Utah Addiction Center

Training Module Three

Goal - The goal of this module is to enable physicians to recognize substance abuse in pregnant women, identify adverse natal effects of specific drugs, and implement a plan of care for mother and child.

Learning Objectives-

  • Identify the diagnostic criteria of substance abuse.
  • Understand the role of the physician is to screen, identify, and counsel women regarding substance abuse.
  • Working with treatment professionals to implement a plan of care for substance abusing individuals including detoxification, pharmacotherapy and behavioral therapy.
  • Identify the adverse natal effects of cocaine, heroine, and marijuana.

Content Outline-

  1. Diagnosis and screening
    1. Diagnostic criteria of substance abuse
    2. Screening questions
    3. Physical Examination
    4. Toxicology Testing
  2. Treatment
    1. Treatment principles
    2. Treatment cost considerations
    3. Detoxification
    4. Behavioral Therapies
  3. Fertility and pregnancy
    1. Incidence and prevalence
    2. Drugs and adverse natal effects

Module Time Frame - 25 minutes


Lecture-

Diagnostic Criteria of Substance Abuse

A maladaptive pattern of substance abuse leading to clinically significant impairment or distress manifested by one or more of the following occurring within a 12 month period:

  • Use results in failure to fulfill major role obligations
    Work: absences, poor performance
    School: absences, suspensions, expulsions
    Home: neglect of children or household
  • Recurrent use in physically hazardous situations
  • Recurrent substance-related legal problems
  • Continued use despite resulting persistent or recurrent social or interpersonal problems

A maladaptive pattern of substance use leading to clinically significant impairment or distress manifested by three or more of the following occurring at anytime within the same 12 month period:

  • Tolerance of the substance: need for markedly increased amounts to achieve intoxication or the desired effect, or markedly diminished effect with continued use of the same amount
  • Withdrawl: the characteristic withdrawal syndrome, or substance taken to relieve or avoid withdrawal symptoms
  • Larger amounts of substance taken or over a longer period than was intended
  • Persistent desire or unsuccessful efforts to cut down or control use
  • Great deal of time spend in activities to obtain, use or recover from substance's effects
  • Important social, occupational and recreational activities given up or reduced because of use
  • Continued use despite knowledge of a persistent or recurrent psychological or physical problem likely to have been cause or exacerbated by use

The role of the OB/GYN physician is screening, identifying and counseling women regarding substance use. It is important to screen all patients since there are no physical symptoms in the majority of abusers. The physician then acts as a triage to community resources.

Screening Questions

First, use ubiquity statements:
"Substance use is so common in our society that I now ask all my patients what, if any, substances they are using?"
Then, ask direct questions:

  • "Have you ever tried…?"
  • "How old were you when you first used…?"
  • "How often; what route; how much?"
  • "How much does your drug habit cost you?"

The patient is far more likely to respond to questions regarding drug use if the physician remains direct, empathetic, respectful and nonjudgmental. If the patient's answers raise concern, the physician should try to elicit information about the effects of the alcohol or drug use on the patient's life. Problems may exist with his or her health, family, job or financial status or within the legal system.

Physical Examination

Early drug abuse disorders are rarely diagnosed on physical examination. A few cases of alcohol abuse are signaled from labile or refractory hypertension or mild upper abdominal tenderness. Some cases of cocaine snorting can be identified by damaged nasal mucosa and some instances of injection drug use by hypodermic marks. The single most useful examination is of the eyes. Nystagmus is often seen in abusers of sedatives/hypnotics or cannabis. Mydriasis is often seen in persons under the influence of stimulants or hallucinogens or in withdrawal from opiates. Miosis is a classis hallmark of opioid effect. Evidence of minor (or past major) injuries can be an indication of substance abuse.

Toxicology Testing

Random toxicology checks without clinical suspicion is considered by many to be unethical and may be illegal in some states. In nonemergency situation, the physician should verbally inform their patients prior to running toxicology tests and document patient permission in medical records. In emergency situations it is often necessary to test toxicology in order to direct immediate medical interventions.

Urinalysis is an inexpensive and quick way to test for the presence of alcohol and other drugs. Urine testing can be very helpful when positive, but the limited slice of time reflected by urine tests for most drugs, other than the lipid-soluble cannabiniods, renders urine testing relatively insensitive for intermittent drug use. Testing of hair for drugs of abuse may eventually become a useful adjunct because hair content reflects drug use over a longer period of time; however, false positives due to environmental exposure and false negatives dues to various technical problems are common.

Time frame for a drug or metabolite to be present:

Marijuana, acute use 3 days
Marijuana, chronic use 30 days
Cocaine 1-3 days
Heroine 1 day
Methadone 3 days

Treatment Principles

It is important to keep the following principles in mind when discussing treatment options with the patient:

  • Drug addiction is a treatable disease
  • No single treatment is appropriate for all individuals
  • Recovery from drug addiction is a long-term process with multiple treatment episodes and relapses
  • Effectiveness is dependent on remaining in treatment for a dedicated period of time
  • Matching multiple needs is critical (medical, psychological, social, legal, vocational
  • In addition to treating expectant mothers, the goal is to deliver healthy, drug-free babies.

