1. Community Approaches to Prevention and Early Intervention Jan Campbell, R.N., B.S.N. Sue Spooner, R.N., C.P.N.P. January 2007

2. The tiny hand of 21-week-old fetus Samuel Alexander Armas emerges from the mother’s uterus to grasp the finger of Dr. Joseph Bruner. “Hand of Hope”

3. The Problem Perinatal Substance Abuse

4. National Pregnancy and Health Survey Illicit drugs5.5% Illicit drugs5.5% Cocaine1.9% Cocaine1.9% Marijuana2.9% Marijuana2.9% Alcohol18.8% Alcohol18.8% Tobacco20.4% Tobacco20.4%

5. CRT vs. SAMHSA Data: Substance Use in Pregnancy

6. Riverside County Substance-Exposed Babies  Preliminary data indicate 13% of women screen positive for substance use  In 2004, there were 29,545 births  Applying 13%, which is considered a low estimate, 3,841 babies were born exposed to drugs and/or alcohol

7. San Luis Obispo County Substance-Exposed Babies Preliminary data indicate 38.5% of women screen positive for substance use Preliminary data indicate 38.5% of women screen positive for substance use In 2005, there were 2,640 births In 2005, there were 2,640 births Applying 38.5% which is considered a low estimate, 1,016 babies were born exposed to drugs and/or alcohol Applying 38.5% which is considered a low estimate, 1,016 babies were born exposed to drugs and/or alcohol

8. Substance Use Rates Across California Counties

9. Alcohol Use Patterns After Knowledge of Pregnancy: San Luis Obispo, Riverside vs. CA

11. Predictors of Low Birth Weight Tobacco has a 3x greater impact than cocaine on predicting low birth weight

12. Tobacco Decreases oxygen to fetus Decreases oxygen to fetus Baby is born too early Baby is born too early Small babies (low birth weight) Small babies (low birth weight) Nicotine withdrawal Nicotine withdrawal More likely to die from SIDS More likely to die from SIDS Learning and behavioral problems Learning and behavioral problems

13. Marijuana Right after birth Right after birth Hard time responding Hard time responding Shakes Shakes Hard time comforting Hard time comforting Long-term affects Long-term affects Trouble paying attention Trouble paying attention Aggressive behaviors Aggressive behaviors

14. Baby Exposed to Cocaine

15. Cocaine, Methamphetamines, Heroin Drugs can starve parts of the baby’s body and Drugs can starve parts of the baby’s body and prevent it from growing prevent it from growing Can cause stroke or heart attack in the womb Can cause stroke or heart attack in the womb Can cause miscarriage, early birth and nervous Can cause miscarriage, early birth and nervous system problems system problems SIDS SIDS Learning and behavioral problems Learning and behavioral problems

16. Alcohol Low birth weight Low birth weight Small brain with brain damage Small brain with brain damage Heart problems Heart problems Kidney problems Kidney problems Malformations Malformations Facial dysmorphology Facial dysmorphology

17. Newborn baby boy with pronounced features of FAS and severe heart disease. Birth weight and length less than 5th percentile for gestational age.

18. Prenatal alcohol exposure is the leading preventable cause of birth defects, developmental disorders, and mental retardation in children Journal of the National Association of Neonatal Nurses 2005

19. Cause of FAS/FASD  The sole cause of FAS/FASD is women drinking alcoholic beverages during drinking alcoholic beverages during pregnancy. pregnancy.  Alcohol is a teratogen. “ Of all the substances of abuse (including cocaine, heroin, and marijuana), alcohol produces by far the most serious neurobehavioral effect in the fetus” IOM report to Congress 1996

20. FASD Facts 100 percent preventable 100 percent preventable Leading cause of preventable mental retardation Leading cause of preventable mental retardation Not caused on purpose Not caused on purpose Can occur anywhere and anytime pregnant women drink Can occur anywhere and anytime pregnant women drink Not caused by biologic father’s alcohol use Not caused by biologic father’s alcohol use Not a new disorder Not a new disorder

21. FASD and the Brain Prenatal alcohol exposure causes brain damage. Prenatal alcohol exposure causes brain damage. Effects of FASD last a lifetime. Effects of FASD last a lifetime. People with an FASD can grow, improve, and function well in life with proper support. People with an FASD can grow, improve, and function well in life with proper support.

