Dept of Alcohol and Drug Services DADS Presented by Lara Windett MA MFT LPPC Certified Addiction Specialist CAS The Department of Alcohol amp Drug Services exists within the overall ID: 157907
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Perinatal Substance Abuse Program
Dept of Alcohol and Drug Services (DADS)Presented by Lara WindettM.A., MFT, LPPC Certified Addiction Specialist (CAS)Slide2
The Department of Alcohol & Drug Services
exists within the overall Santa Clara Valley Health & Hospital System
Dedicated to the health of the whole community
regardless of ability to paySlide3
Background
PSAP was Brainchild of Anthony Puentes, MD, MPH, 1987Funding streamGoal of PSAP ProgramSlide4
PSAP Keeps babies
out of the NICUNICU costs ~$2,100 – 5000 per day2007 140 babies exposed, 30 in NICUAvg Length of Stay: 15 daysSlide5
PSAP Treatment Works!
92% drug/alcohol free - neg tox screensSlide6
Perinatal Drug Exposure Overview
1992 StudyEstimated 15-18% of pregnant women use alcohol or drugs.PSAP Admission StatisticsSlide7
PSAP = Empowerment Model
Comprehensive Intensive Outpatient TreatmentMedically MonitoredMultidisciplinary ApproachDay Care for clients’ childrenTransportationSlide8
PSAP Client Eligibility
Resident of Santa Clara CountyPregnant or Early Parenting Women 18 years or olderOn Methadone (MMT) or opiate dependentHx or DOA abuse or currently usingFamily Wellness Court ReferralsMedi-cal, Valley Care II, sliding scale fee, or other insurance (Kaiser)Slide9
Length of PSAP Stay
Assigned a Licensed Therapist, PSWCase ManagementIndividualized Tx PlanTypical Treatment Episode: 6-12 monthsSlide10
Staff
HCPM II3 Therapists (MFT) MDHealth Ed Specialist1 Health Services Representative3 day care aides (1/2 codes)1 Community Worker (van) (1/2 codes)
VolunteersSlide11
Current PSAP Client Demographics
~Capacity for 65+Women ages 19 to 43 years23% pregnant10 clients on Methadone (3 pregnant)
30% Caucasian
33% Latina,
9 % Asian/Pacific Islander 18% Mixed Race
2% African American
8 % Declined to State
30% in THU’s
CPS Cases ~70%
Prop 36 ~40%
FWC 30%
Probation Only - 20%
DEJ – 10%, Slide12
Out Patient Drug Treatment in Santa Clara County – Including Methadone
On the VMC campusReadily accessible - pregnant OPIOID DEPENDENT patients (Methadone candidates) are scheduled for admission the next business dayAll Patients can call Gateway 1-800-488-9919Providers can call Central Valley Clinic
408 885-5400 Front Desk
408 885-4064 PSAP Cl
ericalSlide13
Items to Remember if a Patient is in PSAP Treatment
We ask for a verification of OB Care/complete the referral to VMC if no care is scheduled for pregnant people.We obtain a release to speak with the OB and all MDs in the patient's life.We obtain a release to Public Health.We obtain a release to the Pedi and we alert the Pedi (and OB) if the patient drops out of treatment.Slide14
Overview of AOD Treatment/Concerns
Red flags
When interviewing/observing the patient
When considering the history
Risks associated with various drugs
To the pregnancy
To the babySlide15
Substances to Be Discussed
Opioids
Cigarettes
Alcohol
Marijuana
MethamphetamineSlide16
Amber
32 y.o. Woman and the mother of an 8 y.o.Unplanned pregnancyUsing dailyHeroin by injection 2 grams/dayCocaineCigarettes 2 PPD
Seeking admission to methadone programSlide17
Amber
Stealing to obtain drugsIsolated – only living relative is maternal grandmother8 y.o. son is being raised by patient’s grandmotherFather of baby is using and at risk of deportation Slide18
Amber
Medically indigentHistory of depression and anxietyHistory of domestic violence (prior relationship) Slide19
Amber
Frustrated – requested tubal ligation at 23Frightened – concerned about damage already done to baby MotivatedRequests residential treatmentResolves to leave boyfriend if he will not get into treatmentSlide20
Red Flags: Multiple & Obvious
Patient volunteering history of substance abuse Physical exam remarkable for multiple tracks and physical withdrawalLife in disarrayChaotic and disrupted family relationshipsSlide21
Why Share this Story?
