Michael Weaver, MD, FASAM Division of Addiction Psychiatry Virginia Commonwealth University Medical Center 2010 Health Summit Substance Abuse and Pregnancy Charlottesville, Virginia

 Substance use and pregnancy  Maternal & fetal effects during pregnancy  Addiction treatment during pregnancy  Neonatal Abstinence Syndrome  Home environment

 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

 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

 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)

 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

 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

 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

 Sedative- hypnotics  Opioids  Stimulants  Nicotine  Marijuana

 CNS depressant  Disinhibition  depress inhibitions first  Reduce anxiety (fun at parties)  Oversedation, ataxia, respiratory depression  Daily drinking leads to tolerance and withdrawal  Delirium tremens

 Benzodiazepines, barbiturates, other sleeping pills (Ambien, Lunesta)  Sedation, anxiolytic  Respiratory depression in overdose  Withdrawal similar to alcohol DT’s

 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

 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

 Fetal Alcohol Syndrome  Fetal Alcohol Effects  Spectrum disorder  Leading preventable cause of mental retardation  Encourage abstinence as soon as pregnancy suspected

 Morphine, heroin, OxyContin, methadone  Analgesics: disconnect from pain  Euphoria, disconnection, sedation  Nausea, constipation, itching  Oversedation, respiratory depression

 No known fetal anomalies  Intrauterine growth retardation  Neonatal abstinence syndrome  Continuous exposure  Use up to delivery

 Cocaine, amphetamine, methylphenidate, MDMA (Ecstasy), caffeine  Enhanced concentration, alertness  Edginess, paranoia, hypervigilance, psychosis  Hypertension, hyperthermia, vasoconstriction  Heart attack, stroke

 Spontaneous abortion  Placental abruption  Fetal hypertension  Intrauterine growth retardation  SIDS  ‘Crack baby syndrome’ disproven

 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

 craving for tobacco  irritability, frustration, anger  anxiety  difficulty concentrating  restlessness  decreased heart rate  increased appetite or weight gain  depression  disrupted sleep  sedation

 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

 Marijuana, hashish, hash oil  active ingredient: THC  relaxation, hallucination  panic attacks  short-term memory impairment, amnesia

 Intrauterine growth retardation  Abnormal startle reflexes in newborns  Reduced memory & verbal skills at age 4 years

 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

 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

 Alienation from family  Multiple jobs  Financial problems  Multiple arrests  Multiple partners  Loss of custody

 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

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

 Detoxification  12-Step groups  Outpatient counseling  Intensive outpatient  Inpatient  Residential  Opioid Maintenance  Methadone  Buprenorphine

 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

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

 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

 A.A., N.A., C.A.  Group format  Anonymous  No cost  No affiliations or endorsement  Different groups have different characteristics

 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

 Network therapy  Family therapy  Supportive psychotherapy  Contingency management  Building Social networks  Twelve-Step facilitation  Perceptual Adjustment therapy  Rational Recovery  Medication management  Brief intervention

 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

 Long-acting medication in controlled setting  Counseling  Social services  Avoid withdrawal & craving  Reduce disease & crime  Maintenance vs. detoxification

 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

 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

 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)

 Pregnancy Category C  Use Subutex instead of Suboxone to avoid naloxone  NAS less intense than with methadone  Studies ongoing, results encouraging

 Characterized by  Hyperactivity, irritable  Hypertonia  Difficulty/excessive sucking  High-pitched cries  Begins 3h to 12d after delivery, depending on drugs used by mother

 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

 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

 Education  Breastfeeding  Umbilical cord care  Approach for ‘fussy’ infant  Age-appropriate discipline for other children  Prevent frustration that leads to relapse

 Encouraged  Promote bonding  Optimal nutrition  Passive immunity  Contraindications  Active substance abuse  HIV +  Methadone or buprenorphine dose not important consideration

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

 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

 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