Transcript Screening - National Abandoned Infants Assistance Resource Center

Incorporating Screening for Substance
Use into Routine Prenatal Care
James J. Nocon, M.D., J.D.
Chairman, Indiana Prenatal Substance Abuse Commission
Director, Prenatal Recovery Clinic
Wishard Memorial Hospital
1001 West 10th Street, F5102
Indianapolis, Indiana 46202
Substance Exposed Newborns; June 23, 2010
[email protected]
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Learning Objectives
Screening for Substance Use in Pregnancy
Upon completion of this activity, participants will
be able to:
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Recognize the ethical and legal duty to screen for
substance use in pregnancy.
Understand the role of Urine Drug Screens.
Understand basic screening strategies.
Advocate detection and treatment of addiction
during pregnancy.
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Addiction is a Chronic Relapsing Disease
of the Adult Brain

Researchers have noted that
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Addiction is a chronic relapsing disease
Successful treatment is comparable to, or better than, compliance
with treatment plans for hypertension, diabetes and asthma
And like diabetes and hypertension, addiction is an interaction
between:
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The substance: alcohol, tobacco and other drugs
The host: genetics, vulnerabilities, co-morbid disorders
The environment: family, culture
McLellen AT, Lewis, DC, O’Brien CP, Kleber HD. Drug dependence, a chronic medical illness:
implications for treatment, insurance and outcomes evaluation. JAMA, 2000;284:1689-1695.
Universal Screening in Pregnancy is a
Recognized Standard of Care

Hypertension: 6-8% Prevalence
 BP and urine tests for proteinuria each visit
 History and simple tests will detect almost 100%

Diabetes: 4-5 %
 Urine test for glucose each visit
 Glucola challenge; 24-28 weeks
 History and simple tests will detect almost 100%

Sexually Transmitted Infections: 4-5%
 Everyone is tested – rare exceptions
 Many state laws require STI testing
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Compare to Substance Use

Prevalence estimated in Indiana: 12-18%
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But patients infrequently screened.
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Detection rates are less than 10%.
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Drug use results in more fetal harm and
preterm delivery than hypertension,
diabetes and STI’s combined.
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Ethical Duty To Screen all Pregnant and
Postpartum Women for Substance Use

The American College of Obstetricians and Gynecologists
(ACOG) Committee Opinion 422 addresses the ethical
rationale for universal screening for at-risk drinking and
illicit drug use.
American College of Obstetricians and Gynecologists. At-risk drinking and illicit drug use: ethical issues in
obstetric and gynecologic practice. ACOG Committee Opinion No. 422, December 2008.

The American Medical Association also endorses universal
screening.
Blum LN, Nielson NH, Riggs, JA. Alcoholism and alcohol abuse among women: report of the Counsel on
Scientific Affairs. American Medical Association. J Womens Health 1998;7:861-871
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Universal Screening means that every obstetrical patient is
asked about substance use:
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At the first prenatal or intake visit, and
At least once per trimester thereafter.
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Why Universal Screening?
Pregnancy Enhances Recovery
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Pregnancy makes a difference in long-term
recovery.
After one year of treatment:
65.7% of women who entered treatment while
pregnant used no drugs, while
 Only 27.7% of non-pregnant women remained drug
free. (p<0.0005)