Opioid dependence requires medical interventionPregnant patients need treatment to prevent adverse outcomes Women caring for infants need treatment to be functional mothers Slide22
Pregnancy can be a Huge Motivation for Change: Amber
Stabilized on methadone maintenanceCompleted residential treatmentPermanently left the boyfriend who continued to useDelivered drug freeSlide23
A Sense of Hope:
12 Years Later Amber is…Abstinent and still in treatmentRaising her daughterWorkingSlide24
Prevalence of AOD Abuse in Pregnancy
2008 and 2009 data from the National Survey on Drug Use and Health found that among pregnant women ages 15 to 44, the youngest ones generally reported the greatest substance use. Also, pregnant women ages 15 to 17 had similar rates of illicit drug use (15.8 percent or 14,000 women) as women of the same age who were not pregnant (13.0 percent or 832,000 women).Slide25
Brenda
Referred to treatment for history of methamphetamine abuseWorked as a medical assistant until about two years agoServed as caretaker for mother who died of breast cancerAfter mother died, dad was diagnosed with lung cancer; patient served as caretaker
Reported having a prescription for vicodin Slide26
Brenda
Reported taking prescribed vicodin for chronic back pain (occasionally)Denied history of prescription opioid abuseWeekly u tox screens consistently positiveFor a variety of prescription opioids
Not just for vicodin
Easy access to unlimited supply of prescription opioids
Transferred to methadone maintenance
26Slide27
Prescription Opioid Abuse May Not Be Obvious
Consider the historyUnusual number of painful conditions for a young healthy patientMultiple opioid prescriptions during pregnancyMultiple ER visits for complaints of painMultiple care providers/no regular providerOpioids for unusual indications
27Slide28
Patient’s Appearance on Opioids
NormalSedated with small pupilsSymptoms of withdrawalSweats/chills/goosefleshLacrimation/rhinorrheaYawning/sneezing
Irritable/anxious/fidgety
VomitingSlide29
Ask About Behaviors: Have you ever?…
Taken more than prescribed?Taken medication after the pain was gone?Gotten pills from a friend or relative?Bought pills on the street?
Written or called in a prescription for yourself?
Tried to stop and found you couldn’t?Slide30
Ask about Reasons for Use
Manage emotions?Deal with stress?Feel high?Numb everything or go to sleep?Slide31
Opioids: Three to Seven Times Higher Rates of…
Still birthFetal growth retardationLow birth weightSmall head circumferencePrematurityNeonatal mortalitySlide32
Heroin: Medical Risks Associated With Injection
CellulitisAbscessesEndocarditisHepatitisHIV infection
Wound BotulismSlide33
Opioid Dependence in Pregnancy: Treatment
Currently, methadone maintenance is the gold standardBuprenorphine maintenance looks promising and may be more available in the future (not FDA approved)A comfortable, stable mother increases the likelihood of a healthy, term deliverySlide34
Impact of Methadone Treatment
Reduced deathsReduced IVDUReduced HIV seroconversionReduced crime daysReduced relapse
Improved health
Improved relationships
Improved productivityImproved social functioningSlide35
Additional Benefits During Pregnancy
Increased participation in prenatal careReduced obstetrical complicationsImproved maternal nutritionDaily observation in clinic while dosingSlide36
Therapeutic Dosing With Methadone
Suppresses opioid withdrawal symptomsReduces opioid cravingsProvides a stable opioid blood levelAllows a patient to concentrate on counseling/program to support recoveryMinimizes side effects; patient should not be sedatedSlide37
Methadone Withdrawal:
Not Recommended During PregnancyThe relapse rate is high (80%) Risk of intrauterine demise Risk of premature labor/miscarriageWhat can you say to a patient wanting to Withdraw from MMT?
