Transcript Overview of Addictions

Pregnancy-Related Issues in the Management of Addictions
Train the Trainer Workshop
Problematic Substance Use in Pregnancy (PSUP)
www.addictionpregnancy.ca
Last modified: March 2008
Conflict of Interest Disclosure

Financial support for this workshop was
provided by Health Canada

Funding for the PRIMA Pocket Reference
was provided by the Lawson Foundation

No commercial sponsorship has been
received to support this program
Pregnancy-Related Issues in the Management of Addictions
Overview of Addictions
Key Concepts
Addiction (dependence)

Women using addictive substances find the
effects of the drug so pleasurable and
reinforcing that they have difficulty controlling
their use of the drug

Reinforcement may be small and multiple, e.g.,
nicotine, or large, e.g., heroin
Many Substance Users are
Survivors of Childhood Trauma
Women in substance abuse treatment report:

A lifetime history of trauma, most commonly
physical or sexual abuse

This ranges from 55% to 99% compared to
women in community samples (36-51%)
Najavits et al, 1997
Addictive Potential of Drugs

Correlates with:

Rapid onset of action

Potency at receptor site (euphoric effect)

Short duration of action (contrast between intoxication
and sober state)

Tolerance (forces woman to escalate dose to achieve
same effect)

Withdrawal (forces woman to use drugs to avoid
withdrawal)
Reward Pathway
All drugs of abuse:

Increased dopamine receptor stimulation in
nucleus accumbens and medial forebrain bundle

Cocaine stimulates it directly

Opioids, alcohol, nicotine stimulate it via effects
on other neurotransmitters
Opiate Use is a Very Powerful selfmedication for:

Blocking out intrusive thoughts, flashbacks
and nightmares

Numbing and avoiding feelings, thoughts,
people

Achieving sleep
Tolerance

Repeated administration alters:



Receptor numbers and sensitivity
Levels of neurotransmitters
Result: decreased effect with same dose


CNS develops ‘resistance’ to drug effect
Adaptive mechanism: can function almost normally
despite very high doses
Tolerance (2)


Rate of development of tolerance depends on
the effects
For example, with opioids:


Analgesia - slow tolerance (months)
Sedation – rapid tolerance (days)
Withdrawal

On sudden cessation of drug, alterations in
receptors take days or weeks to normalize

Receptors that ‘resist’ the drug are now
unopposed, leading to drug-opposite effects:


Sedating drugs: withdrawal -> autonomic hyperactivity
Symptoms appear when drug use decreases,
forcing woman to resume drug use
Genetic Influences on
Drug Dependence

Positive family history increases risk of alcohol
dependence:



Fewer adverse effects
Greater tolerance
More positive effects
Sex and Gender Differences
The Formative Years report from CASA
demonstrates that:






Girls and young women use cigarettes, alcohol
and drugs for reasons different than boys
The signals and situations of high risk are
different
Girls are more vulnerable to substance use and
abuse and its consequences
Girls have incorrect knowledge and beliefs about
substances
Parents are often inattentive
cont’d
CASA. The Formative Years: Pathways to Substance Abuse Among Girls
and Young Women Ages 8-22. 2003. www.casacolumbia.org
Sex and Gender Differences (2)
The Formative Years report indicates that
girls are influenced by:




Substance-using friends
Schools and communities that turn a blind eye
Physicians who are not vigilant to early
warning signs
Exposure to entertainment media and alcohol
and cigarette advertising, which bombard girls
and young women with unhealthy and
unrealistic messages about smoking, drinking
and weight loss
Substance Use by Women

Substance use by women has been viewed by
health professionals as more problematic

This has led to disparities in screening and access
to care and treatment

Poor women, aboriginal women and women of
colour are more frequently screened for substance
use when accessing prenatal care than middle
class and Caucasian women
Risks for Addiction
Psychiatric Risk:



Mood disorders
Anxiety disorders, esp. post-traumatic stress disorder
Personality disorders that effect impulse control
Social, Cultural:



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Lack of meaningful work/school/relationships
Lack of social support
Cultural attitudes towards alcohol, drugs
Poverty
Clinical Features
Drug use becomes major focus of life and the
addicted woman:
 Neglects major responsibilities

