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Michael Weaver, MD, FASAM Division of Addiction Psychiatry Virginia Commonwealth University Medical Center 2010 Health Summit Substance Abuse and Pregnancy Charlottesville, Virginia
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Substance use and pregnancy Maternal & fetal effects during pregnancy Addiction treatment during pregnancy Neonatal Abstinence Syndrome Home environment
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Risk-taking behavior while intoxicated Unprotected sex may lead to pregnancy Drug use causes irregular menstrual cycles, but can still conceive May not realize she is pregnant for several months
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Prostitution Sex for money to pay for drugs “Trading favors” – sex for drugs Consensual transaction Impaired judgment while in “drug den” Unsafe sex Not always able to use a condom Risk of HIV, Hepatitis B & C, other sexually transmitted diseases Risk of violence, fear of prosecution
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May be physical, mental, or social Due to Side effects of drug Isolation (prefer drug to socialization) Cost of obtaining (especially on Black Market) Unknown adulterants Route of administration (injection)
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Co-occurring mental health and substance abuse diagnoses Anxiety Depression Schizophrenia Personality disorders Cognitive-behavioral counseling more challenging Best success with treatment of both conditions simultaneously
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Higher risk for substance use among those with any psychiatric disorder Contact with health care or criminal justice system is opportunity to intervene Earlier detection and intervention prevents problems Screening is not universal
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Substance abuse can masquerade as almost any psychiatric symptom Drug-induced psychiatric symptoms improve markedly over 2-4 weeks following abstinence Risk of suicide among substance dependent patients up to 10 times higher than in the general population
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Sedative- hypnotics Opioids Stimulants Nicotine Marijuana
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CNS depressant Disinhibition depress inhibitions first Reduce anxiety (fun at parties) Oversedation, ataxia, respiratory depression Daily drinking leads to tolerance and withdrawal Delirium tremens
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Benzodiazepines, barbiturates, other sleeping pills (Ambien, Lunesta) Sedation, anxiolytic Respiratory depression in overdose Withdrawal similar to alcohol DT’s
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Common to both: Restlessness Insomnia Nausea/vomiting High blood pressure Rapid heart rate Rapid breathing Seizures Seen in withdrawal, but not pregnancy: Distractibility Impaired memory Agitation Tremor Fever Sweating Hallucinations
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Withdrawal symptoms may be life-threatening to mother and fetus Acute withdrawal treatment should be accomplished in an inpatient setting Risk to mother/fetus of untreated withdrawal is greater than risk from exposure to medications in a controlled setting
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Fetal Alcohol Syndrome Fetal Alcohol Effects Spectrum disorder Leading preventable cause of mental retardation Encourage abstinence as soon as pregnancy suspected
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Morphine, heroin, OxyContin, methadone Analgesics: disconnect from pain Euphoria, disconnection, sedation Nausea, constipation, itching Oversedation, respiratory depression
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No known fetal anomalies Intrauterine growth retardation Neonatal abstinence syndrome Continuous exposure Use up to delivery
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Cocaine, amphetamine, methylphenidate, MDMA (Ecstasy), caffeine Enhanced concentration, alertness Edginess, paranoia, hypervigilance, psychosis Hypertension, hyperthermia, vasoconstriction Heart attack, stroke
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Spontaneous abortion Placental abruption Fetal hypertension Intrauterine growth retardation SIDS ‘Crack baby syndrome’ disproven
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Cigarettes, cigars, pipes, “snuff,” “chew” Stimulant & relaxes Acute effects Vasoconstriction secretions Chronic effects Lung disease, heart disease Cancer Very short-acting, so high-frequency use Very reinforcing
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craving for tobacco irritability, frustration, anger anxiety difficulty concentrating restlessness decreased heart rate increased appetite or weight gain depression disrupted sleep sedation
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Most common fetal exposure Intrauterine growth retardation Higher rates of spontaneous abortion, placenta previa, etc. SIDS risk >4x higher Nicotine patch better than smoking cigarettes
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Marijuana, hashish, hash oil active ingredient: THC relaxation, hallucination panic attacks short-term memory impairment, amnesia
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Intrauterine growth retardation Abnormal startle reflexes in newborns Reduced memory & verbal skills at age 4 years
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White powder Varies dealer to dealer & batch to batch “Buyer beware” Common adulterants Sugar, condensed milk OTC or Rx meds Causes problems when fetus exposed during pregnancy
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All pregnant women should be screened for drug and alcohol use T-ACE: emphasizes tolerance over guilt A positive screen indicates the need for further evaluation
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Alienation from family Multiple jobs Financial problems Multiple arrests Multiple partners Loss of custody
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Continued substance use despite adverse consequences Use in larger amounts or for longer periods than intended Preoccupation with acquiring or using Inability to cut down, stop, or stay stopped, resulting in a relapse Use of multiple substances of abuse
