Identifying and Managing Substance Use During Pregnancy

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1 Identifying and Managing Substance Use During Pregnancy Joseph B. Landwehr, Jr., MD Director, Perinatal Center IU Health Ball Memorial Hospital

2 OBJECTIVES Overview of illicit drug use in pregnant women Chemical dependency in pregnancy Opiate maintenance therapy in pregnancy Withdrawal in pregnancy

3 Overview: Illicit Drug Use Pregnancy presents unique screening opportunity Women present for prenatal care May represent their first encounter with healthcare Many women want to do right thing for their baby Afraid they will lose their baby (CPS)

4 Overview: Illicit Drug Use Drugs in common use Marijuana/hashish Cocaine Heroin Hallucinogens Inhalants Methamphetamine Prescription psychotherapeutics Prescription opiates

5 Overview: Illicit Drug Use Counseling Factual and non judgmental Maternal and fetal risks Cessation potential Unintended pregnancy common (up to 85%) Abstinence common in pregnancy 57% in one national survey ( )

6 Overview: Illicit Drug Use Definitions Use: sporadic, no adverse outcomes Abuse: frequency varies but some adverse outcome Physical dependence: state of adaptation, withdrawal syndrome Psychological dependence: SUBJECTIVE sense of need Addiction: primary chronic disease of brain reward, motivation, memory and related circuitry, inability to abstain, impaired behavioral control, craving, relapse, remission

7 Overview: Illicit Drug Use 2010 National Survey on Drug Use and Health Interviewed 67,000 people (non insitutionalized) Marijuana Non med use of psychotherapeutics Pain meds Tranquilizers Stimulants Sedatives Cocaine Hallucinogens

8 Overview: Illicit Drug Use 2010 Survey (continued) 4.4% pregnant women used in last month y/o 16.2% y/o 7.4% y/o 1.9% Newborn data supports increased usage Opiate use per 1000 ( ) NAS per 1000

9 Screening Universal screening Standard of Care ACOG and SOGC Screening followed by intervention cost effective Initial prenatal visit Repeat each trimester Denial barrier Guilt Fear Prosecution

10 Screening Universal urine screening Expensive Objective Non biased

11 Screening CRAFFT (v. T ACE for adolescents) C : ridden in CAR with someone high R: use alcohol or drugs to RELAX, feel better or fit in A: do you ever use alcohol or drugs while ALONE F: do you ever FORGET things you did? F: FAMILY or friends tell you should cut down T: have you ever gotten in TROUBLE while using

12 Screening T ACE T: TOLERANCE A: ANNOYANCE C: Cut Down E: Eye Opener

13 Assessment Neutrally worded questions when possible Begin with legal substances Tobacco Alcohol Over the counter meds Prescription (legal or not) Illegal

14 Assessment Frequency Length/pattern of use Last time used Route of administration Shared needles Quantity Amount spent Previous treatment attempts

15 Risk Factors Young women, unmarried, lower education Late prenatal care Multiple missed prenatal appointments Impaired school/work performance Sudden behavior change High risk sexual behavior Relational problems/ unstable home Poor OB hx unexplained (SAb s, IUFD s, IUGR, abruptions) Children not living with them Hx of associated medical conditions (cellulitis, endocarditis, hepatitis) Poor dentition Poor weight gain Diagnosis of mental health disorder Family Hx of substance abuse Law enforcement encounters Partner who is a substance abuse

16 Drug Testing Universal Screening?? Indications Previous (+) UDS Monitor compliance with drug Rx Abruptio placentae Idiopathic PTL Idiopathic IUGR Frequent Rx requests Noncompliance Unexplained IUFD

17 General Principles of Prenatal Care Safe prescribing of prescription drugs Referral to local resources??? Many women refrain from illegal substances Opioids?? Treatment options Few trials available, some observational, mostly opinions

18 Prenatal Care Counsel regarding the risk of usage Counsel as specific to drug as possible Encourage moderate use / discontinue Opiate dependency Methadone/Subutex vs. detoxification Benzodiazepine withdrawal Cannabis Cocaine/heroin

19 Prenatal Care Identify comorbid conditions Identify social needs (transportation, homeless) Test for STD s (syphilis, GC, chlamydia, Hep B & C, HIV, +/ TB) Education and support Early US for dating Assess for IUGR Antenatal testing Anesthesia consult?? Inform pediatric services / NICU Breastfeeding??

20 Opiates Financial, social, psychological issues Multiple OB complications Abruptio placentae IUFD Intraamniotic infection IUGR Meconium Preeclampsia PTL and delivery PROM Placental insufficiency Miscarriage PP hemorrhage Septic thrombophlebitis NAS

21 Opioid Substitution Therapy Methadone Buprenorphine Preferable to detoxification Safe Lower rate of resumption to heroin use Behavioral modification Scheduled encounters

22 Marijuana Most common illicit drug used (40% in my practice) Crosses placenta and present in breast milk Effect on pregnancy outcome not clear No evidence of preterm birth or anomalies No link to IUGR Long term neonatal effects

23 Cocaine Smoking, EtOH and marijuana much more prevalent Crack users in 30 s on rise (no other substances) Effects related to dose and stage of pregnancy

24 Cocaine Adverse pregnancy outcomes Preterm birth OR 3.38 ( ) Low birthweight OR 3.66 ( ) SGA OR 3.23 ( ) Shorter GA at del 1.47 week ( 1.97 to 0.98) Reduced BW 492 gms ( 562 to 421) Possible SAb, abruptions, decreased length and HC Avoid beta blockers in Rx of HTN

25 Amphetamines 10 million people have tried Powerfully addictive Clandestine labs?sga, PTL, low birthweight Not well controlled studies

26 Methadone Usage started in 1960 s Stable dose reduces fetal stress due to repeated withdrawal Reduction in drug seeking behavior More likely to receive prenatal care Prevent symptoms of withdrawal and reduce craving

27 Detoxification Aims at lowering dose to achieve lowest possible dose to prevent W/D symptoms??lower dose = lower neonatal sequelae Disadvantages High per cent return to illicit drug use Safety unknown No head to head studies

28 Buprenorhine Any opiate dependent patient candidate regardless of duration Alternative to methadone Potential first line treatment Possible advantages Program availability Availability of comprehensive treatment Patient preference Less overdose (ceiling effect)??less NAS no good trials No good evidence to switch from methadone

29 Summary Identification can decrease drug use, screen all women Drug specific questions and screening tools Combination of substance Rx and comprehensive prenatal care most effective Opiate substitution therapy preferred over detoxification Cocaine can constrict uterine vessels leading to placental complications No evidence for marijuana use and outcomes Less data for methamphetamine

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