Rx15 clinical wed_430_1_wexelblatt-ford_2warner-roussosross

Clinical Track:Maternal-Fetal Issues

for Physicians

Presenters:

• Scott L. Wexelblatt, MD, Regional Medical Director for Newborn Services, Cincinnati Children’s Hospital Medical Center

• Susan Ford, RN, BSN, BEACON Quality Improvement Coordinator, Ohio Perinatal Quality Collaborative

• Tamara D. Warner, PhD, Research Assistant Professor, Department of Pediatrics, University of Florida

• Kay Roussos-Ross, MD, Director of Women’s Health, UF Shands Medical Plaza

Moderator: Carla S. Saunders, NNP-BC, Advance Practice Coordinator, Pediatrix Medical Group, and Neonatal Nurse Practitioner, East TennesseeChildren’s Hospital, and Member, Rx Summit National Advisory Board

Disclosures

• Scott L. Wexelblatt, MD; Susan Ford, RN, BSN; Tamara D. Warner, PhD; and Kay Roussos-Ross, MD, have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.

• Carla Saunders – Speaker’s bureau: Abbott Nutrition

Disclosures

• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.

• The following planners/managers have the following to disclose:– Kelly Clark – Employment: Publicis Touchpoint Solutions;

Consultant: Grunenthal US– Robert DuPont – Employment: Bensinger, DuPont &

Associates-Prescription Drug Research Center– Carla Saunders – Speaker’s bureau: Abbott Nutrition

Learning Objectives

1. Describe an NAS treatment protocol that has decreased opioid treatment days and the length of hospital.

2. Prepare physicians to screen and counsel pregnant patients about prenatal marijuana use.

3. Outline changes in the potency and use of marijuana during the past 30 years that may affect the developmental outcomes of today’s children with prenatal marijuana exposure.

Maternal-Fetal Issues for Physicians: Optimal Care for Infants with

Neonatal Abstinence Syndrome

Scott Wexelblatt, MD

Susan Ford, RN, BSN

Disclosures

• Scott Wexelblatt, MD has disclosed no relevant, real or apparent personal or profession financial relationship with proprietary entities that produce health care goods and services.

• Susan Ford, RN, BSN, has disclosed no relevant, real or apparent personal or profession financial relationship with proprietary entities that produce health care goods and services.

• Disclaimer: The images of people used in this presentation are for visual representations only.

Learning Objectives

• Describe an NAS treatment protocol that has decreased opioid treatment days and the length of hospital.

– NAS diagnoses increased three-fold from 2002 to 2009, according to a 2012 study in JAMA.

– In this session, clinicians will observe that an Ohio pilot study in six children’s hospitals used a stringent weaning protocol to decrease opioid treatment days and the length of hospital stay.

– This work, which was published in Pediatrics in August 2014, is the largest published cohort of over 530 infants pharmacologically treated for NAS.

– Fifty-two hospitals in Ohio now are incorporating this knowledge for a quality improvement initiative and have a goal to reduce the length of stay by 20 percent by June 30, 2015.

Neonatal Abstinence Syndrome

www.cdc.gov/nchs/nvss.htm.

* Per 100,000 population

How did we get here?State by State Comparison 2008

Rate* of unintentional drug overdose deaths per 100,000

Updated 2010 dataRate* of unintentional drug overdose deaths

per 100,000

Ohio had a 440% increase in unintentional drug overdose from 1999 to 2011

Ohio Data:~ 5 fold increase in opioid distribution

Ohio Data:Unintentional Overdose Deaths by Specific Drug

Source: Ohio Department of Health Violence and Injury Prevention Program

Number of Deaths in Ohio

Ohio Children’s Hospital NAS Consortium

• Organized in January 2012

• Chartered by Governor Kasich to work together to improve care of children

• Neo Inaugural Project: NAS- launched Sept 2012

• Form longitudinal cohort of term infants with narcotic abstinence syndrome.• Infants admitted by 6 Ohio Children’s Hospitals to

total of 20 hospitals.

