Jaye M Shyken MD St Louis University School of Medicine October 4 2018 Objectives Important concepts Drug addiction is a disease Addiction is a primary chronic disease of brain reward motivation memory and related circuitry Dysfunction in these circuits leads to characteristic bio ID: 777594
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Identification and Brief intervention for Substance use disorders in pregnancy
Jaye M
Shyken
, MD
St. Louis University School of Medicine
October 4, 2018
Slide2Objectives
Slide3Important conceptsDrug addiction is a diseaseAddiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
Not a character flaw
Slide4Important conceptsRisk Factors for addictionAddiction is not inevitable depends on a number of factorsGeneticBiological factorsAge at first usePsychological (personality)Environmental factors (availability, family and peer dynamics, financial resources, cultural norms, stress, access to social support)Higher riskCo-occurring mental health problemsGenetic and molecular factorsEarly life adverse events
Drug misuse in adolescence
Slide5Numbers of Past Month Illicit Drug Users among People Aged 12 or Older: 2017Note: Estimated numbers of people refer to people aged 12 or older in the civilian, noninstitutionalized population in the United States. The numbers do not sum to the total population of the United States because the population for NSDUH does not include people aged 11 years or younger, people with no fixed household address (e.g., homeless or transient people not in shelters), active-duty military personnel, and residents of institutional group quarters, such as correctional facilities, nursing homes, mental institutions, and long-term care hospitals.Note: The estimated numbers of current users of different illicit drugs are not mutually exclusive because people could have used or misused more than one type of illicit drug in the past month.FFR1.11
Slide6National Survey of Drug Use and Health (NSDUH) 2012-2013Past Month Use, Women 15-44
Pregnant
Nonpregnant
Illicit Drugs
MJ, Cocaine, Heroin, Halucinogens, inhalants, nonmedical use of pain relievers, tranquilizers, stimulants, sedatives
5.4%
11.4%
Tobacco
15.4%
24.0%
Alcohol
9.4%
55.4%
Binge Drinking
2.3%
24.6%
http://www.oas.samhsa.gov/nhsda.htm
Slide7Prevalence of Marijuana UseNational Survey of Drug Use and Health, 2007-2012Ko JY, Farr SL, Rong
VT, et al. Am J Obstet Gynecol 213;201.e1-201.e10 (Aug 2015)
Slide8Prescription opioids: 1999-201080% of the world’s oral opioids are used in the US
CDC, MWWR 2011
Slide9Heroin use: 2002-201380% of heroin users initially used Rx opioids
Slide10Trends in Heroin Use and Heroin Deathswww.cdc.gov/vitalsigns/heroin/infographic.html#graphic, 2016
Slide1164,400 overdose deaths in 201642,249 with any opioid15,469 with heroin33,900 with natural and synthetic opioids (except methadone)
Slide12Opioid Use Disorder at Delivery, 1999-2014
Haight SC, Ko JY, et al. MMWR August 10, 2018;67(31);845-9
Slide132016 MO Medicaid Claims Data for Substance Use in Pregnancy, Summary CountsCounts% of Total Pregnant ♀
Total pregnant women60,310100Alcohol Use Disorder5370.89Cannabis Use Disorder
14182.35%Opioid dependence990
1.64%
Opioid Use Disorder
945
1.57%
Other Substance Use Disorders
1732
2.87%
Any Substance Use Disorder
3707
6.15%
Any SUD, not OUD
in same year
2223
3.69%Any Opioid Use Disorder14842.4%Report Prepared by MO Dept Social Services, MO Healthnet Division, 2017
Slide14Slide15Slide16Patterns of Drug UseUseSporadic consumption with no apparent consequencesMisuseSporadic or more frequent use, some consequences experienced by userPhysical dependence
Drug class-specific withdrawal syndrome produced by abrupt cessation or rapid dose reduction or by administration of an antagonistPsychological dependenceSubjective sense of need, for positive effects or to avoid negative effects of abstinenceAddictionPrimary, chronic, neurobiologic disease. Characterized by impaired control over drug use, compulsive use, continued use despite harm, and craving
Slide17Received Specialty Substance Use Treatment in the Past Year among People Aged 12 or Older Who Needed Substance Use Treatment in the Past Year, by Age Group: 2017FFR1.65
https://www.samhsa.gov/data/report/slides-2017-nsduh-annual-national-report
Slide18Perceived Need for Substance Use Treatment among People Aged 12 or Older Who Needed but Did Not Receive Specialty Substance Use Treatment in the Past Year: 2017FFR1.66
https://www.samhsa.gov/data/report/slides-2017-nsduh-annual-national-report
Slide19Reasons for Not Receiving Substance Use Treatment in the Past Year among People Aged 12 or Older Who Felt They Needed Treatment in the Past Year: Percentages, 2017FFR1.67Note: Respondents could indicate multiple reasons for not receiving substance use treatment; thus, these response categories are not mutually exclusive.
