Transcript Tobacco, Alcohol And Drug Use In Childbearing

Tobacco, Alcohol and
Drug Use
in Childbearing
Families
Margaret H. Kearney,
PhD, RN, FAAN
Substance Abuse During Pregnancy
(SAMHSA, 2005)
Based on data collected from surveys of U.S.
households in 2003 and 2004:
– 18.0 percent of pregnant women reported that
they smoked cigarettes.
– 11.2 percent drank some alcohol.
– 4.5 percent engaged in binge drinking.
– 0.5 percent engaged in heavy drinking.
– 4.6 percent used some kind of illicit drug.
© 2007, March of Dimes
Substance Abuse During Pregnancy
(SAMHSA, 2005) (Continued)
• Pregnant women are less likely to use
substances than their peers.
• The exception is pregnant women aged 15
to 17; this substance use rate is 26
percent for pregnant women, compared
with 19.6 percent for nonpregnant
women.
© 2007, March of Dimes
Substance Abuse During Pregnancy
(SAMHSA, 2005) (Continued)
• Rates of substance abuse in pregnancy
have stayed constant.
• Pregnant women’s tobacco use decreased
from 2002 to 2004, while alcohol and
illicit drug use increased (SAMHSA, 2005).
© 2007, March of Dimes
Substance Abuse During Pregnancy
(SAMHSA, 2005)
Women more prone to substance abuse:
–
–
–
–
–
–
–
–
Earn below poverty level
Were exposed to violence as a child
Have a history of domestic abuse
Suffer depression or other mental health problems
Have less than a high school education
Are unmarried
Are unemployed
Are involved with the criminal justice system
© 2007, March of Dimes
Substance Abuse During Pregnancy
(SAMHSA, 2005)
• Substance use is highest in the first
trimester.
• The most common form of substance use in
pregnancy is smoking among White
women.
• Because tobacco, alcohol and drug use in
pregnancy occurs across all demographic
groups, nurses should screen all women.
© 2007, March of Dimes
The Problem of Addiction
• Addiction does not occur unless
psychological and social conditions
promote continued drug use.
• Nurses are better able to provide support
and nonjudgmental care if they respect
substance users as reasonable and
intelligent persons whose judgment has
been impaired.
© 2007, March of Dimes
Genetic Contributions to Addiction
• The propensity to specific addictions has
been linked to particular genes.
• Genetic differences may affect the
seriousness of biological consequences of
substance exposure in pregnancy.
© 2007, March of Dimes
Addiction as a Biopsychosocial
Problem
• Addiction is produced when biological,
psychological and social predispositions
combine with exposure to substances and
an environment that supports regular
substance use.
• Nursing assessment should focus on a
broad scope of personal, familial and
social stressors and coping skills.
© 2007, March of Dimes
Women’s Treatment Issues
• Women may be more predisposed to
addiction than men.
• Women are adversely affected by smaller
amounts of alcohol and drugs than men.
• Women are more likely than men to lack
resources to pay for drug treatment.
© 2007, March of Dimes
Women’s Treatment Issues (Roberts &
Dunn, 2003) (Continued)
Women’s treatment programs must take a
whole-life approach and address:
– Low self-esteem
– The need for social services and parenting
support
– Protection from violence
– Training in relationship issues and coping skills
– Vocational and legal assistance
© 2007, March of Dimes
Ethical Challenges
• A conflict exists between the woman’s
right to autonomy over her body and
behavior and the nurse’s sense of
obligation to prevent harm to the fetus.
• If nurses are part of an enforcement
system instead of advocates for women’s
needs, women may avoid prenatal care
and social services.
© 2007, March of Dimes
The Nurse’s Role
• In prenatal and acute care settings, nurses
should:
– Thoroughly assess psychosocial risks
– Conduct mutual goal-setting to minimize harm
associated with psychosocial risks
– Offer support and respect
• The sense of being valued can help drug
users begin to make changes.
