Michael Weaver, MD, FASAMDivision of Addiction Psychiatry

Virginia Commonwealth UniversityMedical Center

2010 Health SummitSubstance Abuse and Pregnancy

Charlottesville, Virginia

Substance use and pregnancy Maternal & fetal effects during

pregnancy Addiction treatment during pregnancy Neonatal Abstinence Syndrome Home environment

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

ProstitutionSex for money to pay for drugs

“Trading favors” – sex for drugsConsensual transaction Impaired judgment while in “drug den”

Unsafe sexNot always able to use a condomRisk of HIV, Hepatitis B & C, other sexually

transmitted diseasesRisk of violence, fear of prosecution

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 adulterantsRoute of administration (injection)

Co-occurring mental health and substance abuse diagnosesAnxietyDepressionSchizophreniaPersonality

disorders

Cognitive-behavioral counseling more challenging

Best success with treatment of both conditions simultaneously

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

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 patientsup to 10 times higher than in the

general population

Sedative-hypnotics

Opioids Stimulants Nicotine Marijuana

CNS depressant Disinhibition

depress inhibitions firstReduce anxiety (fun at

parties) Oversedation, ataxia,

respiratory depression

Daily drinking leads to tolerance and withdrawalDelirium tremens

Benzodiazepines, barbiturates, other sleeping pills (Ambien, Lunesta)

Sedation, anxiolytic Respiratory

depression in overdose

Withdrawal similar to alcohol DT’s

Common to both:Restlessness InsomniaNausea/vomitingHigh blood

pressureRapid heart rateRapid breathingSeizures

Seen in withdrawal, but not pregnancy:Distractibility Impaired memoryAgitationTremorFeverSweatingHallucinations

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

Fetal Alcohol Syndrome

Fetal Alcohol Effects Spectrum disorder

Leading preventable cause of mental retardation

Encourage abstinence as soon as pregnancy suspected

Morphine, heroin, OxyContin, methadone

Analgesics: disconnect from pain

Euphoria, disconnection, sedation

Nausea, constipation, itching

Oversedation, respiratory depression

No known fetal anomalies

Intrauterine growth retardation

Neonatal abstinence syndromeContinuous

exposureUse up to delivery

Cocaine, amphetamine, methylphenidate, MDMA (Ecstasy), caffeine

Enhanced concentration, alertness

Edginess, paranoia, hypervigilance, psychosis

Hypertension, hyperthermia, vasoconstriction Heart attack, stroke

Spontaneous abortion

Placental abruption Fetal hypertension Intrauterine growth

retardation SIDS ‘Crack baby

syndrome’ disproven

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

craving for tobacco irritability,

frustration, anger anxiety difficulty

concentrating restlessness

decreased heart rate

increased appetite or weight gain

depression disrupted sleep sedation

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

Marijuana, hashish, hash oil

active ingredient: THC

relaxation, hallucination

panic attacks short-term

memory impairment, amnesia

Intrauterine growth retardation

Abnormal startle reflexes in newborns

Reduced memory & verbal skills at age 4 years

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

All pregnant women should be screened for drug and alcohol useT-ACE: emphasizes

tolerance over guilt A positive screen

indicates the need for further evaluation

Alienation from family

Multiple jobs Financial

problems Multiple arrests Multiple partners Loss of custody

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

• 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

Detoxification 12-Step groups Outpatient counseling Intensive outpatient Inpatient Residential Opioid Maintenance

Methadone Buprenorphine

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

• 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

High rates of non-adherence to pharmacotherapyCareful 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

A.A., N.A., C.A. Group format Anonymous No cost No affiliations or

endorsement Different groups

have different characteristics

Motivational InterviewingMotivate 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

Network therapy Family therapy Supportive

psychotherapy Contingency

management Building Social

networks

Twelve-Step facilitation

Perceptual Adjustment therapy

Rational Recovery Medication

management Brief intervention

Non-hospital therapeutic environmentMay include 12-step groups

Consistency in message conveyed by staff Ideal elements for pregnant addicted women

Childcare (for older children)Coordination with obstetric care

Long-acting medication in controlled settingCounselingSocial services

Avoid withdrawal & craving

Reduce disease & crime

Maintenance vs. detoxification

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

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

Long-acting opioid agonist-antagonist Office-based opioid addiction treatment

Schedule IIIBuy at local pharmacy (Subutex, Suboxone)

Very low risk of overdose Combined with naloxone Used for acute pain treatment

(Buprenex)

Pregnancy Category C

Use Subutex instead of Suboxone to avoid naloxone

NAS less intense than with methadone

Studies ongoing, results encouraging

Characterized by Hyperactivity, irritable Hypertonia Difficulty/excessive

sucking High-pitched cries

Begins 3h to 12d after delivery, depending on drugs used by mother

Initial treatment is supportiveSwaddling, frequent feeding, IV fluids

Assess regularly for symptoms and failure to thrive

PharmacotherapyUsually opioids, occasionally sedative-

hypnoticTincture of opium, paregoric, methadone,

phenobarbital

Addicted pregnant woman often product of poor parenting

Support network for new motherFamily, 12-Step group, health care workersEncourage involvement of significant otherLack of support can lead to relapse

Social services may need to be notified of unsafe living conditions

EducationBreastfeedingUmbilical cord

careApproach for

‘fussy’ infantAge-appropriate

discipline for other children

Prevent frustration that leads to relapse

Encouraged Promote bonding Optimal nutrition Passive immunity

Contraindications Active substance

abuse HIV +

Methadone or buprenorphine dose not important consideration

• 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

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

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