Prenatal Alcohol and Drug Prenatal Alcohol and Drug Exposure:Exposure:

Impact and InterventionImpact and InterventionNovember 7, 2007November 7, 2007

Conjoint 556Conjoint 556 Addiction: Mechanisms, Prevention, Treatment Addiction: Mechanisms, Prevention, Treatment

Therese Grant, Ph.D.Therese Grant, Ph.D.Director, Fetal Alcohol and Drug UnitDirector, Fetal Alcohol and Drug Unit

Associate ProfessorAssociate ProfessorDepartment of Psychiatry & Behavioral SciencesDepartment of Psychiatry & Behavioral Sciences

University of Washington School of MedicineUniversity of Washington School of Medicine

TopicsTopics• Teratogenic effects of alcohol and drugsTeratogenic effects of alcohol and drugs

• Fetal alcohol syndromeFetal alcohol syndrome

• Prevalence of prenatal alcohol usePrevalence of prenatal alcohol use

• Intervention and Prevention: Parent-Intervention and Prevention: Parent-Child Assistance ProgramChild Assistance Program

• Challenges of conducting evidence-Challenges of conducting evidence-based community interventionbased community intervention

T e r a t o g e n sT e r a t o g e n s• Substances that have the potential to damage Substances that have the potential to damage

the fetus when exposure occurs during the fetus when exposure occurs during pregnancy (e.g., radiation, thalidomide, pregnancy (e.g., radiation, thalidomide, alcohol). alcohol).

• Degree of damage depends on timing and Degree of damage depends on timing and dose of exposure.dose of exposure.

• If timing and dose are below the teratogenic If timing and dose are below the teratogenic threshold, some exposures have little risk of threshold, some exposures have little risk of causing malformation.causing malformation.

Prenatal Opiate ExposurePrenatal Opiate Exposure

• Is not considered teratogenic; no known congenital Is not considered teratogenic; no known congenital malformation is associated.malformation is associated.

However:However:• May affect prenatal growth due to maternal malnutrition May affect prenatal growth due to maternal malnutrition

and co-morbid infections. LBW and intrauterine growth and co-morbid infections. LBW and intrauterine growth retardation increase risk of preterm birth.retardation increase risk of preterm birth.

• Newborns of addicted women can suffer withdrawal. If Newborns of addicted women can suffer withdrawal. If mother was IV drug user, children may be at increased mother was IV drug user, children may be at increased risk for HIV, Hepatitis B & C. risk for HIV, Hepatitis B & C.

• It’s difficult to differentiate impact of prenatal heroin It’s difficult to differentiate impact of prenatal heroin exposure and poor postnatal environment on child long-exposure and poor postnatal environment on child long-term outcome.term outcome.

Prenatal Marijuana ExposurePrenatal Marijuana Exposure

• There is no consistent link between prenatal There is no consistent link between prenatal marijuana exposure and other adverse marijuana exposure and other adverse pregnancy outcomes or congenital pregnancy outcomes or congenital malformation.malformation.

• Marijuana use during pregnancy may have a Marijuana use during pregnancy may have a modest effect on prenatal growth, but results modest effect on prenatal growth, but results are inconsistent and diminish when potential are inconsistent and diminish when potential cofounders are controlled.cofounders are controlled.

Prenatal Marijuana ExposurePrenatal Marijuana Exposure

• The principle psychoactive substance in The principle psychoactive substance in marijuana, marijuana, -9-tetrahyrocannabinol (THC), -9-tetrahyrocannabinol (THC), rapidly crosses the placenta and may remain rapidly crosses the placenta and may remain in the body for 30 days, thus prolonging in the body for 30 days, thus prolonging potential fetal exposure. potential fetal exposure.

• Marijuana smoking produces higher levels of Marijuana smoking produces higher levels of carbon monoxide than tobacco, which may carbon monoxide than tobacco, which may be a potential mechanism of action of be a potential mechanism of action of marijuana’s impact on the developing fetus.marijuana’s impact on the developing fetus.

Prenatal Cocaine ExposurePrenatal Cocaine Exposure

• Cocaine and its metabolites readily cross the Cocaine and its metabolites readily cross the

placenta, concentrating in amniotic fluid, and placenta, concentrating in amniotic fluid, and

may produce direct neurotoxic effects, disturb may produce direct neurotoxic effects, disturb

dopamine, norepinephrine, and serotonin dopamine, norepinephrine, and serotonin

pathways, and cause vascular-mediated pathways, and cause vascular-mediated

damage.damage.

