Illicit Drug Abuseand Dependence in Women

                              

A Slide Lecture Presentation 

409 12th Street, SWWashington DC 20024

202/638-5577www.acog.org

Illicit Drug Abuse and Dependence in Women

Ronald A. Chez, MD, FACOGUniversity of South Florida, College of Medicine

Robert L. Andres, MD, FACOGUniversity of Texas Medical School, Houston

Cynthia Chazotte, MD, FACOGAlbert Einstein College of Medicine

Frank W. Ling, MD, FACOGUniversity of Tennessee, College of Medicine

This educational program was funded by the Physician Leadership on National Drug Policy at Brown University, Providence, Rhode Island. (www.plndp.org)

The Physician Leadership on National Drug Policy project is supported through generous contributions from individuals and foundations, primarily the Robert Wood Johnson Foundation and the John D. and Catherine T. MacArthur Foundation.

OverviewAddiction to illegal drugs:

a major national problem causes impaired health, harmful behaviors creates major economic and social burdens

Treatment of drug addiction: efficacy equivalent to other chronic conditions:

hypertension asthma diabetes mellitus

Prevalence and Incidence

Substance use varies among and within different cultural groups:

Present among all socioeconomic, cultural and ethnic groups

Descriptive categories of abusers do not represent distinct, homogenous groups

Prevalence and Incidence30 million Americans have used illegal substances:

40% of 25-30 year olds

Adult monthly cocaine users: 1.5 million abusers 67% are employed full time 53% of their fathers went to college

Age of first use is declining: 23% high school seniors regularly use marijuana 10% of all students have used an illicit drug

Prevalence and Incidence

3.6 million Americans dependent on illicit drugs: 50% have a co-morbid medical condition 19,000 drug addiction deaths annually

$4.5 billion in health expenditures: only 10% used for treatment of addiction

$44 billion productivity loss

Physician BarriersLack of training:

only 1/3 primary care physicians carefully screen for substance abuse only 1/6 believe they are very prepared to spot illegal drug use

Most misunderstand: chronic, relapsing nature of dependence intensity of the urge to use preoccupation with the substance

Physician BarriersLack of awareness:

pervasiveness throughout society treatment options community resources

Skepticism: treatment for illegal drug abuse is not effective patients lie about their substance abuse

Discomfort: difficulty discussing potential of prescription drug abuse

Physician BarriersTime constraints:

impediment to full discussion with patients

Fear of losing patients by asking: resulting in patient fear, anger

Insurance coverage: lack of reimbursement for time to screen lack of reimbursement parity for treatment denial of coverage for referrals

Physician Barriers

Physician as an enabler:

giving tacit approval of the abuse by not addressing the problem

providing patient excuses for work or school

providing prescriptions for inappropriate drugs and in excess quantity including refills

Physician may be a drug abuser

Patient Barriers

Reasons for lying to physician: ashamed, afraid, do not want to stop non-sympathetic, non-confidential setting physician not knowledgeable, acting busy

Abusers’ attitudes toward physicians: do not know how to detect addictions prescribe potentially dangerous drugs never diagnosed the abuse knew about abuse but did nothing about it

Patient BarriersFear of government agencies

Loss of family role with legal and child-custody implications

Societal stigmata

Denial: may be subconscious and unaware a psychological defense against acknowledging the personal pain

Patient Barriers

Enabling by others reinforces patient denial:

covering at work or school

hiding the problem from superiors at work or school

minimizing or ignoring the substance abuse problem

providing drugs to avoid confrontation or unpleasantness

Diagnostic Criteria: Substance Abuse A maladaptive pattern of substance use leading to clinically significant impairment or distress manifested by 1 or more of the following occurring within a 12 month period:

1. use results in failure to fulfill major role obligations: work: absences, poor performance school: absences, suspensions, expulsions home: neglect of children or household

2. recurrent use in physically hazardous situations 3. recurrent substance-related legal problems4. continued use despite resulting persistent or recurrent social or interpersonal problems

Diagnostic Criteria: Substance Dependence

A maladaptive pattern of substance use leading to clinically significant impairment or distress manifested by 3 or more of the following occurring at anytime within the same 12-month period:

1. tolerance of the substance: need for markedly increased amounts to achieve intoxication or the desired effect, or markedly diminished effect with continued use of the same amount

2. withdrawal: the characteristic withdrawal syndrome, or substance taken to relieve or avoid withdrawal symptoms

Substance Dependence (continued)

3. larger amounts of substance taken or over a longer period than was intended

4. persistent desire or unsuccessful efforts to cut down or control use

5. great deal of time spent in activities to obtain, use or recover from the substance’s effects

6. important social, occupational and recreational activities given up or reduced because of use

7. continued use despite knowledge of a persistent or recurrent psychological or physical problem likely to have been caused or exacerbated by use

Role of Ob/Gyn Physician

Screening, identifying and counseling women regarding substance use

Routine screening in history taking: no physical symptoms in majority of abusers screen everyone since no predictors

Know local community resources

Triage to community resources

Screening QuestionsFirst, use ubiquity statements:

“Substance use is so common in our society that I now ask all my patients what, if any, substances they are using?”

