Transcript Drug Dependence

Illicit Drug Abuse
and Dependence in Women
A Slide Lecture Presentation
409 12th Street, SW
Washington DC 20024
202/638-5577
www.acog.org
Illicit Drug Abuse and Dependence in Women
Ronald A. Chez, MD, FACOG
University of South Florida, College of Medicine
Robert L. Andres, MD, FACOG
University of Texas Medical School, Houston
Cynthia Chazotte, MD, FACOG
Albert Einstein College of Medicine
Frank W. Ling, MD, FACOG
University of Tennessee, College of Medicine
This educational program was funded by the
Physician Leadership on National Drug Policy at
Brown University, Providence, Rhode Island.
(www.plndp.org)
The Physician Leadership on National Drug Policy
project is supported through generous contributions
from individuals and foundations, primarily the
Robert Wood Johnson Foundation and the John D.
and Catherine T. MacArthur Foundation.
Overview
 Addiction to illegal drugs:
 a major national problem
 causes impaired health, harmful behaviors
 creates major economic and social burdens
 Treatment of drug addiction:
 efficacy equivalent to other chronic conditions:
 hypertension
 asthma
 diabetes mellitus
Prevalence and Incidence
 Substance use varies among and within
different cultural groups:
 Present among all socioeconomic, cultural
and ethnic groups
 Descriptive categories of abusers do not
represent distinct, homogenous groups
Prevalence and Incidence
 30 million Americans have used illegal substances:
 40% of 25-30 year olds
 Adult monthly cocaine users:
 1.5 million abusers
 67% are employed full time
 53% of their fathers went to college
 Age of first use is declining:
 23% high school seniors regularly use marijuana
 10% of all students have used an illicit drug
Prevalence and Incidence
 3.6 million Americans dependent on illicit drugs:
 50% have a co-morbid medical condition
 19,000 drug addiction deaths annually
 $4.5 billion in health expenditures:
 only 10% used for treatment of addiction
 $44 billion productivity loss
Physician Barriers
 Lack of training:
 only 1/3 primary care physicians carefully
screen for substance abuse
 only 1/6 believe they are very prepared to
spot illegal drug use
 Most misunderstand:
 chronic, relapsing nature of dependence
 intensity of the urge to use
 preoccupation with the substance
Physician Barriers
 Lack of awareness:
 pervasiveness throughout society
 treatment options
 community resources
 Skepticism:
 treatment for illegal drug abuse is not effective
 patients lie about their substance abuse
 Discomfort:
 difficulty discussing potential of prescription
drug abuse
Physician Barriers
 Time constraints:
 impediment to full discussion with patients
 Fear of losing patients by asking:
 resulting in patient fear, anger
 Insurance coverage:
 lack of reimbursement for time to screen
 lack of reimbursement parity for treatment
 denial of coverage for referrals
Physician Barriers
 Physician as an enabler:
 giving
tacit approval of the abuse by not
addressing the problem
 providing
patient excuses for work or school
 providing
prescriptions for inappropriate
drugs and in excess quantity including refills
 Physician may be a drug abuser
Patient Barriers
 Reasons for lying to physician:
 ashamed, afraid, do not want to stop
 non-sympathetic, non-confidential setting
 physician not knowledgeable, acting busy
 Abusers’ attitudes toward physicians:
 do not know how to detect addictions
 prescribe potentially dangerous drugs
 never diagnosed the abuse
 knew about abuse but did nothing about it
Patient Barriers
 Fear of government agencies
 Loss of family role with legal and child-custody
implications
 Societal stigmata
 Denial:
 may be subconscious and unaware
 a psychological defense against acknowledging
the personal pain
Patient Barriers
 Enabling by others reinforces patient denial:
 covering
at work or school
 hiding
the problem from superiors at work or
school
 minimizing
or ignoring the substance abuse
problem
 providing
drugs to avoid confrontation or
unpleasantness
Diagnostic Criteria: Substance Abuse
 A maladaptive pattern of substance use leading to
clinically significant impairment or distress
manifested by 1 or more of the following occurring
within a 12 month period:
1. use results in failure to fulfill major role obligations:
 work:
absences, poor performance
 school: absences, suspensions, expulsions
 home: neglect of children or household
2. recurrent use in physically hazardous situations
3. recurrent substance-related legal problems
4. continued use despite resulting persistent or
recurrent social or interpersonal problems
Diagnostic Criteria: Substance Dependence
 A maladaptive pattern of substance use leading to
clinically significant impairment or distress
manifested by 3 or more of the following occurring
at anytime within the same 12-month period:
1.