Send them to their primary CSLR/the addiction MD to discussSlide38
Methadone Withdrawal:
Not Recommended After Delivery?Like insulin, methadone stabilizes a chronic illnessThe normal brain has an endogenous opioid system that may never function properly in an opioid dependent patientVery high relapse rate when methadone treatment is discontinuedSlide39
Methadone: Effects on the Baby
No known birth defectsMore likely to be born at termLower birth weight/smaller head circumference at birth May experience developmental delay during the first year of lifeNot associated with learning difficultiesIncreased SIDS with opioid exposureSlide40
Methadone and Breastfeeding
Negligible amounts of methadone are passed in breast milkThe American Academy of Pediatrics considers methadone compatible with breastfeeding at any doseSlide41
Methadone: Neonatal Withdrawal
Safer than heroin withdrawal in uteroExperienced by 60-80% of exposed babiesUsually occurs within the first 2-3 days of life; may occur within the first monthUsually treated with an opiate agonist Duration of treatment is days to months
Can be life threatening without treatmentSlide42
Opiates: The Neonatal Abstinence Syndrome
High-pitched cry, irritability Poor feeding, vomiting, diarrheaHyper tonicity (stiff muscles)TremorsSneezingSweatingOccasionally seizuresSlide43
Symptoms of Opioid Withdrawal
W = wakefulness I = irritabilityT = tremulousness, temperature variation, tachypnea
H = hyperactivity, high-pitched persistent cry,
hyperacusia, hyperreflexia, hypertonus
D = diarrhea, diaphoresis, disorganized suckR = rub marks, respiratory distress, rhinorrhea
A = apneic attacks, autonomic dysfunction
W = weight loss or failure to gain weight
A = alkalosis (respiratory)
L = lacrimationSlide44
Clarissa
23 y.o.Pregnant with first childSmoking 1½ - 2 PPD since late teens“I will only quit if the doctor tells me my baby will die if I do not quit now”“My whole family smokes; I grew up with it; I’ve been around it my whole life”Slide45
United States (1996-1998)
National Household Survey on Drug Abuse (NHSDA)Survey of pregnant women
Cigarettes
Alcohol
Any Illicit Drug
% using # fetuses/yr
20.3% 1.2 million
14.8% 0.8 million
2.8% 0.2 million
Ebrahim, SH, Gfroerer, J. Pregnancy-related substance use in the United States during 1996-1998. Obstet Gynecol 2003; 101:374.Slide46
Cigarette Smoking
Smoking during pregnancy is the most modifiable risk factor for poor birth outcomeIt is associated with 5% of infant deaths, 10% of preterm births, and 30% of small for gestational age infants
Trends in smoking before, during, and after pregnancy - Pregnancy Risk Assessment Monitoring System (PRAMS), MMWR Surveill Summ. 2009 May 29;58(4):1-29. Slide47
Cigarettes in Pregnancy:Obstetric Complications
Adverse EventRelative Risk
Placental Abruption
1.4-2.5
dose dependent
Placenta Previa
1.4-4.4
Stillbirth
1.2-1.4
dose dependent
Pre-term
PROM
1.9-4.2
Preterm Birth
1.3-2.5
Low Birth Weight
1.3-10.0
dose dependentSlide48
Clinical Outcomes in Pregnant
Women who Quit Smoking20% reduction in low birth weight babies17% decrease in pre-term birthsAverage increase in birth weight of 280g.Quitting before 30 weeks can still positively affect birth weightSlide49
Cigarette Smoking in Pregnancy & Other Drug Use
10 times higher use of marijuana22 times higher use of cocaine21 times higher use of amphetamine
Vega, WA, Kolody, B, Hwang, J, Noble, A. Prevalence and magnitude of perinatal substance exposures in California. N Engl J Med 1993; 329:850Slide50
In Utero Cigarette Exposure:
Congenital MalformationsMay contribute to anomalies associated with focal vascular disruptionCleft lip with or without cleft palateGastroschisisAnal atresiaTransverse limb reduction defects
Risk may be modified by genetic factorsSlide51
In Utero Cigarette Exposure:
Effects on the NewbornThere is a dose-response relationship between maternal cigarette use and infant…StressHypertonicity
Excitability and irritability
May be due to neurotoxicity or withdrawal
With second hand smoke exposure there is an increased risk of low birth weightSlide52
In Utero Cigarette Exposure:
Postnatal MorbiditiesMorbidity
Neonatal death
RR 1.2 - 1.4
SIDSRR 2.0 – 7.2
Prenatal exposure a higher risk
than postnatal 2
nd
hand exposure
Respiratory infections, asthma, otitis media, infantile colic, bronchiolitis, short stature, childhood obesity, type 2 diabetes in adulthood
Heart disease and lung cancer in never
smokers
Second-hand smoke increases risk by 20-30%
52Slide53
In Utero Cigarette Exposure:
Behavioral ProblemsToddlers (12-24 mo.s) showed a high and escalating pattern of disruptive behaviorChildren developed Oppositional Defiant D
isorder at double the rate of controls
ODD is a precursor of Conduct Disorder
Seen in older children and adolescentsCharacterized by persistent antisocial behaviors (lying truancy, vandalism, aggression)
NIDA Notes 2008: Vol.21 No. 6Slide54
In Utero Cigarette Exposure:
Cognitive Outcomes in 9-12 yr oldsIQ impacted (dose response effect)Poorer impulse controlMany individual WISC tests w/ significant dose response effectsPoorer performance on tests requiring visuoperceptual skills.