Then, ask direct questions: “Have you ever tried . . .?” “How old were you when you first used . . .?” “How often; what route; how much?” “How much does your drug habit cost you?”

History: Red FlagsMaternal chaotic lifestyle:

psychosocial stresses spouse/partner of an alcoholic or drug abuser domestic violence, physical and sexual

Psychiatric diagnosis: depressions, psychosis, anxiety, PTSD lack of functional coping skills unexplained mood swings, personality changes

Late or no prenatal care: missed appointments and compliance problems STDs, sexual promiscuity

Physical Examination

Nothing unusual is the most frequent finding in users of illicit drugs.

Toxicology Testing: Principles

Random checks without clinical suspicion: many consider this unethical may be illegal in some locales

Nonemergency and competent patient: verbally inform prior to testing document permission in medical record

Test if necessary to direct immediate medical interventions

Toxicology Testing: Screening Panel

Usually urine: major route of excretion and concentration inexpensive and quick

Tests include: enzyme multiplied immunoassay techniques thin layer chromatography

Confirmatory tests: gas chromatography, mass spectrometry

Toxicology Drug Screen: Urine

Time frame for drug or metabolite to be present: marijuana, acute use 3 days marijuana, chronic use 30 days cocaine 1–3 days heroin 1 day methadone 3 days

Treatment: PrinciplesDrug addiction is a treatable disease

No single treatment is appropriate for all individuals

Recovery from drug addiction is a long-term process: multiple treatment episodes with relapses

Effectiveness is dependent on remaining in treatment for a dedicated period of time

Matching multiple needs is critical: medical, psychological, social, legal, vocational

Treatment: Cost Considerations

Outpatient $15/day x 120 days $1,800

Intensive outpatient 9 hours/wk + 6 months maintenance

$2,500

Methadone maintenance $13/day x 300 days $3,900

Short termresidential treatment

$130/day x 30 days + $400 x 25 weeks

$4,400

Long termresidential treatment

$49/day x 140 days $6,800

Annual treatment costs for a drug addict:

Year in prison $53 -$71/day $25,900

Plan of CareEstablish a supportive relationship

Educate the patient: ask the patient to describe her understanding of the situation and correct misunderstandings link substance use to patient’s signs & symptoms describe the importance of stopping or cutting down explain consequences of continued use

Refer to specialists for assessment and initiation of a treatment plan

Treatment: Critical ComponentsDetoxification

Medications combined with counseling

Behavioral therapies: skill-building, problem-solving to prevent relapse

Assess for and treat coexisting conditions: mental disorders infectious diseases family planning

Treatment: Behavioral Change

Prochaska’s stages of readiness: assess the patient’s readiness for change and to accept treatment match intervention strategies and goals to the patient’s stage

Stage = precontemplation patient does not believe a problem exists needs evidence of problem and its consequences

Treatment: Behavorial Change

Stage = contemplation

patient recognizes a problem exists: is considering treatment

patient needs: support/encouragement to initiate treatment information on treatment options referral to a specific treatment program

Treatment: Behavioral ChangeStage = action

patient begins treatment: needs ongoing support needs follow up to ensure success

Steps to break the cycle of recurrent binges or daily use:

weekly contact peer support groups family or group therapy urine monitoring

Treatment: Behavioral ChangeIntervention with family, close friends and co-workers:

group meets with patient

each group member states the effects of the patient’s substance use

consequences of not accepting treatment are stated: loss of job; loss of family legal consequences potential of danger from drug access & presence

expressions of concern, support and love

Treatment: Behavioral Change

Stage = relapse

expected, not a failure

prevention is essential: alter life style to reduce their influence develop drug free socialization identify social pressures that may predict use:

rehearse avoidance strategies learn ways to deal with negative feelings:

identify ways to manage distorted thinking

Prevention: Stages

Primary prevention = use has not begun, or use is not problematic

Secondary prevention = treatment of problematic users

Tertiary prevention = preventing and treating complications of substance abuse

Prevention: Prescribing Guidelines

Potentially addictive drugs:

assess option of alternative treatments: nonpharmacological treatments nonaddicting medications

determine risk of developing abuse or dependence

order an initial dose sufficient to provide analgesia, then taper to smallest effective dose

