Pregnancy-Related Issues in the Management of Addictions

1. Pregnancy-Related Issues in the Management of Addictions Train the Trainer Workshop Problematic Substance Use in Pregnancy (PSUP) www.addictionpregnancy.ca Last modified: March 2008

2. Conflict of Interest Disclosure • Financial support for this workshop was provided by Health Canada • Funding for the PRIMA Pocket Reference was provided by the Lawson Foundation • No commercial sponsorship has been received to support this program

3. Pregnancy-Related Issues in the Management of Addictions Problematic Substance Use in Pregnancy Community Presentation

4. Objectives • Define an approach to care for problematic substance use in pregnancy (PSUP) • screening and epidemiology • Describe prenatal care in the context of substance use treatment • Describe the effects of common substances • Describe care at delivery and postpartum • Describe resources available

5. Reasons Women Use Drugs • Cope with history of mental health problems & /or sexual abuse • Cope with stressors of poverty and racism • Cope with problems/stress, e.g., violence, family separation • Cope with feelings of lack of self-worth or inadequacy • Influenced by substance use of partners • Control weight gain • Desire for recreation

6. High Risk Groups of Women • History of abuse (physical, sexual, emotional) • Low income status • Young age with little or no support • Unplanned & unwanted pregnancy • Previous child with developmental delay • History of mood/anxiety disorder or eating disorder

7. Approach to Care - Principles • Woman-centered, nonjudgmental care is crucial • Establishing rapport is the single most important aspect of the initial encounter • Disclosure of use should be seen as positive • The antenatal period is often a time when women are ready to change • Address the woman’s needs and withdrawal symptoms before moving on Try not to fix everything!!!

8. Approach to Care-Principles (2) • Prior relationships with health care providers have often been negative • There is a high percentage of survivors of sexual abuse among women with PSUP - sensitive interviewing is required (defer pelvic exam unless required) • Work to establish trust through communication • Ensure she is safe to leave - increased risk for intimate partner violence • Meet her needs as she identifies them (i.e., food, shelter, etc.) (cont’d)

9. Approach to Care-Principles (3) • Watch for nonverbal cues • Is she feeling vulnerable? • Is she in withdrawal? • Does she understand what you are saying? • Does she appear hungry? • Does she require clothing or shelter? • Does she have a mental health problem? Remember that the appearance of belligerence or anger may signify fear, pain or withdrawal!

10. Identify Key Issues at First Visit • Explore whether she is in withdrawal • Enquire about acute and chronic medical conditions • Ask about medications & OTC and herbal products • Ask if she is safe and has adequate nutrition • FIFE: • What does she feel about her substance use? • What are her ideas about how she started using? • How is she functioning? • What are her expectations about provider involvement? • Plan for follow-up soon after initial encounter It is better to do less than more at the first visit so that she will come back!

11. Comprehensive Assessment • Screening by interviewing for substances used: • Alcohol • Nicotine • Marijuana • Cocaine and other Stimulants • Opiates, illegal and prescribed • Benzodiazepines • Inhalants • Hallucinogens and Designer Drugs (cont’d)

12. Screening Test: T-ACE • T: ToleranceHow many drinks does it take for you to feel the effects? • A: AnnoyedHave people annoyed you by criticizing your drinking? • C: Cut downHave you ever felt you should cut down on your drinking? • E: Eye-openerHave you ever had a drink in the morning to steady your nerves or get going?

13. T-ACE: Scoring • T: 2 points if it takes 2 or more drinks • A,C,E: 1 point each for yes • A total score of 2 points or more indicates the woman is likely to have a problem with alcohol

14. Screening Test: TWEAK • T: How many drinks before you feel high? (Tolerance: record # of drinks) • W: Has anyone worried about your drinking in past year? • E: Do you need a drink in the morning to get going? (Eye opener) • A: Has anyone ever told you about things you said or did while you were drinking that you could not remember? (Amnesia or blackouts) • K (C): Have you felt the need to cut down?

15. TWEAK: Scoring • T: 2 points if it takes 3 or more drinks to feel the effects of alcohol • W: 2 points if yes • E, A, K: 1 point each for yes • A total score of 3 or more points indicates that the woman is likely to have a drinking problem.