Prenatal Cocaine ExposurePrenatal Cocaine Exposure

• Associated with obstetric complications: stillbirth, Associated with obstetric complications: stillbirth, placental abruption, premature rupture of placental abruption, premature rupture of membranes, fetal distress, and preterm delivery. membranes, fetal distress, and preterm delivery.

• Growth restriction, but may require higher levels of Growth restriction, but may require higher levels of exposure and does not seem to persist after birth. exposure and does not seem to persist after birth.

• The few available large, controlled, population-based The few available large, controlled, population-based studies have reached contradictory conclusions. studies have reached contradictory conclusions. CNS lesions (e.g., stroke, possible seizures), cardiac CNS lesions (e.g., stroke, possible seizures), cardiac defects, and genitourinary anomalies have been defects, and genitourinary anomalies have been reported.reported.

Prenatal Methamphetamine Prenatal Methamphetamine ExposureExposure

• Impact of meth use during human pregnancy Impact of meth use during human pregnancy is currently unknown.is currently unknown.

• Animal studies have demonstrated Animal studies have demonstrated neurotoxic effects of amphetamines and neurotoxic effects of amphetamines and alteration of synaptic morphology in alteration of synaptic morphology in response to prenatal methamphetamine response to prenatal methamphetamine exposure.exposure.

Prenatal Methamphetamine Prenatal Methamphetamine ExposureExposure

• Women using meth during pregnancy may have an Women using meth during pregnancy may have an increased rate of premature delivery and placental increased rate of premature delivery and placental abruption. abruption.

• Linked to fetal growth restriction and, occasionally, Linked to fetal growth restriction and, occasionally, withdrawal symptoms requiring pharmacologic withdrawal symptoms requiring pharmacologic intervention at birth. intervention at birth.

• Clefting, cardiac anomalies, and fetal growth reduction Clefting, cardiac anomalies, and fetal growth reduction have been described in infants and have been have been described in infants and have been reproduced in animal studies. reproduced in animal studies.

• Later effects on child health are unknown.Later effects on child health are unknown.

Prenatal Tobacco ExposurePrenatal Tobacco Exposure

• Associated with poor fetal growth; the most Associated with poor fetal growth; the most important cause of LBW in developed important cause of LBW in developed countries.countries.

• Linked to myriad perinatal complications and Linked to myriad perinatal complications and child health problems (along with child health problems (along with environmental smoke exposure, or ESE). environmental smoke exposure, or ESE). ESE is implicated in LBW, fetal death, and ESE is implicated in LBW, fetal death, and preterm delivery. preterm delivery.

• Implicated in a range of adverse behavioral Implicated in a range of adverse behavioral and cognitive outcomes.and cognitive outcomes.

Prenatal Tobacco ExposurePrenatal Tobacco Exposure• Cigarette smoke contains tar, nicotine, and Cigarette smoke contains tar, nicotine, and

carbon monoxide. carbon monoxide.

• Tar contains substances (lead, cyanide, Tar contains substances (lead, cyanide, cadmium, and more) harmful to the fetus. cadmium, and more) harmful to the fetus.

• Intrauterine hypoxia, mediated by carbon Intrauterine hypoxia, mediated by carbon monoxide and reduced uterine blood flow, is a monoxide and reduced uterine blood flow, is a major mechanism of the growth impairment.major mechanism of the growth impairment.

• Nicotine crosses the placenta and distributes Nicotine crosses the placenta and distributes freely to the CNS, having direct and indirect freely to the CNS, having direct and indirect effects on neural development. effects on neural development.

Prenatal Alcohol ExposurePrenatal Alcohol Exposure

Alcohol is a teratogen

Prenatal Alcohol ExposurePrenatal Alcohol Exposure

Effects have been demonstrated in animals and humans

Neurobehavioral effects have been found to

be more injurious and long-lasting than

cocaine and other drugs abused prenatally.

Teratogenic EffectsTeratogenic Effects

of Prenatal Alcohol of Prenatal Alcohol

ExposureExposure

• Direct toxic effect of alcohol on cells

• Hypoxia (inadequate oxygenation of blood) due to impaired placental/fetal blood flow

• Effect on cell migration in the brain

• Effect on apoptosis (a natural process of programmed cell death)

Fetal Alcohol SyndromeFetal Alcohol Syndrome

• A permanent birth defect caused by maternal A permanent birth defect caused by maternal

alcohol use during pregnancy.alcohol use during pregnancy.

