Treatment Programs HARPS Program (Helping At-Risk Pregnant Women Succeed) - Chris Cooper, MSN,...

Substance Dependence

During Pregnancy:

How Big is the Problem?!?

K. Dawn Forbes, MD, MS, FAAPFounder & Medical Director, HARPS

ProgramNeonatologist, Kosair Children's Hospital

Neonatal Specialist

I have no known or

perceived financial or

professional conflict of

interest regarding this

presentation

All images of persons,

place or animal are either

purchased stock images

or personally

photographed images and

have no known affiliation

with drug use/abuse,

addiction, NAS or illicit

activity.

What is Addiction?

Review the epidemiology of substance abuse

Discuss the cost of substance abuse/dependence

Discuss the pregnancy specific cost and impact of addiction/substance abuse

Discuss recommendations to decrease the impact of addiction in pregnancy and improve outcomes

OBJECTIVES

WHAT IS ADDICTION?

Definition of Addiction

Addiction is complex disease, not just a choice

Complex, chronic, relapsing disease of the brain, characterized by craving & compulsivedrug seeking and use, despite harmful consequences.

Affects brain circuits involved in reward and motivation, learning and memory, and inhibitory control

Definition of Addiction

The American Society of Addiction Medicine (ASAM), in April 2011, redefined addiction

“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry”.

Affects neurotransmission such that addictive behaviors replace healthy, self-care related behaviors.

Genetics account for 50% of addiction development

Significant self-deception

Disruption of healthy social supports and problems in interpersonal relationships

History of trauma or stressors that overwhelm an individual’s coping abilities

The presence of co-occurring psychiatric illness

Distortion in meaning, purpose and values that guide attitudes, thinking and behavior

The effects to the brain allow external cues to trigger craving and drug use

Persistent risk of and/or recurrence of relapse

Impaired executive function so that perception, learning, impulse control, compulsivity and judgment are impaired

Why Do People Use/Abuse Drugs? Curiosity

Peer Pressure

To feed good

Stimulants cause feelings of power, energy, and self-confidence

Opiates cause relaxation & satisfaction

To feel better

Decrease social anxiety, stress & depression

To do better

Enhance cognitive or athletic ability

Self medicate

Undiagnosed/untreated mental illness

Prescribed

Post procedure or chronic pain

EPIDEMIOLOGY OF DRUG ABUSE & ADDICTION

Substance Abuse and Mental Health Services Administration:

Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings

NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

What's the most commonly used drug in pregnancy in the US?

a. Marijuana

b. Opiates

c. Cocaine

Past month Illicit Drug Use Among Persons Aged 12 or Older: 2013

/9.4%

/7.5%

/4.5mil Pain Relievers/1.7mil tranquilizers/1.4 mil stimulants/0.25mil sedatives

/2.5%

Trend In Past Month Use of Illicit Drugs 2002-2013

Trend In Past Month Non-Medical Use of Psychotherapeutic Drugs 2002-2013

Past Month & Past Year Heroin Use: 2002-2013

60% increase

57% increase

Marijuana Use in 2013

Marijuana continued to be the most commonly used drug in 2013

Use from 2007 to 2013 increased from 5.8% to 7.5%

19.8 million reported past month use

Of current drug users

81% used THC

65% used THC exclusively

Average age of initiation of THC 18 yrs.

Daily THC use in past year & past Month 2002-2013

First Drug Associated with Initiation of Illicit Drug Use in 12 or older in 2013

6600 new users/day

56.6% where <18 yo

1600 new cocaine users/day

5500 new users/dayAvg age 22.4

7800 new users/day

463 new heroine users/day

Tobacco Product Use in 2013

57.5 mil current cigarette users

5753 new smokers/day in 2013

50% of new smokers < 18 yo

41.3% smoke 16 or more cigs/day

Prescription Drug Abuse

Defined as the intentional use of medication

Without a prescription

In a way not prescribed

For the “feeling” it invokes

The US makes up 5% of the worlds population & consumes 75% of prescription drugs

High prevalence caused by

Misconceptions about safety

Increasing motivations

“get high”

Counter anxiety, pain, insomnia

Improve performance or cognition

Increasing availability0

50

100

150

200

250

Stimulants Opiates

1991

2010

Prescriptions in millions between 1991-2010

NIH. Topics in Brief: Prescription Drug Abuse. December 2011.

