Preventing Substance-Exposed Pregnancies: - PowerPoint Presentation

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Preventing Substance-Exposed Pregnancies:

Presenters:

Rebecca Jones Munger &

Terese Voge

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A common perception is that a pregnant woman would quit using if she really wanted the best for her baby.

Agree

Disagree

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Today’s Discussion

Prevalence and impact of alcohol, tobacco & other drug use by women of reproductive age

Using a Collective Impact approach to move upstream and prevent substance-exposed pregnancies

Unique considerations when addressing substance use among women of childbearing age

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Where do you work?

Health Department

Treatment programs

Clinic/Health center

Education

Child welfare

Criminal justiceOther community-based organization (CBO)

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What is your role?

AOD prevention

Treatment

Case management

Educator

Policy

Other

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Rank your primary interest in attending this session:

Policy/system change

Organizational practices

Program implementation

Patient/client support

Other

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2011: Moving Upstream to Address Preconception

56% of all pregnancies in California are unintended.

Most women realize they are pregnant 4-6 weeks after conception.

 Screen all women of reproductive age for risky behaviors

Source: Guttmacher Policy Review 2011; http://www.guttmacher.org/sections/pregnancy.php

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Prevention of Substance-Exposed Pregnancies Practice Collaborative

Technical assistance October 2011- April 2013 to support local systems change

Funded by CDC – National Center on Birth Defects and Developmental Disabilities

Increase awareness of risks among health care providersIncrease capacity to deliver screening & brief intervention services to women of reproductive age

Six teams: Baltimore, Dayton, Tampa, Denver, Portland, Sonoma

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Source: CDC

Vital Signs January

2013

Alcohol Risk for Women and Girls

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Estimated Alcohol & Drug Use During Pregnancy

Substance Used

(Past Month)

1st Trimester

2nd Trimester

3rd Trimester

Any Illicit Drug

7.2

%

5.0%

2.8%

Alcohol Use

20.7%

7.8%

3.5

%

Binge Alcohol Use

10.3%

1.9%

1.3%

Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use & Health, 2007-08

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Past Month Illicit Drug Use

U.S. by Age, 2009 & 2010

Source: SAMHSA, (2011)

Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings

, NSDUH Series H-41, HHS Publication No. (SMA) 11-4658.

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Illicit Drug Use by Age Group

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Is

this SAMHSA

prevalence data similar to what you see in your community?

Yes

No

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Estimated Alcohol & Drug Use During Pregnancy

Estimated pregnancies impacted based on Sonoma birth data for 2012

(N= 5,132) and SAMHSA National Survey data 2007-08

Substance Used

(Past Month)

1st Trimester

2nd Trimester

3rd Trimester

Any Illicit Drug

7.2

%

370

women

5.0%

257

w

omen

2.8%

144

w

omen

Alcohol Use

20.7%

1,062

women

7.8%

400 women

3.5

%

180 women

Binge Alcohol Use

10.3%

529

women

1.9%

98

women

1.3%

67

women

Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use & Health, 2007-08

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Source: CDPH, MIHA Survey, 2010 & 2011

http://www.cdph.ca.gov/data/surveys/MIHA/Pages/MaternalandInfantHealthAssessment(MIHA)survey.aspx

Any Binge Drinking, 3 Months Before

Pregnancy 2011 Sonoma 15.6% vs. California 13.1% Sonoma Combined 2010 & 2011 = Sonoma: 17.6%

Private Insurance 19.4% vs. Medi-Cal 15.7%

White, non-Hispanic 23% vs. Hispanic 11.1%Any Alcohol Use During 1st or 3rd Trimester2011: Sonoma 26.7% (CI 20.7- 32.8) California 19.6% (CI 17.9 -21.2)

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California

15.0% vs.

