SUBSTANCE ABUSE SCREENING IN PREGNANCY

1. SUBSTANCE ABUSE SCREENING IN PREGNANCY Presented by- Debby Carapezza, RN, MSN Nurse Consultant Utah Department of Health Reproductive Health Program January 2004

2. The Problem: • While many providers know substance abuse during pregnancy is a problem, many assume: • -it only exists among the poor and • -it couldn’t possibly be a problem in their practice! • DATA BEG TO DIFFER!!

3. Maternal alcohol abuse during pregnancy is associated with: • Fetal Alcohol Syndrome (FAS) • Increased risk of spontaneous abortion • Alcohol-related neurodevelopmental disorder (ARND) • Alcohol-related birth defects (ARBD)

4. How Prevalent is FAS? • Prevalence varies by population studied & methods used • According to the CDC, rates vary from 0.2 to 1.5 cases per 1,000 live births in various areas of the US • FAS is one of the leading causes of preventable mental retardation

5. What about ARND & ARBD? • These conditions are believed to occur 3 times more often than FAS.

6. What about the $$$$$? • A North Dakota study found that if a prevention program prevents one new case of FAS/year, it would save that state: • $2,342 in the first year • $128,810 after 10 years • $491,820 after 20 years1 1. Klug, MG, Burd L. “Fetal alcohol syndrome prevention: annual and cumulative cost savings.” Neurotoxicology Teratology. (Nov-Dec. 2003). 25(6): 763-765.

7. But Isn’t Utah Different? • According to birth certificate data from 2002- • 1% of women, or 514 women, experiencing a live birth in that year reported using alcohol while pregnant.

8. ILLICIT DRUGSThe National Survey on Drug Use & Health • During 2002, data were collected from 1,104 pregnant women aged 18-44 years of age2 2. Substance Abuse and Mental Health Services Administration. The National Survey on Drug Use and Health, “Pregnancy and Substance Use.” (Jan 2, 2004). Available at: http://oas.samhsa.gov/2k3/pregnancy/pregnancy.htm

9. Results: • 9% of nonpregnant women ages 15 to 44 years reported use of illicit drugs in the month previous to the survey • 3% of pregnant women reported use of illicit drugs in the month previous to the survey • Pregnant women aged 15 to 25 were more likely to use illicit drugs in the past month than pregnant women aged 26 to 44

10. Results continued: • Among pregnant women aged 15 to 44, approximately 6% of blacks, 4 % of whites and 2% of Hispanics used illicit drugs in the past month • Pregnant white & Hispanic women had lower rates of illicit drug use than nonpregnant women of the same age • Among pregnant, black women, the rate of past month illicit drug use was not statistically different from nonpregnant black women • Marijuana was the most widely used illicit drug among both pregnant and nonpregnant women

11. But Isn’t Utah Different? • During 2000, 13 well baby nurseries & during 2000-2001, 6 NICUs collected anonymous meconium samples on newborns3 • Data were compared to results of a maternal substance abuse prevalence study conducted in the same geographic area in 1991.4 • Buchi KF, Zone S, Langheinrich K, Varner MW. “Changing prevalence of prenatal substance abuse in Utah.” Obstetrics & Gynecology. (2003) Jul; 102(1): 27-30. • Buchi KF, Varner MW, Chase RA. “The prevalence of substance abuse among pregnant women in Utah.” Obstetrics & Gynecology. (1993) Feb; 81(2):239-42.

12. Results: THE GOOD! • No significant differences in the rates of positivity for methamphetamines and marijuana were noted between the 2 studies • Cocaine use had declined from 1.1% in 1991 to 0.3% in 2000/2001

13. Results: THE BAD & UGLY! • Positivity for methamphetamines, marijuana & cocaine was 4.7% among infants in NICUs • Positivity for those 3 drugs was 1.9% for infants in well baby nurseries

14. What is the Impact of Substance Use on the Fetus/Infant? ALCOHOL USE

15. The Impact of Alcohol on the Infant

16. How much alcohol does it take to produce FAS? • The exact levels are unknown. However the following is known:5 • With intake of 4 drinks/day, the risk for FAS may be 20% • With the intake of 5 drinks/day, the risk for FAS increases to 30% • With the intake of 6 drinks/day, the risk for FAS increases to 40% • Maternal binge drinking may also produce substantial risk to the fetus 5. The American College of Obstetrics & Gynecologists. Precis V: An Update in Obstetrics & Gynecology.(1994). Washington DC. p. 140.

17. What is the Impact of Substance Use on the Fetus/Infant? COCAINE

18. What about Cocaine? • A meta-analysis reviewed 33 studies of pregnancy outcomes among cocaine consuming women.6 • Women were categorized into 4 groups by type of exposure: • Mainly cocaine • Cocaine plus polydrug use • Polydrug use but no cocaine • No drug use 6. Addis A, Moretti ME, Syed FA, Einarson TR, Koren G. “Fetal effects of cocaine: an updated meta-analysis.” Reproductive Toxicology. (2001). Jul-Aug; 15(4):341-369.

19. Results • When cocaine exposed children were compared to those with no exposure, the cocaine exposed children had higher risks of: • -Major malformations • -Low birth weights • -Prematurity • -Placental abruption • -Premature rupture of membranes • -Decreased length & head circumference

20. But… • Comparison of cocaine exposed children to children exposed to polydrug used without cocaine revealed- • -That only the risk of placental abruption and PROM were statistically associated with cocaine use • -That many adverse perinatal effects attributed to cocaine may be caused by multiple confounders

21. Recommendation by ACOG: • Substance abuse is one of the most important risks encountered in contemporary obstetrics. Therefore, all patients should be questioned thoroughly about substance abuse (including alcohol and tobacco) at the time of their first prenatal visit. (ACOG, 1994)

22. Not to worry! We all ask about drug & alcohol use – don’t we??? • PRAMS* asks new moms, • “During your prenatal visits, did a doctor, nurse, or other health care worker talk with you about any of the things listed below?” • “How drinking during pregnancy could affect your baby?” • “How using illegal drugs could affect your baby?” *PRAMS is an ongoing, population-based risk factor surveillance system designed to identify and monitor selected maternal experiences that occur before and during pregnancy and experiences of the child’s early infancy.