© 2007, March of Dimes
Tobacco Use in Pregnancy:
Maternal Effects
Cigarette smoking is the most common form
of substance abuse in pregnancy. It is linked
to:
–
–
–
–
–
–
Decreased fertility
Spontaneous abortion
Placenta previa
Placental abruption
Ectopic pregnancy
Preterm premature rupture of membranes
(PPROM)
– Preeclampsia
© 2007, March of Dimes
Tobacco Use in Pregnancy: Fetal
Effects
• Impaired transfer of oxygen and nutrition
• Long-term cognitive function and
increased risk of brain damage
• Chronic low-level hypoxia
• Intrauterine growth restriction (IUGR)
• Preterm delivery
• Low birthweight (LBW) in term infants
© 2007, March of Dimes
Tobacco Use in Pregnancy:
Neonatal Effects
• Impaired respiratory function in
premature infants
• Low neurobehavior scores and higher
withdrawal-symptom scores
• Asthma, respiratory illness and
pneumonia
• Infections of the middle ear
• Increased risk of cancer and SIDS
© 2007, March of Dimes
Alcohol Use in Pregnancy
There is no safe amount of alcohol
consumption during pregnancy (Jones &
Chambers, 1999).
© 2007, March of Dimes
Alcohol Use in Pregnancy:
Maternal Effects
•
•
•
•
•
•
•
Cardiovascular and liver disease
Breast and gynecological cancer
Osteoporosis
Menstrual symptoms
Neurological and mental health problems
Compromised ability to conceive
Spontaneous abortion
© 2007, March of Dimes
Alcohol Use in Pregnancy:
Fetal Effects
• Abnormalities in brain and neuron
development
• Growth deficiency
• Structural changes
• Prematurity
• LBW
• Decreased length and head circumference
© 2007, March of Dimes
Alcohol Use in Pregnancy:
Neonatal Effects
• Fetal alcohol syndrome (FAS)
• Mental retardation
• Developmental, learning and behavior
problems
© 2007, March of Dimes
Marijuana: Maternal Effects
• Is the illicit drug most commonly used
during pregnancy, although only 3.6
percent of pregnant women report using it
(SAMSHA, 2005)
• Does not cause a defined physical
withdrawal syndrome
• Heavy use linked to lung problems
© 2007, March of Dimes
Marijuana: Fetal and Neonatal
Effects
• Does not appear to cause anomalies or
serious effects on the fetus
• Does not appear to decrease intelligence
• Newborns may show increased startle
response, tremors, hand-to-mouth
behavior and disturbed sleep patterns.
© 2007, March of Dimes
Cocaine: Maternal Effects
•
•
•
•
•
•
Hypertension
Tachycardia
Cardiac events and maternal death
Spontaneous abortion
Placental abruption
Premature rupture of membranes (PROM)
© 2007, March of Dimes
Cocaine: Fetal Effects
Fetal effects of cocaine are caused by the
drug’s direct effects (vasoconstriction and
neuroexcitation) and by lifestyle issues that
maternal drug use brings, including poor
nutrition and avoidance of prenatal care.
© 2007, March of Dimes
Cocaine: Neonatal Effects
•
•
•
•
•
Jitteriness
Hyperactivity
Inconsolability
Poor feeding and state regulation
No physiological withdrawal: Neonates are
not dependent on cocaine and do not need
medication to lessen withdrawal.
© 2007, March of Dimes
Amphetamines: Maternal Effects
•
•
•
•
•
•
Stroke
Cardiac problems
Psychiatric emergencies
Growth restriction
Placental abruption
Preterm delivery
© 2007, March of Dimes
Amphetamines: Fetal and Neonatal
Effects
• Similar effects to cocaine, with decreased
fetal growth
• Some researchers expect that, like with
cocaine (Wouldes et al., 2004), effects can be
seen early in life but are quickly
overpowered by environmental factors.
© 2007, March of Dimes
MDMA (Ecstasy): Maternal Effects
•
•
•
•
Anxiety
Twitching
Depression
Impaired cognitive processing and memory
performance
© 2007, March of Dimes
MDMA: Fetal and Neonatal Effects
• Animal studies do not show an increase in
harmful fetal effects.
• A small, uncontrolled, retrospective study
suggests a possible increase in ventricular
septal defects (Bateman et al., 2004).
• Nurses should treat infants and families
based on demonstrated health needs.