Sonoma

19.1

%

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Source: California Healthy Kids Survey 2011-12;

https://chks.wested.org

California Healthy Kids Survey: Sonoma

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Percentage of Students who Used Marijuana in Past 30 days

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Marijuana is Not Safer than Tobacco for Pregnant Women

50-70% more cancer causing agents than tobacco

Smoking marijuana increases carbon monoxide and decreases oxygen in the mother’s blood

5x greater effect than cigarettes

Linked with poor fetal growth & premature birthThird trimester use can lead to withdrawal-like symptoms in newborns (increased crying & tremors)

Source: Gray et al, 2010; Dekker et al, 2012,

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Source:

Hayatbakhsh

et al, (2012) Pediatric Research.

“Birth Outcomes Associated with Cannabis Use Before and During Pregnancy”

Australian study enrolled 28,874 women over 7 years:“Use of cannabis during pregnancy strongly and significantly predicted negative birth outcomes, including low birth weight, preterm birth, SGA, and admission to the NICU. After controlling for mothers’ sociodemographic characteristics, smoking, alcohol consumption, and use of other illicit drugs, these increased levels of poor outcomes remained statistically significant.”

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Percentage of Women Who Smoked Tobacco during 1

st

or 3

rd

Trimester

Source: CDPH, MIHA Survey, 2011

http://www.cdph.ca.gov/data/surveys/MIHA/Pages/MaternalandInfantHealthAssessment(MIHA)survey.aspx

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Source: http://www.cdc.gov/vitalsigns/pdf/2013-07-vitalsigns.pdf

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Overall Female Treatment Admissions for Other Opiates* as Primary Substance of Abuse, Nationally

Retrieved 09/05/13

from

http

://wwwdasis.samhsa.gov/webt/newmapv1.htm

*Other opiates includes non-prescription use of methadone, codeine, morphine, oxycodone, hydromorphone, meperidine, opium, and other drugs with morphine-like effects.

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Female Treatment Admissions for Other Opiates*

as Primary Substance of Abuse

States with Highest Percentage, 2012

Retrieved 09/05/13

from http://wwwdasis.samhsa.gov/webt/newmapv1.htm

*

Other opiates includes non-prescription use of methadone, codeine, morphine, oxycodone, hydromorphone, meperidine, opium, and other drugs with morphine-like effects.

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Incidence of Neonatal Abstinence Syndrome (Nationally)

Neonatal Abstinence Syndrome and Associated Health Care Expenditures. Journal of the American Medical Association (JAMA) 2012; 307(18):1934-1940.

doi

: 10.1001/jama.2012.3951.

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Neonatal

A

bstinence Syndrome (NAS)

Source: CA Office of Statewide Health Planning and Development, Patient Discharge Data, 2000-2011

NAS Rate (diagnoses/1000 newborn discharges) 2004-2006 2008-2010 California 1.1 1.2

Sonoma 1.4 2.4

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Neonatal withdrawal symptoms:

tremors

irritabilityhigh-pitched crying

tight muscle toneseizuresyawning, stuffy nose, sneezingpoor feeding suck

diarrhea/ dehydration40%-60% of infants born to women using opioids develop NASSymptoms can appear 1-10 days after birthNAS requires prolonged hospitalization

29Neonatal Abstinence Syndrome (NAS)

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Different Populations of Women Can Give Birth

to an Infant with NAS Symptoms

Women with chronic pain or other medical condition maintained on medicines

Women

actively abusing or dependent on opioids (e.g. untreated substance use disorder)Includes heroin usersMisuse own prescribed narcotics for acute or chronic pain

Misuse of non-prescribed opioids diverted from legitimate sources from friend of family member

Misuse of opioids obtained through illicit means (purchased, theft)Women in recovery from opioid addiction maintained on methadone through OPT or buprenorphine through office based prescribing*Groups may overlap, adapted from Dr. Cece Spitznas, White House Office of National Drug Control Policy

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Neonatal Abstinence Syndrome Costs

Hospital charges for newborns diagnosed with NAS was $53,400 per infant in 2009

Hospital charges for all other births was $9,500 per infant in 2009

The average length of stay for NAS babies is 16 days, compared to 3 days for all other hospital births Medicaid has paid for the majority of cases (77.6% in 2009)

Neonatal Abstinence Syndrome and Associated Health Care Expenditures. Journal of the American Medical Association (JAMA) 2012; 307(18):1934-1940. doi: 10.1001/jama.2012.3951.