• The leading preventable cause of mental The leading preventable cause of mental

retardation in the Western world.retardation in the Western world.

• Annually: 40,000 infants born with FASD Annually: 40,000 infants born with FASD

(more common than Muscular Dystrophy, (more common than Muscular Dystrophy,

Cystic Fibrosis, Downs Syndrome and Cystic Fibrosis, Downs Syndrome and

Spina Bifida combined).Spina Bifida combined).

FAS

Central Nervous System Dysfunction Organic Brain Damage

• Hyperactivity, attention deficits

• Intellectual deficits, learning disorders

• Problems with memory, language & judgment

• Developmental delay, microcephaly

• Fine & gross motor problems, seizure disorder

• Mental retardation, structural brain damage

Growth Deficiency

Specific Pattern of Facial Anomalies

Fetal Alcohol Spectrum Fetal Alcohol Spectrum Disorders (FASD)Disorders (FASD)

can becan be

“Hidden Disabilities”

FAS Family Resource Institute

FASD

Central Nervous System Central Nervous System Dysfunction Dysfunction

Organic Brain DamageOrganic Brain Damage• Hyperactivity, attention deficitsHyperactivity, attention deficits• Intellectual deficits, learning disordersIntellectual deficits, learning disorders• Problems with memory, language & Problems with memory, language & judgmentjudgment• Developmental delay, microcephalyDevelopmental delay, microcephaly• Fine & gross motor problems, seizure Fine & gross motor problems, seizure disorderdisorder• Mental retardation, structural brain Mental retardation, structural brain damagedamage

FASD: Clinical ImplicationsFASD: Clinical Implications

Poor judgment ………… Easily victimizedPoor judgment ………… Easily victimized

Attention deficits ……… Unfocused / distractibleAttention deficits ……… Unfocused / distractible

Arithmetic disability ….. Can’t handle moneyArithmetic disability ….. Can’t handle money

Memory problems ….. Doesn’t learn from experienceMemory problems ….. Doesn’t learn from experience

Difficulty abstracting …. Doesn’t understand Difficulty abstracting …. Doesn’t understand consequencesconsequences

Disoriented in …………. Fails to perceive social cues Disoriented in …………. Fails to perceive social cues time and spacetime and space

Poor frustration ………... Quick to angerPoor frustration ………... Quick to anger tolerancetolerance

PREVALENCE OF SECONDARY DISABILITIESAcross the Life Span

100

90

80

70

60

50

40

30

20

10

Ages 6-51 (n=408-415) Ages 21-51 (n=89-90)

%

Mental Health Problems

Disrupted School Experience

Trouble With the Law

Confinement

Inappropriate Sexual Behavior

Alcohol & Drug Problems

Dependent Living

Problems with Employment

Ages 6 - 51 Ages 21 - 51

Alcohol Drinking Alcohol Drinking

by Pregnant Women by Pregnant Women

Western WA: 1989-2004Western WA: 1989-2004

We conducted three federally-funded We conducted three federally-funded

studies on problems associated with studies on problems associated with

prenatal substance abuse.prenatal substance abuse.

Study purposes varied, but all involved Study purposes varied, but all involved

screening hospitalized postpartum screening hospitalized postpartum

women shortly after delivery for prenatal women shortly after delivery for prenatal

alcohol and drug use. alcohol and drug use.

Description of the StudiesDescription of the Studies

Study 1:Study 1: Mar. 1989 – Apr. 1991 (Mar. 1989 – Apr. 1991 (N= 7,178N= 7,178))Prospective study investigated neurodevelopmental Prospective study investigated neurodevelopmental

outcomes of children exposed to cocaine in uterooutcomes of children exposed to cocaine in utero (Obstetrics and Gynecology(Obstetrics and Gynecology (1994), 83(4), 524-531) (1994), 83(4), 524-531)

Study 2:Study 2: Jul. 1991 – Dec. 1992 (N=2,330)Jul. 1991 – Dec. 1992 (N=2,330)Tested efficacy of a 3-year home visitation interventionTested efficacy of a 3-year home visitation intervention

(Journal of Community Psychology (2003), 31(3), 211-222)(Journal of Community Psychology (2003), 31(3), 211-222)