Peles E, Adelson M. Gender Differences and Pregnant Women in a Methadone Maintenance
Treatment (MMT) Clinic. J Addictive Diseases 2006; 25: 39-45.
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Why Universal Screening?
Self Reporting Surveys Inadequate
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In a national survey, 2.9% of patients admitted using
marijuana in pregnancy*
Screening in Indiana indicate:
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29% tested positive for THC on the first prenatal visit
in a major Southwestern Indiana Hospital (2006)
40% tested positive for THC in a Indianapolis (IUMG)
center (2005)
In both surveys, all patients were detected by a urine drug
screen at the first prenatal visit.
Self-reporting underestimates prevalence!
* NIDA’s National Pregnancy and Health Survey (1992/1993)
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Compare Detection with
Intervention
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Detection and Simple Intervention
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Detection with Only Routine Prenatal care
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274 patients; 244 clean at delivery (85%)
20% preterm delivery
42 patients: 23 clean at delivery (55%)
But, 33% preterm labor
The process of detection is, in fact, an
intervention.
Why Universal Screening?
Early Detection Leads to Earlier Intervention
Smoking cessation by 20 weeks:
Most or all of adverse effects of nicotine, cigarette smoke and
additives avoided, specifically:
20% of all low birth weight babies
8% of preterm babies
5% of all perinatal deaths
Tobacco and Alcohol causes more fetal damage
than all the other drugs combined.
Cocaine cessation by 24 weeks
Reduces prevalence of low birth weight and preterm labor
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Meconium Testing in 40 Term Newborns of
Cocaine Positive Mothers Treated 2002-2007
All 40 tested positive for cocaine at first prenatal visit.
 27 negative: mean wt/gm: 3253.55; s.d. 473.99
 13 positive. mean wt/gm: 2775.85: s.d. 466.68
 p<0.01
It takes 10-14 weeks for the meconium to “clear” after cessation of
cocaine use - mechanism is unclear.
 Thus, for a term newborn to be negative, the mother had to be
drug free well before the third trimester.
 Early intervention clearly avoids the low birth weight
effects of cocaine use in pregnancy.
Strong and Nocon. Evaluation of a FRAMES-based Intervention for Pregnant Women Using
Cocaine. Indiana University, School of Medicine.
Universal Screening Is Highly Cost Effective

When identified and treated:
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Rate of abstinence increases.
Maternal and fetal complications decrease.
Less Preterm labor - 20% of treated mothers have preterm delivery
Less Growth restriction
Reducing preterm labor and low birth weight account for
the largest savings.
Preterm delivery accounts for the greatest amount of infant
mortality, morbidity and medical costs in the first year of life.
Hubbard RL, French MT. New perspectives on the benefit-cost and cost-effectiveness of drug abuse
treatment. NIDA Res Monogram 1991;113:94-113.
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Universal Screening: Cost Effective
Reduction of Preterm Labor
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About 89,000 deliveries in Indiana
51% funded by Medicaid – 45,390
15% substance use - 6,808
95% are undetected - 6,468
35% Preterm delivery – 2,263
Mean nursery cost per preterm $75,000
Total cost just for the nursery stay
 $169,725,000
Savings If 50% of Medicaid Pregnant
Substance Users are Detected
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3400 detected (D) – 3400 undetected (U)
20% Preterm delivery D = 680
35% Preterm delivery U = 1190
Total is 1870
Difference from 95% U is 2263-1870 = 393
At $75,000 per Premie nursery cost, detection of
50% saves Medicaid at least
$29,475,000.00 – that’s 29 Million dollars just for the
nursery LOS – Saving $140 million
Take Home Message No. 1
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Universal Screening is a standard of care:
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Endorsed by ACOG, AMA and CS*
Detection alone will result in 50-55% of patients using
ATOD to stop using during the pregnancy.
Simple follow-up can result in greater abstinence of longer
duration.
The failure to screen at the first prenatal visit
deprives the patient of effective treatment.
Is it malpractice?
* CS common sense
Screening Strategies and
Interventions
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Attitude – Non Judgmental; Empathetic
Motivational Empowerment
Cognitive Behavioral Therapy
2 Item Screen
4 P’s Plus
T-ACE – alcohol screen
5 A’s – tobacco brief intervention
FRAMES – brief intervention for alcohol and
drugs
Note the Strong Link Between Alcohol/Nicotine Use
and Use of Illicit Drugs

Among Women using BOTH Alcohol and Nicotine
• 20.4% used Marijuana
• 9.5% used Cocaine