Prescription Drug Use

DRUG USE & DEPENDENCE DURING PREGNANCY

Source: Treatment Episode Data Set (TEDS), 2000-2010

Substance Use In Pregnancy: 2000-2010

Drug Use In Pregnancy In 2013

5.4% of pregnant women, 15-44, reported current illicit drug use

14.6% (18.3%) were 15-17 y.o. (20.9% in 2011)

8.6% (9%) were 18-25 y.o. ( 8.2% in 2011)

3.2 (3.4%) were 26-44 y.o. (2.2% in 2011)

Of those using, 9% used in 1st trimester vs 2.4% in 3rd

4.8% of women where pregnant at entry into substance abuse treatment program

1 in 6 pregnancy women (15.4%) smoked cigarettes in past month

Past Month Cigarette Use in Pregnant and Non Pregnant Women 2002-2013

Alcohol Use in Pregnancy in 2013

19% of pregnant women used alcohol in 1st trimester

9.4% pregnant women reported past month alcohol use

2.3% reported binge drinking

0.4% reported heavy drinking

40K babies born with Fetal Alcohol Spectrum Disorder (FASD) in 2012

Cost of Addiction

Social

Economic

Criminal

RetailMorbidity

Health Care

Mortality

Retail Cost of Addiction

Street Drug Prices Amphetamine 10 mg $5 Cocaine 1 gram $45 Marijuana 1 gram $10 Mushrooms 3.5 grams $25 Oxycodone 60 mg $8 Valium 7 mg $7 Alcohol beer 6-pack 12 fl. Oz. $7.99 Heroin 0.10 grams $25 Ecstasy 100 mg $15 Methamphetamines 20 mg $30

*Information provided by the DEA

What America’s Users Spend on Illegal Drugs: 2000-2010. February 2014. Office of National Drug Control Policy. Office of Research and Data Analysis. Under HHS contract number: HHSP23320095649WC Contract Officer Representative: Michael Cala, PhD

Drug users in the United States have consistently spent >$100 billion annually on cocaine, heroin,

marijuana, and methamphetamine

Compositional shifts

Cocaine consumption decreased by about 50 %

Marijuana consumption increased by about 40%

Heroin consumption remained stable

Heroine consumption has remained stable, $21-27 bil/year Majority of users are daily (>80-90%)

Cost of Addiction…Mortality

Cocaine

Heroine**`

**Likely increased heroine deaths since 2007: Increased availability Decreased price but increased purity Decreased prescription opiate availability

Rates of Prescription Painkiller Sales, Deaths and Substance Abuse Treatment Admissions (1999-2010)

CDC. Vital Signs November 2011. Prescription Painkiller Overdoses in the US. http://www.cdc.gov/vital signs/pdf/2011-11-vital signs.pdf

Drug Overdose Death Rates by State Per 100,000 people (2008)

SOURCE: CDC. Vital Signs November 2011. Prescription Painkiller Overdoses in the US. http://www.cdc.gov/vital signs/pdf/2011-11-vital signs.pdfNational Vital Statistics System, 2008

• Drug overdoses killed more than 38,000 people in 2010 (105 deaths per day)

• Prescription painkiller overdoses killed 16,500 people• (45 deaths per day)

Health care costs continue to grow faster than the economy Health share of the Gross Domestic Product (GDP) reached 17.9% in 20111

Aggregate cost for 39 million hospital stays totaled $387 billion in 20112

2005, drug abuse was reported in 1.3 million hospital stays in the U.S. (3.3%) = $9.9 bil in hospital costs

2008, substance abuse (SA) disorders were the principal reason for 2.1% of inpatient community hospital stays = $2.1 billion3

Cost per stay $4600 Cost per day $970 Avg length of stay 4.8 days

Drug abuse stays were six times more likely than typical stays to result in a discharge against medical advice (6.2 percent versus 0.9 percent).

