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Prenatal Alcohol and Drug Prenatal Alcohol and Drug Exposure:Exposure:
Impact and InterventionImpact and InterventionNovember 7, 2007November 7, 2007
Conjoint 556Conjoint 556 Addiction: Mechanisms, Prevention, Treatment Addiction: Mechanisms, Prevention, Treatment
Therese Grant, Ph.D.Therese Grant, Ph.D.Director, Fetal Alcohol and Drug UnitDirector, Fetal Alcohol and Drug Unit
Associate ProfessorAssociate ProfessorDepartment of Psychiatry & Behavioral SciencesDepartment of Psychiatry & Behavioral Sciences
University of Washington School of MedicineUniversity of Washington School of Medicine
TopicsTopics• Teratogenic effects of alcohol and drugsTeratogenic effects of alcohol and drugs
• Fetal alcohol syndromeFetal alcohol syndrome
• Prevalence of prenatal alcohol usePrevalence of prenatal alcohol use
• Intervention and Prevention: Parent-Intervention and Prevention: Parent-Child Assistance ProgramChild Assistance Program
• Challenges of conducting evidence-Challenges of conducting evidence-based community interventionbased community intervention
T e r a t o g e n sT e r a t o g e n s• Substances that have the potential to damage Substances that have the potential to damage
the fetus when exposure occurs during the fetus when exposure occurs during pregnancy (e.g., radiation, thalidomide, pregnancy (e.g., radiation, thalidomide, alcohol). alcohol).
• Degree of damage depends on timing and Degree of damage depends on timing and dose of exposure.dose of exposure.
• If timing and dose are below the teratogenic If timing and dose are below the teratogenic threshold, some exposures have little risk of threshold, some exposures have little risk of causing malformation.causing malformation.
Prenatal Opiate ExposurePrenatal Opiate Exposure
• Is not considered teratogenic; no known congenital Is not considered teratogenic; no known congenital malformation is associated.malformation is associated.
However:However:• May affect prenatal growth due to maternal malnutrition May affect prenatal growth due to maternal malnutrition
and co-morbid infections. LBW and intrauterine growth and co-morbid infections. LBW and intrauterine growth retardation increase risk of preterm birth.retardation increase risk of preterm birth.
• Newborns of addicted women can suffer withdrawal. If Newborns of addicted women can suffer withdrawal. If mother was IV drug user, children may be at increased mother was IV drug user, children may be at increased risk for HIV, Hepatitis B & C. risk for HIV, Hepatitis B & C.
• It’s difficult to differentiate impact of prenatal heroin It’s difficult to differentiate impact of prenatal heroin exposure and poor postnatal environment on child long-exposure and poor postnatal environment on child long-term outcome.term outcome.
Prenatal Marijuana ExposurePrenatal Marijuana Exposure
• There is no consistent link between prenatal There is no consistent link between prenatal marijuana exposure and other adverse marijuana exposure and other adverse pregnancy outcomes or congenital pregnancy outcomes or congenital malformation.malformation.
• Marijuana use during pregnancy may have a Marijuana use during pregnancy may have a modest effect on prenatal growth, but results modest effect on prenatal growth, but results are inconsistent and diminish when potential are inconsistent and diminish when potential cofounders are controlled.cofounders are controlled.
Prenatal Marijuana ExposurePrenatal Marijuana Exposure
• The principle psychoactive substance in The principle psychoactive substance in marijuana, marijuana, -9-tetrahyrocannabinol (THC), -9-tetrahyrocannabinol (THC), rapidly crosses the placenta and may remain rapidly crosses the placenta and may remain in the body for 30 days, thus prolonging in the body for 30 days, thus prolonging potential fetal exposure. potential fetal exposure.
• Marijuana smoking produces higher levels of Marijuana smoking produces higher levels of carbon monoxide than tobacco, which may carbon monoxide than tobacco, which may be a potential mechanism of action of be a potential mechanism of action of marijuana’s impact on the developing fetus.marijuana’s impact on the developing fetus.
Prenatal Cocaine ExposurePrenatal Cocaine Exposure
• Cocaine and its metabolites readily cross the Cocaine and its metabolites readily cross the
placenta, concentrating in amniotic fluid, and placenta, concentrating in amniotic fluid, and
may produce direct neurotoxic effects, disturb may produce direct neurotoxic effects, disturb
dopamine, norepinephrine, and serotonin dopamine, norepinephrine, and serotonin
pathways, and cause vascular-mediated pathways, and cause vascular-mediated
damage.damage.