22. FAS and the Brain

23. Effects of Alcohol on the Brain

24. FAS: CNS Effects Mental retardation Mental retardation Developmental delays Developmental delays Hyperactivity Hyperactivity Behavior problems Behavior problems Speech/language dysfunction Speech/language dysfunction

25. People with FASD have difficulty: Following instructions Following instructions Discerning the difference between truth and fiction Discerning the difference between truth and fiction Thinking about abstract concepts Thinking about abstract concepts Organizing Organizing Storing and retrieving information Storing and retrieving information Understanding social expectations Understanding social expectations Comprehending and responding to other people’s feelings Comprehending and responding to other people’s feelings Bonding or building personal attachment and trust Bonding or building personal attachment and trust

26. Alcohol Dose 1 drink/week 1 drink/week Hyperactive and aggressive behaviors Hyperactive and aggressive behaviors Moderate to heavy use Moderate to heavy use Delinquent behavior and overall problem behavior Delinquent behavior and overall problem behavior Any alcohol use pregnancy Any alcohol use pregnancy 3.2 x risk for delinquent behavior 3.2 x risk for delinquent behavior

27. Comparing FASD to Other Birth Defects

28. Estimated Number of FAS Fetal Alcohol Syndrome (FAS) Fetal Alcohol Syndrome (FAS) 1 in 500 births Combined estimated number of FASD Combined estimated number of FASD 5 in 500 births Journal of the National Association of Neonatal Nurses 2005

29. Economic Cost of FAS Cost the nation $5,400,000,000 in 2003. Cost the nation $5,400,000,000 in 2003. Each individual with FAS will cost US $1,500,000 to $3,000,000 in his or her lifetime. Each individual with FAS will cost US $1,500,000 to $3,000,000 in his or her lifetime.

30. If you are pregnant or think you could be pregnant DO NOT USE ANY: Alcohol (beer, wine, liquor) Alcohol (beer, wine, liquor) Tobacco/Marijuana Tobacco/Marijuana Illicit drugs (methamphetemines, heroine, cocaine) Illicit drugs (methamphetemines, heroine, cocaine) Message

31. What Now?

32. Community Collaboration Development of a Community Team

33. Who Should be on a Community Team? People with passion People with passion Respected leaders in the community Respected leaders in the community People with passion People with passion People with the authority to commit resources and make decisions People with the authority to commit resources and make decisions People with passion People with passion

34. Community Team Considerations Knowledge Knowledge 1. Obstetrics 2. Public Health Nursing 3. Child Protective Services 4. Mental Health 5. Substance Abuse Treatment 6. Healthy Start ( if it exists in the community) Community orientation Community orientation Authority and influence Authority and influence Size Size Compatibility Compatibility Consumer representation Consumer representation

35. Community Team Example Director Maternal and Child Health Director Maternal and Child Health Director Mental Health Director Mental Health Director Substance Abuse Treatment Director Substance Abuse Treatment Director Child Protective Services Director Child Protective Services Director Healthy Start Director Healthy Start Public Health Nursing Public Health Nursing Obstetrician Obstetrician Pediatrician Pediatrician County Board of Supervisors County Board of Supervisors Presiding Judge, Drug Dependency Court Presiding Judge, Drug Dependency Court

36. The Community Team Considerations Make sure there is representation from “the basic six” Make sure there is representation from “the basic six” Recruit people with a community orientation Recruit people with a community orientation Seek people who are respected in the community Seek people who are respected in the community Invite those with authority of influence Invite those with authority of influence Keep the group a manageable size: 8-12 Keep the group a manageable size: 8-12 Make sure team members are compatible Make sure team members are compatible Involve consumers in a useful and respectful way Involve consumers in a useful and respectful way

37. The Leadership Institute A 3½ day learning and planning experience A 3½ day learning and planning experience Intended to give the team a shared understanding of the key issues in substance use among pregnant and parenting women Intended to give the team a shared understanding of the key issues in substance use among pregnant and parenting women Designed to produce an initial plan for the team to use as the members return to their community Designed to produce an initial plan for the team to use as the members return to their community

38. The Core Intervention S creen Screen all pregnant women for substance use. Largely this is accomplished by making screening a fixed part of primary prenatal care. A ssess Those women who screen positive are given a field assessment to determine if they are in fact using drugs. R efer Those women who are found to be using drugs are referred to an appropriate type of drug treatment. T reat Those women who are referred to drug treatment receive quality, gender-specific drug treatment that is appropriate for their circumstances.

39. Where Do We Start?

40. Successful Implementation of a Perinatal Screening, Assessment, Referral and Treatment Program

41. How Do We Begin? Build your support services Referral and treatment Referral and treatment Mental Health Mental Health Drug and Alcohol Drug and Alcohol Private psychologist and therapist Private psychologist and therapist

42. Training It is important to train your provider prior to implementation of the SART Program It is important to train your provider prior to implementation of the SART Program Dinner with providers and wives/husbands Dinner with providers and wives/husbands Key note speaker - a physician knowledgeable and respected in the area of perinatal substance use Key note speaker - a physician knowledgeable and respected in the area of perinatal substance use

43. Establish a Good Support System Needs to be integrated as a routine part of prenatal care (not a psychosocial issue but a health issue) Needs to be integrated as a routine part of prenatal care (not a psychosocial issue but a health issue) This is a health issue for all pregnant women This is a health issue for all pregnant women Present the program as a complete package Present the program as a complete package Provide assessment forms Provide assessment forms Instructions/staff training (ongoing basis) Instructions/staff training (ongoing basis) Collection of Data Collection of Data Educational Materials Educational Materials “I am concerned” brief intervention “I am concerned” brief intervention Pamphlets Pamphlets

