Michael Weaver, MD, FASAM Division of Addiction Psychiatry Virginia Commonwealth University Medical...
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Transcript of Michael Weaver, MD, FASAM Division of Addiction Psychiatry Virginia Commonwealth University Medical...
Michael Weaver, MD, FASAMDivision of Addiction Psychiatry
Virginia Commonwealth UniversityMedical Center
2010 Health SummitSubstance Abuse and Pregnancy
Charlottesville, Virginia
Substance use and pregnancy Maternal & fetal effects during
pregnancy Addiction treatment during pregnancy Neonatal Abstinence Syndrome Home environment
Risk-taking behavior while intoxicated Unprotected sex may
lead to pregnancy Drug use causes
irregular menstrual cycles, but can still conceive May not realize she is
pregnant for several months
ProstitutionSex for money to pay for drugs
“Trading favors” – sex for drugsConsensual transaction Impaired judgment while in “drug den”
Unsafe sexNot always able to use a condomRisk of HIV, Hepatitis B & C, other sexually
transmitted diseasesRisk of violence, fear of prosecution
May be physical, mental, or social Due to
Side effects of drug Isolation (prefer drug to socialization)Cost of obtaining (especially on Black
Market)Unknown adulterantsRoute of administration (injection)
Co-occurring mental health and substance abuse diagnosesAnxietyDepressionSchizophreniaPersonality
disorders
Cognitive-behavioral counseling more challenging
Best success with treatment of both conditions simultaneously
Higher risk for substance use among those with any psychiatric disorder
Contact with health care or criminal justice system is opportunity to intervene
Earlier detection and intervention prevents problems
Screening is not universal
Substance abuse can masquerade as almost any psychiatric symptom
Drug-induced psychiatric symptoms improve markedly over 2-4 weeks following abstinence
Risk of suicide among substance dependent patientsup to 10 times higher than in the
general population
Sedative-hypnotics
Opioids Stimulants Nicotine Marijuana
CNS depressant Disinhibition
depress inhibitions firstReduce anxiety (fun at
parties) Oversedation, ataxia,
respiratory depression
Daily drinking leads to tolerance and withdrawalDelirium tremens
Benzodiazepines, barbiturates, other sleeping pills (Ambien, Lunesta)
Sedation, anxiolytic Respiratory
depression in overdose
Withdrawal similar to alcohol DT’s
Common to both:Restlessness InsomniaNausea/vomitingHigh blood
pressureRapid heart rateRapid breathingSeizures
Seen in withdrawal, but not pregnancy:Distractibility Impaired memoryAgitationTremorFeverSweatingHallucinations
Withdrawal symptoms may be life-threatening to mother and fetus
Acute withdrawal treatment should be accomplished in an inpatient setting
Risk to mother/fetus of untreated withdrawal is greater than risk from exposure to medications in a controlled setting
Fetal Alcohol Syndrome
Fetal Alcohol Effects Spectrum disorder
Leading preventable cause of mental retardation
Encourage abstinence as soon as pregnancy suspected
Morphine, heroin, OxyContin, methadone
Analgesics: disconnect from pain
Euphoria, disconnection, sedation
Nausea, constipation, itching
Oversedation, respiratory depression
No known fetal anomalies
Intrauterine growth retardation
Neonatal abstinence syndromeContinuous
exposureUse up to delivery
Cocaine, amphetamine, methylphenidate, MDMA (Ecstasy), caffeine
Enhanced concentration, alertness
Edginess, paranoia, hypervigilance, psychosis
Hypertension, hyperthermia, vasoconstriction Heart attack, stroke
Spontaneous abortion
Placental abruption Fetal hypertension Intrauterine growth
retardation SIDS ‘Crack baby
syndrome’ disproven
Cigarettes, cigars, pipes, “snuff,” “chew”
Stimulant & relaxes Acute effects
Vasoconstriction secretions
Chronic effects Lung disease, heart
disease Cancer
Very short-acting, so high-frequency use Very reinforcing
craving for tobacco irritability,
frustration, anger anxiety difficulty
concentrating restlessness
decreased heart rate
increased appetite or weight gain
depression disrupted sleep sedation
Most common fetal exposure
Intrauterine growth retardation
Higher rates of spontaneous abortion, placenta previa, etc.