Study 3:Study 3: Jun. 2002 – Mar. 2004 (N=3,145)Jun. 2002 – Mar. 2004 (N=3,145)Evaluated efficacy of a 12-month intervention program Evaluated efficacy of a 12-month intervention program

using a randomized design FAS/ARBD Prevention: using a randomized design FAS/ARBD Prevention: Research to PracticeResearch to Practice

(APHA 133rd Annual Meeting. Dec. 2005. Philadelphia, PA)(APHA 133rd Annual Meeting. Dec. 2005. Philadelphia, PA)

ResultsResults

MONTH BEFORE PREGNANCY DURING PREGNANCY

Any Binge Any Binge

Alcohol Alcohol Alcohol Alcohol

STUDY 1 45% 9% 30% 3%1989-1991

STUDY 2 41% 10% 23% 4% 1991-1992

STUDY 3 43% 14% 12% 1% 2002-2004

The Good NewsThe Good News

Drinking during pregnancy Drinking during pregnancy decreaseddecreased between 1989 and 2004between 1989 and 2004

• Public health messages about drinking Public health messages about drinking during pregnancy have clearly had an during pregnancy have clearly had an impact.impact.

• In general, when women know they are In general, when women know they are pregnant, they decrease their alcohol pregnant, they decrease their alcohol consumption.consumption.

Remaining Challenges Remaining Challenges

Binge drinking “pre-pregnancy” (or prior to Binge drinking “pre-pregnancy” (or prior to pregnancy recognition) has pregnancy recognition) has increasedincreased between between 1989 and 2004 1989 and 2004

• Up to 60% of women don’t know they are pregnant in Up to 60% of women don’t know they are pregnant in early gestation and may unintentionally drink during early gestation and may unintentionally drink during this vulnerable period this vulnerable period

• Heavy drinking may lead to unexpected, unprotected Heavy drinking may lead to unexpected, unprotected sexual activitysexual activity

• More than half of all pregnancies in the U.S. are More than half of all pregnancies in the U.S. are unintended unintended

February 21, 2005February 21, 2005U.S. Surgeon General Releases U.S. Surgeon General Releases

Advisory on Alcohol Use in PregnancyAdvisory on Alcohol Use in Pregnancy

Women who are pregnant or who may become Women who are pregnant or who may become

pregnant should abstain from alcohol pregnant should abstain from alcohol

consumption in order to eliminate the consumption in order to eliminate the

chance of giving birth to a baby with any of chance of giving birth to a baby with any of

the harmful effects of the Fetal Alcohol the harmful effects of the Fetal Alcohol

Spectrum Disorders (FASD).Spectrum Disorders (FASD).

This updates a 1981 Surgeon General's Advisory.This updates a 1981 Surgeon General's Advisory.

If I’m Pregnant, Can I …If I’m Pregnant, Can I …

……Have a beer?Have a beer?The Centers for Disease Control says “no level of The Centers for Disease Control says “no level of alcohol…has been determined safe,” but some alcohol…has been determined safe,” but some doctors feel limited drinking – no more than a doctors feel limited drinking – no more than a pint a day, suggests Dr. Gibb – after the first pint a day, suggests Dr. Gibb – after the first trimester is okay.trimester is okay.

- People Magazine, April 17, 2006, pp - People Magazine, April 17, 2006, pp 102-107102-107

What would aWhat would a

cure for addictioncure for addiction

look like?look like?

WHEN CASE MANAGEMENTWHEN CASE MANAGEMENT ISN’T ENOUGH ISN’T ENOUGH

Community Intervention & Prevention:Community Intervention & Prevention:

Parent-Child Assistance Program (PCAP)Parent-Child Assistance Program (PCAP)

A 3-year intensive home visitation A 3-year intensive home visitation

intervention for high risk mothersintervention for high risk mothers

who abuse alcohol and/or drugs who abuse alcohol and/or drugs

during pregnancyduring pregnancy

The ProblemThe Problem

· possible effects of prenatal exposure on the child’s health

· likelihood of a compromised home environment

· likelihood that these mothers will have more exposed, affected children

Maternal alcohol and drug abuse puts children at risk because of:

PCAP HistoryPCAP History1991-present1991-present• WA State locations: King, Pierce, Yakima, Grant, WA State locations: King, Pierce, Yakima, Grant, Spokane, Cowlitz, Skagit Counties Spokane, Cowlitz, Skagit Counties