https://www.samhsa.gov/data/report/slides-2017-nsduh-annual-national-report
Slide20SBIRTScreening,Brief Intervention, andReferral for Treatment
Slide21ScreeningAssesses substance use and severityChemical ScreeningScreening Tools
Slide22Urine Testing for Drugs of Abuse
DrugDuration in UrineFalse positivesAmphetaminesMethamphetamine2-3 d
3-6 dEphedrine, pseudoephedrine, phenylephrine, chlorpromazine, bupropion, amantadine, ranitidine, metformin, labetalolBarbiturates2-4 d
Ibuprofen, naproxen
Benzodiazepines
Depends, 2 d to 6
wks
Sertraline
Cannabinoids
1-7d episodic
21-30 d chronic
Ibuprofen, naproxen, efavirenz, hemp seed oil
Cocaine
2-3 d
Topical anesthetics containing cocaine
Methadone
3-4 dDoxylamine, diphenhydramine, quetiapineOpiates1-3 dRifampin, fluoroquinolones, poppy seeds, quinine (tonic water), doxylaminePhencyclidine7-14 dKetamine, dextromethorphan, diphenhydramineThe Medical Letter 2002;44:71-7
Slide23Neonatal Urine Testing for Drugs of AbuseDrug
Duration in UrineAmphetaminesMethamphetamine1-2d1-2 dBarbiturates2-6 weeksBenzodiazepines
Moderate: 3 to 5 daysHeavy: 3 to 6 weeksCannabinoidsOne joint: 2 d
3 times per week: 2 weeks
Daily: 3 to 6 weeks
Cocaine
2-4 d
Methadone
2-3 d
Opiates
1-2 d
Phencyclidine
2-8 d
Moses S. Toxicology Screening, Urine Tox Screen.
Family Practice Notebook
; 2005
www.fpnotebook.com/Psych/Lab/TxclgyScrng.htm
Slide24Testing of meconium and umbilical cord tissueMeconiumReflects drug exposure over the last trimester in term infantIf specimen tests positive, reflex to confirmation with mass spectrometryUmbilical cord tissueReflects drug exposure over approximately last trimester in term infantQualitative detection by mass spectrometry
https://arupconsult.com/content/newborn-drug-testing
Slide25Urine Drug Screening by risk factorsObstetric HistoryNo or scant prenatal care (< 3 visits)Preterm labor, preterm delivery, premature rupture of the membranesPlacental abruptionUnexplained fetal demiseUnexplained elevated blood pressure
AAP and ACOG (2017) Guidelines for Perinatal CareACOG Committee Opinion #422, updated Apr 2012Chasnoff IJ, Neuman K, Thornton C, et al. Am J Obstet Gynecol
2001;184:752-8.
Slide26Urine Drug Screening by risk factors: Medical HistorySexually transmitted infectionsHIV/AIDSMultiple STIs with current pregnancyHepatitisGum or periodontal disease Significant weight loss, low BMI, malnutrition
Sexual abusePsychiatric symptoms such as anxiety, panic, hallucinations and psychosisSkin abscessesMyocardial infarction without known etiologyCerebrovascular accident without known etiologySubstance misuse historyHistory of drug use in the past two yearsPositive drug screen in current pregnancyEnrolled in chemical dependency treatment (including methadone)
AAP and ACOG (2017) Guidelines for Perinatal CareACOG Committee Opinion #422, updated Apr 2012Chasnoff IJ, Neuman K, Thornton C, et al. Am J Obstet Gynecol
2001;184:752-8.
