PerinatalPerinatal Substance Substance Abuse Policy ImplicationsAbuse Policy Implications

Kathryn Wells, MD, FAAPKathryn Wells, MD, FAAPMedical Director, Denver Family Crisis CenterMedical Director, Denver Family Crisis Center

Attending, Denver Health and The ChildrenAttending, Denver Health and The Children’’s Hospitals HospitalAssistant Professor in Pediatrics, University of ColoradoAssistant Professor in Pediatrics, University of Colorado

Kathryn.wells@dhha.orgKathryn.wells@dhha.org

NADEC Webcast – September 3, 2008

Objectives –Perinatal Substance Abuse

Define the problem Define the problem Outline the medical implicationsOutline the medical implicationsDescribe the policy issuesDescribe the policy issuesList approaches to address the List approaches to address the issueissue

What is the Problem?What is the Problem?

Effects may be Effects may be fetal, fetal, maternal or bothmaternal or bothAttentionalAttentional, , selfself--regulatoryregulatory, and , and cognitive cognitive difficultiesdifficultiesRisk of Risk of maltreatment maltreatment and and impaired attachmentimpaired attachmentGreat Great variabilityvariability in harmin harmSignificant financial Significant financial costcost

How Prevalent?How Prevalent?Survey of 36 hospitals found Survey of 36 hospitals found an estimated an estimated 375,000 375,000 infantsinfants exposed in utero to exposed in utero to illegal drugs illegal drugs each yeareach year in the in the U.S., or U.S., or 11%11% of all birthsof all births((ChasnoffChasnoff, 1989), 1989)

The American Academy of The American Academy of Pediatrics estimates that Pediatrics estimates that 1 in 1 in 10 newborns10 newborns in the US have in the US have been exposed to an illicit drugbeen exposed to an illicit drug(AAP, 1990)(AAP, 1990)

Obtaining Data DifficultiesObtaining Data DifficultiesThe The unreliabilityunreliability of motherof mother’’s s selfself--reportsreportsThe The limitationslimitations of urine of urine toxicology techniquestoxicology techniquesThe nature of The nature of observableobservableclinical conditionsclinical conditionsDrugDrug--affected affected vs. vs. drugdrug--exposedexposedLack of uniformityLack of uniformity in hospital in hospital policies and procedurespolicies and procedures

Prenatal Substance AbusePrenatal Substance Abuse

Small proportionSmall proportion of the of the children affected by children affected by substance abusesubstance abuseOften not identified for: Often not identified for:

Fear of Fear of prosecution prosecution Fear of Fear of losing their losing their childrenchildren

What Drugs?What Drugs?Legal:Legal: tobacco, tobacco, alcoholalcoholIllegal:Illegal: LSD, LSD, marijuanamarijuanaSubstances with Substances with recognized recognized medical uses:medical uses:cocaine, cocaine, narcotics, narcotics, barbiturates, and barbiturates, and amphetaminesamphetamines

Women Using Illicit Drugs or Women Using Illicit Drugs or Drinking Heavily During Drinking Heavily During PregnancyPregnancy

221

119

45

61

140

0 50 100 150 200 250

women using any illicit drug

women using marijuana

women using cocaine

women using prescription medicationwithout physician's direction

women drinking heavily

Number in Thousands

[Sources: National Pregnancy and Health Survey (National [Sources: National Pregnancy and Health Survey (National Institute on Drug Abuse), 1994 for illicit drug numbers; Center Institute on Drug Abuse), 1994 for illicit drug numbers; Center for for

Disease Control, 1997 for numbers on heavy drinking]Disease Control, 1997 for numbers on heavy drinking]

Indirect Maternal EffectsIndirect Maternal Effects

Infections:Infections: HIV, tuberculosis, hepatitis, HIV, tuberculosis, hepatitis, syphilis, syphilis, endocarditisendocarditis, pulmonary infections , pulmonary infections ToxinToxin--Induced:Induced: nutritional deficiency nutritional deficiency (alcohol), (alcohol), cardiotoxinscardiotoxins (cocaine, alcohol, (cocaine, alcohol, amphetamines), direct pulmonary effects amphetamines), direct pulmonary effects (marijuana, tobacco), (marijuana, tobacco), hepatotoxichepatotoxic(alcohol/cirrhosis, solvent), nephropathy (alcohol/cirrhosis, solvent), nephropathy (heroin)(heroin)

