Presentation on theme: "Perinatal Substance Abuse Program"— Presentation transcript:
1Perinatal Substance Abuse Program Dept of Alcohol and Drug Services (DADS)Presented by Lara WindettM.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…
2The Department of Alcohol & Drug Services exists within the overallSanta Clara Valley Health & Hospital SystemDedicated to the health of the whole communityregardless of ability to pay
3Background PSAP was Brainchild of Anthony Puentes, MD, MPH, 1987 Funding streamGoal of PSAP ProgramThe 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.
4PSAP Keeps babies out of the NICU NICU costs ~$2,100 – 5000 per daybabies exposed, 30 in NICUAvg Length of Stay: 15 daysDo the math (avg 3,550 per day) $1,597,500.
5PSAP 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.
6Perinatal Drug Exposure Overview 1992 StudyEstimated 15-18% of pregnant women use alcohol or drugs.PSAP Admission StatisticsSCC 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.
7PSAP = Empowerment Model Comprehensive Intensive Outpatient TreatmentMedically MonitoredMultidisciplinary ApproachDay Care for clients’ childrenTransportationComprehensive 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 guidelinesDay Care for clients’ childrenTransportation
8PSAP Client Eligibility Resident of Santa Clara CountyPregnant or Early Parenting Women18 years or olderOn Methadone (MMT) or opiate dependentHx or DOA abuse or currently usingFamily Wellness Court ReferralsMedi-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).
9Length of PSAP Stay Assigned a Licensed Therapist, PSW Case Management Individualized Tx PlanTypical Treatment Episode: monthsThe 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.
10Staff HCPM II 3 Therapists (MFT) MD Health Ed Specialist 1 Health Services Representative3 day care aides (1/2 codes)1 Community Worker (van) (1/2 codes)Volunteers
11Current PSAP Client Demographics ~Capacity for 65+Women ages 19 to 43 years23% pregnant10 clients on Methadone (3 pregnant)30% Caucasian33% Latina,9 % Asian/Pacific Islander18% Mixed Race2% African American8 % Declined to State30% in THU’sCPS 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)
12Out Patient Drug Treatment in Santa Clara County – Including Methadone On the VMC campusReadily accessible - pregnant OPIOID DEPENDENT patients (Methadone candidates) are scheduled for admission the next business dayAll Patients can call GatewayProviders can call Central Valley ClinicFront DeskPSAP Clerical
13Items 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.
14Overview of AOD Treatment/Concerns Red flagsWhen interviewing/observing the patientWhen considering the historyRisks associated with various drugsTo the pregnancyTo the baby
15Substances to Be Discussed OpioidsCigarettesAlcoholMarijuanaMethamphetamine
16Amber 32 y.o. Woman and the mother of an 8 y.o. Unplanned pregnancy Using dailyHeroin by injection 2 grams/dayCocaineCigarettes 2 PPDSeeking admission to methadone program
17Amber Stealing to obtain drugs Isolated – only living relative is maternal grandmother8 y.o. son is being raised by patient’s grandmotherFather of baby is using and at risk of deportation
18Amber Medically indigent History of depression and anxiety History of domestic violence (prior relationship)
19Amber Frustrated – requested tubal ligation at 23 Frightened – concerned about damage already done to babyMotivatedRequests residential treatmentResolves to leave boyfriend if he will not get into treatment
20Red Flags: Multiple & Obvious Patient volunteering history of substance abusePhysical exam remarkable for multiple tracks and physical withdrawalLife in disarrayChaotic and disrupted family relationships
21Why Share this Story? Opioid dependence requires medical intervention Pregnant patients need treatment to prevent adverse outcomesWomen caring for infants need treatment to be functional mothers
22Pregnancy can be a Huge Motivation for Change: Amber Stabilized on methadone maintenanceCompleted residential treatmentPermanently left the boyfriend who continued to useDelivered drug free
23A Sense of Hope: 12 Years Later Amber is… Abstinent and still in treatmentRaising her daughterWorking
24Prevalence 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).
25Brenda Referred to treatment for history of methamphetamine abuse Worked as a medical assistant until about two years agoServed as caretaker for mother who died of breast cancerAfter mother died, dad was diagnosed with lung cancer; patient served as caretakerReported having a prescription for vicodin
26BrendaReported taking prescribed vicodin for chronic back pain (occasionally)Denied history of prescription opioid abuseWeekly u tox screens consistently positiveFor a variety of prescription opioidsNot just for vicodinEasy access to unlimited supply of prescription opioidsTransferred to methadone maintenance
27Prescription Opioid Abuse May Not Be Obvious Consider the historyUnusual number of painful conditions for a young healthy patientMultiple opioid prescriptions during pregnancyMultiple ER visits for complaints of painMultiple care providers/no regular providerOpioids for unusual indications
28Patient’s Appearance on Opioids NormalSedated with small pupilsSymptoms of withdrawalSweats/chills/goosefleshLacrimation/rhinorrheaYawning/sneezingIrritable/anxious/fidgetyVomiting
29Ask 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?