Slide27Prevalence of Drug Use by Universal Maternal Drug Testing at Delivery:Performance of screening based on risk factorsWexelblatt, SL, et al. J Pediatr 2015;166:582-6.
Slide28Why you should askBegins the conversationMay identify drug use short of addictionAllows an opportunity for intervention or to congratulate healthy behaviorsMay make speaking about it in the future easier
Slide29Brief screening toolsNIDA Quick ScreenValidated for pregnancySURP-PCRAFFTWIDUS5 PsMissouri State Forms *****
Slide30Principles of screeningAsk everyone! (“It is the standard of care that we ask all women about their history of medication, alcohol and tobacco use.” “We ask these questions of everyone.”)Ask in privateNon-judgmental Open-ended questions
Slide31Perinatal risk assessment for substance use formhttps://health.mo.gov/living/wellness/tobacco/atod/pdf/MCFH-4.pdf
Slide32Perinatal risk assessment for substance use form: tobaccohttps://health.mo.gov/living/wellness/tobacco/atod/pdf/MCFH-4.pdf
Slide33Perinatal risk assessment for substance use form: alcoholhttps://health.mo.gov/living/wellness/tobacco/atod/pdf/MCFH-4.pdf
Slide34Perinatal risk assessment for substance use form: Other drugs
https://health.mo.gov/living/wellness/tobacco/atod/pdf/MCFH-4.pdf
Slide35Wright TE, Terplan M, Ondersma SJ, et al. Am J Obstet Gynecol
2016;215;539-47
Slide36Criteria for Diagnosing Substance Use Disorders: DSM VIncreasing toleranceWithdrawal symptomsUsing larger amounts or for longer than intendedWanting to cut down or stop, but not managing toSpending a lot of time to get, use or recover from drug useCravingInability to manage commitments due to drug useContinuing to use, even when it causes problems in relationshipsGiving up important activities because of drug useContinuing to use, even in dangerous situationsContinuing to use, even when physical or psychological problems may be made worse by drug use
< 2 = no disorder2-3 = mild disorder4-5 = moderate disorder> 6 = severe disorder
Slide37Brief InterventionIncrease intrinsic motivation to affect behavioral change(reduce or stop drug use)
Slide38Brief intervention1-5 patient-centered counseling sessions
Lasting < 15 minutesUses principles of motivational interviewing
Slide39Wright TE, Terplan M, Ondersma SJ, et al. Am J Obstet
Gynecol 2016;215;539-47
Slide40complications from substance use in pregnancy
PregnancyNeonatalCocaineAbruption, LBW, stillbirth, PTD, SGA, hypertension (mimicking preeclampsia)Increased sensitivity to CV toxicityState dysregulation, neonatal tremors, high-pitch cry, irritability, excess suck, hyperalert, abnormal MRI, transient abnormal EEG (Toxidrome)Long term outcome likely minimal effect except, possible attention and agressionAmphetamines
SGA, LBW, ?hypertension, PTD, abruptionNeurobehavioral abnormalities (attention, verbal and spatial memory,)Higher neonatal mortalityMarijuana
Small decrease in BW (100 g)
?Association with small risk of stillbirth (could not be adjusted for tobacco)
LBW when smoke > 1x/
wk
Neurobehavioral effects (attention, visual problem solving)
? Effect of confounders
ACOG Committee Opinion #479, March 2011, reaffirmed 2017
ACOG Committee Opinion #722, October 2017
Conner SN, Bedell V, Lipsey K, et al.