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
2.
withdrawal: the characteristic withdrawal
syndrome, or substance taken to relieve or
avoid withdrawal symptoms
Substance Dependence (continued)
3. larger amounts of substance taken or over a longer
period than was intended
4. persistent desire or unsuccessful efforts to cut
down or control use
5. great deal of time spent in activities to obtain, use
or recover from the substance’s effects
6. important social, occupational and recreational
activities given up or reduced because of use
7. continued use despite knowledge of a persistent or
recurrent psychological or physical problem
likely to have been caused or exacerbated by use
Role of Ob/Gyn Physician
 Screening, identifying and counseling women
regarding substance use
 Routine screening in history taking:
 no physical symptoms in majority of abusers
 screen everyone since no predictors
 Know local community resources
 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?”
History: Red Flags
 Maternal chaotic lifestyle:
 psychosocial stresses
 spouse/partner of an alcoholic or drug abuser
 domestic violence, physical and sexual
 Psychiatric diagnosis:
 depressions, psychosis, anxiety, PTSD
 lack of functional coping skills
 unexplained mood swings, personality changes
 Late or no prenatal care:
 missed appointments and compliance problems
 STDs, sexual promiscuity
Physical Examination
Nothing unusual is the most frequent
finding in users of illicit drugs.
Toxicology Testing: Principles
 Random checks without clinical suspicion:
 many consider this unethical
 may be illegal in some locales
 Nonemergency and competent patient:
 verbally inform prior to testing
 document permission in medical record
 Test if necessary to direct immediate medical
interventions
Toxicology Testing: Screening Panel
 Usually urine:
 major route of excretion and concentration
 inexpensive and quick
 Tests include:
 enzyme multiplied immunoassay techniques
 thin layer chromatography
 Confirmatory tests:
 gas chromatography, mass spectrometry
Toxicology Drug Screen: Urine
 Time frame for drug or metabolite to be present:
 marijuana, acute use
3 days
 marijuana, chronic use
30 days
 cocaine
1–3 days
 heroin
1 day
 methadone
3 days
Treatment: Principles
 Drug addiction is a treatable disease
 No single treatment is appropriate for all individuals
 Recovery from drug addiction is a long-term process:
 multiple treatment episodes with relapses
 Effectiveness is dependent on remaining in treatment
for a dedicated period of time
 Matching multiple needs is critical:
 medical, psychological, social, legal, vocational
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 hours/wk + 6 months
maintenance
$13/day x 300 days
$2,500
$130/day x 30 days +
$400 x 25 weeks
$49/day x 140 days
$4,400
Methadone maintenance
Short term
residential treatment
Long term
residential treatment
$3,900
$6,800
Plan of Care
 Establish a supportive relationship
 Educate the patient:
 ask the patient to describe her understanding of
the situation and correct misunderstandings
 link substance use to patient’s signs & symptoms
 describe the importance of stopping or cutting down
 explain consequences of continued use
 Refer to specialists for assessment and initiation of a
treatment plan
Treatment: Critical Components
 Detoxification
 Medications combined with counseling
 Behavioral therapies: skill-building, problem-solving
to prevent relapse
 Assess for and treat coexisting conditions:
 mental disorders
 infectious diseases
 family planning
Treatment: Behavioral Change
 Prochaska’s stages of readiness:
 assess the patient’s readiness for change and to
accept treatment
 match intervention strategies and goals to the
patient’s stage
 Stage = precontemplation
 patient does not believe a problem exists
 needs evidence of problem and its consequences
Treatment: Behavorial Change
 Stage = contemplation
 patient
recognizes a problem exists:
 is considering treatment
 patient
needs:
 support/encouragement to initiate treatment
 information on treatment options
 referral to a specific treatment program
Treatment: Behavioral Change
 Stage = action
 patient begins treatment:
 needs ongoing support
 needs follow up to ensure success
 Steps to break the cycle of recurrent binges or
