Perinatal Substance Abuse Program Dept of Alcohol and Drug Services (DADS) Presented by Lara Windett M.A., MFT, LPPC Certified Addiction Specialist (CAS) 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 pay Background PSAP was Brainchild of Anthony Puentes, MD, MPH, 1987 Funding stream Goal of PSAP Program PSAP Keeps babies out of the NICU NICU costs ~$2,100 – 5000 per day 2007 140 babies exposed, 30 in NICU Avg Length of Stay: 15 days PSAP Treatment Works! 92% drug/alcohol free - neg tox screens Perinatal Drug Exposure Overview 1992 Study Estimated 15-18% of pregnant women use alcohol or drugs. PSAP Admission Statistics PSAP = Empowerment Model Comprehensive Intensive Outpatient Treatment Medically Monitored Multidisciplinary Approach Day Care for clients’ children Transportation PSAP Client Eligibility Resident of Santa Clara County Pregnant or Early Parenting Women 18 years or older On Methadone (MMT) or opiate dependent Hx or DOA abuse or currently using Family Wellness Court Referrals Medi-cal, Valley Care II, sliding scale fee, or other insurance (Kaiser) Length of PSAP Stay Assigned a Licensed Therapist, PSW Case Management Individualized Tx Plan Typical Treatment Episode: 6-12 months Staff HCPM II 3 Therapists (MFT) MD Health Ed Specialist 1 Health Services Representative 3 day care aides (1/2 codes) 1 Community Worker (van) (1/2 codes) Volunteers Current PSAP Client Demographics ~Capacity for 65+ Women ages 19 to 43 years 23% pregnant 10 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%, Out Patient Drug Treatment in Santa Clara County – Including Methadone On the VMC campus Readily accessible - pregnant OPIOID DEPENDENT patients (Methadone candidates) are scheduled for admission the next business day All Patients can call Gateway 1-800-488-9919 Providers can call Central Valley Clinic 408 885-5400 Front Desk 408 885-4064 PSAP Clerical 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. 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 baby Substances to Be Discussed Opioids Cigarettes Alcohol Marijuana Methamphetamine Amber 32 y.o. Woman and the mother of an 8 y.o. Unplanned pregnancy Using daily Heroin by injection 2 grams/day Cocaine Cigarettes 2 PPD Seeking admission to methadone program Amber Stealing to obtain drugs Isolated – only living relative is maternal grandmother 8 y.o. son is being raised by patient’s grandmother Father of baby is using and at risk of deportation Amber Medically indigent History of depression and anxiety History of domestic violence (prior relationship) Amber Frustrated – requested tubal ligation at 23 Frightened – concerned about damage already done to baby Motivated Requests residential treatment Resolves to leave boyfriend if he will not get into treatment Red Flags: Multiple & Obvious Patient volunteering history of substance abuse Physical exam remarkable for multiple tracks and physical withdrawal Life in disarray Chaotic and disrupted family relationships Why Share this Story? Opioid dependence requires medical intervention Pregnant patients need treatment to prevent adverse outcomes Women caring for infants need treatment to be functional mothers Pregnancy can be a Huge Motivation for Change: Amber Stabilized on methadone maintenance Completed residential treatment Permanently left the boyfriend who continued to use Delivered drug free A Sense of Hope: 12 Years Later Amber is… Abstinent and still in treatment Raising her daughter Working 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). Brenda Referred to treatment for history of methamphetamine abuse Worked as a medical assistant until about two years ago Served as caretaker for mother who died of breast cancer After mother died, dad was diagnosed with lung cancer; patient served as caretaker Reported having a prescription for vicodin Brenda Reported taking prescribed vicodin for chronic back pain (occasionally) Denied history of prescription opioid abuse Weekly u tox screens consistently positive For a variety of prescription opioids Not just for vicodin Easy access to unlimited supply of prescription opioids Transferred to methadone maintenance 26 Prescription Opioid Abuse May Not Be Obvious Consider the history Unusual number of painful conditions for a young healthy patient Multiple opioid prescriptions during pregnancy Multiple ER visits for complaints of pain