Substance Abuse In Pregnancy THE MANAGEMENT OF SUBSTANCE USING PARTURIENTS. Case Study OBJECTIVES

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1 THE MANAGEMENT OF SUBSTANCE USING PARTURIENTS Michael K. Lindsay, MD, MPH Division Maternal-Fetal Medicine Department of Gynecology and Obstetrics Emory University School of Medicine Substance Abuse In Pregnancy I have no commercial disclosures or conflicts of interest. Case Study JT 20 year old G-1 P0 BMI 18, 16 weeks gestation with a history of protracted nausea and vomiting reports that marijuana is only thing that helps nausea. She also reports a ½ pack a day smoking history and admits to weekly crystal meth use What does she need to know? What services are available in your community to help her? Pretest 1. New research shows more pregnant women in drug treatment programs are there due to use than any other drug? A. cocaine B. methamphetamine C. heroin D. alcohol E. marijuana 2. Alcohol related birth defects include defects in the heart. kidney, bones and lungs. 3. The use of marijuana during pregnancy is associated with congenital abnormalities in the fetus? 4. Cocaine causes vasodilatation that results in congenital abnormalities in the fetus such as congenital heart disease? 5. The use of methamphetamines during pregnancy is associated with preterm labor and placental abruption? b. False 6. The most frequently abused drug during pregnancy is? A. cocaine B. methamphetamine C. heroin D. alcohol E. marijuana OBJECTIVES Review the maternal consequences of prenatal drug use Review the perinatal consequences of prenatal drug use Present strategies to prevent or reduce prenatal substance use DIAGNOSTIC CRITERIA: SUBSTANCE ABUSE A maladaptive pattern of substance use manifested by 1 or more of the following 12 month period 1. Use results in failure to fulfill major role obligation work school home 2. Recurrent use in physically hazardous situations 3. Recurrent substance-related legal problems 4. Continued use despite persistent or recurrent social or interpersonal problems DSM-IV 1994 APA 1

2 DIAGNOSTIC CRITERIA: SUBSTANCE DEPENDENCE A maladaptive pattern of substance use leading to clinically significant impairment or distress manifested by 3 or more following 12 month period 1. Tolerance 2. Withdrawal 3. Larger amounts of substance 4. Persistent desire 5. Time mismanagement 6. Give up important activities 7. Persistent use DSM IV 1994 APA HISTORICAL PERSPECTIVES In 19 th century cocaine and morphine isolated, cigarette rolling machines invented 1 st cocaine epidemic Pure Food Drug Act required patent medicine be labeled 1919 Supreme Court ruled illegal maintain addict (indefinite prescriptions) 1960 Methadone maintenance introduced 1980s Crack epidemic 1988 Anti Drug Abuse Act: targeted causal user and dealer, shift enforcement vs. treatment (warning pregnant women) SUBSTANCE USE IN PREGNANCY 4 million women who gave birth in 2010 U.S. 10.8% drank alcohol products 16.3% smoked cigarettes 4.4% used Illicit drugs 2010 National Survey On Drug Use And Health MATERNAL/Fetal CONSEQUENCES Tobacco Alcohol Marijuana Cocaine Opioids Methamphetamine Smoking Most modifiable risk factor for poor birth outcomes Successful treatment of tobacco dependence 20% reduction LBW 17% decrease in PTD Increase birth weight of 28 grams Cochrane Database Sys Rev 2000 Smoking Risk in Pregnancy Ectopic pregnancy IUGR Placenta previa Abruptio placenta PPROM Sp Abort Preterm delivery LBW SIDS Fertility Sterility 2012,Addict Sci Clin Practice

3 Second Hand Smoke Bronchitis Pneumonia Asthma Otitis SIDS Addict Sci Clinic Pract 2011 Five-Step Intervention Program (5A s) 1. Ask (1 minute) 2. Advise (1 minute) 3. Assess (1 minute) 4. Assist (3 minutes) 5. Arrange (1 minute) ACOG 2011 Smoking Cessation During Pregnancy Patients who decline to quit smoking Five R s Relevance Risks Rewards Road blocks Repetition AGOG 2011 Smoking Cessation During Pregnancy Intervention Pregnant Women Behavioral (first line treatment) Pharmacotherapy (may be necessary ) > 1 pack/day smokers Pharmacotherapy and Pregnancy First line buprenorphine (sustained released), nicotine gum, nicotine inhaler, nicotine nasal spray and nicotine patch Second line clonidine Safety and efficacy of these treatments for pregnant smokers remain unknown Use when pregnant women unable to quit and potential benefits outweigh risk of therapy ACOG 2011 Smoking Cessation During Pregnancy Benefits Smoking Cessation Despite effort to reduce tobacco use during pregnancy There have been no significant decreases in the prevalence of smoking among pregnant women aged from MMWR Surveill Summ

