Transcript the alcohol of great britain and tennessee and the tobacco of

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 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
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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
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•
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Poor Pregnancy Self-image
Low Tolerance For Pain
Poor Bonding
Poor Parenting Skills
ADDICTION
FETAL/NEONATAL CONCERNS
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Low Birth Weight
Teratogenicity (Congenital Anomalies)
SIDS
Spontaneous Abortions
Abstinence Syndromes
Future Development
ADDICTION
IS A
CHRONIC RELAPSING,
MEDICAL DISEASE !!
ALCOHOL
• CNS Depressant
• Known Teratogen
• Psychological and Physiological
Dependence
OTHER CNS DEPRESSANTS
• Barbiturates
• Benzodiazepines
• Methaqualone
COCAINE
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•
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•
CNS Stimulant
Psychological Dependence
? Physiological Dependence
? Neonatal Abstinence Syndrome
OTHER CNS STIMULANTS
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Amphetamines
‘Ice’
Diet Pills
Nicotine
Caffeine
COCAINE
MATERNAL COMPLICATION
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•
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Abruptio Placenta
Preterm and/or Precipitous Labor
Pre-eclamptic Like Syndrome
Cardio-pulmonary problems
Seizures
COCAINE
FETAL/NEONATAL COMPLICATION
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•
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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
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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!!
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
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