Women NOT using Alcohol or Nicotine
• 0.2% used Marijuana
• 0.1% used Cocaine
Alcohol and nicotine use are markers for substance use.
Alcohol and nicotine use cause more fetal damage than all the
other drugs combined.
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Start with the Two-Item Screen

In the last year have you ever smoked cigarettes,
drunk alcohol or used any drugs more than you
meant to?
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Have you felt you wanted or needed to cut
down on your smoking or drinking or drug use
in the last year?
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Two Item Screen Results
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Two random samples of primary care patients (434 and 702
participants) aged 18 to 59 had the following results:
“No” to each question: 7.3% chance of a current substance
use disorder
1 yes answer: 36.5% chance
2 positive responses had a 72.4% chance
Likelihood ratios were 0.27, 1.93, and 8.77 respectively
Source: Journal of the American Board of Family Practice, May 2001. Reprint requests to Richard L.
Brown, M.D., M.PH., Department of Family Medicine, University of Wisconsin Madison Medical
School, 777 South Mills St., Madison, Wl 53715
.
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Negative Answers on
Two Item Screen
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If the patient states she does not use ATOD,
she is at low risk for substance use.
Proceed to 5 P’s
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Negative answers
Low risk of addiction – send for routine prenatal care.
 Urine drug screen only if all patients get initial urine
drug screen.
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Five P’s (Modified) Screening
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Did either of your PARENTS have a problem with alcohol
or drugs?
Doe any of you PEERS have a problem with alcohol or
drugs?
Does your PARTNER have a problem with alcohol or
drugs?
Have you ever drunk beer, wine or liquor to excess in the
PAST?
(Modified) Have you smoked any cigarettes, used any alcohol
or any drug at any time in this PREGNANCY?
Morse B, Gehshan S, Hutchins E. Screening for substance abuse during pregnancy: improving care,
improving health. Washington, DC: National Center for Education in Maternal and Child Health; 1977.
Chasnoff, et al. The four P’s plus screen for substance use in pregnancy: clinical application and outcomes. J
Pereinat 2005;25:368-374.
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Five P’s Plus Results
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A “yes” answer to any question was considered positive.
The modified 5 P’s Plus screen adds a question about the current
pregnancy and a positive answer identifies 34% of drug and
alcohol users.
With a positive answer about “partner,” 65% were found to
need drug treatment.
Chasnoff IJ, Hung WC. The 4 P’s Plus. Chicago, IL: NTI Publishing; 1999.
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Negative Answers
Two Item Screen and 4P’s Plus
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This is typical of 85% of your patients and you
have just successfully accomplished universal
screening in about 90 seconds.
These women will be at a very low risk for
addiction and should receive routine prenatal
care for the remainder of the pregnancy.
But, ask about ATOD use in each trimester.
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The Role Of Urine Drug Screens
(UDS)
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Can be used to determine prevalence in a
population:
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Many providers use UDS as a routine prenatal test
at the first visit; this is highly recommended:
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consent not required
both legal and ethical.
use “opt out” approach for informed consent
UDS indicated for any positive answer on drug
screens.
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OPT OUT Approach to Urine Drug Screens
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Inform patient about routine prenatal care and
frequency of visits.
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Inform patient that a number of routine screening
tests are done in pregnancy and include, blood tests,
diabetes tests, genetic tests, tests for sexual
infections, ultrasound, and urine tests for protein,
sugar, infection and drugs.
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Inform patient that she may “opt out” of any test.
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If patient opts out of urine drug screen, inform
her that pediatricians may order drug screens
after baby is born.
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How Long is a Drug Detectable
in Urine After Use?
Alcohol 24 hrs
Amphetamines 48 hrs
Barbiturates
Short acting
48 hrs
Long acting
7 days
Benzodiazepines 72 hrs
Cocaine 72 hrs
Marijuana
Opiates
Single use
72 hrs.
Chronic use
30-40 days
Morphine/Heroin
72 hrs
Methadone
96 hrs
Codeine
Up to 10 days
Nicotine 3-5 days from last use
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Urine Drug Screens
Also Recommended:
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At each prenatal visit for any patient identified
as a substance user.
Any history of drug use.
Missing appointments.
Late Prenatal Care.
Preterm Labor.
Third Trimester Bleeding – Abruption.
Growth restriction.
Incarcerated patients.
Intervention Strategies
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There are well recognized intervention strategies
