Perinatal Substance Abuse Program - PowerPoint Presentation

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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

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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

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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%

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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!