Prevention: Prescribing Guidelines

Analgesics for acute pain symptoms: short period of time for treatment avoid more than one refill avoid telephone refills reassess at frequent intervals prescribe on a fixed schedule vs. prn taper, rather than discontinue if used long term

Write both number and word to minimize alteration

Prevention: Drug Seeking Clues

Patient may be abusing psychoactive medication: exaggerates or feigns symptoms loses prescriptions or medications runs out of medications ahead of time obtains same prescription from multiple doctors claims refill need but original doctor not available insists that only one drug will work demands an immediate prescription for a chronic illness threatens when physician does not comply

FertilityGeneric factors related to substance abuse:

men: impotence decreased semen quality

women: alterations in ovulation menstrual irregularity

libido: variable effect

Pregnancy

Prevalence and incidence: no difference:

indigent/nonindigent patients public and private clinics ethnic groups

4 million women who gave birth: 757,000 drank alcohol products 820,000 smoked cigarettes 221,000 used illegal drugs

Pregnancy: Generic IssuesEducate patient about adverse outcome effectsScreen for domestic violenceScreen for STDs, hepatitis B and C, TBCo-manager or refer to multispecialty clinicRefer to drug counseling programMonitor with urine toxicologySequential antepartum assessment of growthRefer newborn to pediatricsClose postpartum follow up

CocaineAlkaloid from leaves of Erythroxylon coca bush:

marketed as crystals, granules, white powder routes:

intranasal, parenteral, oral, vaginal, rectal decomposes with heating, melts at 195oC water soluble

Crack cocaine alkaloid is free base: soluble in alcohol, oils, acetone, ether colorless, odorless, transparent crystal melts at 98oC not destroyed at higher temperatures

Cocaine

Produces a dose dependent increase in: heart rate and blood pressure arousal, enhanced vigilance and alertness sense of self confidence and well-being

Chronic, heavy use associated with: pronounced irritability paranoid ideations increased risk of violence reduced libido

Cocaine: Adverse Maternal Effects

Possible systemic complications: cardiovascular:

tachycardia and cardiac arrhythmias vasoconstriction and hypertension

central nervous system: hyperthermia CVA seizures

Cocaine: Adverse Fetal Effects

Questionable Congenital anomalies: published data are equivocal reported anomalies include:

limb reduction defects genitourinary tract malformations congenital heart disease central nervous system

Cocaine: Adverse Fetal Effects

Impaired fetal growth: decrease in mean birthweight increase in low birthweight infants increase in intrauterine growth restriction significant correlation between cocaine metabolites in meconium and decreases in birth weight, birth length and head circumference.

Cocaine: Adverse Prenatal Effects

Preterm labor and delivery: no consensus among clinical studies:

Premature separation of the placenta: most studies confirm

Premature rupture of the membranes: controversial association

Cocaine: Adverse Neonatal Effects

Initial neurologic findings: coarse tremor hypertonia extensor leg posture

Increased risk of SIDS (4x)

Long-term consequences: no consistent negative associations developmental outcome similar to drug-free newborns

Cocaine: Treatment

Goal = help patient resist the urge to restart compulsive cocaine use

Options according to personal characteristics: group and individual drug counseling cognitive behavioral therapy to prevent relapse:

ways to act and think in response to cues avoid environmental/social pressures practice drug refusal skills

medications

Opiates and Opioids

Opiates (naturally occurring): derived from the Paper somniferum poppy examples: morphine, codeine

Opioids (synthetic): examples: fentanyl, heroin, hydrocodone,

hydromorphone, meperidine, methadone, and oxycodone

Heroin

Routes: inhaled, intranasal, IV, IM, SQ lipid soluble, rapidly crosses the blood-brain barrier

Constant oscillation between feeling: initial warmth, intense pleasure or rush duration of high between 3-5 hours followed by sedation and tranquility (on the nod) symptoms of early withdrawal

Heroin: Maternal Adverse Effects Short-term adverse effects:

somnolence altered mentation cardiorespiratory arrest (overdose)

Long-term adverse effects: physiologic withdrawal hepatitis B and C STD’s, HIV endocarditis abscesses pneumonia and tuberculosis