Multiple care providers/no regular provider Opioids for unusual indications 27 Patient’s Appearance on Opioids Normal Sedated with small pupils Symptoms of withdrawal Sweats/chills/gooseflesh Lacrimation/rhinorrhea Yawning/sneezing Irritable/anxious/fidgety Vomiting 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? Ask about Reasons for Use Manage emotions? Deal with stress? Feel high? Numb everything or go to sleep? Opioids: Three to Seven Times Higher Rates of… Still birth Fetal growth retardation Low birth weight Small head circumference Prematurity Neonatal mortality Heroin: Medical Risks Associated With Injection Cellulitis Abscesses Endocarditis Hepatitis HIV infection Wound Botulism Opioid Dependence in Pregnancy: Treatment Currently, methadone maintenance is the gold standard Buprenorphine 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 delivery Impact of Methadone Treatment Reduced deaths Reduced IVDU Reduced HIV seroconversion Reduced crime days Reduced relapse Improved health Improved relationships Improved productivity Improved social functioning Additional Benefits During Pregnancy Increased participation in prenatal care Reduced obstetrical complications Improved maternal nutrition Daily observation in clinic while dosing Therapeutic Dosing With Methadone Suppresses opioid withdrawal symptoms Reduces opioid cravings Provides a stable opioid blood level Allows a patient to concentrate on counseling/program to support recovery Minimizes side effects; patient should not be sedated Methadone Withdrawal: Not Recommended During Pregnancy The relapse rate is high (80%) Risk of intrauterine demise Risk of premature labor/miscarriage What can you say to a patient wanting to Withdraw from MMT? Send them to their primary CSLR/the addiction MD to discuss Methadone Withdrawal: Not Recommended After Delivery? Like insulin, methadone stabilizes a chronic illness The normal brain has an endogenous opioid system that may never function properly in an opioid dependent patient Very high relapse rate when methadone treatment is discontinued Methadone: Effects on the Baby No known birth defects More likely to be born at term Lower birth weight/smaller head circumference at birth May experience developmental delay during the first year of life Not associated with learning difficulties Increased SIDS with opioid exposure Methadone and Breastfeeding Negligible amounts of methadone are passed in breast milk The American Academy of Pediatrics considers methadone compatible with breastfeeding at any dose Methadone: Neonatal Withdrawal Safer than heroin withdrawal in utero Experienced by 60-80% of exposed babies Usually occurs within the first 2-3 days of life; may occur within the first month Usually treated with an opiate agonist Duration of treatment is days to months Can be life threatening without treatment Opiates: The Neonatal Abstinence Syndrome High-pitched cry, irritability Poor feeding, vomiting, diarrhea Hyper tonicity (stiff muscles) Tremors Sneezing Sweating Occasionally seizures Symptoms of Opioid Withdrawal W = wakefulness I = irritability T = tremulousness, temperature variation, tachypnea H = hyperactivity, high-pitched persistent cry, hyperacusia, hyperreflexia, hypertonus D = diarrhea, diaphoresis, disorganized suck R = rub marks, respiratory distress, rhinorrhea A = apneic attacks, autonomic dysfunction W = weight loss or failure to gain weight A = alkalosis (respiratory) L = lacrimation Clarissa 23 y.o. Pregnant with first child Smoking 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” 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% 14.8% 2.8% 1.2 million 0.8 million 0.2 million Ebrahim, SH, Gfroerer, J. Pregnancy-related substance use in the United States during 1996-1998. Obstet Gynecol 2003; 101:374. Cigarette Smoking Smoking during pregnancy is the most modifiable risk factor for poor birth outcome It 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. Cigarettes in Pregnancy: Obstetric Complications Adverse Event Relative Risk Placental Abruption 1.4-2.5 Placenta Previa 1.4-4.4 Stillbirth 1.2-1.4 Pre-term PROM 1.9-4.2 Preterm Birth 1.3-2.5 Low Birth Weight 1.3-10.0 dose dependent dose dependent dose dependent Clinical Outcomes in Pregnant Women who Quit Smoking 20% reduction in low birth weight babies 17% decrease in pre-term births Average