4 Maternal Effects AMA High parity AA/Native American Absence of maternal ADH1BX3 allele ALCOHOL ADVERSE MATERNAL EFFECTS Women have higher blood ethanol concentration than men equivalent dose of ethanol Increased risk 1. Breast cancer 2. Cirrhosis 3. Psychiatric symptoms (depression) 4. Spontaneous abortions Association between a history of physical and sexual abuse Alcohol (Neonate) Fetal Alcohol Syndrome( cases per 1000 births) 1. abnormal facial features 2. Growth deficiencies 3. CNS ARND (Alcohol Related Neurodevelopmental Disorder) 1. Learning difficulties 2. Poor school performance 3. Poor impulse control ARBD (Alcohol Related Birth Defects) 1. Malformation skeletal system 2. Defects, heart, kidney, bones, auditory system Stillbirth Alcohol Screening 1977 ACOG recommended screening 1984 Federal warning abstain alcohol use Survey Obstetricians report screening 97% of pregnant women Only 25% used standardized screening tool. Universal Alcohol Screening T-ACE TWEAK T-ACE T: Tolerance 2 drinks=2 points (# drinks to feel high) A: Annoyed Yes= 1 point (criticizing drinking) C: Cut down on drinking Yes= 1 point E: Eye opener Yes= 1 point (early morning drinking) Score 2 or more positive screen Am J Ob Gyn. 1989:160:

5 TWEAK T: Tolerance 5 = 2 points (how many drinks can you hold) W: Friends worried or complain Yes = 2 points E: Eye opener Yes = 1 point (early morning drinking) A: Amnesia Yes = 1 point K(C): need to cut down Yes = 1 point Score 2 or more positive screen Alcohol Clin Exp Resp 1990;17: Alcohol Adverse Effects Effects of alcohol exposure during pregnancy are permanent and cannot be reversed Complete abstinence from alcohol during pregnancy is only certain way to prevent alcohol related birth defects MARIJUANA Marijuana found in leaves of the hemp plant (cannabis sativa) Most commonly used illicit drug in US 2010, estimated 2.1 million people new users No national survey data in pregnancy 6%-35% in some populations MARIJUANA ADVERSE MATERNAL EFFECTS CNS depression Cardiovascular stimulant Respiratory problems (bronchitis, sinusitis, pharyngitis) Learning & social behavior (changes in attention, memory, info processing) Illicit Drug Use Neonatal Outcome Ob Gyn Survey 2007 MARIJUANA PERINATAL EFFECTS Controversial or no clear association Doubt increase in preterm birth Doubt decrease in birth weight No evidence of congenital anomalies Equivocal relationship neurobehavioral outcome No negative long term follow-up growth THC present in breast milk Illicit Drug Use Neonatal Outcome Ob Gyn Survey

6 COCAINE Cocaine available in two forms cocaine HCl, free base 45,000 women used cocaine in pregnancy in 2008 Prevalence prenatal population 5-17% large urban hospitals COCAINE ADVERSE MATERNAL EFFECTS Possible systemic complications 1. cardiovascular 2. tachycardia and cardiac arrhythmia 3. vasoconstriction and hypertension Central Nervous System 1. hyperthermia 2. CVA 3. Seizures 4. Paranoid ideation Illicit Drug Use Neonatal Outcome.Ob Gyn Survey 2007 COCAINE PERINATAL EFFECTS Preterm labor and delivery (equivocal) 1. positive studies (did not control for use other drugs) 2. prospective studies no effect Impaired fetal growth (few studies control for other risk factors) Congenital Anomalies (equivocal) 1. limb reduction defects 2. genitourinary tract malformations 3. congenital heart disease 4. central nervous system Neurobehavioral (questionable withdrawal) Long term follow-up (Inconclusive) SIDS (equivocal) 6

