Substance Abuse During Pregnancy Donna Dunn, PhD, CNM, FNP OB/GYN Update Maternal Substance Abuse Objectives Define substance abuse Differentiate between types of substances commonly used during pregnancy Define current statistics associated with substance abuse during pregnancy Identify common risk factors for the mother and fetus associated with maternal substance abuse Introduction Nurses are in a key position for screening, counseling, and initiating treatment of pregnant women who struggle with substance abuse. 1
Risk Factors for Maternal Substance Use Young women (Especially teens) Unmarried women Lower educational achievement Late initiation of prenatal care Multiple missed prenatal visits Impaired school or work performance High-risk sexual behaviors Sexually transmitted infections Relational problems/unstable home environment Sudden change in behavior Aggression, agitation, somnolence Depression, weight loss sleep disturbance Other Risk Factors Past obstetrical history of unexplained adverse events Poor dentition Poor weight gain Malnutrition Diagnosis of a mental health disorder Family history of substance abuse Having a partner who is a substance abuser Particularly important in female patients with a male partner Law enforcement history Sex trafficking, violence, trauma, theft History of medical problems associated with drug abuse Cellulitis, skin abscess, suspicious trauma, hepatitis, TB Children not living with the mother Involved with child protection agencies 2
Substance Abuse & Sexual Behaviors Risk-taking behaviors while intoxicated or high 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 Sex and Drugs Sex Trafficking Sex for money to pay for drugs Bartering Sex for drugs Consensual transaction Impaired judgment 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 Consequences of Drug Abuse May be physical, mental, or social Due to Side effects of drug Isolation Cost of obtaining Unknown adulterants Route of administration 3
Dual Diagnosis 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 Psychiatric Co-Morbidity 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 Maternal Drug Use & Psychiatric Illness 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 4
Definitions Use: Sporadic consumption of alcohol or drugs with no adverse consequences of that consumption Abuse: Although the frequency of consumption of alcohol or drugs may vary, some adverse consequences of that use are experienced by the user. Dependence: A state of adaptation that is manifested by a substance Addiction: The inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one s behaviors and interpersonal relationships, & a dysfunctional emotional response. It often involves cycles of relapse and remission Alcohol Most commonly used illicit substance for women younger than 21 years old US Surgeon General recommends no alcohol consumption during pregnancy CNS depressant Disinhibition depress inhibitions first Reduces anxiety Delirium tremens Increases incidence of: SpAb, Premature delivery, Stillbirths, Neonatal ethanol withdrawal, & FAS FAS: Most Common Effects on Fetus Fetal Alcohol Syndrome: 0.5-3 cases per 1,000 live births Leading preventable cause of mental retardation Neither a no-effect amount nor a safe amount of alcohol during pregnancy has been determined 5
Maternal Alcohol Use Neonates may be: Irritable Difficult to arouse Blood Alcohol Limit Note: The BAL in Alabama is 0.8. At a BAL of 0.3 an individual starts having symptoms of alcohol use. Cigarettes, cigars, pipes, snuff, chew Stimulant & relaxes Acute effects Vasoconstriction secretions Chronic effects Lung disease, heart disease Cancer Very short-acting, so highfrequency use Very reinforcing Nicotine 6
Maternal Nicotine Withdrawal Craving for tobacco Irritability, frustration, anger Anxiety Difficulty concentrating Restlessness Decreased heart rate Increased appetite or weight gain Depression Disrupted sleep Sedation Smoking: Effects on fetus Most common fetal exposure Associated with: IUGR Hydrocephaly Omphalocele Gastroschisis Cleft lip & palate Hand anomalies Higher rates: SpAB Preterm delivery Placenta previa Placenta abruption Illicit Drugs Marijuana Opioids Cocaine Crystal Meth Inhalants 7
Marijuana Legal in 18 states + D.C. Active ingredient: THC Tetrahydrocannabinol (THC) is the active chemical in cannabis and is one of the oldest hallucinogenic drugs known Thought to: Reduce nausea Relive pain Reduce fatigue Increase relaxation Cause hallucination Cause short-term memory impairment and/or amnesia Marijuana: Effects on the fetus Increased incidence of low birth weight infants Maternal Marijuana Screening Detection Interval: Irregular use: 1-3 days Prolonged use: >1 month Comments: Screening assays detect inactive and active cannabinoids; confirmatory assay detects inactive metabolite. Duration of positivity is highly dependent on screening assay detection limits. 8
Opioids (Narcotics) Morphine, Heroin, OxyContin, Methadone, Fentanyl, Meperidine, Propoxyphene, Tramadol) Analgesics Associated with: Disconnect from pain Euphoria Sedation & Oversedation Respiratory depression Common reactions: Nausea Constipation Itching Maternal Opioid Screening Detection Interval: Irregular use: 1-2 days Prolonged use: 2-4 days Methadone and Pregnancy Standard of care for opioiddependent pregnant women Stabilization of mother and fetus Improves growth of fetus & newborn Decreases practice of high-risk behaviors 9