16. Comprehensive Assessment This comprehensive history may be completed over several visits: • Complete drug history: name of drug, amount, frequency, duration, route(s), last use, needle sharing or injection drug use (IDU) • History of withdrawal symptoms • Consequences of drug use • Previous treatment: programs, mutual aid groups • Medical history: HIV, Hepatitis B & C, STIs • Obstetrical history: GxPy, LMP, cycle regularity • Social History: partner, living children (cont’d)

17. Comprehensive Assessment Further issues to identify after the establishment of a therapeutic relationship: • Psychiatric history: eating disorders, mood disorders • Social history: family situation (partner, # of children), housing & nutrition, legal (current charges & court dates), finances, domestic violence & child abuse (safety) • Family history: substance use, psychiatric disorders, genetic and congenital disorders • Sexual abuse history: very common among substance using women so use sensitive interviewing techniques (cont’d)

18. Comprehensive Assessment • Consider screening for intimate partner violence • ALPHA (Antenatal Psychosocial Health Assessment) • Three key questions: • Have you ever experienced abuse? • Are you or have you ever been afraid of your partner? • Are you safe? ALPHA: http://dfcm19.med.utoronto.ca/research/alpha (cont’d)

19. Comprehensive Assessment Child Protection Concerns • Remember - there is no legal obligation to report the unborn child • Not all women will require child protection services – some will require support services • Be honest about your legal obligation to inform child protection services once the baby is born • Identify any risks to children that may be living with woman - will need to clarify disposition of all living children • Encourage voluntary self-reporting

20. Physical Examination • Unless clear medical emergency can defer detailed medical exam • Vital signs, fetal heart rate and mother’s weight are key components at each encounter • Defer pelvic exam until rapport has been established (possible history of sexual abuse will require sensitivity during exam) • Obstetrical exam - FHR, Symphysis fundal height • Target exam to reflect / detect substance use • Skin for injection sites, cellulitis, cuts, bruises; nasal passages • Cardiac exam: murmur • Abdominal exam: enlarged liver

21. Investigations • Bloodwork: Quantitative Serum B-hcg, routine prenatal bloodwork, liver enzymes, HIV and Hepatitis C serology (with consent) • Urine: routine and microscopy, culture and sensitivity • Ultrasound: for dates (if uncertain) and morphology • Consider drug toxicology testing (with consent), as needed

22. Screening for Infections Screen as required for: • Hepatitis B with HbsAg and Antibody levels • Hepatitis C antibody testing • Syphilis • HIV (requires informed consent to perform test) • Mantoux (need to ascertain her previous status) • Chlamydia and gonorrhea • Retest as exposure dictates due to window periods for conversion

23. Hepatitis C (HCV) Infection • Rates of HCV infection up to 90% following more than 5 years injection drug use • Seroconversion occurs most frequently in the first year of injection use • Rate of vertical transmission 0 to 5% • No treatment for HCV during pregnancy • Confirm if acute or chronic HCV infection • Consider Hepatitis A & B vaccines for Hep C positive mothers

24. Urine Drug Testing (Toxicology) • If urine drug screening is required by protection services, it must be with maternal consent • If there has been maternal drug use, and there are medical concerns for the neonate and mother is unable or unwilling to give consent, then drug screens on neonate may be taken without consent • Note: An unexpected positive result merits confirmatory testing! (same sample if possible) (cont’d)

25. UDS - Toxicology Voluntary urine testing PROS: agreement provides medical information for caregiver and suggests co-operation with medical care • Negative urine toxicology reports can show abstinence has been achieved and is helpful in interviews with child protection agencies • Valuable for monitoring treatment progress and enhancing motivation • Necessary in some centers if considering methadone maintenance therapy CONS: coercion can set up adversarial relationship between woman and care provider - open communication is critical component

26. Ongoing Care • Frequent visits • Consider pros and cons of multiple care providers (i.e., methadone prescriber and obstetrical provider should ideally be the same person or work in the same clinic) • Ongoing fetal health surveillance dependent on care provider