Table 1. Treatment Cost Considerations

Year in prison $53-$71/day $25,900
Annual treatment costs for a drug addict:
Outpatient $15/day x 120 days $1,800
Intensive outpatient 9 hrs/wk + 6 months maintenance $2,500
Methadone maintenance $13/day x 300 days $3,900
Short term residential $130/day x 30 days + $400 X 25 weeks $4,400
Long Term residential $49/day x 140 days $6,800

Plan of Care

After the physician has established a supportive relationship, he/she can begin to educate the patient. Begin by asking the patient to describe his or her understanding of the situation and correct any misunderstandings. Remember to link substance use to patient's signs and symptoms. The physician should stress the possible negative consequences of the patient's drug use, both currently and in the future. Giving the patients educational materials may help reinforce these points. The physician should then refer the patient to specialists for assessment and initiation of a treatment plan.

Critical Components of Treatment:

Detoxification

Many drug-dependent patients can safely undergo withdrawal as outpatients. This approach is less expensive and less disruptive of the patient's life than inpatient therapy. To qualify for outpatient detoxification, the patient must clearly agree to abstain from using any mood-altering agent, other than those prescribed by the treating physician. He or she must also agree to participate in a treatment program.

If the criteria for outpatient therapy are not met, inpatient or residential therapy may be indicated. This has the advantage of placing the patient in a protected setting where access to substances of abuse is restricted. The withdrawal process may be quicker and safer because the patient can be monitored more closely and treatment can be more finely tuned.

Hospital treatment is morel likely to be needed for withdrawal from sedative drugs, such as alcohol, barbiturates, and benzodiazepines. Withdrawal from these drugs can be life-threatening. Hospital treatment is also indicated for patients who have a very high tolerance for the substance of abuse or who developed seizures, delirium or psychosis during a previous withdrawal.

Pharmacotherapy

Traditionally, the physician's role in pharmacological treatment of a drug abuse has largely been limited to the management of withdrawal symptoms and medical complications.

Behavioral Therapies

Physicians should remember that behavior change is rarely a discrete, single event. Physicians sometimes see patients who, after being advised to change negative behavior, readily comply. More often, physicians encounter patients who seem unable or unwilling to change. Understanding the process of change provides physicians with additional tools to assist patients, who are often as discouraged as their physicians with their lack of change.


Stages of Change

The Stages of Change Model, developed by Prochaska and DiClemente, shows that, for most persons, a change in behavior occurs gradually, with the patient moving from being uninterested, unaware or unwilling to make a change (precontemplation), to considering a change(contemplation) to deciding and preparing to make a change. Genuine, determined action is then taken and, over time, attempts to maintain the new behavior occur. Relapses are almost inevitable and become part of the process of working toward a life-long change.

  • Precontemplation Stage
    During the precontemplation stage, patients do not even consider changing. Substance abusers who are "in denial" may not see that the advice applies to them personally. At this point the patient needs evidence of the problem and its consequences.
  • Contemplation Stage
    During the contemplation stage, patients are ambivalent about changing. Giving up an enjoyed behavior causes them to feel a sense of loss despite the perceived gain. The patient needs support and encouragement to initiate treatment. Information on treatment options should be given as well as a referral to a specific treatment program.
  • Preparation Stage
    During the preparation stage, patients prepare to make a specific change. They may experiment with small changes as their determination to change increases. For example, switching to a different brand of cigarettes or decreasing their drinking signals that they have decided a change is needed.
  • Action Stage
    During the action stage the patient begins treatment. The physician will need to follow up with the patient in order to ensure success. During this stage the patient will receive weekly contact, family or group therapy, and urine monitoring.
  • Maintenance and Relapse Prevention
    During the maintenance and relapse stage prevention is essential. The patient will need to alter their lifestyle in order to reduce their susceptibility of relapse. This may involve developing drug free socialization, identifying social pressures that my predict use, and learning new ways to manage distorted thinking. Discouragement over occasional relapses may halt the change process and result in the patient giving up. However, most patients find themselves "recycling" through the stages of change several times before the change become truly established.

Fertility and Pregnancy

Substance abuse may decrease semen quality and cause impotence in men, and may cause menstrual irregularity and alterations in ovulation in women. Substance abuse has a variable effect on libido in men and women. Of the 4 million women who gave birth during 2003, 757,00 drank alcohol products, 820,000 smoked cigarettes and 221,000 used illegal drugs.

It is important to educate the patient about the adverse effects of using drugs and alcohol during pregnancy. Women who use during pregnancy have increased rates of meconium staining, fetal-monitor abnormalities, precipitous delivery, abruptio placentae and premature delivery. Infants born to addicts may be more likely to have birth defects, because most addicted mothers also abuse alcohol, a known teratogen. It is also important to impart a feeling of hope. Remind the patient that she can deliver a healthy baby if she works with doctors and treatment providers to deal with her addiction.

In addition to screening for domestic violence, STDs, hepatitis B and C, and TB, the physician should refer the drug abusing patient to a drug counseling program. Treatment of addicted pregnant women should include prenatal care, parenting and childbirth classes and home visits by public health nurses, as well as treatment of chemical dependence. The newborn should be referred to pediatrics and there should be close postpartum follow up.

