Substance Use & Abuse in Pregnancy Janet L. Mitchell, M.D., M.P.H., F.A.C.O.G. Consultant on...

Substance Use & Abusein

PregnancyJanet L. Mitchell, M.D., M.P.H., F.A.C.O.G.

Consultant on Women’s Health

Addiction Research & Treatment Corporation

Brooklyn, NY

"THE ALCOHOL OF GREAT BRITAIN AND TENNESSEE

AND THE TOBACCO OF KENTUCKY

UNDOUBTEDLY CREATE GREATER RATES OF MORBIDITY AND DEATH

THAN THE POPPY SEED OF TURKEY AND MEXICO”

BLINICK, ET AL., DRUG ADDICTION IN PREGNANCY AND THE NEONATEAMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGYVOL. 125, NO. 2, 1976

Harlem Hospital’s Special Prenatal Program for Chemically

Dependent Women

• 1200 Pregnancies between 1988 - 1996

• 20% were HIV infected, 50% for those with a hx of IDU

• 4% 21 years of age - primary drug of use marijuana

• 80% listed crack and/or cocaine as their primary drug of choice

• Avg # of drugs used 3.5

• Higher rates of HCV then HBV

ADDICTION

• Polydrug Abuse

• Poor Nutritional Status

• STD's

• Hepatitis

• HIV Infection

• Other Medical Problems

ADDICTION and PREGNANCY

• Poor Dates

• Late Registration

• Inadequate Follow-up

ADDICTION and PREGNANCYMATERNAL CONCERNS

• Poor Pregnancy Self-image

• Low Tolerance For Pain

• Poor Bonding

• Poor Parenting Skills

ADDICTIONFETAL/NEONATAL CONCERNS

• Low Birth Weight

• Teratogenicity (Congenital Anomalies)

• SIDS

• Spontaneous Abortions

• Abstinence Syndromes

• Future Development

ADDICTION

IS A

CHRONIC RELAPSINGRELAPSING,

MEDICAL DISEASE !!

ALCOHOL

• CNS Depressant

• Known Teratogen

• Psychological and Physiological Dependence

OTHER CNS DEPRESSANTS

• Barbiturates

• Benzodiazepines

• Methaqualone

COCAINE

• CNS Stimulant

• Psychological Dependence

• ? Physiological Dependence

• ? Neonatal Abstinence Syndrome

OTHER CNS STIMULANTS

• Amphetamines

• ‘Ice’

• Diet Pills

• Nicotine

• Caffeine

COCAINEMATERNAL COMPLICATION

• Abruptio Placenta

• Preterm and/or Precipitous Labor

• Pre-eclamptic Like Syndrome

• Cardio-pulmonary problems

• Seizures

COCAINEFETAL/NEONATAL COMPLICATION

• Low Birth Weight• Seizures• Intracranial Hemorrhage• ? Neonatal Abstinence Syndrome• Not a Teratogen

OPIOIDS

• CNS Euphoria

• Not a Teratogen

• Psychological and Physiological Dependence

• Well Documented Neonatal Abstinence

METHADONE MAINTENANCE

IS THE

TREATMENT OF CHOICE

DURING PREGNANCY!!

METHADONE and PREGNANCYMATERNAL CONCERNS

• Inappropriate Medical Withdrawal

• Inadequate Dosage

• Chronic Constipation

• Pain Management

METHADONE and PREGNANCYFETAL/NEONATAL CONCERNS

• Altered Antepartum Testing

• Neonatal Abstinence Syndrome

METHADONE MAINTENANCE

IS THE

TREATMENT OF CHOICE

DURING PREGNANCY!!

ADDICTION

IS A

CHRONIC RELAPSINGRELAPSING,

MEDICAL DISEASE !!

CONCEPTS

• TREATMENT READINESS

• MOTIVATION TO TREATMENT

DRUG DEPENDENCY AS DESCRIBED BY THE WORLD HEALTH ORGANIZATION (WHO):

“A BEHAVIORAL PATTERN IN WHICH THE USE OF A GIVEN PSYCHOACTIVE DRUG IS GIVEN A SHARPLY HIGHER PRIORITY OVER OTHER BEHAVIORS WHICH ONCE HAD A SIGNIFICANTLY HIGHER VALUE”

WHO, 1982

STAGES TO SUCCESSFUL TREATMENT

• DENIAL

• NEGOTIATION

• ACCEPTANCE

PRENATAL INTAKE PROTOCOL• Complete history, especially psychosocial & drug use• Complete physical examination focusing on the multiple

medical programs• Routine prenatal bloods + hepatitis screen for B & C• Tuberculin test • Counseling for HIV with strong recommendation for testing• Social service referral• Referral to therapeutic drug program• Methadone maintenance for opiod addiction• Establish rules, requirements and goals with patient and

significant others

PRENATAL FOLLOW-UP PROTOCOL

• More frequent visits to identify medical and psychosocial problems early

• Random urine toxicologies

• Order and repeat appropriate tests as necessary

• Establish an ongoing relationship with the patient’s therapeutic drug program

• Establish an ongoing relationship with patient’s significant other(s)

• Began to discuss contraceptive methods

LABOR AND DELIVERY PROTOCOLS

• Complete history and physical, especially recent drug history

• Repeat hepatitis screens and serological test for syphilis

• Urine toxicology• Alert pediatric and nursing staff• Alert social service• Pain management as appropriate• Method of delivery dependent on obstetrical

indications only

POST PARTUM PROTOCOL

• Encourage continuation in a therapeutic drug program

• Encourage use of an appropriate contraceptive method

• Breastfeeding not contraindicated in methadone maintained women

ADDICTION

IS A

CHRONIC RELAPSINGRELAPSING,

MEDICAL DISEASE !!

TREATMENT IMPROVEMENT PROTOCALS (TIPS)FOR

PREGNANT, SUBSTANCE-USING WOMEN

Chair: Janet L Mitchell, MD, MPH, FACOG

The Centers for Substance Abuse Treatment (CSAT)Division for State Programs

Substance Abuse and Mental Health Services AdministrationSAMSA