Prenatal Cocaine ExposurePrenatal Cocaine Exposure
• Associated with obstetric complications: stillbirth, Associated with obstetric complications: stillbirth, placental abruption, premature rupture of placental abruption, premature rupture of membranes, fetal distress, and preterm delivery. membranes, fetal distress, and preterm delivery.
• Growth restriction, but may require higher levels of Growth restriction, but may require higher levels of exposure and does not seem to persist after birth. exposure and does not seem to persist after birth.
• The few available large, controlled, population-based The few available large, controlled, population-based studies have reached contradictory conclusions. studies have reached contradictory conclusions. CNS lesions (e.g., stroke, possible seizures), cardiac CNS lesions (e.g., stroke, possible seizures), cardiac defects, and genitourinary anomalies have been defects, and genitourinary anomalies have been reported.reported.
Prenatal Methamphetamine Prenatal Methamphetamine ExposureExposure
• Impact of meth use during human pregnancy Impact of meth use during human pregnancy is currently unknown.is currently unknown.
• Animal studies have demonstrated Animal studies have demonstrated neurotoxic effects of amphetamines and neurotoxic effects of amphetamines and alteration of synaptic morphology in alteration of synaptic morphology in response to prenatal methamphetamine response to prenatal methamphetamine exposure.exposure.
Prenatal Methamphetamine Prenatal Methamphetamine ExposureExposure
• Women using meth during pregnancy may have an Women using meth during pregnancy may have an increased rate of premature delivery and placental increased rate of premature delivery and placental abruption. abruption.
• Linked to fetal growth restriction and, occasionally, Linked to fetal growth restriction and, occasionally, withdrawal symptoms requiring pharmacologic withdrawal symptoms requiring pharmacologic intervention at birth. intervention at birth.
• Clefting, cardiac anomalies, and fetal growth reduction Clefting, cardiac anomalies, and fetal growth reduction have been described in infants and have been have been described in infants and have been reproduced in animal studies. reproduced in animal studies.
• Later effects on child health are unknown.Later effects on child health are unknown.
Prenatal Tobacco ExposurePrenatal Tobacco Exposure
• Associated with poor fetal growth; the most Associated with poor fetal growth; the most important cause of LBW in developed important cause of LBW in developed countries.countries.
• Linked to myriad perinatal complications and Linked to myriad perinatal complications and child health problems (along with child health problems (along with environmental smoke exposure, or ESE). environmental smoke exposure, or ESE). ESE is implicated in LBW, fetal death, and ESE is implicated in LBW, fetal death, and preterm delivery. preterm delivery.
• Implicated in a range of adverse behavioral Implicated in a range of adverse behavioral and cognitive outcomes.and cognitive outcomes.
Prenatal Tobacco ExposurePrenatal Tobacco Exposure• Cigarette smoke contains tar, nicotine, and Cigarette smoke contains tar, nicotine, and
carbon monoxide. carbon monoxide.
• Tar contains substances (lead, cyanide, Tar contains substances (lead, cyanide, cadmium, and more) harmful to the fetus. cadmium, and more) harmful to the fetus.
• Intrauterine hypoxia, mediated by carbon Intrauterine hypoxia, mediated by carbon monoxide and reduced uterine blood flow, is a monoxide and reduced uterine blood flow, is a major mechanism of the growth impairment.major mechanism of the growth impairment.
• Nicotine crosses the placenta and distributes Nicotine crosses the placenta and distributes freely to the CNS, having direct and indirect freely to the CNS, having direct and indirect effects on neural development. effects on neural development.
Prenatal Alcohol ExposurePrenatal Alcohol Exposure
Alcohol is a teratogen
Prenatal Alcohol ExposurePrenatal Alcohol Exposure
Effects have been demonstrated in animals and humans
Neurobehavioral effects have been found to
be more injurious and long-lasting than
cocaine and other drugs abused prenatally.
Teratogenic EffectsTeratogenic Effects
of Prenatal Alcohol of Prenatal Alcohol
ExposureExposure
• Direct toxic effect of alcohol on cells
• Hypoxia (inadequate oxygenation of blood) due to impaired placental/fetal blood flow
• Effect on cell migration in the brain
• Effect on apoptosis (a natural process of programmed cell death)
Fetal Alcohol SyndromeFetal Alcohol Syndrome
• A permanent birth defect caused by maternal A permanent birth defect caused by maternal
alcohol use during pregnancy.alcohol use during pregnancy.