daily use:
 weekly contact
 peer support groups
 family or group therapy
 urine monitoring
Treatment: Behavioral Change
 Intervention with family, close friends and co-workers:
 group
meets with patient
 each
group member states the effects of the
patient’s substance use
 consequences
of not accepting treatment are stated:
 loss of job; loss of family
 legal consequences
 potential of danger from drug access & presence
 expressions
of concern, support and love
Treatment: Behavioral Change
 Stage = relapse
 expected,
not a failure
 prevention
is essential:
 alter life style to reduce their influence
 develop drug free socialization
 identify social pressures that may predict use:
 rehearse avoidance strategies
 learn ways to deal with negative feelings:
 identify ways to manage distorted thinking
Prevention: Stages
 Primary prevention =
use has not begun, or use is not problematic
 Secondary prevention =
treatment of problematic users
 Tertiary prevention =
preventing and treating complications of
substance abuse
Prevention: Prescribing Guidelines
 Potentially addictive drugs:
 assess
option of alternative treatments:
 nonpharmacological treatments
 nonaddicting medications
 determine
 order
risk of developing abuse or dependence
an initial dose sufficient to provide
analgesia, then taper to smallest effective dose
Prevention: Prescribing Guidelines
 Analgesics for acute pain symptoms:
 short period of time for treatment
 avoid more than one refill
 avoid telephone refills
 reassess at frequent intervals
 prescribe on a fixed schedule vs. prn
 taper, rather than discontinue if used long term
 Write both number and word to minimize alteration
Prevention: Drug Seeking Clues
 Patient may be abusing psychoactive medication:
 exaggerates or feigns symptoms
 loses prescriptions or medications
 runs out of medications ahead of time
 obtains same prescription from multiple doctors
 claims refill need but original doctor not available
 insists that only one drug will work
 demands an immediate prescription for a
chronic illness
 threatens when physician does not comply
Fertility
 Generic factors related to substance abuse:
 men:
impotence
 decreased semen quality

 women:
alterations in ovulation
 menstrual irregularity

 libido:

variable effect
Pregnancy
 Prevalence and incidence:
 no difference:
 indigent/nonindigent patients
 public and private clinics
 ethnic groups
 4 million women who gave birth:
 757,000 drank alcohol products
 820,000 smoked cigarettes
 221,000 used illegal drugs
Pregnancy: Generic Issues
 Educate patient about adverse outcome effects
 Screen for domestic violence
 Screen for STDs, hepatitis B and C, TB
 Co-manager or refer to multispecialty clinic
 Refer to drug counseling program
 Monitor with urine toxicology
 Sequential antepartum assessment of growth
 Refer newborn to pediatrics
 Close postpartum follow up
Cocaine
 Alkaloid from leaves of Erythroxylon coca bush:
 marketed as crystals, granules, white powder
 routes:
 intranasal, parenteral, oral, vaginal, rectal
 decomposes with heating, melts at 195oC
 water soluble
 Crack cocaine alkaloid is free base:
 soluble in alcohol, oils, acetone, ether
 colorless, odorless, transparent crystal
 melts at 98oC
 not destroyed at higher temperatures
Cocaine
 Produces a dose dependent increase in:
 heart rate and blood pressure
 arousal, enhanced vigilance and alertness
 sense of self confidence and well-being
 Chronic, heavy use associated with:
 pronounced irritability
 paranoid ideations
 increased risk of violence
 reduced libido
Cocaine: Adverse Maternal Effects
 Possible systemic complications:
 cardiovascular:
tachycardia and cardiac arrhythmias
 vasoconstriction and hypertension

 central
nervous system:
 hyperthermia
 CVA
 seizures
Cocaine: Adverse Fetal Effects
 Questionable Congenital anomalies:
 published data are equivocal
 reported anomalies include:
 limb reduction defects
 genitourinary tract malformations
 congenital heart disease
 central nervous system
Cocaine: Adverse Fetal Effects
 Impaired fetal growth:
 decrease in mean birthweight
 increase in low birthweight infants
 increase in intrauterine growth restriction
 significant correlation between cocaine
metabolites in meconium and decreases in
birth weight, birth length and head
circumference.
