Outline Substance Abuse Screening in Pregnancy Allison S. Bryant, MD, MPH Department of Obstetrics, Gynecology & RS University of California, San Francisco Antepartum and Intrapartum Management June 7, 2007 Scope of the Problem Definitions Screening in Pregnancy Individual agents Alcohol Opiates Cocaine Methamphetamines Marijuana Tobacco Substance Abuse: Scope of the Problem 30 million Americans have used illegal substances 40% of 25-30 year olds 3.6 million Americans have a dependency on illegal substances 9 th leading cause of death in U.S. $4.5B cost in health expenditures $44B cost in lost productivity Substance Abuse: Scope of the Problem 23% of HS seniors report regular marijuana use 10% of HS students have used an illicit substance SA associated with poor health, harmful behaviors, increased risk of STIs, unintended pregnancy Treatment may have efficacy equivalent to other chronic diseases ACOG, 2000 ACOG, 2000 1
Substance Abuse: Scope of the Problem Prevalence (%) of current use among women age 18 44 years Pregnant Non-pregnant Alcohol 14.8 55.5 Cigarettes 20.3 33.0 Marijuana 1.8 4.9 Cocaine 0.3 0.9 Other illicit drugs 0.7 1.4 National Household Survey on Drug Abuse, 1996-1998 Demographics of Substance Abuse Substance abuse in pregnancy related to Age 18-30 (vs. 31-44) Single marital status Less than high school education NOT related to race/ethnicity May be different prevalence of use of particular substances between women of different races Ebrahim el al., Obstet Gynecol 2003 Chasnoff et al. NEJM 1990 Perinatal Substance Exposure Study California 1992: 2/3 of all CA birthing hospitals sampled at random Urine samples taken from all women admitted for delivery (N = 29,494) 6.7% infants exposed to EtOH, 5.2% to any drug Black women more likely to use cocaine; amphetamines more likely among Whites Neighborhood poverty trumped race in models of prediction Finch et al., Soc Sci Med 2001 Substance Use among Women age 18-44 % Illicit drug use in past month % Binge drinking in past month % Cigarette smoking in past month National Survey of Drug Use and Health Report, 1/2004 2
Pregnancy as teachable moment Definitions: Substance Abuse Recurring pattern of use which substantially impairs functioning in one or more important life areas Family Vocation/employment Psychological Legal Social Physical Ebrahim el al., Obstet Gynecol 2003 Washington State Dept. of Health, 2002 Definitions: Substance Dependency Dependent use which is a primary chronic disease with genetic, psychological and environmental factors influencing its development and manifestations Evidenced by a subjective need for a specific substance Definitions: Addiction Complex, progressive behavior pattern with biological, psychological, sociological and behavioral components Pathological involvement in a behavior Subject to compulsion Reduced ability to exert personal control over use Washington State Dept. of Health, 2002 Washington State Dept. of Health, 2002 3
Universal Screening in Pregnancy Provides opportunity to talk with every patient about risks of alcohol, tobacco, prescription and illicit substances Seeks to eliminate bias Increases likelihood of identifying substance abusers and allows for early intervention Takes ~30 seconds for most patients Ethical Rationale for Universal Screening Beneficence: medical diagnosis of addiction requires intervention in same manner as do other chronic diseases; capacity for marked improvement in health status Nonmaleficence: in the absence of screening, other major health risks may (HIV, other STIs) may be missed ACOG Committee Opinion 294, 2004 Ethical Rationale for Universal Screening Justice: if we fail to apply principles of universal screening, women who are less likely to be screened will have higher burden of disability and lower health status Autonomy: climate of trust and respect must be created to foster effective intervention; must also respect autonomy of woman to refuse screening (in)justice In urban teaching hospital, Black and Hispanic race/ethnicity strongly associated (OR 4.1, 5.3) with documentation of use or non-use of illicit substances (Kerker et al., Ethn Dis 2006) In FL, state with mandatory reporting of mothers known to use alcohol or illicit substances in pregnancy, black women 10 times more likely to be reported (p<0.0001), despite similar rates of positive screens in study (Chasnoff et al., NEJM 1990) ACOG Committee Opinion 294, 2004 4
Screening Tools Self-report Respectful, neutral questions Begin with legal substances, then illicit ones Behavioral patterns Sedation Inebriation Euphoria Agitation Disorientation Prescription drug seeking behavior Screening Tools Medical History Frequent hospitalizations Trauma Unusual infections Cirrhosis, hepatitis, pancreatitis Frequent falls, bruises Chronic mental illness Screening Tools Physical Examination Normal as most common finding in users of illicit drugs Dilated/constricted pupils Tremors Track marks Inflamed/eroded nasal mucosa Increased pulse and BP Screening Tools Laboratory testing Lab testing only acceptable as follow-up for positive interview screen; patient consent needed Time frame for presence of metabolites: Marijuana, acute use 3 days Marijuana, chronic use 30 days Cocaine 1-3 days Amphetamines 1-3 days Heroin 1 day Methadone 3 days 5