Auditory memory particularly impacted
WISC = Wechsler Intelligence Scale for ChildrenSlide55
Medical Issues for the Children of Smokers
Increased incidence of smoking initiation20% higher if mom smoked up to 1PPD60% higher if mom smoked 1PPD or moreDiabetes mellitus
Four times higher with more than 10 cigs/day
Increased asthma in adult offspring
Decreased sperm volume/count in adult male offspringSlide56
Alcohol
“Of all the substances of abuse (including cocaine, heroin, and marijuana), alcohol produces by far the most serious neurobehavioral effects in the fetus.”
IOM Report to Congress, 1996Slide57
A look at Denial/Pre-Contemplation: Denise
28 y.o. pregnant woman and the mother of 7 and 3 y.o. boysPregnant for the 5th timeHistory of two 2nd trimester miscarriagesStarted drinking at 23 (not pregnant)Slide58
Denise
Drinking 1-2 shots of peppermint schnapps daily until about 1 yr agoQuit drinking when learned was pregnant with second child, now age 3GA ~ 9wks when quitGrowth and development of this child appear normalSlide59
Denise
Drinking 5 shots of peppermint schnapps daily for the past yearDrinking this pregnancy until GA ~33 wksNot worried about the baby becauseLast baby was okayU/S during this pregnancy looks normalSlide60
Alcohol Use During Pregnancy:
Obstetrical Complications Increased risk of second-trimester abortion50% increase in fetal mortalityInfant withdrawal (3-12 hrs after delivery)
Fetal Alcohol Spectrum DisordersSlide61
Alcohol is a Teratogen that Freely Passes the Placenta
Teratogen: a substance that causes abnormal physical developmentBehavior teratogen: a substance that causes impaired cognitive, affective, social, reproductive, and/or sensorimotor behavior, even in the absence of obvious physical problemsSlide62
Prenatal Alcohol Exposure Can Cause:
DeathMalformationGrowth deficiencyFunctional deficitsSlide63
Teratogenic Effects Depend On:
Dose of alcoholPattern of exposure (binge vs. chronic)Developmental timing of exposureSusceptibility (genotype of mother and fetus)Synergistic reactions with other drugsInteraction with nutritional variablesSlide64
Dose-Response Effects
Higher maximum blood alcohol levels result in more severe neurotoxicityBinge drinking is particularly dangerousMales appear to be more susceptible than femalesSlide65
SOME CREDIBLE INCREDIBLE WEBSITES!(Thanks Mark Stanford, PhD)
Addiction Technology Transfer Centerhttp://www.nattc.org/asme.aspBrookhaven Addiction Research. Center for Translational Neuroimaging
http://www.bnl.gov/CTN/addiction.asp
National Institute of Drug Abuse (NIDA). Medical and Health Professionals
http://www.nida.nih.gov/medstaff.html
Moyers On Addiction: Addiction As A Disease
http://www.pbs.org/wnet/closetohome/science/
The Institute of Medicine. Marijuana and Medicine: Assessing the Science Base
http://www.nap.edu/readingroom/books/marimed/index.html
NIDA Science & Practice Perspectives
http://www.drugabuse.gov/Perspectives/
National Institute of Mental Health (NIMH). Medications
http://www.nimh.nih.gov/health/publications/medications/complete-publication.shtml
UCLA Addiction Clinic
http://www.uclaisap.org/addclinic/
University of Utah. Genetic Science Learning Center
http://learn.genetics.utah.edu/units/addiction/issues/treatments.cfm
Counselor Magazine for Addiction Professionals
http://www.counselormagazine.com/component/option,com_magazine/Itemid,1/
Society of Neuroscience. Advancing the Understanding of the Brain and Nervous System
http://www.sfn.org/
DADS:
Sccdads.org
Please ask me for more – or e-mail me!!!Slide66
Content Provided by:
Deborah Stephenson, MD, MPH Dept of Alcohol & Drug ServicesSanta Clara Valley Health & Hospital SystemMark Stanford, PhDDept of Alcohol & Drug ServicesSanta Clara Valley Health & Hospital System
Margaret Williams, M.S., RD, H.E.S.
Dept of Alcohol & Drug Services
Santa Clara Valley Health & Hospital SystemSlide67
Thank you!