30Ask about Reasons for Use Manage emotions?Deal with stress?Feel high?Numb everything or go to sleep?
31Opioids: Three to Seven Times Higher Rates of… Still birthFetal growth retardationLow birth weightSmall head circumferencePrematurityNeonatal mortality
32Heroin: Medical Risks Associated With Injection CellulitisAbscessesEndocarditisHepatitisHIV infectionWound Botulism
33Opioid Dependence in Pregnancy: Treatment Currently, methadone maintenance is the gold standardBuprenorphine 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
34Impact of Methadone Treatment Reduced deathsReduced IVDUReduced HIV seroconversionReduced crime daysReduced relapseImproved healthImproved relationshipsImproved productivityImproved social functioning8-10 fold reduction in death rateThe rule of foursDemonstrated to improve pregnancy outcomeBenefits society as well as the individual drug addict
35Additional Benefits During Pregnancy Increased participation in prenatal careReduced obstetrical complicationsImproved maternal nutritionDaily observation in clinic while dosing
36Therapeutic Dosing With Methadone Suppresses opioid withdrawal symptomsReduces opioid cravingsProvides a stable opioid blood levelAllows a patient to concentrate on counseling/program to support recoveryMinimizes side effects; patient should not be sedated
37Methadone Withdrawal: Not Recommended During Pregnancy The relapse rate is high (80%)Risk of intrauterine demiseRisk of premature labor/miscarriageWhat can you say to a patient wanting to Withdraw from MMT?Send them to their primary CSLR/the addiction MD to discuss
38Methadone Withdrawal: Not Recommended After Delivery? Like insulin, methadone stabilizes a chronic illnessThe normal brain has an endogenous opioid system that may never function properly in an opioid dependent patientVery high relapse rate when methadone treatment is discontinued
39Methadone: Effects on the Baby No known birth defectsMore likely to be born at termLower birth weight/smaller head circumference at birthMay experience developmental delay during the first year of lifeNot associated with learning difficultiesIncreased SIDS with opioid exposure
40Methadone and Breastfeeding Negligible amounts of methadone are passed in breast milkThe American Academy of Pediatrics considers methadone compatible with breastfeeding at any dose
41Methadone: Neonatal Withdrawal Safer than heroin withdrawal in uteroExperienced by 60-80% of exposed babiesUsually occurs within the first 2-3 days of life; may occur within the first monthUsually treated with an opiate agonistDuration of treatment is days to monthsCan be life threatening without treatment
43Symptoms of Opioid Withdrawal W = wakefulnessI = irritabilityT = tremulousness, temperature variation,tachypneaH = hyperactivity, high-pitched persistent cry,hyperacusia, hyperreflexia, hypertonusD = diarrhea, diaphoresis, disorganized suckR = rub marks, respiratory distress, rhinorrheaA = apneic attacks, autonomic dysfunctionW = weight loss or failure to gain weightA = alkalosis (respiratory)L = lacrimation
44Clarissa 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”
45United States ( )National Household Survey on Drug Abuse (NHSDA)Survey of pregnant womenCigarettesAlcoholAny Illicit Drug% using # fetuses/yr20.3% million14.8% million2.8% millionEbrahim, SH, Gfroerer, J. Pregnancy-related substance use in the United States during Obstet Gynecol 2003; 101:374.
46Cigarette SmokingSmoking during pregnancy is the most modifiable risk factor for poor birth outcomeIt is associated with 5% of infant deaths, 10% of preterm births, and 30% of small for gestational age infantsThere are a plethora of medical risks for pregnant and non-pregnant patientsPatients who smoke are more likely to relapse to other drugs of abuseCigarettes stimulate the same brain pathway as heroin and cocaineTrends in smoking before, during, and after pregnancy - Pregnancy Risk Assessment Monitoring System (PRAMS), MMWR Surveill Summ May 29;58(4):1-29.