Ask Advise Assess Major Steps to Intervention Pre-contemplation Contemplation Preparation Action Maintenance Relapse Assist Arrange Alcohol Surgeon General and Secretary of HHS recommend complete abstinence from alcohol Safe level of prenatal alcohol consumption not determined Risk of FAS, stillbirth varies in studies No exact dose-response relationship Binge drinking increases risk Older age, high parity, A-A and N-A race increase risk of FAS Alcohol: Screening Traditional screens (e.g. CAGE) developed in male alcoholics T-ACE questions Developed to screen for prenatal use Includes measure of tolerance to inebriating effects of alcohol question which does not trigger psychological denial Sensitivity 69%, Specificity 85%, Positive predictive value 23% T-ACE 1) How many drinks does it take for you to feel high? (Tolerance, if > 2 drinks, 2 points) 2) Do you feel Annoyed by people complaining about your drinking? (1 point) 3) Have you ever felt the need to Cut down on your drinking? (1 point) 4) Have you ever had a drink first thing in the morning (Eye-opener, 1 point) ** Positive score is > 2 points total 6
Treatment Positive screen? Assess current and past alcohol consumption Focus on drinking behavior alone can reduce antepartum alcohol consumption (Chang et al., Obstet Gynecol 2005) Women with heavy drinking patterns should be referred for professional treatment Naturally occurring vs. synthetic Intranasal, inhaled, IV, PO, IM, SQ Intense warmth/rush, followed by sedation No simple screening tool Opiates Opiates Signs/symptoms/behavioral cues Drug craving Anorexia, nausea Hypertension, hyperventilation, tachycardia, yawning, sweating, lacrimation, rhinorrhea, restlessness Late initiation or missed prenatal care visits Impaired work/school performance Poor OB history Children with neurodevelopmental or behavioral problems Children involved with child protective agencies Late to Care Prevalence of Perinatal Drug Exposures, According to Duration of Prenatal Care Vega W et al. NEJM 1993;329:850-854 7
Opiates Perinatal effects IUGR Non-reassuring fetal status Low birth weight Perinatal mortality Neonatal withdrawal SIDS Opiates: Treatment Principle: change from short-acting IV to longacting PO form to reduce craving and withdrawal Methadone Synthetic opioid, blocks heroin effects No euphoria, long half-life Decreased associated maternal morbidity Neonatal abstinence syndrome DOL 2-3 up to a week Buprenorphine May be associated with lower risk of neonatal abstinence syndrome Crystal, granular or powder forms Intranasal, inhaled, IV, PO, PV, PR routes Dose-dependent increase in HR & BP Produces arousal, enhanced alertness, sense of self-confidence Chronic use produces irritability, paranoia, decreased libido Cocaine Cocaine Risk of systemic complications Perinatal effects?congenital anomalies Impaired fetal growth Preterm delivery Placental abruption Neonatal effects Coarse tremor, increased tone Increased risk of SIDS Long-term developmental outcome similar to drugfree newborns 8
Cocaine: Treatment Principle: help patient resist urge to restart compulsive cocaine use Group vs. individual counseling Cognitive behavioral therapy Methamphetamine Intranasal, inhaled, IV, PO 4% of US population have tried meth at some point in their lives Users currently concentrated in West/ SW Neurotoxic agent: enhances dopamine release, enhancing mood and body movement Methamphetamine Increases wakefulness, physical activity, respiration, heart rate, blood pressure, and temperature Other effects: irritability, anxiety, insomnia, confusion, tremors, convulsions, cardiovascular collapse and death Long-term effects: paranoia, aggressiveness, extreme anorexia, memory loss, hallucinations, delusions, and severe dental problems Perinatal effects: not well studied. Increased risk of SGA 9
Methamphetamine: Treatment No specific pharmacologic therapies currently Similar therapeutic approaches to cocaine abuse Cognitive behavioral therapy Causes CNS depression, changes in attention, memory, information processing Onset within 30-60 mins, lasting 3-5 hrs No clear association with adverse perinatal outcomes Marijuana Most important modifiable risk factor associated with adverse birth outcomes Associated with LBW, SAB, stillbirth, PPROM, abruption, previa, PTD, congenital anomalies, postnatal morbidities Tobacco 10
Tobacco Approximately 25% of U.S. women of reproductive age smoke Smoking prevalence during pregnancy 10-22% Self-report = under-report Nondisclosure rates 24-50% high risk among those reporting quitting after conception Why screen for smoking? Prevalence of Perinatal Drug Exposures, According to Self-Reported Tobacco Use during Pregnancy (California, March through October 1992) Vega W et al. N Engl J Med 1993;329:850-854 Smoking Cessation Only 20-40% of smokers stop during pregnancy Risk factors for continuation: Less than high school education More than 10 cigarettes per day Partner who smokes Smoking Cessation Women who receive smoking cessation intervention more likely to have improvement in cessation than those with minimal treatment (70% vs. 0-17%) [Lumley et al., Cochrane Review 2004] Only 49% of OBs routine advise and provide follow-up for smoking cessation 11
Treatment Ask about smoking status Advise to quit, reviewing impact of smoking and quitting on maternal and fetal well-being Assess willingness to make a quit attempt Assist in quitting attempt Arrange follow-up throughout pregnancy Treatment: Pharmacotherapy Nicotine replacement Class D drug ACOG: use only when other attempts fail, increased chance of smoking cessation > unknown risk of nicotine replacement + possible concomitant smoking Bupropion Class B drug Higher abstinence rates as compared to placebo or nicotine patch Summary Universal screening as ethical course of action in preconception/prenatal care Nonjudgmental screening techniques Pregnancy as a teachable moment Be aware of specific concerns for particular drugs of abuse Become familiar with local resources for treatment 12