Heroin: Withdrawal SyndromeSymptoms:

drug craving anorexia, nausea, abdominal cramping increased sensitivity to pain

Signs: hypertension, hyperventilation, tachycardia lacrimation, mydriasis, rhinorrhea yawning, sweating vomiting, diarrhea chills, flushing, muscle spasms restlessness, tremors, and irritability piloerection

Heroin: Adverse Pregnancy EffectsIntrauterine growth restriction

Neonatal abstinence syndrome: central nervous system:

hypertonia, hyperreflexia, tremors, convulsions gastrointestinal system:

fist sucking, poor feeding, vomiting, diarrhea respiratory system:

tachypnea, sneezing, yawning, hiccups autonomic nervous system:

fever, vasomotor instability, sweating, tearing

Heroin: TreatmentPrinciple = change from a short acting IV to long acting oral opioid to relieve drug craving and withdrawal

Methadone: synthetic opioid blocks effect of heroin long half life allows daily dosing no euphoria, no interference with daily activities

New agents: levomethadyl-acetate (LAAM) buprenorphine (combined with naloxone)

Methadone: Perinatal Effects

Pregnancy: continuation of normal daily activities decrease in associated maternal morbidity

Neonatal abstinence syndrome: occurs on day 2-3 up to a week similar to heroin withdrawal syndrome Naloxone (Narcan) contraindicated; severe

withdrawal

Methadone: Treatment Protocol

Initiation of treatment: 10-20 mg initial dose next 24 hours: 5-10 mg every 6 hours per signs and symptoms of opiate withdrawal daily maintenance dose 10-100 mg, qd or bid

Detoxification during pregnancy, controversial: only if 30 mg/day is realistic goal inpatient: 2 mg/day decrease in dose outpatient: 5 -10 mg/week decrease in dose

Methadone: Maintenance Programs

State and federal regulations restrict prescribing: who enters the program daily dosing schedule location of clinic sites specially licensed physicians

Marijuana

Active ingredient = tetrahydrocannabinol (THC):

derived from Cannabis sativa

lipophilic with accumulation in fatty tissues

metabolized by liver and eliminated in feces

effects: onset within 30-60 minutes 3-5 hour duration

Marijuana: Adverse Maternal Effects

CNS depression

May act as a cardiovascular stimulant: tachycardia, hypotension

Respiratory problems similar to tobacco smokers: bronchitis, sinusitis, pharyngitis

Learning & social behavior: changes in attention, memory, information processing

Marijuana: Adverse Perinatal Effects

Controversial or no clear association: no evidence of congenital anomalies doubt decrease in birth weight doubt increase in preterm birth no evidence of long term infant-child neurodevelopmental sequela

THC is present in breast milk

Pregnancy: Ethical IssuesMaternal autonomy:

the pregnant woman’s right to choose or refuse recommended therapy fetal interests do not have to be abandoned

If conflict between maternal and fetal interests: urge the woman to seek consultation refer to institution’s ethics committee document in detail in medical chart

Court orders for treatment can be destructive to: the woman’s autonomy the physician-patient relationship

Summary1. Drug dependence is a chronic, relapsing medical illness.

2. The etiology and course of the disease is influenced by genetic heritability, personal choice and environmental factors.

3. Drug dependence produces lasting change in brain chemistry and function.

4. Effective medications are available to treat opiate dependence and achieve abstinence.

5. Long-term care strategies produce lasting benefits for the patient who can live normal, productive lives.

Sources of Learning MaterialsAmerican College of Obstetricians and Gynecologists

202-638-5577American Society of Addiction Medicine

301-656-3920March of Dimes Birth Defects Foundation

800-367-6630National Clearinghouse for Alcohol & Drug Information

800-729-6686 or 301-468-2600National Institute on Drug Abuse

301-443-1124Physician Leadership on National Drug Policy

401-444-1816

Internet ResourcesAssociation for Medical Education & Research in Substance Abuse

http://www.amersa.org

Center for Alcohol & Addiction Studies, Brown University

http://www.caas.brown.edu

Center for Substance Abuse Treatment (DHHS) http://www.samhsa.gov/csat

Narcotics Anonymous http://www.na.org/index.htm

Internet Resources (continued)

National Advisory Council on Drug Abuse, National Institute on Drug Abuse (NIDA)

http://www.drugabuse.gov

National Clearinghouse for Alcohol & Drug Information http://www.health.org

Physician Leadership on National Drug Policy http://www.plndp.org

US Department of Justice, Drug Enforcement Admin. http://www.usdoj.gov/dea