Objectives. Addiction. Some terms. Some terms. Hierarchy of brain function 9/23/2011 PREGNANCY IN WOMEN WITH SUBSTANCE ABUSE: A DOORWAY TO CHANGE

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1 Objectives PREGNANCY IN WOMEN WITH SUBSTANCE ABUSE: A DOORWAY TO CHANGE Discuss the physiology of addiction Identify barriers to care for women with substance dependence Develop techniques to encourage pre and postnatal care in women with substance dependence Dr. Sandra de la Ronde MD, FRCSC Ottawa, Canada Addiction Some terms is a chronic relapsing disorder; an illness The 4 Cs Impaired Control over drug use Compulsive use Continued used despite harm Craving Substance abuse recurrent and clinically significant consequences related to repeated use; legal, medical, social. Substance dependence cluster of cognitive, behavioural and physiologic symptoms due to continued use of a drug. DSM IV classification: tolerance, increased amounts, unsuccessful attempts to stop, reduction in social and occupational activities, persistent use despite psychological or physical harm. Some terms Hierarchy of brain function Craving intense desire to re-experience the effects of the drug; Cortex- higher level processing, memory leads to Relapse resumption of drug seeking, using; brought on by craving, environmental cues Thalamus, basal ganglia, limbic system; emotion, memory Brain stem and cerebellum; arousal, autonomic function 1

2 Limbic system Plays key role in memory, cognition, mood and anxiety, social behaviour, regulation of drives and impulses Consists of areas in cortex, hippocampus, p thalamus, anterior cingulate gyrus and amygdala. Key neurotransmitters in addiction Dopamine; produced in midbrain For addiction purposes, focus on the mesocorticolimbic pathway. Originates in ventral tegmental area and connects with nucleus accumbens and cortex. Causes pleasure Neural cell changes with addiction Repeated exposures to drugs create changes in cells and affect number of receptors for the drugs and neurotransmitters leads to tolerance, sensitization Dopamine becomes deleted so can t experience same pleasure as 1 st time Withdrawal occurs because lack of drug leaves receptors in excited state End result Neural cell changes are probably permanent Accounts for patterns of relapse when frontal cortex is stimulated by smells, sights of drug use, even years later Sobriety is life-long work Epidemiology Stats - Canada % Canadian women used alcohol in their last pregnancy 17% smoked Health Canada Drug and Alcohol Use Statistics 2010 Overall illicit drug use decreasing in all ages ETOH use remains the same; heavy use 3x greater in youth (15-24 yo) than in adults US data ~ 5% of women use illicit drugs THC most common, cocaine, prescription drugs, pain relievers, opioids, sleeping pills, tranquilizers, antidepressants 2

3 Aboriginal Epidemiology Determinants of health Canada statistics 2003 (on reserve only) Fewer aboriginal people report ETOH use compared with general Canadian population (65% vs 79.3%) Use highest in youth and declines with age binge drinking prevalence higher h than general Canadian population NNADAP questionnaire 1998 re behaviour on reserves 47% stated ETOH use a constant problem 43% stated illicit drug use a constant problem Income and Social Status Social Support Networks Education Employment / Working Conditions Social Environments Personal Health Practices and Coping Skills Physical Environments Healthy Child Development Biology and Genetic Endowment Health Services Gender Culture Aboriginal determinants of health Paper produced for the National Collaborating Centre for Aboriginal Health in 2009 by CL Reading, PhD and F Wien PhD proposes 3 levels: Proximal: health behaviours, physical and social environments Intermediate: community infrastructure, resources, system capacities Distal: historic, political, social, economic Context of Aboriginal view of health (physical, mental, emotional and spiritual) The pregnant woman with substance abuse Most women try to adopt healthy lifestyles during pregnancy for the sake of the fetus Stop or reduce smoking, ETOH intake, take vitamins, modify eating habits Pregnant women with substance dependence are no different Often seek help to stop drug use and change lifestyle Motivation is to keep the baby, especially if previous ones have been apprehended obstacles Personal: Homelessness, lack of health care insurance, finding a caregiver, transportation, drug withdrawal, peer pressure, fear Health care system: Bias and attitudes, office and laboratory routines, hospital routines Case history 25 yo G4P3 referred to an obstetrical outpatient clinic at a tertiary hospital from an inner city clinic. Referring history: cocaine dependence, HIV & Hep C positive, streetworker Misses first appointment, sent from ER (beaten up by john) to clinic, going through drug withdrawal, combative, swearing Estimated at 20 weeks ga, FHR heard 3

