Melanie Watkins, MD

SUBSTANCE ABUSE IN

PREGNANCYMelanie M. Watkins, MD

Staff Psychiatrist

Contra Costa Regional Medical Center

December 15, 2010

Melanie Watkins, MD

DISCLOSURE OF CONFLICT OF INTEREST

Speaker has nothing to disclose

CONTRA COSTA REGIONAL MEDICAL CENTER

NOON CONFERENCE SERIES

Melanie Watkins, MD

OBJECTIVES

Participants will be able to: Take a substance abuse history and learn more

about screening tools used specifically for the pregnant population

Discuss co-occurring medical diagnoses and psychosocial concerns

Understand consequences of substance dependence (medical, legal, social).

Discuss perinatal and neonatal outcomes Discuss management and treatment

Melanie Watkins, MD

OVERVIEW At least 50 percent of women in the U.S. who

use illicit drugs are within childbearing ages of 15 to 44

Best way to decrease the numbers of women who have substance use concerns in pregnancy is to talk with them about family planning to reduce the numbers of pregnancies.

Women who have substance use concerns are less likely to use contraception and are more vulnerable. They may also have underlying mental health concerns.

However, pregnancy can be a great time to intervene—patients tend to be highly motivated.

Melanie Watkins, MD

DEFINITION Use-sporadic consumption of alcohol or drugs with

no apparent consequences Abuse-some consequences of use are experienced Physiological Dependence-state of adaptation that

is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation or rapid dose reduction of a drug, or by administration of an antagonist

Psychological Dependence-subjective need for a specific psychoactive substance for its positive effects or to avoid negative effects a/w abstinence

Addiction-chronic, neurobiologic disease with genetic, psychosocial, and environmental factors. Characterized by impaired control, compulsive use, continued use despite consequences

Melanie Watkins, MD

PREVALENCE Approximately 5% of pregnant women

use illicit substances* Larger proportion use cigarettes and

alcohol Many use more than one substance Among women aged 15 to 17 who were

pregnant had a higher rate of use than those who were not pregnant (21.6 v 12.9)

*National Survey on Drug Use and Health: National Findings. Department of Health and Human Services.

(http://oas.samhsa.gov/NSDUH)

Melanie Watkins, MD

RISK FACTORS Late initiation of prenatal care Multiple missed prenatal visits Impaired school or work performance Past OB history of: miscarriage, growth

restriction, prematurity, placental abruption, stillbirth, precipitous delivery

Offspring with neurodevelopmental or behavioral pblms

Offspring not living with mother or involved with CPS

Melanie Watkins, MD

RISK FACTORS H/o drug or alcohol related problems

(e.g. pancreatitis, skin abscesses, SBE) Family history of substance use (genetic

and environmental factors) Frequent encounters with law

enforcement agencies Having a partner who abuses

substances**(particularly important for women who may have been introduced to and supplied with drugs from partner)

Melanie Watkins, MD

SCREENING AND HISTORY Who? What? When? Where? Why? How?

Melanie Watkins, MD

SCREENING• What to ask? (History of use, frequency

of use, route of administration)• Previous treatment (self help groups,

residential, etc)• Previous consequences of use (children

taken away, jail, )• Factors: denial, stigma, shame• Urine drug screen/urine toxicology

Melanie Watkins, MD

SCREENING TOOLS

The T-ACE questions are: How many drinks does it take for you to feel high (TOLERANCE)? Do you feel ANNOYED by people complaining about your drinking? Have you ever felt the need to CUT down on your drinking? Have you ever had a drink first thing in the morning (EYE-

OPENER)?

TWEAK is another screening instrument used in pregnant women:T = TOLERANCE for alcoholW = WORRY or concern by family or friends about drinking behaviorE = EYE OPENER, the need to have a drink in the morningA = "blackouts" or AMNESIA while drinkingK = the self-perception of the need to CUT DOWN on alcohol

4P’s Plus Screen for Perinatal Substance Use “Parents, Partner, Past, and Pregnancy”

Melanie Watkins, MD

SCREENING (PHYSICAL AND BEHAVIORAL) Mood changes Appetite changes (weight loss/decreased

appetite) Sleep disturbances Infections (endocarditis, hepatitis, HIV) Skin (tracks, absecesses, perforation of

nasal septum) STDs Bizarre behavior Physical changes such as tachycardia,

pupillary size, sweating, conjunctival injection, arousal (agitation or sedation)

Melanie Watkins, MD

SUBSTANCE ABUSE HISTORY Previous treatment (self help,

residential, etc) Longest periods of sobriety/abstinence. History of IVDU/shared needles (even if

not currently using this route) Patterns of use (time of day, social,

when stressed, etc) What has been helpful in the past and

what hasn’t worked? Why?