• The leading preventable cause of mental The leading preventable cause of mental
retardation in the Western world.retardation in the Western world.
• Annually: 40,000 infants born with FASD Annually: 40,000 infants born with FASD
(more common than Muscular Dystrophy, (more common than Muscular Dystrophy,
Cystic Fibrosis, Downs Syndrome and Cystic Fibrosis, Downs Syndrome and
Spina Bifida combined).Spina Bifida combined).
FAS
Central Nervous System Dysfunction Organic Brain Damage
• Hyperactivity, attention deficits
• Intellectual deficits, learning disorders
• Problems with memory, language & judgment
• Developmental delay, microcephaly
• Fine & gross motor problems, seizure disorder
• Mental retardation, structural brain damage
Growth Deficiency
Specific Pattern of Facial Anomalies
Fetal Alcohol Spectrum Fetal Alcohol Spectrum Disorders (FASD)Disorders (FASD)
can becan be
“Hidden Disabilities”
FAS Family Resource Institute
FASD
Central Nervous System Central Nervous System Dysfunction Dysfunction
Organic Brain DamageOrganic Brain Damage• Hyperactivity, attention deficitsHyperactivity, attention deficits• Intellectual deficits, learning disordersIntellectual deficits, learning disorders• Problems with memory, language & Problems with memory, language & judgmentjudgment• Developmental delay, microcephalyDevelopmental delay, microcephaly• Fine & gross motor problems, seizure Fine & gross motor problems, seizure disorderdisorder• Mental retardation, structural brain Mental retardation, structural brain damagedamage
FASD: Clinical ImplicationsFASD: Clinical Implications
Poor judgment ………… Easily victimizedPoor judgment ………… Easily victimized
Attention deficits ……… Unfocused / distractibleAttention deficits ……… Unfocused / distractible
Arithmetic disability ….. Can’t handle moneyArithmetic disability ….. Can’t handle money
Memory problems ….. Doesn’t learn from experienceMemory problems ….. Doesn’t learn from experience
Difficulty abstracting …. Doesn’t understand Difficulty abstracting …. Doesn’t understand consequencesconsequences
Disoriented in …………. Fails to perceive social cues Disoriented in …………. Fails to perceive social cues time and spacetime and space
Poor frustration ………... Quick to angerPoor frustration ………... Quick to anger tolerancetolerance
PREVALENCE OF SECONDARY DISABILITIESAcross the Life Span
100
90
80
70
60
50
40
30
20
10
Ages 6-51 (n=408-415) Ages 21-51 (n=89-90)
%
Mental Health Problems
Disrupted School Experience
Trouble With the Law
Confinement
Inappropriate Sexual Behavior
Alcohol & Drug Problems
Dependent Living
Problems with Employment
Ages 6 - 51 Ages 21 - 51
Alcohol Drinking Alcohol Drinking
by Pregnant Women by Pregnant Women
Western WA: 1989-2004Western WA: 1989-2004
We conducted three federally-funded We conducted three federally-funded
studies on problems associated with studies on problems associated with
prenatal substance abuse.prenatal substance abuse.
Study purposes varied, but all involved Study purposes varied, but all involved
screening hospitalized postpartum screening hospitalized postpartum
women shortly after delivery for prenatal women shortly after delivery for prenatal
alcohol and drug use. alcohol and drug use.