© 2007, March of Dimes
Heroin: Maternal Effects
Heroin can cause severe physiological
withdrawal symptoms, including fatal
seizures when withheld for 12 to 48 hours.
© 2007, March of Dimes
Heroin: Treatment
• Methadone
– The most common treatment for heroin
abuse in pregnant women
– During pregnancy, brings addicted women
into agencies that promote prenatal care
• Buprenorphine
– Linked to better treatment adherence with
fewer side effects and overdoses than
methadone
© 2007, March of Dimes
Heroin: Fetal Effects
• Opiates, such as heroin, methadone and
buprenorphine, have not been linked to
fetal anomalies.
• Fetal withdrawal responses include
arrhythmias, seizure activity and fetal
demise.
© 2007, March of Dimes
Heroin: Neonatal Effects
•
•
•
•
•
•
•
•
•
Drug withdrawal
Suck-swallow difficulties
Central nervous system (CNS) irritability
Gastrointestinal upset
Yawning
Sneezing
Frantic sucking with uncoordinated feeding
High-pitched cry
Increased or decreased muscle tone
© 2007, March of Dimes
Comprehensive Psychosocial
Assessment: Setting the Stage
• A woman should only have to provide
sensitive personal information once, in an
environment most likely to produce
support and appropriate follow-up.
• The nurse should provide privacy and a
comfortable setting and view the session
as the beginning of an important personal
relationship with the woman.
© 2007, March of Dimes
Introducing Social Issues
The nurse should begin to explore the
woman’s home situation, including:
– Stress related to work, finances, family
and pregnancy
– Satisfaction with the amount and kind of
support in her social network
– Feelings about self-esteem and ability to
cope with stressors
© 2007, March of Dimes
Three-question Substance-use
Screen
• Have you ever drunk alcohol?
• How much alcohol did you drink in the
month before pregnancy?
• How many cigarettes did you smoke in the
month before pregnancy?
© 2007, March of Dimes
Substance Abuse Assessment
• In no case should urine or blood testing be
used without consent.
• If a woman admits to substance abuse,
testing is not needed to confirm the
presence of a problem.
© 2007, March of Dimes
Tobacco Use Assessment
• Women generally report their smoking
status fairly accurately.
• The Fagerstrom Test for Nicotine
Dependence is used to assess the level of
addiction to tobacco (Heatherton et al., 1991).
© 2007, March of Dimes
The Fagerstrom Test for
Nicotine Dependence
• How soon after you wake up do you smoke your
first cigarette?
• Do you find it difficult to refrain from smoking in
places where it is forbidden?
• Which cigarette would you hate most to give up?
• How many cigarettes per day do you smoke?
• Do you smoke more frequently in the first hours
after waking than during the rest of the day?
• Do you smoke if you are so ill that you are in bed
most of the day?
© 2007, March of Dimes
Alcohol Use Assessment
• Women are quite reliable in reporting
alcohol use in pregnancy (Jacobson et al., 2002).
• The TWEAK is used to screen pregnant
women for alcohol misuse.
© 2007, March of Dimes
TWEAK Alcohol Dependence
Screening Tool
T Tolerance
How many drinks does it take to make you feel high?
Have close friends or relatives worried or complained
about
your drinking in the past year?
Do you sometimes have a drink in the morning when you
E Eyefirst
Opener
get up?
Has a friend or family member ever told you about things
A Amnesia
you
(blackouts) said or did while you were drinking that you could not
remember?
Do you sometimes feel the need to cut down on your
K Cutting
drinking?
down
W Worry
© 2007, March of Dimes
Illicit Drug Use Assessment
• There is no standardized screening tool
for illicit drug use in pregnancy.
• Most women are unlikely to admit the
extent of drug use.
• Nurses should observe physical and
behavioral signs that may indicate illicit
drug use, and follow these over time.
© 2007, March of Dimes
Illicit Drug Use Assessment (Continued)
• Nursing assessment should focus on
opening the door to further discussion and
possible referral.
• Goals in prenatal settings:
– To identify women at risk for consequences of
drug use
– Offer continuing obstetric assessment
– Provide support and resources for further
treatment
© 2007, March of Dimes
Principles of Brief Intervention:
Problem Recognition and Goal-Setting
1. Provide feedback on problems, symptoms and
historical events that suggest a substance abuse
problem. Offer simple, realistic information
about the effects on mother and baby.