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The number of infants affected by NAS & FASD accurately reflects the impact of perinatal substance use.

True

False

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Estimated Number of Infants Affected by Prenatal Exposure,

by Type of Substance and Infant Disorder

*Includes nine categories of illicit drug use: use of marijuana, cocaine, heroin, hallucinogens, and inhalants, as well as the nonmedical use of prescription-type pain relievers, tranquilizers, stimulants, and sedatives.

Estimates based on: National Survey on Drug Use and Health, 2010; Hamilton, Martin, & Ventura. Births: Preliminary Data for 2010. National Vital Statistics Report, Volume 60, Number 2; Patrick, Schumacher, Benneyworth, et al. NAS and Associated Health Care Expenditures. Journal of the American Medical Association (JAMA) 2012; 307(18):1934-1940. doi: 10.1001/jama.2012.3951.

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Cost Benefits for Medical System

Pregnancy Complication

+ Substance

Use

Screen positive only

n = 156

Treatment GroupScreen positive, assessed & treated

n= 2073

Controls

Screen negative

Preterm

delivery <37 weeks

17.4%

8.1%

6.8%

Placental abruption

6.5%

0.9%

0.9%

Low Birth

Weight

<2500 grams

12.4%

6.5%

4.7%

Neonatal-assisted Ventilation

6.9%

3.2%

2.2%

Intrauterine fetal demise

7.1%

0.5%

0.6%

Kaiser’s

Early Start

Program at Ten Bay Area Facilities

N = 49,985 pregnant members

Source:

Goler

, Armstrong,

Taillac

&

Osejo

,

Journal of

Perinatology, 2008

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Relationship between Substance Abuse, Mental Health Problems and Trauma

Adverse Childhood Experiences (ACE) Study

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Prevalence Major

Depression in U.S. Women

Pregnancy: 9

-13 % U.S. Postpartum: 7

% first 3 months; 22 % first 12 months Women experiencing depressive disorders are at increased risk of substance use

Detection of prenatal depression without formal screening 6

% compared to 34% with Edinburgh screening tool Sources: Gaynes et al. 2005

Depressive Disorders in Pregnancy

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Intimate Partner Violence (IPV)

Lifetime prevalence of having been raped and/or physically assaulted by a current or former partner

1 in 4 U.S. women

(Futures Without Violence)Abused women are at increased risk for substance abuseSpousal abuse scores are the strongest predictor of alcoholism in womenIPV during the first year of marriage is highly predictive of heavy, episodic drinking one year later

Source:

Kaysen et al, 2007; Miller et al, 1989; Plichta, 1992

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Are coordinated services addressing perinatal substance abuse, co-occurring disorders and intimate partner violence available in your community?

Well coordinated

Somewhat coordinated

Little to no coordinated

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Goal: Improve

the health of women and children by reducing risky substance use, intimate partner violence and untreated mental health disorders

among women of reproductive age.

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CityMatCH PSEP Timeline

http://www.citymatch.org

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Collective Impact

http://www.ssireview.org/images/articles/2011_WI_Feature_Kania.pdf

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On a scale from 1 to 5, to what degree does your community work together to address substance exposed pregnancies?

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

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Who serves as the backbone organization in your community?

Local public health

Alcohol and other drug programs

CBO

Hospital/health plan

Other

None

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Strategy 1: Screening

& Brief Intervention

Strategy 2: Prevention

of Unintended Pregnancy

Strategy 3: Prescription Drug Abuse/Misuse

Sonoma County Team

Workgroups

6 Teams

Baltimore

Dayton

Denver

Portland

Tampa

Technical Assistance

Organizing Our Collaborative Work

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Strategy 1: Reduce Risky Alcohol Use

Screen

all women of reproductive age for risky alcohol use, tobacco, marijuana, and drugs in primary care settings.

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Brief intervention

Give feedback with clear, unambiguous recommendation Refer women to the most appropriate resource Help women align their birth control method with behavior Integrate with screening for intimate partner violence and depressive disorders

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Source: NIAAA

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Identify & Address Risky Alcohol Use

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What is “risky drinking” for women?