23. And the results were…7 • Only 55.4% of women reported discussion of the affects of alcohol on a baby • Only 47.6% of women reported discussion of how using illegal drugs affects a baby • Women receiving prenatal care through a private provider had the lowest rates of counseling 7. Utah Department of Health, Reproductive Health Program. “Prenatal Education in Utah.” PRAMS Perspectives: A Pregnancy Risk Assessment Monitoring System Quarterly Report. V.3 No. 1. p. 2-4.

24. SCREENING! WHEN?

25. In a perfect world- • Preconceptionally during routine primary care visits • Preconceptionally during family planning visits

26. During pregnancy- • At the first prenatal visit • During each trimester • At the postpartum visit • More frequently if risk factors are present

27. I don’t screen all of my prenatal clients because… I don’t want to offend anyone!

28. To avoid problems, before you start screening: • Train involved staff in interviewing techniques • Train involved staff in use of the screening tool • Assure a non-judgmental & supportive attitude • Assure confidentiality to the extent permitted by law • Involved staff should have an on-going relationship with the client • Screen all clients to decrease subjectivity & bias • Screen in a language understood by the client

29. Remember: • Screening provides the opportunity to begin an open discussion of substance abuse! • During the screening whether the screening is positive or negative for substance abuse, the health implications of use and the benefits of reduction/abstinence should be stressed!

30. I don’t screen because… in my busy office, I just don’t have time!

31. Most screening can be accomplished in a short time. • For the majority of clients, screening can take 30 seconds • For women with a problem, screening can often be accomplished in 5 to 10 minutes

32. Try these strategies for women with a positive screen: • Review for the client the information she has just reported to you • State your concern for both her & her baby’s health • State your belief that you know she want to have a healthy baby and that abstinence from alcohol & drugs will improve her baby’s health

33. Try these strategies for women with a positive screen: • State the need for her to stop using alcohol & drugs during pregnancy • Assure the client you will work with her to achieve a substance free pregnancy • Know your referral sources

34. Try these strategies for women with a positive screen: • Discuss possible strategies for her to stop: • Individual counseling • 12-step programs • Addiction treatment programs

35. Try these strategies for women with a positive screen: • Suggest referral source(s) for a more in-depth assessment by a specialist • If possible, make an appointment for her while in your office • Make a follow-up appointment to see the client after her assessment • Keep an on-going interest in her progress • Praise any reported reduction in use • Maintain communication with the treatment provider to monitor progress

36. Emphasize to the client struggling with substance abuse… • The benefits will begin as soon as she reduces or stops her substance use – the earlier the better – but it is never too late!

37. The 4 Ps Screening Tool

38. A word (or 2) about the tool… • This tool has been chosen to screen for alcohol & drug use during pregnancy due to its brevity, validity, specificity and sensitivity. • It has been used with populations of pregnant women • It is public domain and may be copied without permission

39. And a few more words about the tool… • It has been recommended for use by the National Center for Education in Maternal & Child Health • Its screening questions can be included in other areas of the visit, i.e., in the family history review or when discussing the home environment • However, providers should select a tool with which they are comfortable and that fits their interview style

40. General Instructions on Use of the Tools: • Substance abuse screening should ideally occur face-to-face • Screening can be accomplished via a client completed questionnaire administered prior to the visit & reviewed with the woman during her intake & history

41. 4Ps • Have you ever used drugs or alcohol during the Pregnancy? • Have you had a problem with drugs or alcohol in the Past? • Does your Partner have a problem with drugs or alcohol? • Do you consider one of your Parents to be an addict or alcoholic? • Any woman who answers yes to 1 or more questions should be referred for further assessment

42. Other screening tools are available. • You may also wish to consider the following: • T-ACE • Tweak • TQDH • AUDIT

43. Resources: • For substance abuse: • Utah Department of Human Services • Division of Substance Abuse & Mental Health • 120 N 200 W • Salt Lake City, UT 84103 • 801-58-4379 • www.utahdsa.com

44. Substance Abuse Resources, continued • Substance Abuse & Mental Health Services Administration • Local treatment centers can be found by city, address or zip code at the following website: • http://findtreatment.samhsa.gov/facilitylocatordoc.htm

45. Mental Health Resources- • Mental Health Association in Utah • 1800 S W Temple, Suite 501 • Salt Lake City, UT 84115 • 801-569-3705 • http://www.xmission.com/~mhaut/index.htm

46. Mental Health Resources, continued- • National Alliance for the Mentally Ill – Utah • 309 E 100 S • Salt Lake City, UT 84111 • 801-323-9900 • Bridges Program, Kim Haws, Program Director • Family to Family (provides support to individuals coping with mentally ill family members)

47. Substance Abuse Resources, continued- • Medicaid • Utah Department of Health • Division of Health Care Financing • PO Box 143106 • Salt Lake City, UT 84114-3106 • 801-538-6155 • Toll-free: 800-662-9651

48. In Summary: • All pregnant women should be screened for substance abuse at the first prenatal visit, every trimester thereafter and at the postpartum visit • Women with positive screens should be referred for more detailed assessment / treatment • Screening provides the opportunity to begin an open discussion of substance abuse!