SIDS risk >4x higher Nicotine patch better
than smoking cigarettes
Marijuana, hashish, hash oil
active ingredient: THC
relaxation, hallucination
panic attacks short-term
memory impairment, amnesia
Intrauterine growth retardation
Abnormal startle reflexes in newborns
Reduced memory & verbal skills at age 4 years
White powder Varies dealer to
dealer & batch to batch
“Buyer beware” Common
adulterants Sugar, condensed
milk OTC or Rx meds
Causes problems when fetus exposed during pregnancy
All pregnant women should be screened for drug and alcohol useT-ACE: emphasizes
tolerance over guilt A positive screen
indicates the need for further evaluation
Alienation from family
Multiple jobs Financial
problems Multiple arrests Multiple partners Loss of custody
Continued substance use despite adverse consequences
Use in larger amounts or for longer periods than intended
Preoccupation with acquiring or using Inability to cut down, stop, or stay
stopped, resulting in a relapse Use of multiple substances of abuse
• High-risk Obstetrics Clinic– Screening, evaluation
• Team approach in hospital setting– Certified Addictions
Nurse– Clinical Social Worker– Obstetrics/Pediatrics
• Continuity after hospitalization– Healthy Start
Initiative through Community Services Board
• Medical management of withdrawal
• Motivational interviewing approach
• Linkage to resources in community
• Good professional relationships– Child Protective
Services– Criminal Justice
System
Detoxification 12-Step groups Outpatient counseling Intensive outpatient Inpatient Residential Opioid Maintenance
Methadone Buprenorphine
Women wary of acknowledging problem Fear of legal consequences (loss of custody)
Reporting requirements Public health authorities, child protective services Criminal justice system When identified or at time of delivery Inform patient of legal obligation
• Sustained remission rates of up to 60%– Better success than
treatment of hypertension, diabetes
• Every $1 spent on treatment saves $7 in costs to society
• Lots of new research
High rates of non-adherence to pharmacotherapyCareful monitoring
of adherence Long-acting
preparations may be beneficial for severe chronic mental illness
Some psychiatric meds can be problematic in pregnancy Weigh risks vs. benefits
A.A., N.A., C.A. Group format Anonymous No cost No affiliations or
endorsement Different groups
have different characteristics
Motivational InterviewingMotivate the patient to reduce/stop
drinking and/or seek further treatment Cognitive-Behavioral Treatment
Identify life stressors, high-risk situations for drinking, and coping skills deficits
Use modeling and rehearsal Relapse Prevention
Identify triggers, practice avoiding, emphasize responsibility
A ‘slip’ is a learning opportunity
Network therapy Family therapy Supportive
psychotherapy Contingency
management Building Social
networks
Twelve-Step facilitation
Perceptual Adjustment therapy
Rational Recovery Medication
management Brief intervention
Non-hospital therapeutic environmentMay include 12-step groups
Consistency in message conveyed by staff Ideal elements for pregnant addicted women
Childcare (for older children)Coordination with obstetric care
Long-acting medication in controlled settingCounselingSocial services
Avoid withdrawal & craving
Reduce disease & crime
Maintenance vs. detoxification
Long-acting pure opioid agonist Available for opioid addiction treatment only
in federally licensed programs Requires daily clinic visits, but may get take-
home dose privileges Significant street reputation Also used for pain like other Schedule II
opioids
Standard of care for opioid-dependent pregnant women
Stabilization of mother and fetus Medical and social Higher dose in 3rd
trimester Improves growth of
fetus & newborn Decreases practice
of high-risk behaviors
Long-acting opioid agonist-antagonist Office-based opioid addiction treatment
Schedule IIIBuy at local pharmacy (Subutex, Suboxone)
Very low risk of overdose Combined with naloxone Used for acute pain treatment
(Buprenex)
Pregnancy Category C
Use Subutex instead of Suboxone to avoid naloxone
NAS less intense than with methadone
Studies ongoing, results encouraging
Characterized by Hyperactivity, irritable Hypertonia Difficulty/excessive
sucking High-pitched cries
Begins 3h to 12d after delivery, depending on drugs used by mother
Initial treatment is supportiveSwaddling, frequent feeding, IV fluids
Assess regularly for symptoms and failure to thrive
PharmacotherapyUsually opioids, occasionally sedative-
hypnoticTincture of opium, paregoric, methadone,
phenobarbital
Addicted pregnant woman often product of poor parenting
Support network for new motherFamily, 12-Step group, health care workersEncourage involvement of significant otherLack of support can lead to relapse
Social services may need to be notified of unsafe living conditions
EducationBreastfeedingUmbilical cord
careApproach for
‘fussy’ infantAge-appropriate
discipline for other children
Prevent frustration that leads to relapse
Encouraged Promote bonding Optimal nutrition Passive immunity
Contraindications Active substance
abuse HIV +
Methadone or buprenorphine dose not important consideration
• Young children don’t have to use drugs themselves to be affected– Child neglect &
abuse– Loss of family
structure– Inappropriate role
models• Impair intellectual,
social, & ethical behavior
Drug use behaviors may increase risk for unplanned pregnancy
Nicotine replacement is preferable to smoking during pregnancy
Fetal Alcohol Syndrome is the leading preventable cause of mental retardation
Alcohol and sedative withdrawal should be treated in an inpatient setting
Adulterants also harm mother and fetus
Most common obstetrical effect of illicit drugs is low birthweight
Methadone maintenance is treatment of choice for opioid-addicted pregnant women
Breastfeeding is encouraged (as long as not actively using illicit drugs or alcohol)
Support for mother is essential Anticipate and educate to prevent
relapse