Maternal & Newborn Effects of Perinatal Substance Abuse

1. 2010 Health Summit Substance Abuse and Pregnancy Charlottesville, Virginia Maternal & Newborn Effectsof Perinatal Substance Abuse Michael Weaver, MD, FASAM Division of Addiction Psychiatry Virginia Commonwealth University Medical Center

2. Objectives • Substance use and pregnancy • Maternal & fetal effects during pregnancy • Addiction treatment during pregnancy • Neonatal Abstinence Syndrome • Home environment

3. Substance abuseand sexual behaviors • 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

4. Sex and Drugs • Prostitution • Sex for money to pay for drugs • “Trading favors” – sex for drugs • Consensual transaction • Impaired judgment while in “drug den” • Unsafe sex • Not always able to use a condom • Risk of HIV, Hepatitis B & C, other sexually transmitted diseases • Risk of violence, fear of prosecution

5. Consequences of drug use • 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 adulterants • Route of administration (injection)

6. Dual Diagnosis • Co-occurring mental health and substance abuse diagnoses • Anxiety • Depression • Schizophrenia • Personality disorders • Cognitive-behavioral counseling more challenging • Best success with treatment of both conditions simultaneously

7. Psychiatric Co-Morbidity • 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

8. Psychiatric consequences • 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 patients • up to 10 times higher than in the general population

9. Drug Classes • Sedative-hypnotics • Opioids • Stimulants • Nicotine • Marijuana

10. Alcohol • CNS depressant • Disinhibition • depress inhibitions first • Reduce anxiety (fun at parties) • Oversedation, ataxia, respiratory depression • Daily drinking leads to tolerance and withdrawal • Delirium tremens

11. Sedatives • Benzodiazepines, barbiturates, other sleeping pills (Ambien, Lunesta) • Sedation, anxiolytic • Respiratory depression in overdose • Withdrawal similar to alcohol DT’s

12. Sedative Withdrawal in Pregnancy • Common to both: • Restlessness • Insomnia • Nausea/vomiting • High blood pressure • Rapid heart rate • Rapid breathing • Seizures • Seen in withdrawal, but not pregnancy: • Distractibility • Impaired memory • Agitation • Tremor • Fever • Sweating • Hallucinations

13. Sedative Withdrawal Treatmentin Pregnancy • 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

14. Alcohol: Effects on fetus • Fetal Alcohol Syndrome • Fetal Alcohol Effects • Spectrum disorder • Leading preventable cause of mental retardation • Encourage abstinence as soon as pregnancy suspected

15. Opioids • Morphine, heroin, OxyContin, methadone • Analgesics: disconnect from pain • Euphoria, disconnection, sedation • Nausea, constipation, itching • Oversedation, respiratory depression

16. Opioids: Effects on fetus • No known fetal anomalies • Intrauterine growth retardation • Neonatal abstinence syndrome • Continuous exposure • Use up to delivery

17. Stimulants • Cocaine, amphetamine, methylphenidate, MDMA (Ecstasy), caffeine • Enhanced concentration, alertness • Edginess, paranoia, hypervigilance, psychosis • Hypertension, hyperthermia, vasoconstriction • Heart attack, stroke

18. Stimulants: Effects on fetus • Spontaneous abortion • Placental abruption • Fetal hypertension • Intrauterine growth retardation • SIDS • ‘Crack baby syndrome’ disproven

19. Nicotine • 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

20. Nicotine Withdrawalin Mother • craving for tobacco • irritability, frustration, anger • anxiety • difficulty concentrating • restlessness • decreased heart rate • increased appetite or weight gain • depression • disrupted sleep • sedation

21. Smoking: Effects on fetus • 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

22. Marijuana • Marijuana, hashish, hash oil • active ingredient: THC • relaxation, hallucination • panic attacks • short-term memory impairment, amnesia

23. Marijuana: Effects on fetus • Intrauterine growth retardation • Abnormal startle reflexes in newborns • Reduced memory & verbal skills at age 4 years

24. Adulteration • 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

25. Screening • All pregnant women should be screened for drug and alcohol use • T-ACE: emphasizes tolerance over guilt • A positive screen indicates the need for further evaluation

26. Social indicatorsof addiction • Alienation from family • Multiple jobs • Financial problems • Multiple arrests • Multiple partners • Loss of custody

27. Diagnosis of Addiction • 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

28. The VCU Medical Center Experience • 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

29. Types of treatment • Detoxification • 12-Step groups • Outpatient counseling • Intensive outpatient • Inpatient • Residential • Opioid Maintenance • Methadone • Buprenorphine

30. Barriers to treatment • 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

31. Treatment works • 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

32. Mental health andaddiction treatment • High rates of non-adherence to pharmacotherapy • Careful 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

33. 12-Step Groups • A.A., N.A., C.A. • Group format • Anonymous • No cost • No affiliations or endorsement • Different groups have different characteristics

34. Counseling • Motivational Interviewing • Motivate 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

35. Addiction Counseling • Network therapy • Family therapy • Supportive psychotherapy • Contingency management • Building Social networks • Twelve-Step facilitation • Perceptual Adjustment therapy • Rational Recovery • Medication management • Brief intervention

36. ResidentialAddiction Treatment • Non-hospital therapeutic environment • May include 12-step groups • Consistency in message conveyed by staff • Ideal elements for pregnant addicted women • Childcare (for older children) • Coordination with obstetric care

37. Maintenance pharmacotherapy • Long-acting medication in controlled setting • Counseling • Social services • Avoid withdrawal & craving • Reduce disease & crime • Maintenance vs. detoxification

38. Methadone • 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

39. Methadone and Pregnancy • 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

40. Buprenorphine • Long-acting opioid agonist-antagonist • Office-based opioid addiction treatment • Schedule III • Buy at local pharmacy (Subutex, Suboxone) • Very low risk of overdose • Combined with naloxone • Used for acute pain treatment (Buprenex)

41. Buprenorphine and Pregnancy • Pregnancy Category C • Use Subutex instead of Suboxone to avoid naloxone • NAS less intense than with methadone • Studies ongoing, results encouraging

42. Neonatal Abstinence Syndrome • Characterized by • Hyperactivity, irritable • Hypertonia • Difficulty/excessive sucking • High-pitched cries • Begins 3h to 12d after delivery, depending on drugs used by mother

43. Treatment of N.A.S. • Initial treatment is supportive • Swaddling, frequent feeding, IV fluids • Assess regularly for symptoms and failure to thrive • Pharmacotherapy • Usually opioids, occasionally sedative-hypnotic • Tincture of opium, paregoric, methadone, phenobarbital

44. Home Environment • Addicted pregnant woman often product of poor parenting • Support network for new mother • Family, 12-Step group, health care workers • Encourage involvement of significant other • Lack of support can lead to relapse • Social services may need to be notified of unsafe living conditions

45. Parenting Skills • Education • Breastfeeding • Umbilical cord care • Approach for ‘fussy’ infant • Age-appropriate discipline for other children • Prevent frustration that leads to relapse

46. Breastfeeding • Encouraged • Promote bonding • Optimal nutrition • Passive immunity • Contraindications • Active substance abuse • HIV + • Methadone or buprenorphine dose not important consideration

47. Children & Addiction • 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

48. Summary • 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

49. Summary • 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

50. Questions?