increase in birth weight of 280g. Quitting before 30 weeks can still positively affect birth weight Cigarette Smoking in Pregnancy & Other Drug Use 10 times higher use of marijuana 22 times higher use of cocaine 21 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; 329:850 In Utero Cigarette Exposure: Congenital Malformations May contribute to anomalies associated with focal vascular disruption Cleft lip with or without cleft palate Gastroschisis Anal atresia Transverse limb reduction defects Risk may be modified by genetic factors In Utero Cigarette Exposure: Effects on the Newborn There is a dose-response relationship between maternal cigarette use and infant… Stress Hypertonicity Excitability and irritability May be due to neurotoxicity or withdrawal With second hand smoke exposure there is an increased risk of low birth weight In Utero Cigarette Exposure: Postnatal Morbidities Morbidity Neonatal death RR 1.2 - 1.4 SIDS RR 2.0 – 7.2 Prenatal exposure a higher risk than postnatal 2nd 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% 52 In Utero Cigarette Exposure: Behavioral Problems Toddlers (12-24 mo.s) showed a high and escalating pattern of disruptive behavior Children developed Oppositional Defiant Disorder at double the rate of controls ODD is a precursor of Conduct Disorder Seen in older children and adolescents Characterized by persistent antisocial behaviors (lying truancy, vandalism, aggression) NIDA Notes 2008: Vol.21 No. 6 In Utero Cigarette Exposure: Cognitive Outcomes in 9-12 yr olds IQ impacted (dose response effect) Poorer impulse control Many individual WISC tests w/ significant dose response effects Poorer performance on tests requiring visuoperceptual skills. Auditory memory particularly impacted WISC = Wechsler Intelligence Scale for Children Medical Issues for the Children of Smokers Increased incidence of smoking initiation 20% higher if mom smoked up to 1PPD 60% higher if mom smoked 1PPD or more Diabetes mellitus Four times higher with more than 10 cigs/day Increased asthma in adult offspring Decreased sperm volume/count in adult male offspring 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, 1996 A look at Denial/PreContemplation: Denise 28 y.o. pregnant woman and the mother of 7 and 3 y.o. boys Pregnant for the 5th time History of two 2nd trimester miscarriages Started drinking at 23 (not pregnant) Denise Drinking 1-2 shots of peppermint schnapps daily until about 1 yr ago Quit drinking when learned was pregnant with second child, now age 3 GA ~ 9wks when quit Growth and development of this child appear normal Denise Drinking 5 shots of peppermint schnapps daily for the past year Drinking this pregnancy until GA ~33 wks Not worried about the baby because Last baby was okay U/S during this pregnancy looks normal Alcohol Use During Pregnancy: Obstetrical Complications Increased risk of second-trimester abortion 50% increase in fetal mortality Infant withdrawal (3-12 hrs after delivery) Fetal Alcohol Spectrum Disorders Alcohol is a Teratogen that Freely Passes the Placenta Teratogen: a substance that causes abnormal physical development Behavior teratogen: a substance that causes impaired cognitive, affective, social, reproductive, and/or sensorimotor behavior, even in the absence of obvious physical problems Prenatal Alcohol Exposure Can Cause: Death Malformation Growth deficiency Functional deficits Teratogenic Effects Depend On: Dose of alcohol Pattern of exposure (binge vs. chronic) Developmental timing of exposure Susceptibility (genotype of mother and fetus) Synergistic reactions with other drugs Interaction with nutritional variables Dose-Response Effects Higher maximum blood alcohol levels result in more severe neurotoxicity Binge drinking is particularly dangerous Males appear to be more susceptible than females SOME CREDIBLE INCREDIBLE WEBSITES! (Thanks Mark Stanford, PhD) Addiction Technology Transfer Center http://www.nattc.org/asme.asp Brookhaven 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!!! Content Provided by: Deborah Stephenson, MD, MPH Dept of Alcohol & Drug Services Santa Clara Valley Health & Hospital System Mark Stanford, PhD Dept of Alcohol & Drug Services Santa Clara Valley Health & Hospital System Margaret Williams, M.S., RD, H.E.S. Dept of Alcohol & Drug Services Santa Clara Valley Health & Hospital System Thank you!