• Replication sites: MN, NC, AK, TX, NV, LA, PA; Replication sites: MN, NC, AK, TX, NV, LA, PA; multiple sites in Canada multiple sites in Canada

We thank our sponsors:We thank our sponsors:Substance Abuse and Mental health Services Substance Abuse and Mental health Services Administration (SAMHSA) Administration (SAMHSA)WA State Dept. Social and Health Services WA State Dept. Social and Health Services Division of Alcohol and Substance AbuseDivision of Alcohol and Substance AbuseMarch of DimesMarch of DimesNesholm Family FoundationNesholm Family FoundationPrivate PhilanthropyPrivate Philanthropy

Parent-Child Assistance ProgramParent-Child Assistance Program

To prevent future births To prevent future births

of alcohol and drug exposed of alcohol and drug exposed

childrenchildren

Primary Goal:Primary Goal:

Theoretical Framework of the Theoretical Framework of the InterventionIntervention

Relational TheoryRelational Theory

A woman’s sense of connectedness to A woman’s sense of connectedness to others is central to her growth, others is central to her growth,

development, definition of selfdevelopment, definition of self

PCAP InterventionPCAP Intervention

Long term, positive interpersonal Long term, positive interpersonal relationship with case manager relationship with case manager

Relational TheoryRelational Theory

Consequences of alcohol and drug abuse differ among women and men in terms of physiological effects and social consequences.

Positive relationships within the intervention, treatment, and recovery setting are critical.

The quality of interpersonal relationships:

• may determine whether or not a woman remains in an intervention

• may be more important to improvement than concrete services received

PCAP Case ManagersPCAP Case Managers

• • Have experienced some of the same Have experienced some of the same types of adverse life circumstances as types of adverse life circumstances as clients, but seldom to same degreeclients, but seldom to same degree

• • Have subsequently achieved success in Have subsequently achieved success in important waysimportant ways

• • Are positive role models and offer clients Are positive role models and offer clients hope and motivation from a realistic hope and motivation from a realistic

perspective perspective

Washington State Washington State PCAPPCAP

(2007 Annual Work (2007 Annual Work Session)Session)

Theoretical FrameworkTheoretical Framework

Stages of ChangeStages of Change

Clients will be at different stages of readiness Clients will be at different stages of readiness for change. Motivation is a process for for change. Motivation is a process for change that occurs within the context of change that occurs within the context of interpersonal relationships.interpersonal relationships.

PCAP InterventionPCAP Intervention

Motivational InterviewingMotivational Interviewing

• • acknowledge client’s perception of situationacknowledge client’s perception of situation• • encourage her to explore + and – aspectsencourage her to explore + and – aspects

From Prochaska & DiClementeFrom Prochaska & DiClemente

MOTIVATIONMOTIVATION

DECISION-MAKINGDECISION-MAKING

SELF-EFFICACYSELF-EFFICACY

CONTEMPLATIONCONTEMPLATION

PRE-CONTEMPLATIONPRE-CONTEMPLATION

PREPARATIONPREPARATION

ACTIONACTION

MAINTENANCEMAINTENANCE

Theoretical FrameworkTheoretical Framework

Harm ReductionHarm Reduction Addiction and associated risks are on a Addiction and associated risks are on a continuum. The goal is to reduce continuum. The goal is to reduce harmful harmful consequences of the habit for consequences of the habit for mother and mother and her child.her child.

PCAP InterventionPCAP Intervention

Any steps toward decreased risk are Any steps toward decreased risk are steps in the right direction.steps in the right direction.

Characteristics of Effective Case Management Characteristics of Effective Case Management

Community Providers

Juvenile Justice

Probation

Alc/DrugTx

Mental HealthTX

Health Care

FamilyPlanning

Job Training

Schools BioBio MomMom BioBio

DaDaddSiblingsSiblings

FriendsFriends

PartnersPartners

ChildrenChildren

NeighborsNeighbors

ExtendedExtendedFamilyFamily

Care-Care-takerstakers

PCAP Case Managers:PCAP Case Managers:

• Work with a caseload of 16 families, Work with a caseload of 16 families, make home visits, transportmake home visits, transport

• Help client identify personal goals, Help client identify personal goals, and teach “baby steps” to achieve and teach “baby steps” to achieve these goalsthese goals

• Collaborate with network of serviceCollaborate with network of serviceproviders to develop specific providers to develop specific plans with client inputplans with client input

• Connect clients with services, monitor Connect clients with services, monitor progressprogress

The goal The goal

is to help the client is to help the client

move along a continuum, move along a continuum,

from dependence on the case manager, from dependence on the case manager,

to interdependence with the case manager, to interdependence with the case manager,

to independence and strength on her own.to independence and strength on her own.