Cocaine: Adverse Prenatal Effects
 Preterm labor and delivery:
 no consensus among clinical studies:
 Premature separation of the placenta:
 most studies confirm
 Premature rupture of the membranes:
 controversial association
Cocaine: Adverse Neonatal Effects
 Initial neurologic findings:
 coarse tremor
 hypertonia
 extensor leg posture
 Increased risk of SIDS (4x)
 Long-term consequences:
 no consistent negative associations
 developmental outcome similar to drug-free
newborns
Cocaine: Treatment
 Goal = help patient resist the urge to restart
compulsive cocaine use
 Options according to personal characteristics:
 group and individual drug counseling
 cognitive behavioral therapy to prevent relapse:
 ways to act and think in response to cues
 avoid environmental/social pressures
 practice drug refusal skills
 medications
Opiates and Opioids
 Opiates (naturally occurring):
 derived from the Paper somniferum poppy
 examples: morphine, codeine
 Opioids (synthetic):
 examples: fentanyl, heroin, hydrocodone,
hydromorphone, meperidine, methadone,
and oxycodone
Heroin
 Routes:
 inhaled, intranasal, IV, IM, SQ
 lipid soluble, rapidly crosses the blood-brain barrier
 Constant oscillation between feeling:
 initial warmth, intense pleasure or rush
 duration of high between 3-5 hours
 followed by sedation and tranquility (on the nod)
 symptoms of early withdrawal
Heroin: Maternal Adverse Effects
 Short-term adverse effects:
 somnolence
 altered mentation
 cardiorespiratory arrest (overdose)
 Long-term adverse effects:
 physiologic withdrawal
 hepatitis B and C
 STD’s, HIV
 endocarditis
 abscesses
 pneumonia and tuberculosis
Heroin: Withdrawal Syndrome
 Symptoms:
 drug craving
 anorexia, nausea, abdominal cramping
 increased sensitivity to pain
 Signs:
 hypertension, hyperventilation, tachycardia
 lacrimation, mydriasis, rhinorrhea
 yawning, sweating
 vomiting, diarrhea
 chills, flushing, muscle spasms
 restlessness, tremors, and irritability
 piloerection
Heroin: Adverse Pregnancy Effects
 Intrauterine growth restriction
 Neonatal abstinence syndrome:
 central nervous system:
 hypertonia, hyperreflexia, tremors, convulsions
 gastrointestinal system:
 fist sucking, poor feeding, vomiting, diarrhea
 respiratory system:
 tachypnea, sneezing, yawning, hiccups
 autonomic nervous system:
 fever, vasomotor instability, sweating, tearing
Heroin: Treatment
 Principle = change from a short acting IV to long
acting oral opioid to relieve drug craving and
withdrawal
 Methadone:
 synthetic opioid blocks effect of heroin
 long half life allows daily dosing
 no euphoria, no interference with daily activities
 New agents:
 levomethadyl-acetate (LAAM)
 buprenorphine (combined with naloxone)
Methadone: Perinatal Effects
 Pregnancy:
 continuation of normal daily activities
 decrease in associated maternal morbidity
 Neonatal abstinence syndrome:
 occurs on day 2-3 up to a week
 similar to heroin withdrawal syndrome
 Naloxone (Narcan) contraindicated; severe
withdrawal
Methadone: Treatment Protocol
 Initiation of treatment:
 10-20 mg initial dose
 next 24 hours: 5-10 mg every 6 hours per signs
and symptoms of opiate withdrawal
