Transcript File - Physician Classroom

Tobacco, Alcohol and
Drug Use
in Childbearing
Families
Presented by:
Dona Dei, RN/MSN
[email protected]
Smoking and Pregnancy
© 2007, March of Dimes
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
Pregnancy and Smoking
16.2 % of women
smoke cigarettes
Smoking is an
important
determinant of
health status and
a major
contributor to
prematurity, low
birth weight and
© 2007, March of Dimes
© 2007, March of Dimes
Smoking Risks in Pregnancy
Ectopic pregnancy
Intrauterine growth
restriction
Placenta previa
Abruptio placentae
PROM
Spontaneous abortion
Preterm delivery
SIDS (up to 4 times
greater occurrence in
smoking mothers)
© 2007, March of Dimes
Smoking and Pregnancy
Black smokers had substantially higher
cotinine concentrations at all levels
of cigarette smoking than White
smokers.
Caraballo, JAMA 280:135, 1998
© 2007, March of Dimes
Smoking and Child Health
© 2007, March of Dimes
Cost of Complicated* Births
© 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
Smoking and Pregnancy
Smoking during pregnancy is
responsible for:
– 20% of all LBW
– 8% of preterm births
– 5% of all perinatal deaths
Pregnant smokers compared to
nonsmokers are:
– 2.0-5.0 times as likely to experience
PPROM
© 2007, –
March
of Dimes
1.2-2.0
times as likely to deliver preterm
– 1.5-10 times as likely to deliver a SGA
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
The 5 A’s
1. Ask about tobacco use
2. Advise to quit
3. Assess willingness to make a
quit attempt
4. Assist in quit attempt
5. Arrange follow-up
© 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
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
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: 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: 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
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