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![Page 1: Michael Weaver, MD, FASAM Division of Addiction Psychiatry Virginia Commonwealth University Medical Center 2010 Health Summit Substance Abuse and Pregnancy.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649cb15503460f94976646/html5/thumbnails/1.jpg)
Michael Weaver, MD, FASAMDivision of Addiction Psychiatry
Virginia Commonwealth UniversityMedical Center
2010 Health SummitSubstance Abuse and Pregnancy
Charlottesville, Virginia
![Page 2: Michael Weaver, MD, FASAM Division of Addiction Psychiatry Virginia Commonwealth University Medical Center 2010 Health Summit Substance Abuse and Pregnancy.](https://reader036.fdocuments.us/reader036/viewer/2022062515/56649cb15503460f94976646/html5/thumbnails/2.jpg)
Substance use and pregnancy Maternal & fetal effects during
pregnancy Addiction treatment during pregnancy Neonatal Abstinence Syndrome Home environment
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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
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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
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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)
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Co-occurring mental health and substance abuse diagnosesAnxietyDepressionSchizophreniaPersonality
disorders
Cognitive-behavioral counseling more challenging
Best success with treatment of both conditions simultaneously
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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
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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
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Sedative-hypnotics
Opioids Stimulants Nicotine Marijuana
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CNS depressant Disinhibition
depress inhibitions firstReduce anxiety (fun at
parties) Oversedation, ataxia,
respiratory depression
Daily drinking leads to tolerance and withdrawalDelirium tremens
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Benzodiazepines, barbiturates, other sleeping pills (Ambien, Lunesta)
Sedation, anxiolytic Respiratory
depression in overdose
Withdrawal similar to alcohol DT’s
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Common to both:Restlessness InsomniaNausea/vomitingHigh blood
pressureRapid heart rateRapid breathingSeizures
Seen in withdrawal, but not pregnancy:Distractibility Impaired memoryAgitationTremorFeverSweatingHallucinations
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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
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Fetal Alcohol Syndrome
Fetal Alcohol Effects Spectrum disorder
Leading preventable cause of mental retardation
Encourage abstinence as soon as pregnancy suspected
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Morphine, heroin, OxyContin, methadone
Analgesics: disconnect from pain
Euphoria, disconnection, sedation
Nausea, constipation, itching
Oversedation, respiratory depression
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No known fetal anomalies
Intrauterine growth retardation
Neonatal abstinence syndromeContinuous
exposureUse up to delivery
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Cocaine, amphetamine, methylphenidate, MDMA (Ecstasy), caffeine
Enhanced concentration, alertness
Edginess, paranoia, hypervigilance, psychosis
Hypertension, hyperthermia, vasoconstriction Heart attack, stroke
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Spontaneous abortion
Placental abruption Fetal hypertension Intrauterine growth
retardation SIDS ‘Crack baby
syndrome’ disproven
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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
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craving for tobacco irritability,
frustration, anger anxiety difficulty
concentrating restlessness
decreased heart rate
increased appetite or weight gain
depression disrupted sleep sedation
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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
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Marijuana, hashish, hash oil
active ingredient: THC
relaxation, hallucination
panic attacks short-term
memory impairment, amnesia
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Intrauterine growth retardation
Abnormal startle reflexes in newborns
Reduced memory & verbal skills at age 4 years
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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
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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
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Alienation from family
Multiple jobs Financial
problems Multiple arrests Multiple partners Loss of custody
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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
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• 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
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Detoxification 12-Step groups Outpatient counseling Intensive outpatient Inpatient Residential Opioid Maintenance
Methadone Buprenorphine
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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
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• 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
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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
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A.A., N.A., C.A. Group format Anonymous No cost No affiliations or
endorsement Different groups
have different characteristics
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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
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Network therapy Family therapy Supportive
psychotherapy Contingency
management Building Social
networks
Twelve-Step facilitation
Perceptual Adjustment therapy
Rational Recovery Medication
management Brief intervention
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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
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Long-acting medication in controlled settingCounselingSocial services
Avoid withdrawal & craving
Reduce disease & crime
Maintenance vs. detoxification
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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
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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
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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)
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Pregnancy Category C
Use Subutex instead of Suboxone to avoid naloxone
NAS less intense than with methadone
Studies ongoing, results encouraging
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Characterized by Hyperactivity, irritable Hypertonia Difficulty/excessive
sucking High-pitched cries
Begins 3h to 12d after delivery, depending on drugs used by mother
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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
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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
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EducationBreastfeedingUmbilical cord
careApproach for
‘fussy’ infantAge-appropriate
discipline for other children
Prevent frustration that leads to relapse
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Encouraged Promote bonding Optimal nutrition Passive immunity
Contraindications Active substance
abuse HIV +
Methadone or buprenorphine dose not important consideration
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• 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
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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
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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
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