PCAP Enrollment CriteriaPCAP Enrollment Criteria

1) Currently pregnant or up to six months postpartum

2) Used alcohol/drugs heavily during pregnancy

3) Not effectively connected with community resources

- OR -

Have delivered a child with a diagnosis of FAS/FASD

The Formula for Preventing The Formula for Preventing Alcohol/Drug Exposed BirthsAlcohol/Drug Exposed Births

• • Motivate women to stop drinking Motivate women to stop drinking or using drugs before and or using drugs before and

during pregnancyduring pregnancy

• • Help women who can’t stop Help women who can’t stop drinking or using drugs to drinking or using drugs to avoid avoid becoming pregnantbecoming pregnant

Blended Evaluation DesignBlended Evaluation Design

1. Original Demonstration Cohort (1991 – 1995)1. Original Demonstration Cohort (1991 – 1995)Quasi-experimental, non-randomized comparison group, Quasi-experimental, non-randomized comparison group, pretest-posttest pretest-posttest

2. Post-Program Follow-Up Cohort (1997 – 1998)2. Post-Program Follow-Up Cohort (1997 – 1998)Follow-up interview 2.5 yrs after PCAP exitFollow-up interview 2.5 yrs after PCAP exit

3. 3. Seattle and Tacoma Replication Cohorts (1996 - 2003)Seattle and Tacoma Replication Cohorts (1996 - 2003)Study compared pretest/posttest outcomes across 3 Study compared pretest/posttest outcomes across 3 sites: OD, SR, TR; no comparison groupsites: OD, SR, TR; no comparison group

PCAP Outcomes at 36 MonthsPCAP Outcomes at 36 Months

Current OutcomesCurrent Outcomes N = 403N = 403

Inpatient or Outpatient Treatment Inpatient or Outpatient Treatment Completed or in ProgressCompleted or in Progress 89%89%

Clean & Sober Clean & Sober >> 6 months at exit 6 months at exit 41%41%

Clean & Sober Clean & Sober >> 1 yr during program 1 yr during program 56%56%

Received Mental Health ServicesReceived Mental Health Services 70%70%

In Permanent, Stable HousingIn Permanent, Stable Housing 67%67%

Drug-free Housing/TreatmentDrug-free Housing/Treatment 7%7%

PCAP Outcomes at 36 MonthsPCAP Outcomes at 36 Months

Current OutcomesCurrent Outcomes N = 403N = 403

Regular Family PlanningRegular Family Planning 60%60%

More Reliable MethodMore Reliable Method 46%46%

Any Subsequent BirthAny Subsequent Birth 25%25%

Any exposed subsequent birthAny exposed subsequent birth 14%14%

Custody of Target ChildCustody of Target Child

Bio MomBio Mom 61%61%

Other FamilyOther Family 17%17%

Foster CareFoster Care 12%12%

AdoptedAdopted 8%8%

Good things happen Good things happen when communities when communities implement effective implement effective programs and states programs and states

implement strong implement strong policy.policy.

Systems Working TogetherSystems Working Together

WA State Division of Alcohol & Substance AbuseWA State Division of Alcohol & Substance Abuse

(DASA)(DASA) i increased treatment beds for women: ncreased treatment beds for women: 55 to 153 (1991 - 2007)55 to 153 (1991 - 2007)

Systems Working Together Systems Working Together

Substance Abuse TreatmentSubstance Abuse Treatment

DSHS “Take Charge” program (1989-present)DSHS “Take Charge” program (1989-present)

• Developed to help low income pregnant Developed to help low income pregnant women obtain serviceswomen obtain services

• Recent development:Recent development:Free family planning supplies for women Free family planning supplies for women and men at 200% below FPLand men at 200% below FPL

Systems Working TogetherSystems Working Together

Family PlanningFamily Planning

Preventing Future Exposed BirthsPreventing Future Exposed Births

At PCAP replication sites, 78 women were binge drinkers (>5 drinks/occasion) during the index pregnancy.

At PCAP exit, 51 (66%) were no longer at present risk of having another alcohol exposed pregnancy:

• 24 (31%) using reliable contraception;

• 18 (23%) abstinent from alcohol/drugs >= 6 months;

• 9 (12%) both reliable contraceptive and abstinent.