Description of the StudiesDescription of the Studies
Study 1:Study 1: Mar. 1989 – Apr. 1991 (Mar. 1989 – Apr. 1991 (N= 7,178N= 7,178))Prospective study investigated neurodevelopmental Prospective study investigated neurodevelopmental
outcomes of children exposed to cocaine in uterooutcomes of children exposed to cocaine in utero (Obstetrics and Gynecology(Obstetrics and Gynecology (1994), 83(4), 524-531) (1994), 83(4), 524-531)
Study 2:Study 2: Jul. 1991 – Dec. 1992 (N=2,330)Jul. 1991 – Dec. 1992 (N=2,330)Tested efficacy of a 3-year home visitation interventionTested efficacy of a 3-year home visitation intervention
(Journal of Community Psychology (2003), 31(3), 211-222)(Journal of Community Psychology (2003), 31(3), 211-222)
Study 3:Study 3: Jun. 2002 – Mar. 2004 (N=3,145)Jun. 2002 – Mar. 2004 (N=3,145)Evaluated efficacy of a 12-month intervention program Evaluated efficacy of a 12-month intervention program
using a randomized design FAS/ARBD Prevention: using a randomized design FAS/ARBD Prevention: Research to PracticeResearch to Practice
(APHA 133rd Annual Meeting. Dec. 2005. Philadelphia, PA)(APHA 133rd Annual Meeting. Dec. 2005. Philadelphia, PA)
ResultsResults
MONTH BEFORE PREGNANCY DURING PREGNANCY
Any Binge Any Binge
Alcohol Alcohol Alcohol Alcohol
STUDY 1 45% 9% 30% 3%1989-1991
STUDY 2 41% 10% 23% 4% 1991-1992
STUDY 3 43% 14% 12% 1% 2002-2004
The Good NewsThe Good News
Drinking during pregnancy Drinking during pregnancy decreaseddecreased between 1989 and 2004between 1989 and 2004
• Public health messages about drinking Public health messages about drinking during pregnancy have clearly had an during pregnancy have clearly had an impact.impact.
• In general, when women know they are In general, when women know they are pregnant, they decrease their alcohol pregnant, they decrease their alcohol consumption.consumption.
Remaining Challenges Remaining Challenges
Binge drinking “pre-pregnancy” (or prior to Binge drinking “pre-pregnancy” (or prior to pregnancy recognition) has pregnancy recognition) has increasedincreased between between 1989 and 2004 1989 and 2004
• Up to 60% of women don’t know they are pregnant in Up to 60% of women don’t know they are pregnant in early gestation and may unintentionally drink during early gestation and may unintentionally drink during this vulnerable period this vulnerable period
• Heavy drinking may lead to unexpected, unprotected Heavy drinking may lead to unexpected, unprotected sexual activitysexual activity
• More than half of all pregnancies in the U.S. are More than half of all pregnancies in the U.S. are unintended unintended
February 21, 2005February 21, 2005U.S. Surgeon General Releases U.S. Surgeon General Releases
Advisory on Alcohol Use in PregnancyAdvisory on Alcohol Use in Pregnancy
Women who are pregnant or who may become Women who are pregnant or who may become
pregnant should abstain from alcohol pregnant should abstain from alcohol
consumption in order to eliminate the consumption in order to eliminate the
chance of giving birth to a baby with any of chance of giving birth to a baby with any of
the harmful effects of the Fetal Alcohol the harmful effects of the Fetal Alcohol
Spectrum Disorders (FASD).Spectrum Disorders (FASD).
This updates a 1981 Surgeon General's Advisory.This updates a 1981 Surgeon General's Advisory.
If I’m Pregnant, Can I …If I’m Pregnant, Can I …
……Have a beer?Have a beer?The Centers for Disease Control says “no level of The Centers for Disease Control says “no level of alcohol…has been determined safe,” but some alcohol…has been determined safe,” but some doctors feel limited drinking – no more than a doctors feel limited drinking – no more than a pint a day, suggests Dr. Gibb – after the first pint a day, suggests Dr. Gibb – after the first trimester is okay.trimester is okay.
- People Magazine, April 17, 2006, pp - People Magazine, April 17, 2006, pp 102-107102-107
What would aWhat would a
cure for addictioncure for addiction
look like?look like?