7 Methamphetamine Meth, speed, crystal, glass and crunk Closely related to amphetamine longer lasting Ingested, IV, smoked (Ice) Less than 1% pregnant women used in past year Methamphetamines Releases neurotransmitters into the brain-dopamine and Serotonin Neurotransmitters vital to brain functions that control 1. Mood 2. Memory 3. Sleep 4. Movement 5. Decision making Brain neurons that release Dopamine and Serotonin become damaged Characteristics of Methamphetamine Pregnancy Unplanned Late/no prenatal care Poor nutrition Increase risk adverse pregnancy outcome Addiction 2009:104: METHAMPHETAMINE MATERNAL ADVERSE EFFECTS Short term Tachycardia Wakefulness Decreased appetite Sexually transmitted diseases Long term Toxic psychosis Hallucinations Change in brain structure Severe dental problems METAMPHETAMINE PERINATAL EFFECTS Spontaneous Abortion IUGR Premature Labor Placental abruption Withdrawal syndrome Long term effects? Potential bias: small sample size, maternal use of other drugs 7

8 Meth Mouth Source: New York Times, June 11, 2005 Ecstasy(Molly) Synthetic amphetamine similar structure to methamphetamine and mescaline Acts centrally via serotonin Used night club settings Produces feelings of euphoria, decreases anxiety First trimester exposure increased risk cardiovascular and musculoskeletal anomalies Lancet 1999(354): Bath Salts New class synthetic drugs Effects similar to cocaine and LSD Synthetic stimulant (mephedrone, methylenedioxyprovalezone, methylone) Not use for bathing, marketed not for human contact Recent reports use in pregnancy HEROIN Synthetic opioid derived from poppy seed (papver somniferum) Estimated 250,000 women IVDA 90% of reproductive age 1996 National Household Survey 216,000 report use in pregnancy Lipid soluble rapidly crosses blood-brain barrier Duration high 3-5 hours HEROIN MATERNAL ADVERSE EFFECTS Short term 1. somnolence 2. altered mentation 3. Cardio-respiratory arrest (overdose) Long term 1. physiologic withdrawal 2. hepatitis B and C 3. STDS, HIV 4. endocarditis 5. abscesses 6. pneumonia and TB Illicit Drug Use Neonatal Outcome. Ob Gyn Survey 2007 Heroin Passage through placenta within 1 hour Accumulates in amniotic fluid Limited fetal detoxification More significant placenta clearance and LBW than methadone or buprenorphine 8

9 HEROIN PERINATAL EFFECTS Fetal growth 1. LBW 2. IUGR Premature birth (equivocal) Meconium Stillbirth (equivocal) Neonatal Abstinence Syndrome Methadone METHADONE (HEROIN) Principle short acting IV long acting methadone to relieve drug craving and withdrawal Methadone 1. synthetic opioid blocks effect of heroin 2. long half life allows daily dosing 3. no euphoria, no interference with daily activity New agents 1. levomethadyl-acetate (LAAM) 2. buprenorphine (combine with naloxone) METHADONE PERINATAL EFFECTS Pregnancy 1. continuation of normal daily activity 2. decrease in associated maternal morbidity Neonatal Abstinence Syndrome 1. occurs on day 2-3 up to a week 2. similar to heroin withdrawal syndrome 3. Naloxone (narcan) contraindicated severe withdrawal METHADONE (HEROIN) Principle short acting IV long acting methadone to relieve drug craving and withdrawal Methadone 1. synthetic opioid blocks effect of heroin 2. long half life allows daily dosing 3. no euphoria, no interference with daily activity New agents 1. levomethadyl-acetate (LAAM) 2. buprenorphine (combine with naloxone) Subutex Buprenorphine (Category C) Long acting partial mu opiod agonist & kappa antagonist May have less placenta exposure than methadone Cochrane review favors subutex over methadone Higher infant BW Shorter hospital stay Less severe NAS 9