Melanie Watkins, MD

SUBSTANCE ABUSE HISTORYMore specifically: Quantity Amount spent Time spent Time of last use Frequency Consequences of use (arrests, loss of

custody, accidents, DUIs, etc)

Melanie Watkins, MD

MEDICAL AND LEGAL CONCERNSAccording to Guttmacher institute (as of

December 1, 2010): 15 states consider substance abuse

during pregnancy child abuse and 3 consider it grounds for civil commitment

14 states require health care professionals to report suspected prenatal drug abuse and 4 states require testing for exposure if suspect abuse

Melanie Watkins, MD

AMERICAN PSYCHIATRIC ASSOCIATION POSITION STATEMENT ON THE CARE OF PREGNANT AND NEWLY DELIVERED WOMEN ADDICTS

APA opposes the criminal prosecution and incarceration of pregnant and/or newly delivered women on child abuse charges based solely on the use of substances during pregnancy.  (Child abuse charges may be appropriate if positive evidence of abuse or neglect is found following the birth of a child.)  The best way to prevent abuse and neglect in this situation is adequate treatment for the mother and family.

APA advocates that adequate prenatal care be available to all pregnant women, including pregnant addicts, irrespective of ability to pay and without fear of punitive consequences.

APA urges that societal resources be directed not to punitive actions but to adequate preventive and treatment services for these women and children. APA strongly advocates the development and funding of the necessary inpatient, outpatient, and residential programs for mothers with their children.  Services should address and foster the parental functions, as well as the care of individual mother and child.

APA opposes involuntary commitment laws that are applied only to pregnant women in ways that do not apply to men or women who are not pregnant.

Melanie Watkins, MD

MATERNAL LABORATORY TESTING Urine, blood, hair, saliva and sweat. Implications and ethical considerations States requirements vary for testing

and reporting drug test results*

*Guttmatcher institute handout

Melanie Watkins, MD

NEONATAL LABORATORY TESTING Usually urinalysis May detect only recent maternal use May test meconium (begins to form at

12 weeks gestation and the presence and concentration of drug in meconium is thought to be related to the amount, timing and duration of drug exposure during intrauterine life). Can test meconium up to three days after delivery

Neonatal hair can be tested for narcotics, marijuana and cocaine use

Melanie Watkins, MD

COMORBID ILLNESS AND CONDITIONS Medical (HIV/Hepatitis) Homeless Unemployment Mental illness Abuse (physical, sexual, emotional) Lack of transportation

Melanie Watkins, MD

PATIENT SCREENS POSITIVE, NOW WHAT?

Counseling regarding risks of substances Multidisciplinary team (nurses, social worker, case

manager, etc) Testing for STDs Increased frequency of prenatal visits to monitor

mother and fetus and to provide additional support Early ultrasound to confirm GA and accurate

baseline to follow fetal growth Begin antepartum surveillance if evidence of

complications (IUGR, 3rd trimester bleeding maternal withdrawal)

Informing pediatrician of mother’s substance use history

Discouraging breastfeeding if continuing to abuse illicit drugs

Melanie Watkins, MD

MARIJUANA USE IN PREGNANCY Most commonly used illicit substance taken during

pregnancy Prevalence varies based on age, ethnicity, SES Impact of prenatal marijuana use unclear Some studies indicate that heavy users may have

offspring with smaller head circumference. There may be a trend towards decrease in birthweight.

As with other substances, there are likely confounding variables. Pregnant persons who use marijuana are also more likely to drink alcohol and smoke cigarettes.

Emerging data indicate there may be effects on later functioning and even an increased of some cancers.

Cannabinoids relax uterine muscle (no a/w PTL)

Melanie Watkins, MD

METHAMPHETAMINE USE IN PREGNANCY Diagnosis is becoming more common in

hospitalized pregnant women The drug most often produced by clandestine

laboratories in the U.S. Speed, meth, chalk (or as ice, crystal, and

glass when smoked) Known neurotoxic agent-damages endings of

brain cells containing dopamine Studies have shown neonates to be 3.5x likely

to be SGA and there is an association with poor neurobehavioral outcomes (decreased arousal, increased stress, poor quality of movement) first five days of life.

