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Identification and Brief intervention for Substance use disorders in pregnancy Identification and Brief intervention for Substance use disorders in pregnancy

Identification and Brief intervention for Substance use disorders in pregnancy - PowerPoint Presentation

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Identification and Brief intervention for Substance use disorders in pregnancy - PPT Presentation

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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Slide1

Identification and Brief intervention for Substance use disorders in pregnancy

Jaye M

Shyken

, MD

St. Louis University School of Medicine

October 4, 2018

Slide2

Objectives

Slide3

Important 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

Slide4

Important 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

Slide5

Numbers 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

Slide6

National 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

Slide7

Prevalence 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)

Slide8

Prescription opioids: 1999-201080% of the world’s oral opioids are used in the US

CDC, MWWR 2011

Slide9

Heroin use: 2002-201380% of heroin users initially used Rx opioids

Slide10

Trends in Heroin Use and Heroin Deathswww.cdc.gov/vitalsigns/heroin/infographic.html#graphic, 2016

Slide11

64,400 overdose deaths in 201642,249 with any opioid15,469 with heroin33,900 with natural and synthetic opioids (except methadone)

Slide12

Opioid Use Disorder at Delivery, 1999-2014

Haight SC, Ko JY, et al. MMWR August 10, 2018;67(31);845-9

Slide13

2016 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

Slide14

Slide15

Slide16

Patterns 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

Slide17

Received 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

Slide18

Perceived 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

Slide19

Reasons 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

Slide20

SBIRTScreening,Brief Intervention, andReferral for Treatment

Slide21

ScreeningAssesses substance use and severityChemical ScreeningScreening Tools

Slide22

Urine 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

Slide23

Neonatal 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 

Slide24

Testing 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

Slide25

Urine 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.

Slide26

Urine 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.

Slide27

Prevalence 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.

Slide28

Why 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

Slide29

Brief screening toolsNIDA Quick ScreenValidated for pregnancySURP-PCRAFFTWIDUS5 PsMissouri State Forms *****

Slide30

Principles 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

Slide31

Perinatal risk assessment for substance use formhttps://health.mo.gov/living/wellness/tobacco/atod/pdf/MCFH-4.pdf

Slide32

Perinatal risk assessment for substance use form: tobaccohttps://health.mo.gov/living/wellness/tobacco/atod/pdf/MCFH-4.pdf

Slide33

Perinatal risk assessment for substance use form: alcoholhttps://health.mo.gov/living/wellness/tobacco/atod/pdf/MCFH-4.pdf

Slide34

Perinatal risk assessment for substance use form: Other drugs

https://health.mo.gov/living/wellness/tobacco/atod/pdf/MCFH-4.pdf

Slide35

Wright TE, Terplan M, Ondersma SJ, et al. Am J Obstet Gynecol

2016;215;539-47

Slide36

Criteria 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

Slide37

Brief InterventionIncrease intrinsic motivation to affect behavioral change(reduce or stop drug use)

Slide38

Brief intervention1-5 patient-centered counseling sessions

Lasting < 15 minutesUses principles of motivational interviewing

Slide39

Wright TE, Terplan M, Ondersma SJ, et al. Am J Obstet

Gynecol 2016;215;539-47

Slide40

complications 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

Slide41

complications 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

Slide42

Nutritional 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

Slide43

Referral for TreatmentProvide to those identified to be at high risk (SUD) who are in need of specialty addiction care

Slide44

Referral for TreatmentBehavioral therapy (chemical dependency treatment)MAT (now MT for OUD)Buprenorphine

Methadone

Slide45

Behavioral 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

Slide46

ResourcesSAMHSA (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)

Slide47

resources

Slide48

Key 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

Slide49

Requirements 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

Slide50

How 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

Slide51

Questions?