for specific drugs:
Alcohol: T-ACE; TWEAK
 Tobacco: 5 A’s
 Alcohol and Other Drugs – FRAMES
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FRAMES is “generic intervention” and can
be used for almost all substances and
addictive behaviors.
Positive Response with Respect to
Alcohol
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In the last year, have you ever drank, smoked
cigarettes or used drugs more than you meant to?
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Would you like to talk about that?
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Yes
Yes, I lost my job and I have been drinking a lot more
beer than I usually do
How much is a lot more?
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About 3 or 4 beers a night.
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Follow-up Questions About
Alcohol Use In Pregnancy
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Ask about most recent alcohol use
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Dates: what did she use? how often?
Type – social? Binge?
Document last use in record.
Ask about consumption.
Go to T-ACE
If T-ACE score negative – ask her to commit to stop
using any alcohol in this pregnancy.
If positive - Intervention
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Ask About Alcohol Consumption
Consumption – do you have more than 1 drink a day?
Consumption – do you have more than 3 drinks per social
occasion?
At risk consumption:
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Consumption is > 14/drinks/week or > 4 drinks per occasion
(men)
Consumption is > 7/drinks/week or > 3 drinks per occasion
(women)
Document the consumption
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Alcohol Consumption Can Be Tricky
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A Standard Drink is defined as
12 ounces of beer,
5 ounces of wine, and
1.5 ounces of 80 proof distilled spirits
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In a study of pregnant drinkers, the median patient-defined
“drink” size was:
22 ounces of malt liquor, or
8 ounces of fortified (up to 20%) wine, or
2 ounces of 100 proof spirits
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T-ACE – A Screening Tool for
Alcohol Use in Pregnancy
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T: Tolerance: How many drinks does it take you to feel high?
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More than 2 drinks is a positive response – score 2 points
A: Annoyed: Have people annoyed you by criticizing your
drinking? (Yes – score 1 point)
C: Cut down: Have you ever felt you ought to cut down on your
drinking? (Yes – score 1 point)
E: Eye Opener: Have you ever had a drink first thing in the
morning to steady your nerves or get rid of a hangover? (Yes –
score 1 point.)
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T-ACE: Scoring
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A score of 2 or more points indicates at-risk
drinking in pregnancy.
Intervention indicated and may need more
aggressive referral:
Treatment center
 AA
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Sokol RJ; Martier SS; Ager JW. The T-ACE questions: Practical prenatal detection of risk
drinking. American Journal of Obstetrics and Gynecology 160(4): 863-870, 1989.
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Summary of Alcohol Screening
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Get Consumption History
Assess with T-ACE
Use FRAMES intervention.
If continues to use – refer for treatment.
The 5 A’s: Tobacco Use
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ASK – identify and document tobacco status for every patient
at every visit
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ADVISE – in a clear, strong and personalized manner, inform
the patient of the effects of smoking
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ASSESS – willingness to quit
ASSIST – refer to smoking cessation program if available and
use nicotine patch or gum
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ARRANGE – schedule follow up contact in one week after
the quit date.
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Example: Using the 5 A’s for
Tobacco Use
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Ask: How much do you smoke?
Advise: I want you to know that tobacco is the leading cause of
low birth weight in the US. I advise that you cut down and stop.
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Assess: Are you willing to stop? When?
Assist: Would you like to try a nicotine patch or gum?
Arrange: Here’s a list of the smoking cessation programs –
which one will you go to this week?
Thus, you will need to have a list of smoking cessation
programs in your area.
How to ASSESS the Willingness to Quit and
Give Feedback.
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Use this formula: Data; Feeling; Opinion; Want
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Example: tobacco use
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The data is that you are smoking a pack a day
I am afraid that this may affect you baby’s growth
My opinion is that almost all women can quit or cut down
significantly
I want you to quit smoking
Then ask:
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Are you willing to do so?
When will you stop? (get a date)
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FRAMES Intervention
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FRAMES was used in a World Health Organization study to