Obstetrical ComplicationsObstetrical Complications

Placental abruptionPlacental abruptionPremature rupture of Premature rupture of membranesmembranesAmnionitisAmnionitisPrePre--eclampsiaeclampsia/ / EclampsiaEclampsiaPlacental Placental insufficiencyinsufficiency

Intrauterine growth Intrauterine growth retardationretardationPremature laborPremature laborBreech presentationBreech presentationPostPost--partum partum hemorrhagehemorrhageIntrauterine deathIntrauterine deathSpontaneous abortionSpontaneous abortion

Fetal EffectsFetal EffectsDoseDose and dosage and dosage intervalintervalRouteRoute of administration (IV, PO, SQ, of administration (IV, PO, SQ, inhalation)inhalation)Rate of Rate of absorptionabsorptionLipid Lipid solubilitysolubilityRate of Rate of eliminationeliminationConcomitant maternal Concomitant maternal pathologypathology (renal, (renal, hepatic, etc.)hepatic, etc.)PlacentalPlacental wellwell--beingbeingGestational Gestational ageage

Relationship to Relationship to Gestational AgeGestational Age

First 6 weeks:First 6 weeks: most severe most severe systemic malformations systemic malformations Up to 12 weeks:Up to 12 weeks: malformations of malformations of the abdominal wall, gastrointestinal the abdominal wall, gastrointestinal tract, reproductive system and tract, reproductive system and urinary tracturinary tractSecond and third trimesters:Second and third trimesters:intrauterine growth retardation and intrauterine growth retardation and vascular disruption syndromesvascular disruption syndromes

Neonatal Medical Neonatal Medical ComplicationsComplications

Intrauterine growth Intrauterine growth retardationretardationMeconiumMeconiumaspirationaspirationAutoimmune Autoimmune deficiency syndromedeficiency syndromeHyperbilirubinemiaHyperbilirubinemiaHypocalcemiaHypocalcemiaHypoglycemiaHypoglycemia

Intracranial Intracranial hemorrhagehemorrhageRespiratory distress Respiratory distress syndromesyndromePneumoniaPneumoniaSepticemiaSepticemiaNeonatal abstinence Neonatal abstinence syndromesyndromeSudden infant death Sudden infant death syndromesyndrome

The FactsThe Facts……

Infants born to women with addictions Infants born to women with addictions are at risk for are at risk for birth defects, birth defects,

premature birth, and complicationspremature birth, and complicationsafter birth such as withdrawal. In after birth such as withdrawal. In addition, these infants addition, these infants display a display a

higher incidence of child abuse and higher incidence of child abuse and neglectneglect..

FEBRUARY 3, 1997 VOL. 149 NO. 5FEBRUARY 3, 1997 VOL. 149 NO. 5

SPECIAL REPORTSPECIAL REPORT

FERTILE MINDS FERTILE MINDS FROM BIRTH, A BABY'S BRAIN CELLS PROLIFERATE WILDLY, MAKING FROM BIRTH, A BABY'S BRAIN CELLS PROLIFERATE WILDLY, MAKING CONNECTIONS THAT MAY SHAPE A LIFETIME OF EXPERIENCE. THE FIRST CONNECTIONS THAT MAY SHAPE A LIFETIME OF EXPERIENCE. THE FIRST THREE YEARS ARE CRITICALTHREE YEARS ARE CRITICALBY J. MADELEINE NASHBY J. MADELEINE NASH

What We DonWhat We Don’’t Knowt Know

Effect of other factorsEffect of other factors•• Other Other exposures exposures (i.e. drugs)(i.e. drugs)•• EnvironmentEnvironment (i.e. (i.e. methmeth labs, labs,

maternal state of mind, home)maternal state of mind, home)•• BrainBrain effectseffectsLongLong--term term outcomesoutcomesMost effective Most effective approachapproach

What Happens Next?What Happens Next?