Obstet
Gynecol
2016;128:713-23
Gouin K, Murphy K, Shah PS, et al. Am J Obstet Gynecol 2011;204:340.e1-12
Slide41complications from substance use in pregnancy
PregnancyNeonatalOpioids(untreated heroin) IUGR, abruption, fetal death, preterm labor, meconiumNASTobaccoMiscarriage, stillbirth (dose-related),PPROM, LBW, abruption, placenta previa, Increased irritability and hypertonicity, SIDS, asthma
BenzodiazepinesWithdrawalWithdrawal
Alcohol
FASD, teratogenic, characteristic facial features,
LBW, growth
restriction, cardiac
, skeletal, renal ocular anomalies
Neurobehavioral impairment, hyperactivity, inattention, learning disability, seizures, deficits in memory and reasoning, poor executive function, poor school performance, conduct disorder, postnatal growth delay
ACOG Committee Opinion #711, August 2017
Partnode
CD, Henderson JT, Thompson JH, et al. Ann Intern Med 2015;163:608-21
Pruett D, Waterman EH,
Caugher
AB.
Obstt
Gynecol Surv 2013;68:62-9
Slide42Nutritional concerns for substance use in pregnancyActive addiction associated with poor quality dietBMIVitamin deficiency (thiamine, vitamin D, B12, folic acid)Iron deficiencyDental issuesInflammatory state (immune function)RecoveryWeight gain and obesityPersistent of poor eating habits
Slide43Referral for TreatmentProvide to those identified to be at high risk (SUD) who are in need of specialty addiction care
Slide44Referral for TreatmentBehavioral therapy (chemical dependency treatment)MAT (now MT for OUD)Buprenorphine
Methadone
Slide45Behavioral Interventions For SUDContingency management (CM). Systematically use reinforcement techniques, usually monetary vouchersOriginally use for cocaine. Now for opioids, MJ, tobacco, alcohol, benzodiazepines, otherMotivational Interviewing (MI)Patient-centered, collaborative, highly empathic counseling style to elicit behavior changeHelps patients explore and resolve ambivalence
Cognitive Behavioral Therapy (CBT)Strategies to help patients understand situations that bring about undesirable thoughts, feelings or behaviors (to then avoid when possible)Goal to break old patterns and replace with new onesForray A. F1000Res. 2016;5:F1000 Faculty Rev-887
Slide46ResourcesSAMHSA (Substance Abuse and Mental Health Services Administration) Treatment FinderBuprenorphine provider locator
https://www.samhsa.gov/medication-assisted-treatment/physician-program-data/treatment-physician-locatorMissouri state resource800-TEL-LINK (800 835-5465)
Slide47resources
Slide48Key screening conclusion by expert groupScreening for substance use should be done on all pregnant women at first prenatal visit and subsequently throughout pregnancy for those at high riskScreening can be done using a validated instrument with follow-up by provider or by asking standardized questions during interviewNonjudgmentalOpen-ended questionsUrine toxicology should not be used in place of substance use screening questions
Wright TE, Terplan M, Ondersma SJ, et al. Am J Obstet Gynecol 2016;215;539-47
Slide49Requirements of SB 190 (implemented July 1992)
Counsel pregnant women about the adverse effects of tobacco, alcohol and drugsIdentify pregnancies at risk, provided for prevalence studiesInform pregnant women of addiction servicesOffer referrals to DHSS for service coordinationImmunity from civil liability for clinicians who comply with the requirements of SB 190
Slide50How Missouri/Illinois Handles Drug Use During Pregnancy
MissouriIllinoisSubstance use in pregnancy is a crimeNo
NoProsecutions for drug use during pregnancyYes
Yes
Substance use in pregnancy is child abuse
No specific law*
Yes
Substance use in pregnancy grounds for civil commitment
No
No
Health care workers must report drug use during pregnancy
No specific law
Yes
Testing required if drug use during pregnancy is suspected
No
No
Targeted program createdYes*Yes*Pregnant women given priority access for drug treatmentYesYesPregnant women protected from discrimination in publicly funded programsYesYesPublished on Guttmacher Institute (https://www.Guttmacher.org) Date: 01-Sep-2018
Slide51Questions?