Substance Use & Abuse in Pregnancy Janet 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 NEONATE AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY VOL. 125, NO. 2, 1976

Harlem Hospital’s Special Prenatal Program for Chemically Dependent Women 1200 Pregnancies between % 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 PREGNANCY MATERNAL CONCERNS Poor Pregnancy Self-image Low Tolerance For Pain Poor Bonding Poor Parenting Skills

ADDICTION FETAL/NEONATAL CONCERNS Low Birth Weight Teratogenicity (Congenital Anomalies) SIDS Spontaneous Abortions Abstinence Syndromes Future Development

RELAPSING ADDICTION IS A CHRONIC RELAPSING, 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

COCAINE MATERNAL COMPLICATION Abruptio Placenta Preterm and/or Precipitous Labor Pre-eclamptic Like Syndrome Cardio-pulmonary problems Seizures

COCAINE FETAL/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 PREGNANCY MATERNAL CONCERNS Inappropriate Medical Withdrawal Inadequate Dosage Chronic Constipation Pain Management

METHADONE and PREGNANCY FETAL/NEONATAL CONCERNS Altered Antepartum Testing Neonatal Abstinence Syndrome

METHADONE MAINTENANCE IS THE TREATMENT OF CHOICE DURING PREGNANCY!!

RELAPSING ADDICTION IS A CHRONIC RELAPSING, 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

RELAPSING ADDICTION IS A CHRONIC RELAPSING, 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 Administration SAMSA