27. Strategies to Engage Women into Care • Reduce harm related to drug use - if abstinence is not achievable at present, focus on harm reduction • Focus on woman’s needs (woman-centered care; food, housing, safety, emotional support) • Help women re-connect with the healthcare and social systems • Advocate on behalf of women with substance use issues with child protection authorities

28. Harm Reduction • When abstinence is not an option - consider harm reduction philosophies • Harm Reduction: refers to any strategy that focuses on reducing the harmful consequences of drug use and associated high-risk behaviors Example:With some substances, abstinence is not a safe option during pregnancy – methadone maintenance therapy is considered a harm reduction approach for opioid dependence in pregnancy

29. Management of Drug Use • Manage withdrawal symptoms • Consider pharmacological maintenance options, e.g., nicotine replacement therapy (NRT), methadone maintenance therapy (MMT) for opioid dependence • Encourage treatment program attendance if the patient is at a stage of change where she is ready for treatment • Discuss inpatient versus outpatient programs • Educate about fetal and maternal effects • Counsel about risks of Hepatitis B&C, HIV

30. Management of Withdrawal • Drug withdrawal can potentially cause miscarriage in T1, premature labour in T3,adverse fetal effects including fetal distress • If a woman wishes to withdraw from Methadone or opiates, T2 (12-28 weeks GA) may besafest time for taper • The woman should be aware of her increased opiate needs during pregnancy, and risk of relapse with taper • Treatment is based on specific substance(s) used by woman so enquire about polydrug use (very common) • Medical detoxification recommended for opiates, benzodiazepines and alcohol

31. Management of Hepatitis C in Labourand Postpartum • Counsel all women about risk factors for hepatitis C and offer screening (repeat lab work if re-exposed) • If anti-HCV positive, monitor liver enzymes • Mode of delivery and breastfeeding have not been documented in transmission • Role of scalp clip in possible transmission may alter care patterns • Test babies with PCR at 3 to 6 months and if positive, repeat again at 18 months

32. Hospital factors Lack of support Unwanted support Loss of control Hypervigilence Lack of privacy Harsh behaviour by staff Pain Management in LabourWhat can affect a woman’s pain? Personal factors • Past negative experience • Sexual abuse history • Fear, anxiety • Cultural perspective • Tolerance • Labour: Occiput Posterior position • Previous pelvic fracture

33. Labour and Delivery Issues • Adequate analgesia: opioid-dependent women may require larger doses of analgesics  will not worsen addiction • Avoid a fetal scalp clip to prevent transmission of Hep B/C & HIV • Injection drug users may have poor IV access  planned IV access is recommended in case of emergency

34. Postpartum Issues • Rooming-in is the best option to encourage attachment and good parenting • Women may room in even if there is a planned removal of infant (to promote bonding and resilience) • If baby needs to go nursery, parents should accompany and be encouraged to hold and cuddle infant 24/7 if wanted • Encourage breastfeeding and regular visits with infant • Frequent f/u visits for mom & baby to assess coping skills and neonatal growth • If UDS are medically needed, better to obtain consent from the mother

35. Postpartum Care • Ensure there are enough community supports in place before discharge to prevent relapse • Assess social support • Assist with basic needs (food, clothing, shelter) • Monitor for mood disorders • Link parents to community supports and parenting resources • Work with child protection as needed

36. Risks of Heavy Prenatal Alcohol Use • Alcohol passes through placenta & fetus has limited ability to metabolize alcohol • Alcohol is a known teratogen  can damage developing fetal cells, umbilical cord & placenta • Prenatal exposure to alcohol results in: • Increased risk of spontaneous abortion and stillbirth • Increased risk of fetal alcohol spectrum disorder (FASD) – umbrella term encompassing fetal alcohol syndrome (FAS), alcohol-related birth defects and alcohol-related neurodevelopmental disorders

37. Safe Limits of Alcohol • Dose-response relationship between the amount of prenatal alcohol consumed and the extent of damage in the infant • There is NO safe timing for alcohol use during pregnancy • There is NO confirmed safe limit for alcohol use in pregnancy Therefore, NO alcohol is the safest choice!