1 Centers for Medicare & Medicaid Services. National Health Expenditure Accounts. http://www.cms.gov/Research-Statistics-Data- and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html . Accessed July 17, 2013.)2 Health Care Cost and Utilization Project, SB # 168, December 2013. Costs for Hospital Stays in the United States, 2011 Anne Pfuntner, Lauren M. Wier, M.P.H., and Claudia Steiner, M.D., M.P .H.3 Health Care Cost and Utilization Project, statistical brief 117; June 2011 State Variation in Inpatient Hospitalizations for Mental Health and Substance Abuse Conditions, 2002 2008 Elizabeth Stranges, M.S., Katharine Levit, Carol Stocks, R.N., M.H.S.A., Pat Santora, Ph.D.

Cost of Addiction…Health Care Cost

Cost of Addiction…Health Care Admissions

Hospital Inpatient Utilization Related to Opioid Overuse Among Adults, 1993-2012. Pamela L Owens, Ph.D., Marguerite L. Barrett, M.S., Audrey J. Weiss, Ph.D., Raynard E. Washington, Ph.D., and Richard Kronick, Ph.D.

Hospital Inpatient Utilization Related to Opioid Overuse Among Adults, 1993-2012

Cost of Addiction…Health Care In-Patient

Cost of Addiction…Fetal & Newborn Morbidity & Mortality

From Conception the pregnancy & fetus are at risk of

Spontaneous abortion

Fetal Hypoxia

Preterm labor

Preterm delivery

Exposure to violence

Exposure to infection

In early Gestation some drugs can be teratogenic

Alcohol

After structural development is complete the fetus is at risk of:

?Alterations in neurotransmitters & receptors (GABA, Dopa, serotonin)

?Altered brain organization

Placental insufficiency & poor maternal nutrition=IUGR/LBW

Opiates THC Nicotine cocaine

NAS X ? X X

Withdrawal X ?

Toxicity X X

Learning Disabilities X X

Hyperactivity X X X X

Inattention X X X X

Impulsivity X X

Memory Problems X X X

Poor Language X X

Altered response to Visual Stimuli

X

IUGR X X X

Low Birth Weight X X X

SIDS X X

Cost of Addiction…Fetal & Newborn Morbidity & Mortality

Cost of Addiction…NAS from 2000-2009

Maternal opiate use increased from 1.19 to 5.63/1000 live births

NAS increased from 1.2 to 3.39/1000 live births

NAS affected more than 13,539 infants in 2009

1.5 infants born per hour with symptoms of withdrawal

Total hospital charges for NAS increased from $190 million to $720 million

Mean hospital charge per infant has increased from $39, 400 to $53,400

77.6% of charges attributed to State Medicaid

Neonatal Abstinence Syndrome and Associated Health Care Expenditures US 2000-2009. SW Patrick et al; JAMA, May 9, 2012. Vol 307, No. 18

Cost of addiction…

In 2007, total cost of illicit drug use was

Crime: $61,376,694

Health Care $11, 416,232

Productivity $120,304,004

0 100 200 300 400

Drug Misuse

Diabetes

Smoking

Obesity

Heart Disease

Cost in Billions of Drug Misuse as Compared to Chronic Health Problems

$316 B

$147 B

$193 B

$174 B

$157 B

$193 Billion

Total Cost of Substance Abuse & Addiction

Health Care Cost, Billions

Total Cost,Billions

Illicit Drugs $11 $193

Tobacco $96 $193

Alcohol $30 $235

Total Cost: $ 621 Billion

How Do We Break the Cycle and Decrease the Cost and Impact of Addiction & Substance abuse???