assess brief interventions. The study evaluated heavy male
drinkers from 12 countries with obvious cultural differences in
alcohol use.
A brief intervention resulted in a decrease in alcohol use of
27%, compared to 7% among controls, still present 9
months after the intervention.
FRAMES also works well with other drug use.
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World Health Organization Brief Intervention Study Group. A cross national trial
of brief interventions with heavy drinkers. Am J Public Health 1996;86:948-955.
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Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems: a
review. Addiction 1993 Mar;88(3):315-35.
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FRAMES: A Brief Intervention
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F - Feedback about the adverse effects of drugs or
alcohol
R - Responsibility for a change in behavior:
A - Advise to reduce or stop use:
M - Menu of options: treatment; medications
E - Empathy is central to the intervention.
S - Self-empowerment: You can change.
Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems; a
review. Addiction 1993;88:315-335
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FRAMES Intervention
Feedback
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F - Feedback
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About the adverse effects of Cocaine
Specific feedback for specific drug
Use Formula: Data-Feeling-Opinion-Want
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Example
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The data is your urine screen was positive for cocaine
I’m afraid that if you are positive at delivery, CPS will investigate and
may put the baby in foster care
My opinion is that you can stop using
I want you to stop using now
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FRAMES Intervention
Responsibility
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R - Responsibility for a change in behavior:
two simple statements
“Only you can decide that you want to stop using.”
 “Are you willing to stop using now?”
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You may add, “I’m proud of you for choosing to
stop.”
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FRAMES Intervention
Advise
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A - Advise to reduce or stop use:
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"For the next week, will you cut down your use of cocaine by 2 times per
week. Can you make that stretch?
Set up a “win-win” for the patient, that is, challenge her to do
something she can do.
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This is called a “stretch.”
It builds self-esteem.
And it works.
Since cocaine costs you 40 dollars a “hit,” that means you will
have 80 dollars more.
I want you to buy something for yourself with the money. What
will you buy? (reward success)
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FRAMES Intervention
Menu of options:
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"If you find that cutting back for the next week is
impossible, then we should consider other options.”
Or, “You may need additional support for your choice
to stop using”
For example:
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Referral to counseling services/social services
Adjunct medications;
Support Groups: AA, NA, Smoking cessation groups
Inpatient treatment.
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FRAMES Intervention
Empathy and Self Empowerment
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Empathy is central to the intervention.
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“I realize this must be real hard to do.”
“I am proud of you for considering a change.”
“I am proud of you for being honest with me.”
Self-empowerment:
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I am proud of you for agreeing to cut back.
You will find that you can succeed.
“I am glad that you continue to come for prenatal care.”
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FRAMES is a Motivational Empowerment
Approach
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Less emphasis on diagnostic label: “alcoholic;” “addict.”
Reduces risk of “shaming”
Motivation empowers patient to make choices and take
action – we call this “accountability.”
Emphasizes personal accountability to change.
Remember to order a UDS for each prenatal visit:
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Document the date of the negative test
Tell her you are proud of her for getting clean
This is very powerful reinforcement
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The Motivating Questions
(to ask at every visit)
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“How will your life be better by not using (fill in with
substance)?”
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I’ll be a better mother – of course you will.
I’ll have more money – how much more?
I have a safer house – what do you need to be safe?
When she is clean ask, “How is your life better now
that you are not using (substance)?”
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Record specific answers
Say, “I’m proud of you.”
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Take Home Message Number 2

What works - just about anything:
Identifying the problem: at least 50% will
abstain
 Motivating the patient: 80-85% will abstain
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What doesn’t work - ignoring the problem.
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