WHEN CASE MANAGEMENTWHEN CASE MANAGEMENT ISN’T ENOUGH ISN’T ENOUGH
Community Intervention & Prevention:Community Intervention & Prevention:
Parent-Child Assistance Program (PCAP)Parent-Child Assistance Program (PCAP)
A 3-year intensive home visitation A 3-year intensive home visitation
intervention for high risk mothersintervention for high risk mothers
who abuse alcohol and/or drugs who abuse alcohol and/or drugs
during pregnancyduring pregnancy
The ProblemThe Problem
· possible effects of prenatal exposure on the child’s health
· likelihood of a compromised home environment
· likelihood that these mothers will have more exposed, affected children
Maternal alcohol and drug abuse puts children at risk because of:
PCAP HistoryPCAP History1991-present1991-present• WA State locations: King, Pierce, Yakima, Grant, WA State locations: King, Pierce, Yakima, Grant, Spokane, Cowlitz, Skagit Counties Spokane, Cowlitz, Skagit Counties
• Replication sites: MN, NC, AK, TX, NV, LA, PA; Replication sites: MN, NC, AK, TX, NV, LA, PA; multiple sites in Canada multiple sites in Canada
We thank our sponsors:We thank our sponsors:Substance Abuse and Mental health Services Substance Abuse and Mental health Services Administration (SAMHSA) Administration (SAMHSA)WA State Dept. Social and Health Services WA State Dept. Social and Health Services Division of Alcohol and Substance AbuseDivision of Alcohol and Substance AbuseMarch of DimesMarch of DimesNesholm Family FoundationNesholm Family FoundationPrivate PhilanthropyPrivate Philanthropy
Parent-Child Assistance ProgramParent-Child Assistance Program
To prevent future births To prevent future births
of alcohol and drug exposed of alcohol and drug exposed
childrenchildren
Primary Goal:Primary Goal:
Theoretical Framework of the Theoretical Framework of the InterventionIntervention
Relational TheoryRelational Theory
A woman’s sense of connectedness to A woman’s sense of connectedness to others is central to her growth, others is central to her growth,
development, definition of selfdevelopment, definition of self
PCAP InterventionPCAP Intervention
Long term, positive interpersonal Long term, positive interpersonal relationship with case manager relationship with case manager
Relational TheoryRelational Theory
Consequences of alcohol and drug abuse differ among women and men in terms of physiological effects and social consequences.
Positive relationships within the intervention, treatment, and recovery setting are critical.
The quality of interpersonal relationships:
• may determine whether or not a woman remains in an intervention
• may be more important to improvement than concrete services received
PCAP Case ManagersPCAP Case Managers
• • Have experienced some of the same Have experienced some of the same types of adverse life circumstances as types of adverse life circumstances as clients, but seldom to same degreeclients, but seldom to same degree
• • Have subsequently achieved success in Have subsequently achieved success in important waysimportant ways
• • Are positive role models and offer clients Are positive role models and offer clients hope and motivation from a realistic hope and motivation from a realistic
perspective perspective
Washington State Washington State PCAPPCAP
(2007 Annual Work (2007 Annual Work Session)Session)
Theoretical FrameworkTheoretical Framework
Stages of ChangeStages of Change
Clients will be at different stages of readiness Clients will be at different stages of readiness for change. Motivation is a process for for change. Motivation is a process for change that occurs within the context of change that occurs within the context of interpersonal relationships.interpersonal relationships.
PCAP InterventionPCAP Intervention
Motivational InterviewingMotivational Interviewing
• • acknowledge client’s perception of situationacknowledge client’s perception of situation• • encourage her to explore + and – aspectsencourage her to explore + and – aspects
From Prochaska & DiClementeFrom Prochaska & DiClemente
MOTIVATIONMOTIVATION
DECISION-MAKINGDECISION-MAKING
SELF-EFFICACYSELF-EFFICACY
CONTEMPLATIONCONTEMPLATION
PRE-CONTEMPLATIONPRE-CONTEMPLATION
PREPARATIONPREPARATION
ACTIONACTION
MAINTENANCEMAINTENANCE
Theoretical FrameworkTheoretical Framework
Harm ReductionHarm Reduction Addiction and associated risks are on a Addiction and associated risks are on a continuum. The goal is to reduce continuum. The goal is to reduce harmful harmful consequences of the habit for consequences of the habit for mother and mother and her child.her child.
PCAP InterventionPCAP Intervention
Any steps toward decreased risk are Any steps toward decreased risk are steps in the right direction.steps in the right direction.
Characteristics of Effective Case Management Characteristics of Effective Case Management
Community Providers
Juvenile Justice
Probation
Alc/DrugTx
Mental HealthTX
Health Care
FamilyPlanning
Job Training
Schools BioBio MomMom BioBio
DaDaddSiblingsSiblings
FriendsFriends
PartnersPartners
ChildrenChildren
NeighborsNeighbors
ExtendedExtendedFamilyFamily
Care-Care-takerstakers
PCAP Case Managers:PCAP Case Managers:
• Work with a caseload of 16 families, Work with a caseload of 16 families, make home visits, transportmake home visits, transport
• Help client identify personal goals, Help client identify personal goals, and teach “baby steps” to achieve and teach “baby steps” to achieve these goalsthese goals
• Collaborate with network of serviceCollaborate with network of serviceproviders to develop specific providers to develop specific plans with client inputplans with client input
• Connect clients with services, monitor Connect clients with services, monitor progressprogress
The goal The goal
is to help the client is to help the client
move along a continuum, move along a continuum,
from dependence on the case manager, from dependence on the case manager,
to interdependence with the case manager, to interdependence with the case manager,
to independence and strength on her own.to independence and strength on her own.