1. Gender gap is narrowing for substance use across ethnicities, particularly among young women.

2. Women are more likely to be introduced to and initiate substance use through significant relationships

Boyfriend, family, or friend More likely to have partners who have substance use disorders 2

Perceive shared drug use with their partner as a means of connection or of maintaining the relationship

Status change-death, divorce, separation3. Women accelerate to injecting drugs at a faster rate than men

High-risk behaviors with IV drug use influenced by relationships4. Earlier age of initiation associated with higher risks for dependency5. Women progress faster from initiation substance-related adverse

consequences 3

6. Women are more likely to alter pattern of use for caregiver responsibilities

1 Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series, No. 51. HHS Publication No. (SMA) 14- 4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009. 2 Klein et al. 2003 Klein, H., Elifson, K.W., and Sterk, C.E. Perceived temptation to use drugs and actual drug use among women. Journal of Drug Issues 33(1):161–192, 2003. 3 Antai-Otong, D. Women and alcoholism: Gen der-related medical complications: Treat ment considerations. Journal of Addictions Nursing 17(1):33–45, 2006

Emerging Trends of Substance Abuse among Women 1

Poor availability of treatment centers Lack of collaboration among social service

systems Stigma of substance abuse & treatment

Lack of culturally congruent programming Limited options for women who are pregnant Few resources for women with children Fear of loss of child custody Greater risk of history of abuse (sexual, physical,

psychological) Greater co-morbidity with depression, anxiety,

other mental illnesses

Obstacles for Women in Engaging in Treatment Services

Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series, No. 51. HHS Publication No. (SMA) 14- 4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.

Mental Illness & Substance Abuse

Of the 20.7 mil adults with substance use disorder (SUD)in 2012

40.7% had co-occurring mental illness (AMI)

12.6% had a serious mental illness (SMI)

Those with an AMI & SUD were more likely:

To have past month cigarette use

To have past month binge or heavy alcohol use

To be male (4.1 vs. 3.1%)

To be American Indian or Alaska Native (14%)

To not have graduated from college or HS

To be unemployed

To live below federal poverty line

To be covered by Medicaid or CHIP

Maternal Treatment for Opioid Addiction

Treatment is complex

2012-23 mil needed treatment but only 2.5 mil received treatment*

Effective treatment is multidimensional

Medications, Counseling and Behavioral Therapies

Medically assisted detoxification is only the first stage of treatment

Extended treatment duration is critical

Treatment must help one

Stop using drugs

Maintain a drug-free lifestyle

Become functioning and productive in society

Engage in healthy family and social relationships

Address underlying triggers for use

Most patients require long-term or recurrent treatment before sustained abstinence and recovery


Medications (Methadone, Buprenorphine)

Relieve withdrawal symptoms

Diminish cravings

Repair normal brain function

Decrease relapse

Behavioral

Engages one in treatment

Modifies their attitudes about drug abuse

Increases healthy life skills

Enhances the effectiveness of medications

Keeps people in treatment compliant longer

NIDA. Info Facts. Treatment approaches for drug Addiction

Maternal Treatment for Opioid Addiction Methadone nor Buprenorphine are approved for use in pregnancy

Methadone is the most commonly used maintenance treatment in opioid dependent pregnant women

Advantages of Methadone

Reduces variation in serum opiate levels

Protects fetus from in-utero withdrawal

Decrease illicit opioid craving & use

Blocks heroin induced euphoria

Improves maternal physical and mental health

Improves compliance with prenatal care and nutrition

Improve obstetric outcomes

Allows for anticipation of neonatal withdrawal

Improve chances of stable postnatal environment for the infant


Disadvantages of Methadone

Withdrawal can be harmful by

Increasing risk of fetal death

Increasing risk of illicit drug abuse

Risk of fetal dependence

Risk of NAS (60-90%)

Pain/Pain medications Sleep deprivation Stress of caring for a newborn (+/- other children) Shifts in relationships with partners and family Interactions with child welfare agencies

Court proceedings Temporary or permanent loss of custody Reunification after temporary loss of infant custody.