• Describe the maternal and neonatal characteristics

• Determine the “potentially better practice” for narcotic abstinence treatment.

• Identify variation and areas for future research.

Consortium Objectives:

Maternal Descriptors: n=553 (2012- 2013)

Mean Range

Maternal Age 26.7 y 17-44

Maternal Race:

White, Non-Hispanic ( %) 92%

Single 84%

Insurance:

Public

None

80%

10%

N= 553

Any Prenatal Care 89%

Hep. C 25.9%

Sexually Transmitted Disease 7%

HIV 0

Hep. B 1.0%

Maternal Drug Use

Site A Site B Site C Site D Site E Site F Total

N=102 N=183 N=187 N=29 N=32 N=14 N=547

Buprenorphine (%) 55.9 23.5 46.0 31.0 18.8 14.3 37.1

Heroin (%) 16.7 36.1 20.3 37.9 25.0 42.9 26.7 (30%)

Hydrocodone (%) 9.8 14.2 9.6 6.9 6.3 28.6 11.3

Hydromorphone (%) 4.9 2.7 2.1 3.5 0.0 0.0 2.7

Methadone (%) 10.8 41.5 18.7 41.4 31.3 35.7 27.2

Morphine (%) 2.0 3.8 0.0 3.5 0.0 7.1 2.0

Oxycodone (%) 27.5 25.7 44.9 24.1 28.1 42.9 33.1

Unspecified Opiates (%) 24.5 55.7 38.0 34.5 71.9 71.4 44.1

More than One Narcotic (%) 4.9 33.9 17.7 10.3 15.6 28.6 20.5

Polysubstance by Toxicology (%) 27.5 47.0 37.9 24.1 34.4 57.1 36.9

Illicit Narcotics (%) 23.5 57.9 36.9 37.9 43.8 71.4 42.8

Any Illicit Substance (%) 47.1 68.9 56.6 48.3 46.9 78.6 58.1

Needle exchange program…

Updated data through 994 mothers:• Heroin use: 30% (n=298)• Hepatitis C rate: 26% (n=257)

• Under current law, needle exchanges can be created in Ohio only with a declared local health emergency.

Prevention Not Permission Portsmouth City Health Department

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Tobacco

Marijuana

Cocaine

Alcohol

Amphetamine

Poly Exposures82% by self report95% by cord

Infant Treatment

Characteristic N=994

Symptoms Started (hours; Mean) 44

Treatment Length (days; Mean) 19

Hospital Stay (days; Mean) 22.5

Number of Drugs Used (Mean) 1.4

Drugs used:MorphineMethadone

55%44%

Phase 1 Collaboration Data by Center

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N=102 N=183 N=187 N=29 N=32 N=14 N=547

A B C D E F Total

Opiate Treatment days

Day of Life of Discharge

Phase 1 Collaboration Data3 centers with weaning protocol in place prior to onset of OCHA

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N=77 N=476

No Protocol Protocol

Opiate Treatment Days


P=<0.0001 P=0.004

Phase 1 Collaboration Data by GroupMethadone n= 224, Morphine n= 276

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20

25

Day of life discharged Days total opiate treatment

Morphine only

Methadone only

P=0.79P=0.9

Different levels of care

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Total treatment days Day of life of discharge

Level 2 n=218

Level 3 n=330

0%

10%

20%

30%

40%

50%

60%

70%

Home with mother Home with family

member other than

mother

Foster care / adoption

Disposition

OCHA Publication

Paper in Pediatrics August 2014

Neonatal Narcotic Abstinence Syndrome:

A Multicenter Cohort Study of Treatments and Hospital Outcomes

Eric S Hall, PhD1*, Scott L Wexelblatt, MD1*, Moira Crowley, MD2,

Jennifer L Grow, MD3, Lisa R Jasin, MSN, NNP-BC4, Mark A Klebanoff,

MD5, Richard E McClead, MD6, Jareen Meinzen-Derr, PhD1,7, Vedagiri K

Mohan, MD8, Howard Stein, MD8, and Michele C Walsh, MD, MS Epi2

on behalf of the OCHNAS Consortium

Impact of Ohio OCHA Weaning Protocol• In July 2013 a standard “Potentially Better” weaning protocol was adopted by all six groups.