44. Referral Process Easy to use Easy to use Clear easy to use forms Clear easy to use forms Minimal information to fill out Minimal information to fill out Contact numbers answered by a person Contact numbers answered by a person Followed up in a timely manner Followed up in a timely manner Contact clients within 2 to 3 days Contact clients within 2 to 3 days Feedback to the physician Feedback to the physician Respond back to referring physician regarding outcome of referral Respond back to referring physician regarding outcome of referral

45. Share Data Give feedback on screening data to physician on a regular basis Give feedback on screening data to physician on a regular basis Physician’s practice compared to overall Physician’s practice compared to overall county results county results

46. Value of Respect Respect professionalism of OB providers by Respect professionalism of OB providers by Providing scientific proof Providing scientific proof Best Practices Best Practices Respect provider’s time by Respect provider’s time by Bringing all necessary materials Bringing all necessary materials Providing training and ongoing support Providing training and ongoing support Respect provider as a partner by Respect provider as a partner by Visiting as often as necessary Visiting as often as necessary What can we do for you What can we do for you

47.  Respect provider’s commitment to SART by  Acknowledging their contribution  Respect provider’s commitment to their patients’ means patients’ means  Providing accurate and timely feedback  Respect provider’s interest in real results means means  Working with other agencies to make sure referrals are acted upon referrals are acted upon

48. What does a screening program look like?

49. The SART System S creening S creening A ssessment A ssessment R eferral R eferral T reatment T reatment

50. Screening P arents Did either of your parents ever have a problem with alcohol or drugs? P arents Did either of your parents ever have a problem with alcohol or drugs? P artner Does your partner have a problem with alcohol or drugs? P artner Does your partner have a problem with alcohol or drugs? P ast Have you ever drunk alcohol? P ast Have you ever drunk alcohol? Pregnancy Pregnancy In the month before you knew you were pregnant, how many cigarettes did you smoke? In the month before you knew you were pregnant, how many cigarettes did you smoke? In the month before you knew you were pregnant, how many beers did you drink? In the month before you knew you were pregnant, how many beers did you drink? In the month before you knew you were pregnant, how much marijuana did you smoke? In the month before you knew you were pregnant, how much marijuana did you smoke?

51. Assessment What? What? When? When? How much? How much?

52. Referral: A Brief Intervention “I am concerned….” “I am concerned….” Abstain from drugs or alcohol Abstain from drugs or alcohol “I see you are upset….” “I see you are upset….” Come to consensus Come to consensus Refer: a “warm handoff” Refer: a “warm handoff”

53. Treatment: Level of Care neg handshake neg “handshake” pos FA - brochure pos FA - brochure 4P’s+ FA+ pretreatment group group outpatient outpatient residential residential I II IIIa IIIb IVa IVb

54. The Perinatal Substance Abuse 4P’s Plus Assessment Program Seeks to address the impact of alcohol, tobacco and illicit drug use during pregnancy and the benefits of early intervention Seeks to address the impact of alcohol, tobacco and illicit drug use during pregnancy and the benefits of early intervention Works with prenatal providers on integrating substance abuse screening, assessment and referral as a routine part of prenatal care Works with prenatal providers on integrating substance abuse screening, assessment and referral as a routine part of prenatal care Focuses on the education of the professional community and the community at large regarding the impact of alcohol, tobacco and illicit drugs during pregnancy and the benefits of early intervention Focuses on the education of the professional community and the community at large regarding the impact of alcohol, tobacco and illicit drugs during pregnancy and the benefits of early intervention

55. Funding

56.  Helped fund Leadership Team  Funded 2 years of training and consultation with National Training Institute (Dr. Ira Chasnoff) National Training Institute (Dr. Ira Chasnoff)  Provided funding for infrastructure for Beginnings

57. March of Dimes March of Dimes Funded Funded Printing of brochures, posters Printing of brochures, posters Trainings Trainings Media campaigns Media campaigns

59. Maternal Child and Adolescent Heath Title V Funds Licensure of 4P’s Plus assessment tool Licensure of 4P’s Plus assessment tool Purchase of “I am concerned” brief intervention books Purchase of “I am concerned” brief intervention books Printing of 4P’s Plus assessment tool Printing of 4P’s Plus assessment tool Staff two positions for perinatal substance abuse program Staff two positions for perinatal substance abuse program Educational materials Educational materials

60. The California Endowment Pamphlets Pamphlets Website Website Posters Posters

61. Federal Grants Healthy Start Healthy Start

62. Local Resources Universities Universities Cal Poly San Luis Obispo Cal Poly San Luis Obispo Graphic arts and photography for poster Graphic arts and photography for poster Web design Web design Community Foundations Community Foundations Preventive Health Grants Preventive Health Grants Hospitals Hospitals

63. We Can Make A Difference

64. For more information… Please call for questions or additional information: Jan Campbell, MCAH Director, San Luis Obispo (805) 781-5592 Sue Spooner, MCAH Director, Riverside (951) 358-5192

65. Thank you