Continues to use despite knowledge of
consequences

Repeatedly tries to quit but relapses

Develops tolerance and can go into withdrawal

Experiences powerful urges to use (cravings)
The 4 C’s of Addiction

Continued use despite Consequences

Unable to Cut down
 Cravings
 Compulsive drug use
Classification of Drugs of Abuse
Alcohol
 Benzodiazepines and other sedatives
 Opioids
 Stimulants: cocaine, amphetamines
 Nicotine
 Cannabis
 Hallucinogens

Psychological Treatment

Natural Recovery

Mutual Help Groups

Outpatient Counseling

Residential Treatment


Minnesota model (28 or 21 day)
Therapeutic community (months to years)
Treatment of Substance
Dependence: Prognosis

Approx. 30% abstinent one year post-treatment

Prognosis worse if:



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Older
Longer drinking history
Other substance use
Untreated psychiatric disorder(s)
Social instability

Physician’s warning associated with better
prognosis at 2 years

Treatment is cost-effective
Success Rates of Formal
Treatment (6 month follow-up)
Addiction Severity Index (ASI)
Substance
dependence
Alcohol
Success rate
(>50% dec. in ASI)
(%)
50 (40-70)
Opioids
60 (50-80)
Cocaine
55 (50-60)
Nicotine
30 (20-40)
Lancet 1996; 347: 237-40
Treatment for Women and Mothers

When mothers and babies stay together in
treatment, women indicate that
maintaining close contact with their
children was integral to their recovery
efforts.
Besinger, B.A. 2003. Mothers in addiction treatment: The role of onsite childcare.
University of Cincinnati, Cincinnati)

Women stayed in treatment longer, had
less depression and higher measures of
self-esteem than women separated from
their infants.
Wobbie, K., & Eyler F.D., 1997. Women and Children in Residential Treatment: Outcomes for
Mothers and their Infants. Journal of Drug Issues, 27 (3), 585-607
Cost-effectiveness of Treatment:
Matched Case-control Study

300% reduction in health care costs in treated
group vs. waiting list controls
Holder HD, Blose JO. J Stud Alcohol 1992; 53: 293-302
Role of the Health Care Providers

Most substance users do not go to formal treatment

BUT they make frequent use of health care provider
(HCP) services

Women often have considerable trust in their
nurse/midwife/physician

Health Care Providers should see women over long
periods of time and build therapeutic relationships in
order to effect long-term change
cont’d
Role of Health Care Providers (2)

Smoking cessation counselling: one of the
most cost-effective interventions we can do

At-risk drinking: often brief advice (5-15
minutes) is enough to get women to reduce
drinking to low-risk levels

Alcohol and drug dependence: many women
will accept HCP advice to attend treatment
program
cont’d
Role of Health Care Providers (3)

Treatment of withdrawal is first step to recovery

Pharmacotherapy (methadone, bupropion, NRT,
etc.) greatly increases success rates of
counselling
Failure to Understand and Address
Trauma Can Lead to:

Retraumatization of the woman

Increase in symptoms

Increase in management problems

Increase in relapse

Withdrawal from service relationship
(Finkelstein, 2006)
Approach to the Woman who is
Addicted to Substance(s)
Do’s: Like any other disease…
Express concern
 Review diagnosis and health effects
 Present range of treatment options
 Acknowledge woman’s efforts and successes
 Arrange follow-up

Approach for Provider/Counselor
and Woman

Meet basic needs

Build positive social network

Advise group and individual support

Teach techniques to avoid drugs and triggers
for substance use

Encourage to have a structured day, keep busy
Pregnancy-Related Issues in the Management of Addictions
Slide presentation developed by members of
the National PRIMA group:
Ron Abrahams*
 Talar Boyajian
 Jennifer Boyd
 Wendy Burgoyne
 Katherine Cardinal
 Rosa Dragonetti
 Lisa Graves*
 Phil Hall

*Principal Authors
Samuel Harper
 Georgia Hunt*
 Meldon Kahan
 Theresa Kim
 Lisa Lefebvre
 Nick Leyland
 Margaret Leslie
 Deana Midmer*

Stephanie Minorgan*
 Pat Mousmanis*
 Alice Ordean*
 Sarah Payne*
 Peter Selby
 Melanie Smith
 Ron Wilson
 Suzanne Wong

[email protected]