PCAP Enrollment CriteriaPCAP Enrollment Criteria
1) Currently pregnant or up to six months postpartum
2) Used alcohol/drugs heavily during pregnancy
3) Not effectively connected with community resources
- OR -
Have delivered a child with a diagnosis of FAS/FASD
The Formula for Preventing The Formula for Preventing Alcohol/Drug Exposed BirthsAlcohol/Drug Exposed Births
• • Motivate women to stop drinking Motivate women to stop drinking or using drugs before and or using drugs before and
during pregnancyduring pregnancy
• • Help women who can’t stop Help women who can’t stop drinking or using drugs to drinking or using drugs to avoid avoid becoming pregnantbecoming pregnant
Blended Evaluation DesignBlended Evaluation Design
1. Original Demonstration Cohort (1991 – 1995)1. Original Demonstration Cohort (1991 – 1995)Quasi-experimental, non-randomized comparison group, Quasi-experimental, non-randomized comparison group, pretest-posttest pretest-posttest
2. Post-Program Follow-Up Cohort (1997 – 1998)2. Post-Program Follow-Up Cohort (1997 – 1998)Follow-up interview 2.5 yrs after PCAP exitFollow-up interview 2.5 yrs after PCAP exit
3. 3. Seattle and Tacoma Replication Cohorts (1996 - 2003)Seattle and Tacoma Replication Cohorts (1996 - 2003)Study compared pretest/posttest outcomes across 3 Study compared pretest/posttest outcomes across 3 sites: OD, SR, TR; no comparison groupsites: OD, SR, TR; no comparison group
PCAP Outcomes at 36 MonthsPCAP Outcomes at 36 Months
Current OutcomesCurrent Outcomes N = 403N = 403
Inpatient or Outpatient Treatment Inpatient or Outpatient Treatment Completed or in ProgressCompleted or in Progress 89%89%
Clean & Sober Clean & Sober >> 6 months at exit 6 months at exit 41%41%
Clean & Sober Clean & Sober >> 1 yr during program 1 yr during program 56%56%
Received Mental Health ServicesReceived Mental Health Services 70%70%
In Permanent, Stable HousingIn Permanent, Stable Housing 67%67%
Drug-free Housing/TreatmentDrug-free Housing/Treatment 7%7%
PCAP Outcomes at 36 MonthsPCAP Outcomes at 36 Months
Current OutcomesCurrent Outcomes N = 403N = 403
Regular Family PlanningRegular Family Planning 60%60%
More Reliable MethodMore Reliable Method 46%46%
Any Subsequent BirthAny Subsequent Birth 25%25%
Any exposed subsequent birthAny exposed subsequent birth 14%14%
Custody of Target ChildCustody of Target Child
Bio MomBio Mom 61%61%
Other FamilyOther Family 17%17%
Foster CareFoster Care 12%12%
AdoptedAdopted 8%8%
Good things happen Good things happen when communities when communities implement effective implement effective programs and states programs and states
implement strong implement strong policy.policy.
Systems Working TogetherSystems Working Together
WA State Division of Alcohol & Substance AbuseWA State Division of Alcohol & Substance Abuse
(DASA)(DASA) i increased treatment beds for women: ncreased treatment beds for women: 55 to 153 (1991 - 2007)55 to 153 (1991 - 2007)
Systems Working Together Systems Working Together
Substance Abuse TreatmentSubstance Abuse Treatment
DSHS “Take Charge” program (1989-present)DSHS “Take Charge” program (1989-present)
• Developed to help low income pregnant Developed to help low income pregnant women obtain serviceswomen obtain services
• Recent development:Recent development:Free family planning supplies for women Free family planning supplies for women and men at 200% below FPLand men at 200% below FPL
Systems Working TogetherSystems Working Together
Family PlanningFamily Planning
Preventing Future Exposed BirthsPreventing Future Exposed Births
At PCAP replication sites, 78 women were binge drinkers (>5 drinks/occasion) during the index pregnancy.
At PCAP exit, 51 (66%) were no longer at present risk of having another alcohol exposed pregnancy:
• 24 (31%) using reliable contraception;
• 18 (23%) abstinent from alcohol/drugs >= 6 months;
• 9 (12%) both reliable contraceptive and abstinent.