48Clinical Outcomes in Pregnant Women who Quit Smoking 20% reduction in low birth weight babies17% decrease in pre-term birthsAverage increase in birth weight of 280g.Quitting before 30 weeks can still positively affect birth weight
49Cigarette Smoking in Pregnancy & Other Drug Use 10 times higher use of marijuana22 times higher use of cocaine21 times higher use of amphetamineVega, WA, Kolody, B, Hwang, J, Noble, A. Prevalence and magnitude of perinatal substance exposures in California. N Engl J Med 1993; 329:850
50In Utero Cigarette Exposure: Congenital Malformations May contribute to anomalies associated with focal vascular disruptionCleft lip with or without cleft palateGastroschisisAnal atresiaTransverse limb reduction defectsRisk may be modified by genetic factors
51In Utero Cigarette Exposure: Effects on the Newborn There is a dose-response relationship between maternal cigarette use and infant…StressHypertonicityExcitability and irritabilityMay be due to neurotoxicity or withdrawalWith second hand smoke exposure there is an increased risk of low birth weight
52In Utero Cigarette Exposure: Postnatal Morbidities MorbidityNeonatal deathRRSIDSRR 2.0 – 7.2Prenatal exposure a higher risk than postnatal 2nd hand exposureRespiratory infections, asthma, otitis media, infantile colic, bronchiolitis, short stature, childhood obesity, type 2 diabetes in adulthoodHeart disease and lung cancer in never smokersSecond-hand smoke increases risk by 20-30%
53In Utero Cigarette Exposure: Behavioral Problems Toddlers (12-24 mo.s) showed a high and escalating pattern of disruptive behaviorChildren developed Oppositional Defiant Disorder at double the rate of controlsODD is a precursor of Conduct DisorderSeen in older children and adolescentsCharacterized by persistent antisocial behaviors (lying truancy, vandalism, aggression)NIDA Notes 2008: Vol.21 No. 6
54In Utero Cigarette Exposure: Cognitive Outcomes in 9-12 yr olds IQ impacted (dose response effect)Poorer impulse controlMany individual WISC tests w/ significant dose response effectsPoorer performance on tests requiring visuoperceptual skills.Auditory memory particularly impactedWISC = Wechsler Intelligence Scale for Children
55Medical Issues for the Children of Smokers Increased incidence of smoking initiation20% higher if mom smoked up to 1PPD60% higher if mom smoked 1PPD or moreDiabetes mellitusFour times higher with more than 10 cigs/dayIncreased asthma in adult offspringDecreased sperm volume/count in adult male offspringNeonatal withdrawals are similar to opiate withdrawals less severeSIDS risk is significant…dose response curveIncreased risk of asthma
56Alcohol“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
57A look at Denial/Pre-Contemplation: Denise 28 y.o. pregnant woman and the mother of 7 and 3 y.o. boysPregnant for the 5th timeHistory of two 2nd trimester miscarriagesStarted drinking at 23 (not pregnant)
58DeniseDrinking 1-2 shots of peppermint schnapps daily until about 1 yr agoQuit drinking when learned was pregnant with second child, now age 3GA ~ 9wks when quitGrowth and development of this child appear normal
59Denise Drinking 5 shots of peppermint schnapps daily for the past year Drinking this pregnancy until GA ~33 wksNot worried about the baby becauseLast baby was okayU/S during this pregnancy looks normal
60Alcohol Use During Pregnancy: Obstetrical Complications Increased risk of second-trimester abortion50% increase in fetal mortalityInfant withdrawal (3-12 hrs after delivery)Fetal Alcohol Spectrum Disorders
61Alcohol is a Teratogen that Freely Passes the Placenta Teratogen: a substance that causes abnormal physical developmentBehavior teratogen: a substance that causes impaired cognitive, affective, social, reproductive, and/or sensorimotor behavior, even in the absence of obvious physical problems
62Prenatal Alcohol Exposure Can Cause: DeathMalformationGrowth deficiencyFunctional deficits
63Teratogenic Effects Depend On: Dose of alcoholPattern of exposure (binge vs. chronic)Developmental timing of exposureSusceptibility (genotype of mother and fetus)Synergistic reactions with other drugsInteraction with nutritional variables
64Dose-Response Effects Higher maximum blood alcohol levels result in more severe neurotoxicityBinge drinking is particularly dangerousMales appear to be more susceptible than females
65SOME CREDIBLE INCREDIBLE WEBSITES! (Thanks Mark Stanford, PhD) Addiction Technology Transfer CenterBrookhaven Addiction Research. Center for Translational NeuroimagingNational Institute of Drug Abuse (NIDA). Medical and Health ProfessionalsMoyers On Addiction: Addiction As A DiseaseThe Institute of Medicine. Marijuana and Medicine: Assessing the Science BaseNIDA Science & Practice PerspectivesNational Institute of Mental Health (NIMH). MedicationsUCLA Addiction ClinicUniversity of Utah. Genetic Science Learning CenterCounselor Magazine for Addiction ProfessionalsSociety of Neuroscience. Advancing the Understanding of the Brain and Nervous SystemDADS:Sccdads.orgPlease ask me for more – or me!!!
66Content Provided by:Deborah Stephenson, MD, MPH Dept of Alcohol & Drug Services Santa Clara Valley Health & Hospital SystemMark Stanford, PhD Dept of Alcohol & Drug Services Santa Clara Valley Health & Hospital SystemMargaret Williams, M.S., RD, H.E.S. Dept of Alcohol & Drug Services Santa Clara Valley Health & Hospital System