Melanie Watkins, MD

COCAINE USE IN PREGNANCY More pregnant women smoke

cigarettes, drink alcohol, or smoke marijuana than use cocaine

5.3 million Americans ages 12 and older had abused cocaine (in any form) according to National Survey on Drug Use and Health in 2008.

Melanie Watkins, MD

COCAINE USE IN PREGNANCYVASOCONTRICTION is the major mechanism

for fetal and placental damage.Effects on fetus: SAB Prematurity Placental Abruption Fetal death LBW, shorter length and smaller head

circumference*Teratogenic effects have not been definitely

established

Melanie Watkins, MD

COCAINE EXPOSURE: LONG TERM EFFECTSPreschoolers who were exposed to

cocaine: Have verbal and performance IQ scores

similar to unexposed children Visual spatial skills, general knowledge

and arithmetic skills are lower Lower likelihood of IQ score above the

mean for the general population

*Quality of home environment is most important predictor of outcome

Melanie Watkins, MD

ALCOHOL USE IN PREGNANCY

Melanie Watkins, MD

PREGNANT WOMEN AGES 15-44 Current alcohol usage: 10.6% Binge drinking: 4.5% Heavy drinking: 0.8%

Melanie Watkins, MD

ALCOHOL USE AND PREGNANCY Alcohol freely crosses the placenta and

is known to be teratogenic. Infants whose mothers consume alcohol during pregnancy can have acute withdrawal presenting several hours after birth, have chronic non-reversible sequelae defined as the fetal alcohol spectrum disorder (FASD), or they may be normal

Melanie Watkins, MD

ALCOHOL USE IN PREGNANCYHow much is too much? *Risk drinking during pregnancy has beendefined as an average of more than 1 drink(e.g. 5 ounce glass of wine) per day or

binges of > 5 drinks per episode.*Recent research documents deleteriousoutcomes for children prenatally exposed tosmall amounts of alcohol (e.g. one drink of

wine per day)* No proven safe amount of alcohol use

during pregnancy.

Melanie Watkins, MD

ALCOHOL USE AND PREGNANCY Older maternal age, high parity, and being African-

American or Native American appear to increase the risk of FAS for unknown reasons.

Maternal polymorphisms of the alcohol dehydrogenase gene (ADH) that encodes an enzyme responsible for alcohol metabolism could explain variations in the extent of neonatal damage among individuals ingesting the same amount of ethanol . The presence of the ADH1B*3 allele in the mother appears to protect the fetus from the effects of prenatal exposure of alcohol. This allele results in an isoenzyme that is associated with more rapid metabolism of alcohol.

Binge drinking during pregnancy exerts a potentially greater negative effect than comparable consumption of low amounts of alcohol that results in the same volume of consumption (eg, four drinks in one sitting versus one drink a day for four days) .

FASD (FETAL ALCOHOL SPECTRUM DISORDERS)FASD is an umbrella term describing the range of

effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects may include physical, mental, behavioral, and/or learning disabilities with possible lifelong implications.

FASD includes the following conditions: – Fetal alcohol syndrome (FAS), including partial

FAS – Fetal alcohol effects (FAE) – Alcohol-related birth defects (ARBD) – Alcohol-related neurodevelopmentaldisorder

(ARND)

www.fasdpn.org Melanie Watkins, MD

Melanie Watkins, MD

DIAGNOSIS OF FETAL ALCOHOL SYNDROME

Evidence of intrauterine and postnatal growth retardation (height or weight ≤10th percentile , failure to thrive not caused by inadequate intake, disproportionate growth e.g. low weight to height)

Evidence of deficient brain growth or brain malformation (structural brain abnormalities , head circumference ≤10th percentile , abnormal neurologic examination )

Evidence of a characteristic pattern of minor facial anomalies (short palpebral fissures (≤10th percentile), thin vermilion border of the upper lip, smooth philtrum, flattened midface)

Adapted from American Academcy of Pediatrics. Pediatrics 2005; 115:39.

Melanie Watkins, MD

CIGARETTE SMOKING AND PREGNANCY Cigarette smoking during pregnancy has

been associated with complications and adverse effects at delivery including:

placental abruption, premature rupture of membranes placenta previa preterm labor and delivery, and low birth

weight (LBW) *These complications contribute to an

increase in neonatal mortality of infants prenatally exposed to tobacco compared to unexposed infants

Melanie Watkins, MD

CIGARETTE USE IN PREGNANCY Sudden infant death syndrome (SIDS) — Several

prospective case controlled studies from different countries have shown that maternal smoking during pregnancy increases the risk of SIDS two to four-fold . Smoking also increases other known risk factors for SIDS such as preterm birth and low birth weight.