2. Advise the woman to stop (or cut down) using
substances.
3. Emphasize that any action taken is the woman’s
choice.
4. Give options for treatment.
5. Get agreement from the woman on at least one
action to take.
© 2007, March of Dimes
Follow-up During Pregnancy
and Postpartum
At each visit, the nurse should:
1. Ask the woman about psychosocial
issues.
– Progress in reducing substance use
– Use of treatment options
– Health changes
2. Impart good news.
© 2007, March of Dimes
Harm Reduction
• Harm reduction is an important principle
for care of substance users (MacMaster, 2004).
• When abstinence is not achieved, reducing
the harm of substance use is an important
goal.
© 2007, March of Dimes
Recognizing the Full Scope of the
Problem
• Few substance users are able to quit on
their first attempt.
• Nurses should view any progress as
worthwhile and recognize that recovery is
a lifelong process.
• Women need to develop entirely new
social support systems.
© 2007, March of Dimes
Smoking Treatment:
Stages of Change Model
1. Precontemplation: No intention of
quitting
2. Contemplation: Considering quitting
within 6 months
3. Action: Taking active steps to quit
4. Maintenance: Maintaining successful
cessation for 6 months or more
© 2007, March of Dimes
Smoking Treatment:
Self-Determination Model
• The nurse uses motivational interviewing
or autonomy-promoting counseling to
elicit the woman’s personal values and
goals.
• The nurse and woman explore the aspects
of unhealthy behavior, focusing on the
discrepancy between the desired goals
and the behavior.
© 2007, March of Dimes
Smoking: Brief Interventions
• Up to 40 percent of pregnant smokers quit
on their own during pregnancy without
intervention.
• A brief, 5-minute intervention can
produce an additional 30 percent quit rate
(Lerman et al., 2005).
© 2007, March of Dimes
Smoking Treatment: The Five A’s
(Fiore et al., 2000)
1.
2.
3.
4.
5.
Ask about tobacco use.
Advise to quit.
Assess willingness to quit.
Assist in attempting to quit.
Arrange follow-up.
The Five A’s are recommended for patients who
are willing to quit.
© 2007, March of Dimes
Smoking Treatment: The Five R’s
(Fiore et al., 2000)
1. Relevance of quitting
2. Risks of continued smoking
3. Rewards of quitting
4. Roadblocks to quitting
5. Repetition
The Five R’s are recommended for patients who are
unwilling to quit.
© 2007, March of Dimes
Smoking Treatment: Follow-up
During Pregnancy
• One of the least expensive and most
effective forms of follow-up is telephone
contact.
• Follow-up should focus on how the effort
is going; support and reinforcement for
even small successes; suggestions to
overcome obstacles; and health progress
reports.
© 2007, March of Dimes
Smoking Treatment: Nicotine
Replacement
• Use of nicotine replacement in pregnancy
is controversial.
• Levels of nicotine in the mother’s body
are lower with nicotine replacement than
with smoking, and she does not ingest
other toxins found in tobacco smoke.
© 2007, March of Dimes
Smoking Treatment: Bupropion
(Zyban)
• Used as an antidepressant and as a
smoking cessation aid
• Shows no harmful effects on pregnant
women treated for depression (Kuller et al.,
1996)
© 2007, March of Dimes
Smoking Treatment: Reducing
Postpartum Relapse
• Thirty percent to 70 percent of smokers
who quit during pregnancy relapse by
1 year postpartum (Secker-Walker et al., 1998).
• Postpartum follow-up is essential.
• Nurses can offer the same tips they gave
to pregnant smokers, with emphasis on
planning ahead to avoid excessive fatigue
and isolation.
© 2007, March of Dimes
Alcohol and Illicit Drug Treatment:
The Nurse’s Role
• Work with the woman to identify the
problem and its risks.
• Agree on initial steps to take.
• Plan for follow-up, as needed.