• We documented management of 462 infants prior to statewide adoption of the weaning protocol, and 392 infants after adoption.

o We removed infants who completed therapy as an outpatient, as this center did not adopt the protocol.

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N=102 N=183 N=187 N=29 N=32 N=14 N=547

A B C D E F Total

Opiate Treatment days


Phase 2

N DOT P LOS PAdjuvant

Therapy NAdjuvant

Therapy %P

Existing Protocol Sites 357 17.5 0.2 23.3 0.2 146 40.90% 0.05

Protocol Adopting Sites 35 17.1 <.001 22.9 <.001 2 5.70% 0.01

Total 392 17.5 0.4 23.3 0.5 148 37.80% 0.6

Phase 1

N DOT LOSAdjuvant

Therapy NAdjuvant Therapy%

Existing Protocol Sites 415 16.5 22.1 140 33.70%

Protocol Adopting Sites 47 33.7 39.9 14 29.80%

Total 462 18.2 23.9 154 33.30%

Impact of Ohio OCHA Weaning Protocol

Conclusions: • Adoption of standard opioid weaning guidelines for

NAS reduced the duration of opiate exposure and

length of hospital stay.

• Outcomes among infants managed by providers with

existing explicit weaning protocols were sustained

after statewide adoption.


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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

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Infants Treated for NAS through 2014

Neonatal Abstinence Syndrome Length of Stay2012-2014

length of treatment Avg length of stay Average length of treatment

Inter-observerreliability began

Oct 2012Decreased average

Length of treatment to 38 days

New treatment protocol initiated

Decreased to average length of treatment

17 days


The OPQC NAS Project is funded by The Ohio Department of

Medicaid

Social Media

Projects: OCHA & OPQC

OCHA: Ohio Children’s Hospital Association

• September 2012 –September 2014

• Six children’s hospitals and their affiliates (20 total)

• 994 infants

• Included only infants that required pharmacological treatment for NAS

OPQC: Ohio Perinatal Quality Collaborative

• January 2014-June 2015

• 52 sites:– Cohort 1: Level 3 NICU’s and

their Level 2 affiliates

– Cohort 2: Remaining Level 2 Special Care Nurseries in OH

• Over 2100+ infants

• Includes infants that received both non-pharmacological AND pharmacological treatment