Most Most go homego home –– 7575--90% of substance90% of substance--exposed infants are undetected and go exposed infants are undetected and go homehomeWhy?Why?–– Testing only detects very recent useTesting only detects very recent use–– Many hospitals donMany hospitals don’’t screen/test or dont screen/test or don’’t t

systematically refer to CPSsystematically refer to CPS–– State laws may not require report or referralState laws may not require report or referral

(Source: Nancy Young, PhD, National Center on Substance Abuse an(Source: Nancy Young, PhD, National Center on Substance Abuse and Child Welfare)d Child Welfare)

The Policy ContextThe Policy ContextChild Abuse Prevention and Treatment Act Child Abuse Prevention and Treatment Act (CAPTA)(CAPTA) amendments of 2003amendments of 2003Increasing number of pregnant women and Increasing number of pregnant women and children affected by maternal use of children affected by maternal use of methamphetaminemethamphetamineResearch on fetal Research on fetal alcoholalcohol spectrum disorders spectrum disorders and alcoholand alcohol--related related neurodevelopmentalneurodevelopmentaldisordersdisordersRenewed proposals of State Renewed proposals of State legislationlegislation aimed at aimed at both fetal alcohol exposure and maternal abuse both fetal alcohol exposure and maternal abuse of illegal drugsof illegal drugs

(Source: Nancy Young, PhD, National Center on Substance Abuse an(Source: Nancy Young, PhD, National Center on Substance Abuse and Child Welfare)d Child Welfare)

ControversiesControversiesState of Florida v. JohnsonState of Florida v. Johnson

First First criminal convictioncriminal conviction of a woman for health of a woman for health endangering behavior during pregnancyendangering behavior during pregnancyCriminally charged with Criminally charged with child abusechild abuse for for delivering delivering illegal substancesillegal substances to a minor under age 18to a minor under age 18Sentenced to one year of community control in Sentenced to one year of community control in drug treatment program, 14 years of probation drug treatment program, 14 years of probation and 200 hours of community serviceand 200 hours of community serviceRuling included that if she ever conceived again, Ruling included that if she ever conceived again, she must advise probation officer of the she must advise probation officer of the pregnancy and enter a prenatal care program pregnancy and enter a prenatal care program approved by the courtapproved by the courtOverturnedOverturned

Controversies (cont.)Controversies (cont.)Roe v. WadeRoe v. Wade

Unresolved issues of Unresolved issues of fetal rightsfetal rights and and legal intervention in the lives of pregnant legal intervention in the lives of pregnant womenwomenTo force a pregnant woman to abstain To force a pregnant woman to abstain from certain deleterious behavior is from certain deleterious behavior is unlawful under Roe v. Wade as an unlawful under Roe v. Wade as an infringement infringement on the on the womanwoman’’s s constitutionally protected constitutionally protected right right to to autonomy and bodily integrity during autonomy and bodily integrity during pregnancypregnancy

Controversies (cont.)Controversies (cont.)

WhitnerWhitner v. South Carolinav. South CarolinaCriminal prosecutionCriminal prosecution of women of women positive for illegal drug usepositive for illegal drug useOnly state Supreme Court that has Only state Supreme Court that has upheld the prosecution of a mother upheld the prosecution of a mother who used drugs while pregnant who used drugs while pregnant (1992)(1992)Overturned by U.S. Supreme CourtOverturned by U.S. Supreme Court

Colorado LawColorado LawTitle 19 ChildrenTitle 19 Children’’s Codes Code (Civil Code)(Civil Code)1919--11--103. Definitions103. Definitions

(1)(a) (1)(a) ““AbuseAbuse”” or or ““child abuse or neglectchild abuse or neglect”” ……means an act or omission in the following means an act or omission in the following categories that threatens the health or welfare categories that threatens the health or welfare of a child:of a child:

