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1 gnidnats Orders etaipo Protocols REHTO MEDICAL MANAGEMENT ISUES,ycnangerP Adiction and Mental Health FO SUBSTANCES DURING PREGNANCY TABLE OF CONTENTS i",- PREFACE 1 INTRODUCTION NOISIMDA AND DISCHARGE POLICIES (INCLUDING SCREENING AND INTAKE PROCEDURES), Screening and Intake Forms 32 CONSENT FORMS 83 DETOXIFICATION PROTOCOLS Alcohol Protocols 132 L eniacoc Protocols Sedative - Hypnotic Protocols Acupuncture Protocols PERINATAL RISKS ASSOCIATED WITH THE USE MANAGEMENT AND TESTING OF PREGNANT SUBSTANCE ABUSING WOMEN WITH HEPATITIS B AND HIV INFECTION LINKAGES TO MEDICAL CARE AND OBSTETRICAL BACK-UP 298 \ 315 ARTICLES OF INTEREST

2 by Marty Jessup, RN,MS "Detoxification Considerations In The Medical Management Of Substance Abuse In Pregnancy" by Machelle Harris Allen, MD "Substance Abuse And Treatment During Pregnancy" by Machelle Harris Allen, MD "Women's Reproductive Rights In The Age Of AIDS: New Threats To Infonned Choice" by Hortensia Amaro, Ph D """" "The Treatment Of Perinatal Addiction: Identification, Intervention, And Advocacy" "Providing Prenatal Care To Women With Alcohol And Drug Problems" by Margaret Lynn Yonekura, MD 346

3 "-"' "'- INTRODUCTION Alcohol and drug dependent women suffer from a myriad of social, psychological, physical, and economic problems The chaotic lives of most substance abusing women represent the cumulative, interrelated and complex effects of social problems including isolation, health and mental health issues, poverty, lack of safe and affordable housing, and lack of equal access to social opportunities and resources In addition, pregnant and parenting women who abuse alcohol and other drugs suffer from the social stigma and blame that continues to declare substance abuse a moral issue and often keeps women from accessing critical services further isolating them from necessary support systems For pregnant women this is especially true, as illustrated by the recent efforts across the United States to criminalize the use of alcohol and other drugs during pregnancy These efforts arise from the anger and blame that society has attached to alcohol and drug dependent women Yet it must be recognized that women hold key roles in relational and multi-generational family systems and women are central and valuable members of their communities These roles, such as mother or wife, reduce society's tolerance to alcohol and drug dependent women and at the same time act as barriers to many women trying to access treatment, ie few treatment programs take women with children Additionally, the medical, social, and emotional consequences of alcohol and other drug addiction among women, especially pregnant and parenting women, are amplified due to these roles For example, alcohol and other drug addiction has always been recognized as a family disease A majority of alcohol and drug dependent women report corning from substance abusing families as well as being currently involved with partners who are alcohol and drug abusers This intergenerational pattern of addiction can only be impacted by treatment which includes the women's children and other significant family members Therefore, efforts at prevention and treatment must respond to the roles of women within a family system and must include a comprehensive continuum of care Detoxification is often the entry into that continuum Alcohol and drug dependent women have been challenged by a variety of obstacles when seeking detoxification and treatment Presented below are two lists of issues related to the treatment of substance abusing women The first is taken from the work of Norma Finkelstein, PhD The second is excerpted from a publication of the Washington State Department of Social and Health Services Substance abuse staff as well as other medical staff need to be aware of these issues to better identify and assist pregnant alcohol and drug dependent pregnant women in accessing the services that are critical to their well-being '- 2

