleber HD. JAMA 2000;284:
63Sources of Learning Materials American College of Obstetricians and GynecologistsAmerican Society of Addiction MedicineMarch of Dimes Birth Defects FoundationNational Clearinghouse for Alcohol & Drug InformationorNational Institute on Drug AbusePhysician Leadership on National Drug PolicyBibliography:Osborn JE, Bristow LR, Lewis DC. PLNDP Action Kit. Physician Leadership on National Drug Policy, Brown University Center for Alcohol and Addiction Studies, Rhode Island, 1998.American College of Obstetricians and Gynecologists. ACOG Technical Bulletin Number Substance Abuse, Washington, DC. July 1994.Andres RL. Social and illicit drug use in pregnancy. In: Creasy and Resnik. Maternal-Fetal Medicine 4th Edition . Saunders, 1999.
64Internet Resources Association for Medical Education & Research in Substance AbuseCenter for Alcohol & Addiction Studies,Brown UniversityCenter for Substance Abuse Treatment (DHHS)Narcotics AnonymousBibliography (continued):Center for Substance Abuse Prevention. Pregnant, substance-using women. Treatment Improvement Protocol (TIP) Series No. 2. US Public Health Service Substance Abuse and Mental Health Services Administration, Rockville, MD, 1993.Chazotte C, Rosen RK, Tsamas AC, et al. The March of Dimes Substance Abuse Curriculum for Obstetricians and Gynecologists March of Dimes Birth Defects Foundation, White Plains, NY, 1995.National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. Effective medical treatment of opiate addiction. JAMA 1998;280:O’Brien CP. Drug addiction and drug abuse. In: Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 9th Edition McGraw-Hill, 1996.
65Internet Resources (continued) National Advisory Council on Drug Abuse, NationalInstitute on Drug Abuse (NIDA)National Clearinghouse for Alcohol & Drug InformationPhysician Leadership on National Drug PolicyUS Department of Justice, Drug Enforcement Admin.Bibliography (continued):Principles of Addiction Medicine. 2nd Edition. Graham AW and Schultz TK eds. American Society of Addiction Medicine, Chevy Chase, MDSullivan E, Flemming M. A Guide to Substance Abuse Services for Primary Care Clinicians. Treatment Improvement Protocol (TIP) series. Substance Abuse and Mental Health Services Administration. Center for Substance Abuse Treatment, US Department of Health and Human Services; DHMS Publication No. (SMA)