(VII) Any case in which a child (VII) Any case in which a child tests positivetests positiveat birth for either a at birth for either a scheduleschedule--I I …… or scheduleor schedule--II II controlled substancecontrolled substance …… unless the child tests unless the child tests positive for a schedulepositive for a schedule--II controlled substance II controlled substance as a result of the motheras a result of the mother’’s lawful intake of such s lawful intake of such substance as prescribedsubstance as prescribed

Solutions Solutions

Comprehensive servicesComprehensive servicesProvided along a continuum of prevention, Provided along a continuum of prevention, intervention and treatmentintervention and treatmentAt different developmental stages in the At different developmental stages in the life of the child and familylife of the child and family

NO single agency can deliver all of theseNO single agency can deliver all of these

(Source: Nancy Young, PhD, National Center on Substance Abuse an(Source: Nancy Young, PhD, National Center on Substance Abuse and Child Welfare)d Child Welfare)

Needed PartnersNeeded PartnersHospitalsHospitalsPrivate physiciansPrivate physiciansHealth care management Health care management plansplansMaternal and child healthMaternal and child healthChildrenChildren’’s and adult s and adult mental healthmental healthDomestic violence Domestic violence agenciesagenciesChild welfareChild welfareDrug and alcohol Drug and alcohol prevention, treatment, prevention, treatment, and aftercareand aftercare

Developmental Developmental disabilities agenciesdisabilities agenciesSchools and special Schools and special educationeducationFamily/dependency Family/dependency courtscourtsChild care and Child care and developmentdevelopmentEmployment and family Employment and family support agenciessupport agenciesAnd moreAnd more……

Five Points of InterventionFive Points of Intervention1.1. PrePre--PregnancyPregnancy2.2. Prenatal Screening and ServicesPrenatal Screening and Services3.3. Screening and Testing at BirthScreening and Testing at Birth4.4. PostPost--Natal Services to Infants and Natal Services to Infants and

ChildrenChildren5.5. PostPost--Natal Services to ParentsNatal Services to Parents

(Source: Nancy Young, PhD, National Center on Substance Abuse an(Source: Nancy Young, PhD, National Center on Substance Abuse and Child Welfare)d Child Welfare)

PrePre--Pregnancy and Prenatal Pregnancy and Prenatal Screening and ServicesScreening and Services

State and local State and local preventionprevention effortseffortsPrenatal screeningPrenatal screening protocolsprotocolsNo states No states require require prenatal screening for prenatal screening for substance abusesubstance abuseGive pregnant women Give pregnant women priority statuspriority status in in entering entering treatmenttreatment, in accord with Federal , in accord with Federal requirementsrequirements

Screening and Testing at Screening and Testing at BirthBirth

Great potential for Great potential for preventing preventing negative outcomesnegative outcomes if identified if identified earlyearlyPolicies on screening/testing at Policies on screening/testing at birth are based on birth are based on local hospital local hospital policypolicyLegal drugsLegal drugs –– alcohol and nicotinealcohol and nicotineDefiningDefining substance exposure as substance exposure as evidence of evidence of abuse or neglectabuse or neglectReporting requirementsReporting requirements –– recent recent legislationlegislationStates do not States do not monitor monitor

Screening vs. TestingScreening vs. Testing

Infants vs. mothersInfants vs. mothersScreen forScreen for tobaccotobacco and and alcoholalcohol as well as as well as illicit drugsillicit drugsFollow an Follow an objective protocolobjective protocolUniversal vs. targeted testingUniversal vs. targeted testing

Reliability and fairnessReliability and fairnessCost from financial or civil rights perspectiveCost from financial or civil rights perspectiveDonDon’’t miss the t miss the ““big picturebig picture””

Indications for TestingIndications for Testing

Placental abruptionPlacental abruption““DropDrop--inin”” deliverydeliveryHistory of drug useHistory of drug usePreterm birthPreterm birthLate/no prenatal Late/no prenatal carecareCigarette smokingCigarette smoking[Adolescent [Adolescent pregnancy (?) pregnancy (?) –– any any age!]age!]