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High-risk Obstetrics Clinic – Screening, evaluation Team approach in hospital setting – Certified Addictions Nurse – Clinical Social Worker – Obstetrics/Pediatrics Continuity after hospitalization – Healthy Start Initiative through Community Services Board Medical management of withdrawal Motivational interviewing approach Linkage to resources in community Good professional relationships – Child Protective Services – Criminal Justice System
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Detoxification 12-Step groups Outpatient counseling Intensive outpatient Inpatient Residential Opioid Maintenance Methadone Buprenorphine
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Women wary of acknowledging problem Fear of legal consequences (loss of custody) Reporting requirements Public health authorities, child protective services Criminal justice system When identified or at time of delivery Inform patient of legal obligation
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Sustained remission rates of up to 60% – Better success than treatment of hypertension, diabetes Every $1 spent on treatment saves $7 in costs to society Lots of new research
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High rates of non- adherence to pharmacotherapy Careful monitoring of adherence Long-acting preparations may be beneficial for severe chronic mental illness Some psychiatric meds can be problematic in pregnancy Weigh risks vs. benefits
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A.A., N.A., C.A. Group format Anonymous No cost No affiliations or endorsement Different groups have different characteristics
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Motivational Interviewing Motivate the patient to reduce/stop drinking and/or seek further treatment Cognitive-Behavioral Treatment Identify life stressors, high-risk situations for drinking, and coping skills deficits Use modeling and rehearsal Relapse Prevention Identify triggers, practice avoiding, emphasize responsibility A ‘slip’ is a learning opportunity
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Network therapy Family therapy Supportive psychotherapy Contingency management Building Social networks Twelve-Step facilitation Perceptual Adjustment therapy Rational Recovery Medication management Brief intervention
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Non-hospital therapeutic environment May include 12-step groups Consistency in message conveyed by staff Ideal elements for pregnant addicted women Childcare (for older children) Coordination with obstetric care
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Long-acting medication in controlled setting Counseling Social services Avoid withdrawal & craving Reduce disease & crime Maintenance vs. detoxification
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Long-acting pure opioid agonist Available for opioid addiction treatment only in federally licensed programs Requires daily clinic visits, but may get take-home dose privileges Significant street reputation Also used for pain like other Schedule II opioids
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Standard of care for opioid-dependent pregnant women Stabilization of mother and fetus Medical and social Higher dose in 3 rd trimester Improves growth of fetus & newborn Decreases practice of high-risk behaviors
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Long-acting opioid agonist-antagonist Office-based opioid addiction treatment Schedule III Buy at local pharmacy (Subutex, Suboxone) Very low risk of overdose Combined with naloxone Used for acute pain treatment (Buprenex)
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Pregnancy Category C Use Subutex instead of Suboxone to avoid naloxone NAS less intense than with methadone Studies ongoing, results encouraging
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Characterized by Hyperactivity, irritable Hypertonia Difficulty/excessive sucking High-pitched cries Begins 3h to 12d after delivery, depending on drugs used by mother
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Initial treatment is supportive Swaddling, frequent feeding, IV fluids Assess regularly for symptoms and failure to thrive Pharmacotherapy Usually opioids, occasionally sedative-hypnotic Tincture of opium, paregoric, methadone, phenobarbital
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Addicted pregnant woman often product of poor parenting Support network for new mother Family, 12-Step group, health care workers Encourage involvement of significant other Lack of support can lead to relapse Social services may need to be notified of unsafe living conditions
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Education Breastfeeding Umbilical cord care Approach for ‘fussy’ infant Age-appropriate discipline for other children Prevent frustration that leads to relapse
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Encouraged Promote bonding Optimal nutrition Passive immunity Contraindications Active substance abuse HIV + Methadone or buprenorphine dose not important consideration
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Young children don’t have to use drugs themselves to be affected – Child neglect & abuse – Loss of family structure – Inappropriate role models Impair intellectual, social, & ethical behavior
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Drug use behaviors may increase risk for unplanned pregnancy Nicotine replacement is preferable to smoking during pregnancy Fetal Alcohol Syndrome is the leading preventable cause of mental retardation Alcohol and sedative withdrawal should be treated in an inpatient setting Adulterants also harm mother and fetus
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Most common obstetrical effect of illicit drugs is low birthweight Methadone maintenance is treatment of choice for opioid-addicted pregnant women Breastfeeding is encouraged (as long as not actively using illicit drugs or alcohol) Support for mother is essential Anticipate and educate to prevent relapse
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