1 drink a day

2 drinks a day

3 drinks a day

4 drinks a day

5 drinks a day

6 drinks a day

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http://rethinkingdrinking.niaaa.nih.gov/isyourdrinkingpatternrisky/whatsatriskorheavydrinking.asp

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600 Women Screened

70%  for 1 or more areas

 20%  risky ETOH - one third were < 21 yrs

 14%  depressive disorder9.5%

 intimate partner violence23%  marijuana &/or tobacco42% of non-pregnant women reported using either tobacco or marijuana Less than a quarter of providers assessed birth control50

Plan-Do-Study-Act Pilot Results

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Screening, Brief Intervention & Referral to Treatment

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

4% of women dependent

 Referral to Treatment

Intended Outcomes:

Decreased or cessation of alcohol & other substance useLink women experiencing IPV &/or mood disorders with servicesPrevention of unintended pregnancy those with risky useWomen enter pregnancy healthier  Improved maternal & infant outcomes

Screening

&

Assessment

Brief Intervention for Other + Findings

Verbal recommendations

Reinforce in writing

Facilitated Referrals

Warm hand-off to behavioral health staff

Contraception assessment

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Brief Intervention for Risky Alcohol Use

Brief intervention can help some (

not all

) to reduce hazardous & harmful drinking

Based on Stages of ChangeAmbivalence is normalGive women feedback on their useCompare to CDC guidelinesProvide clear adviceStructured conversationLow intensity & short durationMotivational!52

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ACA and Substance Use Disorder Prevention

Prevention Priorities in Health Care Reform: Requires insurers to cover certain services that were rated highly by the U.S. Preventive Services Task Force.

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ACA Included Preventive Services

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No co-pay for:

Yearly physical

Well women checksRoutine prenatal care visitsEarly detection screenings,Immunizations,Breast-feeding counseling and supportContraceptive methods

Screenings for domestic violence ….Etc.

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ACA & SBIRT

Under the Affordable Care Act,

Medi

-Cal managed care programs mandated to provide SBIRT in primary care clinics.SBIRT (Screening, Brief Intervention, Referral and Treatment): evidence-based public health approach to provide prevention and early intervention

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Strategy 2: Prevent Unintended Pregnancies

Focus Group Findings

Women commonly try multiple methods of birth control

Consistent use of birth control can be difficult to maintain because it requires significant amounts of time, money and partner cooperation

Partners often refuse to use condoms &/or sabotage BCWomen want more ready access to services & information about side effects from their providers.Women need support to make the connection between planned pregnancies and emotional wellbeing

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Tier 1 Contraceptives: Access & Acceptance

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Develop & pilot My Life Plan curriculum into perinatal treatment Increase awareness of LARCs by home visitors and perinatal staff Provider training on IUDs & implants

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Strategy 3: Promote Responsible Opioid Use

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Partnered with Managed Medi-Cal program to host p

rofessional conferences on best practices for prescribing

Published article in local medical journal on the local trend

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Community Education

Support safe medication storage & disposal

Educate parents on risks of poisoning & diversion

Classroom education in middle & high schools

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Opportunities & Next Steps

Expansion of SBIRT in primary care settings

Embed screening tools into EMR systems

Increase provider confidence in using motivational interviewing techniques

Help women match their birth control method with their pregnancy intention (LARCs)Expand access to mental health services for womenUnderstand the health impacts of marijuana use and strengthen prevention efforts

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Resources

Links

http://fasdeducation.org

http://www.choiceproject.wustl.eduhttp://www.cdc.gov/ncbddd/fasd/freematerials.html http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm http://www.citymatch.org/projects/prevention-substance-exposed-pregnancies-collaborative-psep http://www.sonoma-county.org/health/topics/reproductiveproviders_citymatch.asp

http://www.uvm.edu/medicine/vchip/documents/ICONFULLTREATMENTGUIDELINESFINAL.pdf

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Contact

Rebecca Jones Munger, RN, CNM, MPH

Rebecca.Munger@sonoma-county.org

707-565-4553Terese Voge, MPATerese.Voge@sonoma-county.org

707-565-6682