38. Social Alcohol Use Prior to Pregnancy • A meta-analysis failed to show any adverse fetal effects after social drinking (defined as greater than 2 drinks/week and up to and including 2 drinks/day) • Moderate alcohol consumption before realizing that conception had occurred showed no increased risk of spontaneous abortion, stillbirth or premature birth • Women should be reassured and counseled to abstain for the duration of the pregnancy • Advise Folic Acid during pregnancy

39. Assisting if Low-Risk Alcohol Use • Brief interventions have been shown to be effective in modifying alcohol use during pregnancy • Consider the following for pregnant woman with history of low-risk drinking: • Advise patient that it is safest to stop drinking. • Advise patient to reduce drinking, if unable to stop. • Advise by providing personalized feedback & info. • Assist by providing continued follow-up & support and referral to appropriate resources, as needed.

40. Assisting if High-Risk Use If the pregnant woman indicates high-risk drinking: • Assess level of motivation and readiness to change drinking behaviour & severity of dependence • Offer intervention(s) depending on stage of change and level of alcohol dependence (e.g., medical detoxification) • Advise her to reduce drinking, if unable to stop • Arrange referral to appropriate programs/services • Deal with barriers to attending treatment (e.g., family)

41. Effects of Smoking in Pregnancy • Increased risk of spontaneous abortion • Increased risk of vaginal bleeding (placental abruption and placenta previa) and premature delivery • Increased risk of lower birth weight baby (150-200g less) • Increased risk of sudden infant death syndrome (SIDS), bronchitis & pneumonia, otitis media in children

42. Smoking Cessation • Advise women to quit smoking • Advise woman to avoid exposure to second-hand smoke – family/friends should not smoke around pregnant woman or infant, do not allow smoking in home or vehicle • Educate about effects of smoking in pregnancy • Refer to Smokers’ Helpline or Motherisk • Offer Nicotine Replacement Therapy (NRT)

43. Nicotine Replacement Therapy • Nicotine replacement therapy (NRT) poses no more adverse effects than smoking during pregnancy • Offer NRT if unable to quit on own • 1 pack/day = 20mg nicotine (plasma level) • 1 Patch = 7-21mg • Gum = 2-4 mg/piece (max 12mg/day) • NRT doubles smoking cessation rates at 1 year

44. Marijuana • No studies have established safe limits in pregnancy • No significant neonatal effects • Heavy users may be at risk for preterm delivery • Possible neurobehavioural effects in neonate (increased jitteriness, increased tremors) • Possible long-term effects described in children exposed in utero cont’d

45. Marijuana (2) • No specific therapy for withdrawal • Dependence managed by encouraging decrease in amount used if unable to abstain from marijuana use (harm reduction) • Marijuana is transferred into breast milk and abstinence is encouraged

46. Cocaine and Other Stimulants • Possibly teratogenic renal tract abnormalities (conflicting evidence in the literature) • Increased rate of obstetrical complications • Spontaneous abortion • Placental abruption, placenta previa • Premature rupture of membranes • Preterm labour • Low birth rate • Cerebral hemorrhage in utero cont’d

47. Cocaine and Other Stimulants(2) • Can stop use safely during pregnancy • No specific therapy for withdrawal – care is supportive • Can initially use short-acting benzodiazepines for anxiety and craving cont’d

48. Cocaine and Other Stimulants(3) • If mother intoxicated at time of delivery neonate can have mild central nervous system effects – such as poor feeding and sleepiness • Comfort Measures for neonate • Touch and cuddles by mother • Room-in with mother • Breastfeeding cont’d

49. Cocaine and Other Stimulants(4) • Enters breast milk • Avoid breastfeeding within three days of use (pump and discard) • Long-term effects have been reported in literature (not definitive) • Language delays (expressive and verbal comprehension) • Behavioural problems at school

50. Opiates (1) • Women can take medically prescribed opiates in moderate doses during pregnancy without being considered dependent • Opioids can have a direct effect on fetal outcome with intrauterine growth restriction and low-birth weight – especially heroin use and prescription opioid abuse • Women who are opioid-dependent also have higher rates of obstetrical complications: spontaneous abortion, preterm labour in T3 and fetal distress cont’d