Duration of Positive Tests Duration of Positive Tests (Urine) (Adults)(Urine) (Adults)

AmphetaminesAmphetaminesAlcoholAlcoholBarbituratesBarbituratesValiumValiumCocaineCocaineHeroinHeroinMarijuanaMarijuanaMethadoneMethadone

48 hours48 hours12 hours12 hours10 10 –– 30 days30 days4 4 –– 5 days5 days24 24 –– 72 hours72 hours24 hours24 hours3 3 –– 30 days30 days3 days3 days

(USDHHS, SAMHSA, CSAT TIP #5, 1993)(USDHHS, SAMHSA, CSAT TIP #5, 1993)

MeconiumMeconium TestingTesting

High sensitivityHigh sensitivityEasy collectionEasy collectionDetects illicit Detects illicit drug use from drug use from 24 24 weeks gestationweeks gestationuntil birthuntil birth

What Happens Next?What Happens Next?

ReferralReferral for services/report to DSS for services/report to DSS Care planCare plan establishedestablishedSupportSupport servicesservicesMonitoringMonitoring of progressof progress

Pregnancy Is Only A Pregnancy Is Only A PartPart……..

Factors in the Factors in the postnatal postnatal

environment environment mediate prenatal mediate prenatal

factors in factors in predicting predicting

developmental developmental outcomesoutcomes

PostPost--Natal Services to Natal Services to Infants and ChildrenInfants and Children

Early intervention policies and process for Early intervention policies and process for referrals for referrals for IDEA/developmental IDEA/developmental screeningscreeningChild welfare Child welfare developmental assessmentsdevelopmental assessmentson substanceon substance--exposed infants or older exposed infants or older children just entering the systemchildren just entering the systemMonitoring through a Monitoring through a medical homemedical home

Treatment of Drug Exposed Treatment of Drug Exposed Infants and ChildrenInfants and Children

Symptoms may Symptoms may varyvaryDiagnosis based on a Diagnosis based on a detailed evaluationdetailed evaluationincluding a including a detailed historydetailed history of drug/alcohol of drug/alcohol use during pregnancyuse during pregnancyTreatment based onTreatment based on symptomssymptoms that the that the infant/child is exhibiting, not solely on the infant/child is exhibiting, not solely on the history of drug/alcohol exposurehistory of drug/alcohol exposureNot allNot all drug/alcohol exposed infants and drug/alcohol exposed infants and children will children will have problemshave problems

The Solution?The Solution?CriminalizingCriminalizing prenatal use prenatal use will not solve the problemwill not solve the problemand will likely result in and will likely result in avoiding prenatal care avoiding prenatal care TreatmentTreatment is needed for is needed for mothers who use drugs mothers who use drugs during pregnancyduring pregnancyHelpingHelping these parents these parents access treatment is a better access treatment is a better solution than criminalizationsolution than criminalization

Treatment is the Answer!Treatment is the Answer!The The United States Supreme CourtUnited States Supreme Court and the and the health care communityhealth care community -- drug addiction is drug addiction is an illnessan illnessThe The American Medical AssociationAmerican Medical Association has has unequivocally stated that unequivocally stated that ““it is clear that it is clear that addiction is not simply the product of the addiction is not simply the product of the failure of individual willpower. Instead, failure of individual willpower. Instead, dependency is the product of complex dependency is the product of complex hereditary and environmental factors. It is hereditary and environmental factors. It is properly viewed as a disease, and one that properly viewed as a disease, and one that physicians can help many individuals physicians can help many individuals control and overcome.control and overcome.””