PromedicaToledo Children’s

Miami Valley

Mercy Anderson

Aultman

Mt. Carmel EastOSU

UH Rainbow Babies & Children’s

Bethesda North Hospital

Nationwide Dublin Methodist

Akron Children’s Summa

Cincinnati Children’s

Hillcrest HospitalFairview Hospital

ClevelandClinic

Dayton Children’s

NationwideRiverside Methodist

Nationwide Grant

Nationwide Mt. Carmel St. Ann’s

UH Cincinnati

Good Samaritan Hospital

MetroHealth

Mt. Carmel WestNationwide Doctor’s

Akron Children’s

NationwideChildren’s

Mercy Children’s Hospital

Atrium Medical Center

Fort Hamilton

Mercy Hospital Fairfield

Mercy Medical Center Canton

The Christ Hospital

St. Rita’sMedical Center

Southview Medical Center

Good Samaritan Hospital Dayton

Kettering

Mercy Health West

Southern Ohio Medical Center

Genesis Healthcare System

OhioHealth MedCentral Mansfield

Marion General

Elyria Medical Center -UH

Mercy Regional Medical Center Lorain

ProMedica Bay Park

Lima Memorial Health System

Springfield RegionalMedical Center

Adena Regional

Medical Center

Soin Medical Center

Upper Valley Medical Center

Licking Memorial Health System

52 NAS Participating Sites 20141/2014 start Level 3 and Level 2 teams

Akron Children’s St. Elizabeth

Health Center/Mahoning

Valley

Trumbull Memorial

4/2014 start; remaining Level 2 sites

Key Driver DiagramProject Name: OPQC Neonatal NAS Leader: Walsh

SMART AIM

KEY DRIVERSINTERVENTIONS

By increasing identification of and

compassionate withdrawal treatment for full-term infants born with

Neonatal Abstinence Syndrome (NAS), we will reduce length of stay by 20% across participating sites by June 30, 2015.

Improve recognition and non-judgmental support for Narcotic

addicted women and infants

Connect with outpatient support and treatment program prior to

discharge

Standardize NAS Treatment Protocol

Optimize Non-Pharmacologic Rx Bundle

• Initiate Rx If NAS score > 8 twice.•Stabilization/ Escalation Phase•Wean when stable for 48 hrs by 10% daily.

•Swaddling, low stimulation.•Encourage kangaroo care•Feed on demand- MBM if appropriate or lactose free, 22 cal formula

•All MD and RN staff to view “Nurture the Mother- Nurture the Child”•Monthly education on addiction care

Attain high reliability in NAS scoring by nursing staff

Partner with Families to Establish Safety Plan for Infant

Fulltime RN staff at Level 2 and 3 to complete D’Apolito NAS scoring training video and achieve 90% reliability.

• Establish agreement with outpatient program and/or Mental Health•Utilize Early Intervention Services

Collaborate with DHS/ CPS to ensure infant safety.

Prenatal Identification of MomImplement Optimal Med Rx

Program

Engage families in Safety Planning. Partner with other stakeholders to influence policy and primary

prevention.

Provide primary prevention materials to sites.

To reduce the number of moms and babies with narcotic exposure, and

reduce the need for treatment of NAS.

GLOBAL AIM

Improve Consistency in Modified Finnegan Scoring

• All sites use same tool

• Train RN staff to 90% reliability in scoring using D’Apolito Training System

• In Pilot work, we were able to see drop in max score when training completed

• OPQC has sent out DVD’s to each site

Attain high reliability in NAS scoring by nursing

staff

Intervention:

Fulltime RN staff at Level 2 and 3 to complete D’Apolito NAS scoring training video and achieve 90% reliability.

Non-Pharmacologic Management of Infants with NAS

• Feeding on Demando Breast Milk Feeds

(contraindicated if Mom not in Treatment program/still using illicit drugs/HIV+)

o Low Lactose Formula

o 22 kcal/oz feeds

• Swaddling

• Low Stimulation

• Rooming In

Other interventions in the literature: Skin-to-Skin/Kangaroo Care Rocker Beds Massage therapy Music therapy Aromatherapy (lavender,

mother’s scent) Color Therapy (B&W

more soothing?)

Optimize Non-Pharmacologic Rx Bundle

Key Driver:

Key Driver:

Intervention:

Pharmacological Bundle

Standardize NAS Treatment Protocol

• Initiate Rx If NAS score > 8 twice.•Stabilization/ Escalation Phase•Begin wean when stable for 48hrs•Discharge home after 48hrs (Morphine) to 72hrs (Methadone)

Source: https://neoadvances.org

Source: https://abcnews.com

Key Driver:

Intervention:

Relationships with Support Services

•Establish agreement with outpatient program and/or Mental Health Services•Utilize Early Intervention Services

Connect with outpatient support and treatment

program prior to dischargeExamples of organizations our hospital teams have partnered with:• County Drug Courts• MAT Treatment Centers• Homeless Shelters (gender specific)• ADAMHS Board (Alcohol, Drug Addiction

and Mental Health Services) throughout the state of Ohio• Under Ohio law, the ADAMHS Board is one of

50 Boards coordinating the public behavioral health system in Ohio.

Key Driver:

Non-Judgemental Support and Compassionate Care

Improve recognition and non-judgmental support for Narcotic addicted women and infants

Collaborative Aggregate

Nuts and Bolts of QI

• 21 Outpatient OB Centers• 48 NICU’s and Special Care Nurseries • Centers for Disease Control and Prevention• Ohio Department of Health• Ohio Department of Medicaid• Ohio Hospital Association• Ohio Children's Hospital Association• Ohio Child Welfare Training Program• Government Resource Center• State Board of Nursing• State Board of Medicine • State Board of Dentistry• Graham's Foundation • Ohio Department of Mental Health and Addiction

Services • XIX Recovery Support Services• North Carolina Perinatal Quality Collaborative• First Step Home• Brigid’s Path• Lily’s Place• The Turning Point Program• Ohio Managed Care Organizations • Ohio Collaborative to Prevent Infant Mortality

It’s Not Your Mother’s Marijuana:Effects on Maternal-Fetal Health and

the Developing Child

Dr. Kay Roussos-Ross, MDDirector of Women’s Health, Dept. of Ob/Gyn

University of Florida

Dr. Tamara Warner, Ph.D.Research Assistant Professor, Dept. of Pediatrics

University of Florida

Disclosures

Dr. Roussos-Ross and Dr. Warner have no conflicts of interest to disclose.

Objectives

• Prepare physicians to screen and counsel pregnant patients about prenatal marijuana use.

• Outline changes in the potency and use of marijuana during the past 30 years that may affect the developmental outcomes of today’s children with prenatal marijuana exposure.

Clinics in Perinatology (December 2014) Vol. 41, Issue 4, pages 877-894.

DOI: http://dx.doi.org/10.1016//j.clp.2014.08.009

http://www.perinatology.theclinics.com/article/S0095-5108(14)00085-2/abstract

Part 1

Pro-Marijuana Advocacy Efforts and Changes in Marijuana Potency and Use

Societal Shift in Attitudes About Marijuana

States Legalizing “Medical” Marijuana

1. Alaska2. Arizona3. California4. Colorado5. Connecticut6. DC7. Delaware8. Hawaii9. Illinois10. Maine11. Maryland12. Massachusetts

13. Michigan14. Minnesota15. Montana16. Nevada17. New Hampshire18. New Jersey19. New Mexico20. New York21. Oregon22. Rhode Island23. Vermont24. Washington

Pending Legislation in 2015(as of 2/19/15)

1. Florida

2. Georgia

3. Indiana

4. Kansas

5. Kentucky

6. Missouri

7. Nebraska

8. North Dakota

9. Pennsylvania

10. South Carolina

11. Tennessee

States Legalizing Recreational Marijuana

Legal Status of Medical Marijuana?

• Marijuana is a Schedule I drug under the Controlled Substance Act, a federal law that preempts action taken by individual states to legalize its use, cultivation and distribution.

• When used for medicinal purposes, marijuana should be considered a pharmaceutical agent governed by the Food Drug & Cosmetic Act – Regulatory oversight including evaluation of its

safety & efficacy by the Food & Drug Administration.

Does legalizing marijuana result in higher marijuana use?

Higher use in states that:

• Allow home cultivation

• Allow legal dispensaries

Lower use (and treatment admissions) in states that:

• Restrict broad access by requiring annual registration of patients

A: Yes, but it depends on the specific aspects of state laws and policies.

Unintended Consequences of Pro-Marijuana Advocacy Efforts?

• Growing pro-marijuana advocacy efforts are taking place in a very different environment than the 1960s.

• In the absence of strong public health messages about the possible dangers of marijuana, marijuana use may increase among pregnant women.

It’s Not Your Mother’s Marijuana

• The potency of marijuana has significantly increased in potency during the past 40 years.

• The amount of marijuana consumed, on average, among young adults also seems to increasing significantly.

• Marijuana is perceived as relatively “safe” and, in some areas, the cost is comparable to tobacco.