Increased risk of developing asthma. Diabetes mellitus — Cigarette smoking by the individual

has been associated with an increased risk of type 2 diabetes.

Cognitive ability — Several cohort studies have reported an inverse association between maternal smoking during pregnancy and offspring cognitive ability. However, in many of these studies, confounding variables (particularly maternal characteristics such as socioeconomic status, use of other drugs of abuse, and maternal cognitive ability) were not well controlled.

Melanie Watkins, MD

OPIATE USE IN PREGNANCY Growing problem in U.S. Long term prescription use in young

women and pregnant women warrants assessment for addiction.

Melanie Watkins, MD

OPIATE USE IN PREGNANCY 25 percent of women of reproductive

age who abuse substances use heroin. (Short term) Maternal concerns are:

infection, psychosocial stress, violence. Prescription opiates are a more and

more of a concern

Melanie Watkins, MD

OPIATE DEPENDENCE: PERINATAL OUTCOMES Preeclampsia 3rd Trimester bleeding Malpresentation NRFHT Passage of meconium LBW Perinatal mortality Perinatal morbidity

Melanie Watkins, MD

OPIATE DEPENDENCE: NEONTAL OUTCOMES Prematurity Opiate withdrawal Post natal growth deficiency Microcephaly Neurobehavioral deficits SIDS***Sometimes difficult to determine if

prblms are due to opiates or due to coexistent medical, nutritional, psychological and socioeconomic concerns.

Melanie Watkins, MD

OPIATE DEPENDENCE: TREATMENT Methadone Used for over 30 years Oral adminstration (liquid or pills) Not associated w/ birth defects, but a/w

fetal and neonatal effects Several maternal, obstetrical, and

neonatal benefits Barriers to treatment

Melanie Watkins, MD

METHADONE MAINTENACE DURING PREGNANCYBroad topic!Important to know: Avoid detox in the first or third trimester Dosing is usually BID or TID Women are more likely to receive PNC Pregnant women usually require higher doses Patients are screened weekly for drug use (one third

to two-thirds of women enrolled in methadone maintenance programs continue to use alcohol and other drugs)

Dose is usually decreased immediately postpartum Pain control and anesthesia are challenging and

complex American academy of pediatrics lists methadone as

compatible with breastfeeding (any dose).

Melanie Watkins, MD

OPIATE DEPENDENCE: TREATMENTBuprenorphine

Can “continue” buprenorphine, but need more data.

No “new starts”, but may be alternative to methadone

Administered by specially certified physicians

Lower, but still substantial, risk of NAS (neonatal abstinence syndrome)

Not a standard treatment at this point

Melanie Watkins, MD

MANAGEMENTFactual and non-judgmental informationDiscussion about maternal and fetal riskTesting (UDS) Assessing motivationDiscussing factors that may influence

treatment

Melanie Watkins, MD

TREATMENT AA and NA (self help) Residential treatment Substance dependence treatment

programs (outpatient, PHP, IOP) Smoking cessation programs 1-800-NO

BUTTS Medication (e.g. methadone, buproprion,

nicotine patch) Treating underlying disorder Social support (social services) Collaborative care (ob/gyn, psychiatrist,

case management/social services, etc)

Melanie Watkins, MD

RESOURCES FOR PREGNANT WOMEN WITH SUBSTANCE USE CONCERNS IN CONTRA COSTA COUNTY Born Free Program 925-431-2440 (east

county) or 510-231-1390 (west county) Perinatal Outpatient Substance Abuse

(New Connections 925-363-5000 Ujima East 925-427-9100 (east county) Ujima Family Recovery Services 925-

229-0230 (central county)

Melanie Watkins, MD

FOR MORE INFORMATION UptoDate.com (recent journal articles) Guttmatcher institute American Psychiatric Association (APA) American College of Obstetrics and

Gynecology(ACOG) Pubmed NIH and NIMH US Department of Health and Human Services NIDA (National Institute on Drug Abuse) Maternal, Child and Adolescent Health

Program, California Department of Public Health (Publication on Perinatal Substance Use Screening in California).

Melanie Watkins, MD