Treatment and Child Treatment and Child CustodyCustody

Child Custody is an Important Reason For Substance Abuse Treatment Entry Among

Women With Children, 1994

44% of female drugtreatment clients whohave children reportthey entered substanceabuse treatment inorder to retain orregain custody of their

[Source: U.S. Department of Health and Human Services, Substance[Source: U.S. Department of Health and Human Services, Substance Abuse and Abuse and Mental Health Administration. Mental Health Administration. National Treatment Improvement Evaluation StudyNational Treatment Improvement Evaluation Study(retabulations from 1996 study data by CSTAT(retabulations from 1996 study data by CSTAT’’s National Evaluation Data s National Evaluation Data Services)]Services)]

Motherhood as IncentiveMotherhood as IncentiveMotherhood is often the Motherhood is often the only legitimate social roleonly legitimate social rolevalued by drug dependent valued by drug dependent womenwomenMost women in treatment Most women in treatment are are very concernedvery concerned about about how their substance how their substance abuse had affected their abuse had affected their childrenchildren

Pregnancy and motherhood are times of Pregnancy and motherhood are times of increased motivationincreased motivation for treatmentfor treatment

PostPost--Natal Services to Natal Services to ParentsParents

Significant gapsSignificant gapsCapacity of programs not sufficient to Capacity of programs not sufficient to serve all those in need of treatmentserve all those in need of treatmentConsider setting aside supplemental Consider setting aside supplemental federal funding for treatment for pregnant federal funding for treatment for pregnant and parenting womenand parenting womenFamilyFamily--centered servicescentered services

(Source: Nancy Young, PhD, National Center on Substance Abuse an(Source: Nancy Young, PhD, National Center on Substance Abuse and Child Welfare)d Child Welfare)

Successful Treatment Successful Treatment Programs for WomenPrograms for Women

Removed barriersRemoved barriers to attendanceto attendanceallowing childrenallowing childrentransportationtransportation

Addressed Addressed childrenchildren’’s emotional and s emotional and behavioral problemsbehavioral problems

therapeutic child caretherapeutic child carechildrenchildren’’s social skills training s social skills training substance abuse education for the children substance abuse education for the children

Provide Provide parent support servicesparent support servicesParenting classesParenting classesHome visitationHome visitationJob skills trainingJob skills training

WomenWomen’’s Treatments TreatmentAddressing more than substance abuse Addressing more than substance abuse alone:alone:

mental illnessmental illnessdomestic violencedomestic violencelow incomeslow incomesinadequate or unsafe housinginadequate or unsafe housingHIV/AIDSHIV/AIDS

Must Must remove all barriersremove all barriers to successful to successful treatment and recoverytreatment and recovery

Family Drug Courts?Family Drug Courts?OneOne-- to twoto two--year processyear process of of outpatient treatment and aftercare, outpatient treatment and aftercare, culminating with educational, jobculminating with educational, job--training or work programstraining or work programsOffers the client the opportunity to Offers the client the opportunity to contract with the court to seek contract with the court to seek treatmenttreatment instead of potentially losing instead of potentially losing their childtheir childReport Report to case manager and judge to case manager and judge on on a regular basisa regular basisDrug testedDrug tested at least once a weekat least once a week

Drug TreatmentDrug Treatment

Treatment for drug addiction can be Treatment for drug addiction can be effectiveeffectiveImportant component in order to Important component in order to break the cyclebreak the cycleWe all can We all can influenceinfluence a parenta parent’’s desire s desire to participate in treatmentto participate in treatmentAddiction is not a moral failing but Addiction is not a moral failing but rather a brain diseaserather a brain disease

But RememberBut Remember……

Every child Every child deserves a parentdeserves a parentwhose abilities are whose abilities are not hampered by not hampered by substance abuse substance abuse or addictionor addiction

Building a Stronger Building a Stronger Continuum of InterventionsContinuum of InterventionsStrengthened Strengthened partnerships partnerships between between multiple multiple agenciesagencies are key to are key to many of these many of these innovationsinnovationsPossible with Possible with little or little or nono additional additional expendituresexpendituresCompromiseCompromise on a on a unified planunified plan

Drug Exposed ChildrenDrug Exposed Children

NOT NOT ““doomeddoomed”” for life!for life!Need:Need:

PatiencePatienceConsistencyConsistencyLoveLoveHopeHope

Questions?Questions?