Information regarding specific drugs and adverse natal effects

Cocaine
Brief:
Description
A powerfully addictive drug that is snorted, sniffed, injected, or smoked. Crack is cocaine that has ben processed from cocaine hydrochloride to a free base for smoking.
Street Names: Coke, snow, flake, blow, and many others.
Effects: A powerfully addictive drug, cocaine usually makes the user feel euphoric and energetic. Common health effects include heart attacks, respiratory failure, strokes, and seizures. Large amounts can cause bizarre and violent behavior. In rare cases, sudden death can occur on the first use of cocaine or unexpectedly thereafter.
Statistics and Trends: Adults age 26 and older have the highest rate of current cocaine use, compared to other age groups. Source: National Survey on Drug Use and Health - SAMHSA web site.
Adverse Maternal Effects: Possible systemic complications to the cardiovascular (cardiac arrhythmias, vasoconstriction, and hypertension) and central nervous system (hyperthermia, CVA, and seizures).
Adverse Fetal Effects: Possible congenital anomalies include limb reduction, genitourinary trace malformations, and congenital heart disease. Babies born to mothers who abuse cocaine during pregnancy are often prematurely delivered, have low birth weights and smaller head circumferences, and are often shorter in length.
Adverse Prenatal Effects: Most studies confirm that cocaine abuse during pregnancy results in premature separation of the placenta and premature rupture of the membranes.
Adverse Neonatal Effects: Initial neurological findings include coarse tremor, hypertonia, extensor leg posture, and increased risk of SIDS. Long term consequences may include deficits in some aspects of cognitive performance, information-processing, and attention to tasks.
Treatment: The goal of treatment is to help patient resist the urge to restart compulsive cocaine use. Possible treatment options include group and individual drug counseling, cognitive behavioral therapy to prevent relapse, and medications.

Heroine
Brief Description The goal of treatment is to help patient resist the urge to restart compulsive cocaine use. Possible treatment options include group and individual drug counseling, cognitive behavioral therapy to prevent relapse, and medications.
Street Names: Smack, H, ska, junk, and many others.
Effects: Short-term effects include a surge of euphoria followed by alternately wakeful and drowsy states and cloudy mental functioning. Associated with fatal overdose and- particularly in users who inject the drug-infectious diseases such as HIV/AIDS and hepatitis. Long-term users may develop collapsed veins, liver disease, and lung complications.
Statistics and Trends: NIDA's 2005 Monitoring the Future study showed that 1.5% of 10th and 12th graders had used heroin at least once. Source: NIDA Infofacts: High School and Youth Trends.
Withdrawal Syndrome: Symptoms include drug craving, anorexia, nausea, abdominal cramping and increases sensitivity to pain. Signs include hypertension, hyperventilation, tachycardia, lacrimation, mydriasis, rhinorrhea, yawning, sweating, vomiting, diarrhea, chills, flushing, muscle spasms, restlessness, tremors, irritability and piloerection.
Adverse Maternal Effects: Short-term effects include somnolence, altered mentation, and cardiorespiratory arrest (overdose). Long-term effects include physiologic withdrawal, hepatitis B and C, STD's, HIV, endocarditis, abscesses, pneumonia and tuberculosis.
Adverse Pregnancy Effects: Adverse effects include intrauterine growth restriction and neonatal abstinence syndrome including hypertonia, hyperreflexia, tremors, convulsions, fist sucking, poor feeding, vomiting, diarrhea, tachypnea, fever, vasomotor instability, sweating and tearing.
Treatment: Goal is to change from a short acting IV to a long acting oral opioid to relieve drug craving and withdrawal. Possible treatment vehicles include methadone, levomethadyl-acetate, and buprenorphine.
Methadone: Blocks heroin's narcotic effects without creating a drug "high," eliminates withdrawal symptoms, and relieves the craving associated with addiction.
Methadone Perinatal Effects: Methadone allows for a continuation of normal daily activities and decreases maternal morbidity associated with heroine. Neonatal abstinence syndrome occurs on day 2-3 and is similar to heroin withdrawal syndrome.
Methadone Treatment Protocol: Initial dose is 10-20 mg, during the next 24 hours 5-10 mg every 6 hours per signs and symptoms of opiate withdrawal, daily maintenance dose is 10-100 mg

Marijuana
Brief Description The most commonly used illegal drug in the U.S. The main active chemical is THC.
Street Names: Pot, ganga, weed, grass, and many others.
Effects: Short-term effects include memory and learning problems, distorted perception, and difficulty thinking and solving problems.
Statistics and Trends: Nearly 45% of U.S. teenagers try marijuana before finishing high school. Source: NIDA Infofacts: High School and Youth Trends.
Adverse Maternal Effects: Adverse effects include CNS depression, tachycardia, hypotension, respiratory problems similar to tobacco smokers (bronchitis, sinusitis, pharyngitis) and changes in attention, memory, and information processing.
Adverse Perinatal Effects: There are no clear associations between marijuana use during pregnancy and congenital anomalies. However, THC is present in breast milk.