Methadone Long-acting pure opioid agonist Available for opioid addiction treatment only in federally licensed programs Requires daily clinic visits, but may get takehome dose privileges Significant street reputation Also used for pain like other Schedule II opioids Buprenorphine and Pregnancy Long-acting opioid agonistantagonist Office-based opioid addiction treatment Schedule III Very low risk of overdose Pregnancy Category C Subutex is used instead of Suboxone whenever possible to avoid opioid overdose Naloxone is used for opioid overdose reversal Opioids: Effects on fetus Women who receive low-dose methadone and routine prenatal care have birth outcomes similar to nonusers, but they are still at risk for pregnancy-related complications. IUGR No known fetal anomalies documented Increased risk for SIDS Neonatal withdrawal syndrome Continuous exposure of opioids during the pregnancy 10
Signs & Symptoms of Neonatal Opioid Withdrawal Neurologic Excitability Gastrointestinal Dysfunction Autonomic Signs Irritability Dehydration Fever Frequent Yawning & Sneezing Diarrhea Increased Sweating High-Pitched Crying Poor Feeding Nasal Stuffiness Hyperactive Deep Tendon Reflexes Increased Muscle Tone Increased Wakefulness Exaggerated Moro Reflex Poor Weight Gain Uncoordinated & Constant Sucking Vomiting Temperature Instability Mottling Seizures Tremors Note: Occurs within 2 weeks of birth. Symptoms may last days to weeks. Sedatives & Anxiolytics Benzodiazepines Anxiolytics Pregnancy Category D Detection Interval: 1-30 days Barbiturates Insomnia, Anxiolytic, Sedative, Psychotropic Agent Pregnancy Category D Detection Interval: 2-4 days Sleeping pills (Ambien, Lunesta) Pregnancy Category C Sedative Withdrawal in Pregnancy Common to both sedative withdrawal & pregnancy: 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 11
Sedative Withdrawal Treatment in Pregnancy 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 Stimulants Cocaine Amphetamine Methylphenidate MDMA/Ecstasy Caffeine Stimulants: Effects on fetus Spontaneous abortion Placental abruption Fetal hypertension Intrauterine growth restriction Premature delivery Delivery of a baby with withdrawal symptoms: Tremors Sleeplessness Muscle spasms 12
Maternal Stimulant Screening Detection Intervals: Amphetamines Irregular use: 1-2 days Prolonged use: 2-4 days Cocaine Irregular use: 2 days Prolonged use: 1 week Inhalant Abuse Sniffing: Inhalation of a volatile substance directly from a container Example: Rubber cement Huffing: Pouring a volatile liquid onto fabric and placing it over the mouth &/or nose while inhaling Most common form of volatile-substance abuse Example: Glue, paint, household cleaners, Whip-It, PAM, Bagging: Instilling a solvent into a plastic or paper bag and rebreathing it from the bag several times Example: Spray paint Dusting: Inhalation of compressed air cleaners containing halogenated hydrocarbons Example: Dust Off Inhalant Abuse Short term effects: hallucinations, dizziness, & delusions Long term effects: Seizures & tremors Lethal effects: Sudden death from heart failure & suffocation from displacing oxygen 13
Diagnosis of Addiction 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 Types of treatment Detoxification 12-Step groups Outpatient counseling Inpatient facilities Residential facilities Opioid Maintenance Methadone Buprenorphine Barriers to treatment Fear of legal consequences Reporting requirements: Public health authorities, child protective services Criminal justice system When identified or at time of delivery Inform patient of legal obligation 14
Consent for Drug Screening The practitioner is required to obtain a consent form if there is a chance that the UDS may be needed for legal purposes. OB patient Breastfeeding Encouraged Promote bonding Optimal nutrition Passive immunity Contraindications Active substance abuse HIV + Methadone or buprenorphine dose not important consideration Small amounts confirmed in breast milk. Unlikely to have negative effects on the developing infant Summary 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 15
Summary Most common obstetrical effect of illicit drugs is low birth weight Methadone maintenance is treatment of choice for opioid-addicted pregnant women Breastfeeding is encouraged (as long as not actively using illicit drugs or alcohol & HIV Negative) Support for mother is essential Anticipate and educate to prevent relapse References American College of Obstetricians & Gynecologists (2012). Opioid Abuse, Dependence, and Addiction in Pregnancy. Obstetrics & Gynecology, 119(5), 1070-1076. Jansson, L.M. & The Academy of Breastfeeding Medicine Protocol Committee. (2009). ABM Clinical Protocol #21: Guidelines for Breastfeeding and the Drug- Dependent Woman. Breastfeeding Medicine, 4(4), 225-228. Shieh, C. & Kravitz, M. (2006). Severity of Drug Use, Initiation of Prenatal Care, and Maternal-Fetal Attachment in Pregnant Marijuana and Cocaine/Heroin Users. JOGNN, 35, 499-508. 16