4 Case history 3 previous vaginal deliveries, babies all apprehended. married, partner also uses drugs they have housing on and off she has been on streets since early teens probably a victim of sexual abuse by family member likely has FASD has been in previous drug treatment programmes but has difficulty completing Facilitating change Seize the moment; care available when woman first makes contact; community centres or walk-in clinics often POC Welcome, reinforce positive aspect of seeking care Have established professional contacts so referral for care, if needed, can be done promptly. Provide transportation or an attendant to appointment Facilitating change One-stop shopping Medical services Social support services (housing, food) Addiction workers Laboratory and diagnostic services Mental health care Frequent visits; weekly, every 2 weeks Establishes a relationship, allows the caregiver to observe health, follow-up on missed appointments Developing trust is the key Our approach to pregnant women with addiction All staff in clinic facilitate intake of pregnant women; pregnant women are offered care, routine AN bloods are taken, referral to NP, or next available clinic detailed d obstetric history taken; questions about substance use are asked T-ACE questionnaire; tolerance, angry, cut down, eye-opener Facilitating change Prioritize care issues; ask her what she wants and needs the most, what are her goals for the pregnancy Safe housing (may be a treatment facility) Harm reduction for drug use Needle exchange, condoms, STI testing and treatment Pregnancy and health issues Biggest asset for the health care team is to develop a network of community and medical resources; can then fill woman s needs as they are identified Non-judgmental open-ended questions explain rationale for all questions on history if woman resistant t to talking about substances, leave it to another time if open, elicit amount and timing of exposure 4

5 Ask when and why they use substances: partner, peers, depression, etc. elicit their knowledge about effects of drugs on them, fetus clarify misunderstandings reduction in use first step offer access to support systems Reinforce positive steps to stop, reduce no condemnation for falling off the wagon or slipping find out what precipitated the slip ask what she can do if faced with the same situation again encourage contact with supports if slipping Consider the 4 elements when assessing her history and needs physical, mental, emotional and spiritual Identify those determinants of health that contribute to her needs income social support system education culture personal health and coping skills biology and genetic background physical environment Does this approach work? Seattle, Wash.- major centre for diagnosis and reduction of incidence of FASD has intensive programme for pregnant women have shown that such an approach reduced or eliminated ETOH use in majority of women some pregnant women have FASD themselves: change approach to care simple instructions, repeat info concept of external brain Other programmes have shown that this approach works for women with drug dependence Special considerations Inpatient/residential treatment probably most effective to start sobriety; location depends on the substance and timing in pregnancy, ETOH and benzodiazepines require medical detoxification for maternal and fetal safety Opioid dependent women should be offered methadone treatment; safest to do transition in hospital, especially after 24 weeks. Your client s peer support has been her fellow drugtakers; she will require a safe alternative: treatment counsellors, spiritual leaders, clinic staff Delivery Advocacy for your clients especially important in hospitals Describe your programme Educate medical and other staff about drug dependence Establish contact with the social workers Establish contacts with child support services Become knowledgeable about legal rights and requirements for drug testing in the mother and baby Only exception to breastfeeding is an HIV positive mother and current illicit drug use e.g. cocaine 5

6 After delivery Greatest risk of relapse is in first 2 years after delivery stress of new baby possible lack of safe support system old friends may be from drug life Intensive support just as important postpartum frequent maternal and well-baby visits ask about mood (Edinborough postpartum depression scale) ask about steps to maintain sobriety educate about family planning Creating a space for women with substance dependence Can your clinic/office commit to providing care visits are longer, flexibility needed to accommodate walk-ins and missed appointments, access to co-services onsite ideal Have you identified potential biases in yourself and your staff and what will you do to overcome them What education/contacts do you need to set up a care programme for these women Creating a safe programme Key issues to success Non-judgemental atmosphere ) Establishes Flexibility; go with the flow ) street creds Advocacy for your women ) trust Collaborative care model One-stop services Education of yourselves and others Networking: 2 directional access to services for your women establish yourselves as a programme that will look after these women Case history We have gone through 5 pregnancies together By definition, she has had AIDS during last 2 takes her medication during the pregnancy and viral load is always undetectable in the last trimester has stable housing husband works; still uses THC but no cocaine she uses cocaine intermittently but no longer works the street She is a survivor and a loving individual People not programmeschange people 6

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