Preventing Future Exposed BirthsPreventing Future Exposed Births
Without PCAP about 30% (or 23) of 78 drinking mothers Without PCAP about 30% (or 23) of 78 drinking mothers would have had another highly exposed birth; would have had another highly exposed birth;
We reduced that by 66%, preventing about 15 alcohol-We reduced that by 66%, preventing about 15 alcohol-exposed births; exposed births;
Incidence of FAS is estimated at 4.7% to 21% among Incidence of FAS is estimated at 4.7% to 21% among heavy drinkers; heavy drinkers;
Therefore we estimate PCAP prevented at least one and Therefore we estimate PCAP prevented at least one and up to 3 new cases of FAS.up to 3 new cases of FAS.
Cost SavingsCost Savings
The average lifetime cost for an individual with FAS The average lifetime cost for an individual with FAS
is $1.5 million.is $1.5 million.
PCAP costs about $15,000/ client for 3-years PCAP costs about $15,000/ client for 3-years
(intervention, administration, evaluation). (intervention, administration, evaluation).
If we prevented just If we prevented just oneone new case of FAS, the new case of FAS, the
estimated lifetime cost savings = cost of PCAP estimated lifetime cost savings = cost of PCAP
for 102 women. for 102 women.
BenefitsBenefits CostsCosts
BenefitsBenefitsper per
Dollar of Dollar of CostCost
BenefitsBenefitsMinusMinusCostsCosts
$11,089$11,089 $4,892$4,892 $2.27$2.27 $6,197$6,197* Home Visiting Programs
for At-Risk Mothers and Children
Washington State Institute for Public Policy, July 2004 found Washington State Institute for Public Policy, July 2004 found
an average net benefit of $6197 per client among selected an average net benefit of $6197 per client among selected
well-researched home visiting programs, well-researched home visiting programs, including PCAPincluding PCAP..**
www.wsipp.wa.govwww.wsipp.wa.gov
Benefits and Costs of Prevention and Early Benefits and Costs of Prevention and Early Intervention Programs for YouthIntervention Programs for Youth
Challenges of Practicing Good Science In Challenges of Practicing Good Science In Community Intervention StudiesCommunity Intervention Studies
• Randomized trial: Randomized trial: may be perceived as unethical may be perceived as unethical (solution: one health care provider training (solution: one health care provider training project uses a “wait list” control group)project uses a “wait list” control group)
• ““Treatment as usual” problem: Treatment as usual” problem: standard treatment or control condition standard treatment or control condition
may may vary in multi-site studiesvary in multi-site studies
• Meeting study recruitment goals: Meeting study recruitment goals: may require multiple strategiesmay require multiple strategies
Challenges of Practicing Good Science In Challenges of Practicing Good Science In Community Intervention StudiesCommunity Intervention Studies
• Measuring exposure: Measuring exposure: High-risk women may not present High-risk women may not present
prenatally, and postnatal assessment may be prenatally, and postnatal assessment may be biasedbiased
• Measuring fidelity of the interventionMeasuring fidelity of the intervention
• Standardize intervention:Standardize intervention: Describe in detail so it can be replicated for Describe in detail so it can be replicated for research, clinical purposesresearch, clinical purposes
True or False?True or False?
• The global war on drugs can be won.The global war on drugs can be won.
• We can reduce the demand for drugs.We can reduce the demand for drugs.
• Reducing the supply of drugs is the Reducing the supply of drugs is the answer.answer.
• U.S. drug policy is the world’s drug U.S. drug policy is the world’s drug policy.policy.
• Legalization is the best approach.Legalization is the best approach.
• Legalization will never happen.Legalization will never happen.
True or False? True or False? Legalization would result in….Legalization would result in….
• purity assurance under FDA regulationpurity assurance under FDA regulation• labeled concentration of the product (to avoid labeled concentration of the product (to avoid
overdose)overdose)• obliteration of vigorous marketing (“pushers”)obliteration of vigorous marketing (“pushers”)• obliteration of drug crime and reduction of theft crimeobliteration of drug crime and reduction of theft crime• savings in expensive enforcementsavings in expensive enforcement• significant tax revenuessignificant tax revenues
Effort and funds can then be directed to educating Effort and funds can then be directed to educating the public about the hazards of all drugs.the public about the hazards of all drugs.
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