Increased Potency of Marijuana

• Potency is measured by the percentage of Δ9-

tetrahydrocannabinol (THC), the most psychoactive of the 70 cannabinoids found in marijuana.

• From the 1970s to the 2000s, there has been an estimated 6- to 7-fold increase in the percentage of THC found in seized marijuana.


“It is now possible to mass product plants with potencies inconceivable when concerted monitoring efforts started 40 years ago.”

-- Mehmedic et al. (2010)

Potency Trends of Δ9-THC and Other Cannabinoids in

Confiscated Cannabis Preparations from 1993 to 2008


From 1993 to 2008, the percentage of high potency THC (> 9%) increased from 3.23% to 21.47%.

Mehmedic et al. 2010 doi: 10.1111/j.1556.4029.2010.01441.x

//localhost/doi/ 10.1111:j.1556.4029.2010.01441.x


Potency of non-domestic samples is increasing while domestic samples are relatively stable.

Non-domesticAll samples

Domestic

But There’s More

• There are more than 100 different cannabinoids found in marijuana.

• Not all cannabinoids have psychoactive properties.

• Cannabidiol (CBD) is non-psychotropic and displays many beneficial properties:– Antipsychotic

– Antihyperalgesic

– Anticonvulsant

– Neuroprotective

– Antiemetic properties

The Ratio is Important, Too

• As the percentage of THC has been increasing, the percentage of CBD has been decreasing.

• This is particularly true in sinsemilla – the flowering tops of unfertilized female plants with no seeds, which is gaining market share (commonly called “skunk”)

The Ratio is Important, Too

• The higher ratio of THC/CBD likely makes the marijuana even more potent & dangerous.

– Increased risk for cannabis dependence

– Increased treatment seeking for cannabis-related problems

– Increased vulnerability to psychosis

–May predispose users to adverse psychiatric effects

Amount of Marijuana Use

• Amount of marijuana consumed, on average, may be increasing among younger adults, especially minorities

• Growing popularity of blunts (marijuana-filled cigars) compared to joints and pipes

Amount of Marijuana Use

• Blunts contain significantly more marijuana

–1 blunt = 1.5 joints

–1 blunt = 2.5 pipes

• Blunts are often shared among several people making it difficult to quantify individual usage

FIGURE 6

Marijuana: Trends in Annual Use, Risk, Disapproval, and Availability

Grades 8, 10, and 12

Source. The Monitoring the Future study, the University of Michigan.

Use% who used in last 12 months

Risk% seeing "great risk" in using regularly

Disapproval% disapproving of using regularly

Availability% saying "fairly easy" or "very easy" to get

PE

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Perceptions of Marijuana

• In general, there is less stigma associated with marijuana use.

• Among adolescents, the perceived risk of regular use has declined sharply since 2005.

FIGURE 6

Marijuana: Trends in Annual Use, Risk, Disapproval, and Availability

Grades 8, 10, and 12

Source. The Monitoring the Future study, the University of Michigan.

Use% who used in last 12 months

Risk% seeing "great risk" in using regularly

Disapproval% disapproving of using regularly

Availability% saying "fairly easy" or "very easy" to get

PE

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'74 '76 '78 '80 '82 '84 '86 '88 '90 '92 '94 '96 '98 '00 '02 '04 '06 '08 '10 '12 '14

8th Grade10th Grade12th Grade

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Perceptions of Marijuana

• One study of urban pregnant women found that marijuana was perceived as “safer” to use during pregnancy than cigarettes or alcohol.

• Misperceptions may be due to the relative absence of strong public health messages.

• Cost of marijuana was comparable to tobacco; price is no longer a deterrent.

Part 2

The Epidemiology of Marijuana Use Among Pregnant Women: Who Uses?

Epidemiology of Marijuana Use Among Pregnant Women

• Most commonly used illicit drug during pregnancy.

• Estimated 115,000 pregnant women annually.