Preventing Future Exposed BirthsPreventing Future Exposed Births

Without PCAP about 30% (or 23) of 78 drinking mothers Without PCAP about 30% (or 23) of 78 drinking mothers would have had another highly exposed birth; would have had another highly exposed birth;

We reduced that by 66%, preventing about 15 alcohol-We reduced that by 66%, preventing about 15 alcohol-exposed births; exposed births;

Incidence of FAS is estimated at 4.7% to 21% among Incidence of FAS is estimated at 4.7% to 21% among heavy drinkers; heavy drinkers;

Therefore we estimate PCAP prevented at least one and Therefore we estimate PCAP prevented at least one and up to 3 new cases of FAS.up to 3 new cases of FAS.

Cost SavingsCost Savings

The average lifetime cost for an individual with FAS The average lifetime cost for an individual with FAS

is $1.5 million.is $1.5 million.

PCAP costs about $15,000/ client for 3-years PCAP costs about $15,000/ client for 3-years

(intervention, administration, evaluation). (intervention, administration, evaluation).

If we prevented just If we prevented just oneone new case of FAS, the new case of FAS, the

estimated lifetime cost savings = cost of PCAP estimated lifetime cost savings = cost of PCAP

for 102 women.  for 102 women.  

BenefitsBenefits CostsCosts

BenefitsBenefitsper per

Dollar of Dollar of CostCost

BenefitsBenefitsMinusMinusCostsCosts

$11,089$11,089 $4,892$4,892 $2.27$2.27 $6,197$6,197* Home Visiting Programs

for At-Risk Mothers and Children

Washington State Institute for Public Policy, July 2004 found Washington State Institute for Public Policy, July 2004 found

an average net benefit of $6197 per client among selected an average net benefit of $6197 per client among selected

well-researched home visiting programs, well-researched home visiting programs, including PCAPincluding PCAP..**

www.wsipp.wa.govwww.wsipp.wa.gov

Benefits and Costs of Prevention and Early Benefits and Costs of Prevention and Early Intervention Programs for YouthIntervention Programs for Youth

Challenges of Practicing Good Science In Challenges of Practicing Good Science In Community Intervention StudiesCommunity Intervention Studies

• Randomized trial: Randomized trial: may be perceived as unethical may be perceived as unethical (solution: one health care provider training (solution: one health care provider training project uses a “wait list” control group)project uses a “wait list” control group)

• ““Treatment as usual” problem: Treatment as usual” problem: standard treatment or control condition standard treatment or control condition

may may vary in multi-site studiesvary in multi-site studies

• Meeting study recruitment goals: Meeting study recruitment goals: may require multiple strategiesmay require multiple strategies

Challenges of Practicing Good Science In Challenges of Practicing Good Science In Community Intervention StudiesCommunity Intervention Studies

• Measuring exposure: Measuring exposure: High-risk women may not present High-risk women may not present

prenatally, and postnatal assessment may be prenatally, and postnatal assessment may be biasedbiased

• Measuring fidelity of the interventionMeasuring fidelity of the intervention

• Standardize intervention:Standardize intervention: Describe in detail so it can be replicated for Describe in detail so it can be replicated for research, clinical purposesresearch, clinical purposes

True or False?True or False?

• The global war on drugs can be won.The global war on drugs can be won.

• We can reduce the demand for drugs.We can reduce the demand for drugs.

• Reducing the supply of drugs is the Reducing the supply of drugs is the answer.answer.

• U.S. drug policy is the world’s drug U.S. drug policy is the world’s drug policy.policy.

• Legalization is the best approach.Legalization is the best approach.

• Legalization will never happen.Legalization will never happen.

True or False? True or False? Legalization would result in….Legalization would result in….

• purity assurance under FDA regulationpurity assurance under FDA regulation• labeled concentration of the product (to avoid labeled concentration of the product (to avoid

overdose)overdose)• obliteration of vigorous marketing (“pushers”)obliteration of vigorous marketing (“pushers”)• obliteration of drug crime and reduction of theft crimeobliteration of drug crime and reduction of theft crime• savings in expensive enforcementsavings in expensive enforcement• significant tax revenuessignificant tax revenues

Effort and funds can then be directed to educating Effort and funds can then be directed to educating the public about the hazards of all drugs.the public about the hazards of all drugs.