 daily maintenance dose 10-100 mg, qd or bid
 Detoxification during pregnancy, controversial:
 only if 30 mg/day is realistic goal
 inpatient: 2 mg/day decrease in dose
 outpatient: 5 -10 mg/week decrease in dose
Methadone: Maintenance Programs
 State and federal regulations restrict prescribing:
 who enters the program
 daily dosing schedule
 location of clinic sites
 specially licensed physicians
Marijuana
 Active ingredient = tetrahydrocannabinol (THC):
 derived
from Cannabis sativa
 lipophilic
with accumulation in fatty tissues
 metabolized
by liver and eliminated in feces
 effects:
onset within 30-60 minutes
 3-5 hour duration

Marijuana: Adverse Maternal Effects
 CNS depression
 May act as a cardiovascular stimulant:
 tachycardia, hypotension
 Respiratory problems similar to tobacco smokers:
 bronchitis, sinusitis, pharyngitis
 Learning & social behavior:
 changes in attention, memory, information
processing
Marijuana: Adverse Perinatal Effects
 Controversial or no clear association:
 no evidence of congenital anomalies
 doubt decrease in birth weight
 doubt increase in preterm birth
 no evidence of long term infant-child
neurodevelopmental sequela
 THC is present in breast milk
Pregnancy: Ethical Issues
 Maternal autonomy:
 the pregnant woman’s right to choose or
refuse recommended therapy
 fetal interests do not have to be abandoned
 If conflict between maternal and fetal interests:
 urge the woman to seek consultation
 refer to institution’s ethics committee
 document in detail in medical chart
 Court orders for treatment can be destructive to:
 the woman’s autonomy
 the physician-patient relationship
Summary
1. Drug dependence is a chronic, relapsing medical
illness.
2. The etiology and course of the disease is
influenced by genetic heritability, personal
choice and environmental factors.
3. Drug dependence produces lasting change in
brain chemistry and function.
4. Effective medications are available to treat
opiate dependence and achieve abstinence.
5. Long-term care strategies produce lasting
benefits for the patient who can live normal,
productive lives.
Sources of Learning Materials
 American College of Obstetricians and Gynecologists
 202-638-5577
 American Society of Addiction Medicine
 301-656-3920
 March of Dimes Birth Defects Foundation
 800-367-6630
 National Clearinghouse for Alcohol & Drug Information
 800-729-6686
or 301-468-2600
 National Institute on Drug Abuse
 301-443-1124
 Physician Leadership on National Drug Policy
 401-444-1816
Internet Resources
 Association for Medical Education & Research
in Substance Abuse
 http://www.amersa.org
 Center for Alcohol & Addiction Studies,
Brown University
 http://www.caas.brown.edu
 Center for Substance Abuse Treatment (DHHS)
 http://www.samhsa.gov/csat
 Narcotics Anonymous
 http://www.na.org/index.htm
Internet Resources (continued)
 National Advisory Council on Drug Abuse, National
Institute on Drug Abuse (NIDA)
 http://www.drugabuse.gov
 National Clearinghouse for Alcohol & Drug Information
 http://www.health.org
 Physician Leadership on National Drug Policy
 http://www.plndp.org
 US Department of Justice, Drug Enforcement Admin.
 http://www.usdoj.gov/dea