© 2007, March of Dimes
Alcohol and Illicit Drug Treatment:
Theoretical Frameworks
• Psychodynamic insight-oriented models
• Cognitive-behavioral models
• Relapse prevention
© 2007, March of Dimes
Alcohol and Illicit Drug Treatment:
Treatment Formats
• Outpatient counseling
• Intensive outpatient treatment for 6 to 12
weeks or longer
• Partial hospitalization or day treatment
• Inpatient treatment in a hospital setting
• Residential treatment for 28 days to 6
months or longer
© 2007, March of Dimes
Alcohol and Illicit Drug Treatment:
Treatment Formats (Continued)
•
•
•
•
Twelve-step and faith-based programs
Home-visiting programs
Pharmacologic treatment
Women-oriented treatment programs
© 2007, March of Dimes
Addiction Recovery (Kearney, 1998)
Recovery involves:
– Abstinence
– Self and psychological issues
– Connections and relationships with men and
women, family, community and culture
© 2007, March of Dimes
Addiction Recovery
(Continued)
The most intensive and woman-specific drug
treatment programs have a 50 percent
abstinence rate 1 year after program
completion; a rate closer to 20 percent is
not uncommon (Eisen et al., 1998).
© 2007, March of Dimes
Alcohol and Illicit Drug Treatment:
Ongoing Support and Prenatal Care
• Nurses should carefully observe women on
methadone or heroin for withdrawal
symptoms and report any sudden changes
in patterns of fetal movement.
• Fetal heart checks are important in the
second and third trimesters.
• Providers should conduct fetal non-stress
tests (NSTs) at each visit in the third
trimester.
© 2007, March of Dimes
Care of the Chemically Dependent
Woman in Labor
• The nurse can use the three-question
substance-use screen when admitting a
woman to a labor unit and ask follow-up
questions, as needed.
• In general, epidural anesthesia is
preferred for substance users if pain
management is needed.
© 2007, March of Dimes
Interacting with Laboring Women
Under the Influence of Substances
Nurses must:
– Have great patience and tolerance
– Provide constant warmth and vigilance
– Closely monitor maternal and fetal well-being
© 2007, March of Dimes
Parenting Issues: Child Custody
Nurses must:
– Provide accurate and realistic information to
women about the risk of custody loss in the
perinatal period
– Be familiar with local laws and practices
© 2007, March of Dimes
Handling Alcohol and
Drug-exposed Infants
• Alcohol-exposed infants can be hypotonic
or floppy and may have difficulty feeding
and gaining weight.
• Cocaine-exposed infants may be rigid,
irritable, resistant to holding and feeding
and hard to soothe.
• Providers should use slow, gentle
interactions when caring for these infants.
© 2007, March of Dimes
Feeding Alcohol and Drug-exposed
Infants
Feedings should be slow and relaxed. If the
baby sucks so vigorously that choking is a
hazard, pause the feeding frequently, or use
a bottle nipple with a smaller hole or a
preemie nipple (Villarreal et al., 1992).
© 2007, March of Dimes
Soothing Alcohol and
Drug-exposed Infants
• Excessive crying is a symptom of drug
exposure. The infant may be soothed by:
–
–
–
–
Swaddling
Positioning on the side or back
Reducing room light and stimulation gentle
Stroking or massage
• There may be times when nothing can be
done for a crying infant.
© 2007, March of Dimes
Early Intervention
and Respite Care
• Providers should refer all alcohol- and
drug-exposed infants to early intervention
programs.
• Social and financial services are important
parts of discharge planning.
• Parents and caregivers may need respite;
the nurse can help the mother arrange for
alternate caregivers and support.
© 2007, March of Dimes
Promoting Positive Maternal-child
Interaction
• Nurses can make a critically important
contribution by working to improve the
woman’s parenting knowledge and skills.
• A mother’s psychological state strongly
influences her interaction with her infant
(Fineman et al., 1997).
• Simple interventions can help mothers
parent more effectively.
© 2007, March of Dimes
Summary
Nurses can:
– Provide life-changing interventions for
vulnerable families
– Advocate for increased funding for women’s
substance-abuse treatment
– Work to reduce harmful stigma
– Advocate for healthy environments that reduce
exposure to substances
© 2007, March of Dimes