Guilt and grief related to infant illness or death Added expense of newborn depleting funds for continued treatment Stressors of daily living Returning to activities abstained from during pregnancy

Drinking Smoking Going out with friends (bars, clubs)

1 Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series, No. 51. HHS Publication No. (SMA) 14- 4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009. 2 Mullen, P.D. How can more smoking suspension during pregnancy become lifelong absti nence? Lessons learned about predictors, interventions, and gaps in our accumulated knowledge. Nicotine & Tobacco Research 6(Suppl2):S217–S238, 2004.

Postpartum Period Triggers for Relapse in Drug Dependent Mothers

Supportive therapy Collaborative therapeutic alliance Onsite child care and children services Comprehensive treatment services Socio-demographics (income, age, safe home, transportation) Support and participation of significant others Having at least a high school education Criminal justice system or child protective service involvement (positive) Prior success in other life areas Confidence in the treatment process and outcome

Pregnancy may motivate women in initiating treatment, BUT pregnant women do not stay in treatment as long as non-pregnant women


Factors that Encourage a Woman to Stay in Treatment

Services Needed in Women’s Substance Abuse Treatment Medical Services

Gynecological care Family planning Prenatal care Pediatric care HIV/AIDS services Treatment for infectious diseases Nicotine cessation services

Health Promotion Nutrition Reproductive health Wellness programs Sleep and dental hygiene Preventive Education about STDs and other infectious diseases Preventative education on the effects of alcohol and drugs on

prenatal and child development


Services Needed in Women’s Substance Abuse Treatment


Gender-Specific Needs Women-only programming (same-sex versus mix-gender program due to

trauma history, pattern of withdrawal among men, and other issues?) Lesbian services Cultural and Language Needs (interpreter) Culturally appropriate programming

Life Skills Money management/budgeting Stress reduction Coping skills



Family and Child-Related Services Childcare services, including homework assistance, nurseries and

preschool programs Family treatment services including education re: addiction and its impact

on family function Couples counseling Parent/child services

Age-appropriate programs Child safety education Parenting education Infant/child nutrition Children’s substance abuse prevention Children’s mental health needs



Comprehensive Case Management Intensive case management, including case management for children Link to welfare system, employment opportunities, and housing Transportation Domestic violence services, including referral to safe houses Legal services Assistance for funding for treatment services Assistance in obtaining a GED/continued education Career counseling/vocational training/employment assistance Housing, including referral to transitional living or supervised housing



Mental Health Services Trauma-specific services Eating disorder and nutrition services Access to psychological and pharmacological treatments for depression,

mood/anxiety disorders, other mental illnesses Children’s mental health services



Staff and Treatment Program Development Strong female role models in terms of both leadership and personal

recovery Peer support Adequate staffing to meet added program demands Staff training and gender-competence in working with women Staff training and program development centered upon incorporating

cultural and ethnic influences on parenting styles, attitudes toward discipline, children’s diet, level of parenting supervision, and adherence to medical treatment

Flexible scheduling and staff coordination Adequate time for parent–child bonding and interactions Administrative commitment to addressing the unique needs of women in

treatment Staff training and administrative policies to support the integration of

treatment services with clients on methadone maintenance Culturally appropriate programming that matches specific socialization

and cultural practices for women

THE END

Treatment Programs HARPS Program (Helping At-Risk Pregnant Women Succeed) - Chris Cooper, MSN,...

Healthcare

Transcript of Treatment Programs HARPS Program (Helping At-Risk Pregnant Women Succeed) - Chris Cooper, MSN,...