Tobacco, Alcohol and Drug Use in Childbearing Families

1. Tobacco, Alcohol and Drug Use in Childbearing Families Margaret H. Kearney, PhD, RN, FAAN

2. 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.

3. 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.

4. 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).

5. 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

6. 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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

12. 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.

13. 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.

14. 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

15. 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

16. 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

17. Alcohol Use in Pregnancy • There is no safe amount of alcohol consumption during pregnancy (Jones & • Chambers, 1999).

18. Alcohol Use in Pregnancy: Maternal Effects • Cardiovascular and liver disease • Breast and gynecological cancer • Osteoporosis • Menstrual symptoms • Neurological and mental health problems • Compromised ability to conceive • Spontaneous abortion

19. Alcohol Use in Pregnancy: Fetal Effects • Abnormalities in brain and neuron development • Growth deficiency • Structural changes • Prematurity • LBW • Decreased length and head circumference

20. Alcohol Use in Pregnancy: Neonatal Effects • Fetal alcohol syndrome (FAS) • Mental retardation • Developmental, learning and behavior problems

21. Marijuana: Maternal Effects • Is the illicit drug most commonly used during pregnancy, although only 3.6 percent of pregnant women report using it (SAMSHA, 2005) • Does not cause a defined physical withdrawal syndrome • Heavy use linked to lung problems

22. Marijuana: Fetal and Neonatal Effects • Does not appear to cause anomalies or serious effects on the fetus • Does not appear to decrease intelligence • Newborns may show increased startle response, tremors, hand-to-mouth behavior and disturbed sleep patterns.

23. Cocaine: Maternal Effects • Hypertension • Tachycardia • Cardiac events and maternal death • Spontaneous abortion • Placental abruption • Premature rupture of membranes (PROM)

24. Cocaine: Fetal Effects • Fetal effects of cocaine are caused by the drug’s direct effects (vasoconstriction and neuroexcitation) and by lifestyle issues that maternal drug use brings, including poor nutrition and avoidance of prenatal care.

25. Cocaine: Neonatal Effects • Jitteriness • Hyperactivity • Inconsolability • Poor feeding and state regulation • No physiological withdrawal: Neonates are not dependent on cocaine and do not need medication to lessen withdrawal.

26. Amphetamines: Maternal Effects • Stroke • Cardiac problems • Psychiatric emergencies • Growth restriction • Placental abruption • Preterm delivery

27. Amphetamines: Fetal and Neonatal Effects • Similar effects to cocaine, with decreased fetal growth • Some researchers expect that, like with cocaine (Wouldes et al., 2004), effects can be seen early in life but are quickly overpowered by environmental factors.

28. MDMA (Ecstasy): Maternal Effects • Anxiety • Twitching • Depression • Impaired cognitive processing and memory performance

29. MDMA: Fetal and Neonatal Effects • Animal studies do not show an increase in harmful fetal effects. • A small, uncontrolled, retrospective study suggests a possible increase in ventricular septal defects(Bateman et al., 2004). • Nurses should treat infants and families based on demonstrated health needs.

30. Heroin: Maternal Effects • Heroin can cause severe physiological withdrawal symptoms, including fatal seizures when withheld for 12 to 48 hours.

31. Heroin: Treatment • Methadone • The most common treatment for heroin abuse in pregnant women • During pregnancy, brings addicted women into agencies that promote prenatal care • Buprenorphine • Linked to better treatment adherence with fewer side effects and overdoses than methadone

32. Heroin: Fetal Effects • Opiates, such as heroin, methadone and buprenorphine, have not been linked to fetal anomalies. • Fetal withdrawal responses include arrhythmias, seizure activity and fetal demise.

33. Heroin: Neonatal Effects • Drug withdrawal • Suck-swallow difficulties • Central nervous system (CNS) irritability • Gastrointestinal upset • Yawning • Sneezing • Frantic sucking with uncoordinated feeding • High-pitched cry • Increased or decreased muscle tone

34. Comprehensive Psychosocial Assessment: Setting the Stage • A woman should only have to provide sensitive personal information once, in an environment most likely to produce support and appropriate follow-up. • The nurse should provide privacy and a comfortable setting and view the session as the beginning of an important personal relationship with the woman.

35. 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

36. 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?

37. 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.

38. 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).

39. 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?

40. Alcohol Use Assessment • Women are quite reliable in reporting alcohol use in pregnancy (Jacobson et al., 2002). • The TWEAK is used to screen pregnant women for alcohol misuse.

41. TWEAK Alcohol Dependence Screening Tool

42. Illicit Drug Use Assessment • There is no standardized screening tool for illicit drug use in pregnancy. • Most women are unlikely to admit the extent of drug use. • Nurses should observe physical and behavioral signs that may indicate illicit drug use, and follow these over time.

43. Illicit Drug Use Assessment (Continued) • Nursing assessment should focus on opening the door to further discussion and possible referral. • Goals in prenatal settings: • To identify women at risk for consequences of drug use • Offer continuing obstetric assessment • Provide support and resources for further treatment

44. Principles of Brief Intervention:Problem Recognition and Goal-Setting • 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. • Advise the woman to stop (or cut down) using substances. • Emphasize that any action taken is the woman’s choice. • Give options for treatment. • Get agreement from the woman on at least one action to take.

45. Follow-up During Pregnancy and Postpartum • At each visit, the nurse should: • Ask the woman about psychosocial • issues. • Progress in reducing substance use • Use of treatment options • Health changes • Impart good news.

46. 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.

47. 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.

48. Smoking Treatment: Stages of Change Model • Precontemplation: No intention of quitting • Contemplation: Considering quitting within 6 months • Action: Taking active steps to quit • Maintenance: Maintaining successful cessation for 6 months or more

49. Smoking Treatment: Self-Determination Model • The nurse uses motivational interviewing or autonomy-promoting counseling to elicit the woman’s personal values and goals. • The nurse and woman explore the aspects of unhealthy behavior, focusing on the discrepancy between the desired goals and the behavior.

50. Smoking: Brief Interventions • Up to 40 percent of pregnant smokers quit on their own during pregnancy without intervention. • A brief, 5-minute intervention can produce an additional 30 percent quit rate (Lerman et al., 2005).