10 Prescribed Opioids Codeine-congenital anomalies, NAS, 2007 FDA advisory Demerol-maternal overdose, death, NAS Oxycontin-$2.9 billion sales 2009, opiate choice rural regions, NAS PREGNANCY MANAGEMENT Prenatal Care Substance abuse treatment Psychosocial services PRENATAL CARE Educate patient about adverse outcome effects Screen for domestic violence Screen for STDs hepatitis B and C, TB Refer to drug counseling program Monitor with urine toxicology Sequential antepartum assessment of growth Refer newborn to Peds Close postpartum follow-up PRENATAL CARE Drug abusing pregnant women 7X less likely receive prenatal care vs. women not using drugs Barriers (fear, physiologic, psychological) Establish special care prenatal clinic ROLE HEALTH CARE PROVIDER Screening, identifying and counseling women regarding substance use Routine screening in history taking 1. No physical symptoms in majority of abusers 2. Screen everyone since no predictors Know local community resources SUBSTANCE ABUSE TREATMENT Drug addiction is a treatable disease No single treatment is appropriate for all individuals Recovery from drug addiction is a long term process (relapses) Effectiveness is dependent on remaining in treatment Matching multiple needs is critical 1. medical 2. psychosocial 3. social 4. legal 5. vocational 10

11 PSYCHOSOCIAL SERVICES Comprehensive psychosocial assessment Case management Disposition conference Screen for physical and sexual abuse Posttest 1. New research shows more pregnant women in drug treatment programs are there due to use than any other drug? A. cocaine B. methamphetamine C. heroin D. alcohol E. marijuana 2. Alcohol related birth defects include defects in the heart. kidney, bones and lungs. 3. The use of marijuana during pregnancy is associated with congenital abnormalities in the fetus? 4. Cocaine causes vasodilatation that results in congenital abnormalities in the fetus such as congenital heart disease? 5. The use of methamphetamines during pregnancy is associated with preterm labor and placental abruption? b. False 6. The most frequently abused drug during pregnancy is? A. cocaine B. methamphetamine C. heroin D. alcohol E. marijuana References 1. Diagnostic and statistical manual of Mental Disorders. Text Revision DSM-IV TR. American Psychiatric Association June Siciski LA. Infants of mother with substance abuse. UpToDate.com Schempf AH. Illicit drug use and neonatal outcomes: A critical review. Obstet Gynecol Survey 2007;67: Binder T, Vavlinkovi B. Prospective RCT of the effect of buprenorphine methadone and heroin on the course of the neonatal abstinence syndrome in women followed up in the outpatient department. Neuroendocrinology Letters 2008;29: A clinical guide to help pregnant women quit smoking Lumley J, Oliver S, Waters E. Intervention for promoting smoking cessation during pregnancy. Cochrane Data base Systematic Review 2000 (2) C Women and smoking: A report of the Surgeon General CDC 8. Colby SM, Barnett NP, Monti PM et al. Brief motivational interviewing in a hospital setting for adolescents smoking: A preliminary study. J Consult Con Psych 1999;66: Fiore MC, Bailey WC, Cohen SJ et al. Treating tobacco use and dependence. Clinical Practice Guidelines. Rockville MD, June Kahila H, Saisto T, Kivitie-Kallio S et al. A prospective study on buprenorphine use during pregnancy effects on maternal and neonatal outcome. Acta Obstetricia Gynecolog 2007;86: Buprenorphine versus methadone in the treatment of pregnant opioid dependent patients: effects on neonatal abstinence syndrome. Drug and Alcohol Dependence 2005;79: Sokol RJ, Martier SS, Ager JW. The T-ACE questions: Practical prenatal detection of riskdrinking. Am J Obstet Gynecol 1989; References 13. Substance Abuse and Menatal Health Service Administration Results from 2010 National Survey on Drug Use and Health. HHS Publication No(SMA) Goldschmidt L, Richardson GA, Willford J, Day NL. Prenatal marijuna exposure and intelligence test performance at age 6. J Am Acad Child Adol Psychiatry 2008;47: Practice Committee of the American Society for Reproductive Medicine Smoking and Infertility A Committee Opinion. Fertility Sterility 2012;98: Smoking Cessation During Pregnancy 2011.Self Instruction Guide Tool Kit. ACOG 17.Minnes S,Lang A,Singer L. Prenatal tobacco., marijuna, stimulant and opiate exposure outcomes and practice implication. Addict Sci Clin Practice.2011;6: Tong V,Lones J,Dietz P. et al. Trends in smoking before, during and after pregnancy. PRAMS,US 31 sites, MMWR Surveill Summ 2009;58(SS04):