4 Excerpted from Finkelstein, N (~990), Treatment Issues: Women & Substance Abuse Paper Prepared for the National Coalition on Alcohol & Drug Dependent Women and Their Children \,, Stigma: A substance abusing woman is "often considered a second class citizen, and she is seen as sexually promiscuous, weakwilled, shamefully negligent of her children and irresponsible in her 'decisions' to bear more children" Feelings of guilt, shame and low self-esteem emerge and are coupled with depression, having an immobilizing effect on women Denial: "This shame and guilt lead to high denial of drinking/drug problems both on the part of the woman herself as well as family members and friends who tend to conceal substance abuse problems from outsiders and 'protect' the female substance abuser" Lack of Gender SDecific Treatment Services for Women: "Since most treatment programs were designed initially by and for men, and women were admitted as an afterthought, little attention has been paid to specific women's treatment issues including the different emotional, social and economic realities of women's lives" "Any discussion of the treatment needs of alcohol and drug abusing women must start with the understanding that substance abuse in women is a complex problem surrounded by multiple individual, interpersonal, familial and social issues that require many different levels of intervention and treatment" "- Social/Economic: "The social and economic context of the lives of many substance abusing women is often one of inadequate financial resources, lack of affordable housing and non-marketable job skills Many are single parents, socially isolated and without adequate support systems" Clinical: "substance abusing women should be viewed within the context of their relationships to others: ie, recognizing that they are part of larger, relational andmultigenerational systems" "Alcohol and drug abusing women experience multiple social and personal losses of disconnections in their lives which too often result in a deep sense of isolation Women may in fact turn to alcohol and/or drugs as a way of relieving the anxiety and pain caused by severe disruptions" Systemic Treatment Issues: The controversy and misunderstanding surrounding the detoxification of pregnant women has too frequently led to the discrimination of pregnant women and their exclusion from substance abuse treatment programs Lack of research on treatment and pregnancy outcomes has led to great concern of liability issues in treating this population Legal issues such as the purpose of toxicology screens, the filing of child abuse and neglect reports and the current criminalization efforts also raise questions about maternal vs fetal rights as well as issues of bias against the woman in need of detoxification Providers of substance abuse services treating pregnant and parenting women ~ 3

5 Excerpted from Finkelstein, N (1990), Treatment Issues: Women & Substance Abuse Paper Prepared for the National Coalition on Alcohol & Drug Dependent Women and Their Children often find themselves to be one of many caregivers involved in a fragmented system The systems frequently involved with this population are the child welfare, public assistance, medical care (prenatal, postnatal and pediatric) and criminal justice systems 4

6 Excerpted from Treatment Intervention Matrix for Chemical-Usinq Preqnant and Postt>artum Women, Washington State Department of Social and Health Services, 1990 WOMENS/MATERNITY ISSUES There are characteristics of women who need treatment for chemical dependency which differ from chemically dependent men and women who do not have difficulties with dependency on chemicals (Reed 1985) The addition of a pregnancy further complicates treatment needs The Division of Alcohol and Substance Abuse treatment facilities providing specialized services to chemically dependent pregnant and postpartum women will consider each of the following issues in addition to the standard clinical issues surrounding the treatment of addicted disease PREGNANCY/POSTPARTUM ISSUES FAMILY Prevention of subsequent pregnancy (planned parenthood/family planning) Pregnancy/child birth counseling Nutrition Pre and postnatal medical care and support services pediatric care Ongoing health care, including dental care Adoption counseling Extended Significant Children family others involvement ANCILLARY ISSUES Transportation to treatment, medical and health appointments Public assistance/medical assistance/food stamps/wic Child care (day, foster care) Child Protective Service involvement MATERNAL AND LIFE SKILLS ISSUES Peer directed pre and postpartum support groups Ongoing support groups Parenting skill building Parents Anonymous support Parent aide match program Education and support Home management: cooking skills, budgeting limited income Recreation Career issues: work training, GED, learning disabilities Legal services Sober and safe housing access Transition back to independent living I:;

7 Excerpted from Treatment Intervention Matrix for Chemica1-Usinq Pre~ant and PostDartum Women, Washington State Department of Social and Health Services, 1990 Exercise Narcotics Anonymous and Alcoholics Anonymous support COUNSELING AND MENTAL HEALTH ISSUES ' ~ -- Unresolved childhood sexual and physical victimization Unresolved childhood parenting issues Prevention Prevention of Acquire of Sexually Immune Deficiency Syndrome Transmitted Disease (STD) Sexual assault Domestic violence Cultural issues Eating disorders 6

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