Marijuana Use Among Pregnant Women

Epidemiology: Bottom Line #1

Teratogen = causes birth defects

• Cigarettes are the most commonly used teratogen (15.9%)

• Alcohol is 2nd most commonly used teratogen (8.5%)

• While marijuana is the commonly used illicit drug, it is not the most common teratogen.

Epidemiology: Bottom Line #2

• Young adolescents (ages 15 to 17) have the highest rate of marijuana use during pregnancy (16.5%)

• Marijuana use is highest (10.7%) during the first trimester then declines significantly.

• Use rebounds quickly after delivery.

Who Uses Illicit Drugs During Pregnancy?

• Pre-pregnancy BMI is underweight

• No folic acid supplementation

• Alcohol use

• Cigarette smoking

• Partners are drug users

• Intimate partner violence

• Lower levels of education

• Lower levels of income

• Higher rates of unemployment

Common Factors

Who Uses Marijuana During Pregnancy?

• Excessive weight gain during pregnancy

• More likely to be nulliparous (no other children)

• More likely to have had an induce abortion in the past

Possible Unique Factors*

Data from a population-based study using the National Birth Defects Prevention Study with a small sample (n = 189).

Part 3

Issues Related to Marijuana Use During Pregnancy

Recommendations

American Society of Addiction Medicine

• Prenatal education about all drugs for all pregnant women

• Universal screening to identify “at risk” women including repeated follow-up assessments

• Culturally competence public prevention programs to educate the public about realistic dangers of drug use in pregnancy

• Education of health care providers in the care and managements of women with evidence of drug use before, during, and after pregnancy

• Women who are pregnant should receive priority admission to substance treatment facilities.

The CRAFFT Screening Interview

Begin: “I’m going to ask you a few questions that I ask all my patients. Please be honest. I will keep your answers confidential.”

Part A

During the PAST 12 MONTHS, did you: No Yes

1. Drink any alcohol (more than a few sips)? (Do not count sips of alcohol taken during family or religious events.)

2. Smoke any marijuana or hashish?

3. Use anything else to get high?

(“anything else” includes illegal drugs, over the counter and prescription drugs, and things that you sniff or “huff”)

For clinic use only: Did the patient answer “yes” to any questions in Part A?

No Yes

Ask CAR question only, then stop Ask all 6 CRAFFT questions

Part B No Yes

1. Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?

2. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?

3. Do you ever use alcohol or drugs while you are by yourself, or ALONE?

4. Do you ever FORGET things you did while using alcohol or drugs?

5. Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?

6. Have you ever gotten into TROUBLE while you were using alcohol or drugs?

CONFIDENTIALITY NOTICE: The information recorded on this page may be protected by special federal confidentiality rules (42 CFR Part 2), which prohibit disclosure of this information unless authorized by specific written consent. A general authorization for release of medical information is NOT sufficient for this purpose.

© CHILDREN’S HOSPITAL BOSTON, 2009. ALL RIGHTS RESERVED. Reproduced with permission from the Center for Adolescent Substance Abuse Research, CeASAR, Children’s Hospital Boston. (www.ceasar.org)

CRAFFT

Part 4

The Developmental Effects of Prenatal Marijuana Exposure

Longitudinal Studies

1. The Ottawa Prenatal Prospective Study (OPPS) began in 1978 and enrolled a predominantly middle-class, low-risk, Caucasian sample from Ottawa, Canada

2. The Maternal Health Practice and Child Development Study (MHPCD) started in 1982 and enrolled a high-risk, low socioeconomic status mixed Caucasian and African-American sample from Pittsburgh, Pennsylvania

Longitudinal Studies

3. The Generation R study started in 2010 and recruited a multi-ethnic population-based cohort in Rotterdam, The Netherlands

Difficult Research

• It is difficult to ascertain developmental effects that are specific to prenatal marijuana exposure.

• Why? Most pregnant women who use marijuana also smoke cigarettes and/or drink alcohol.

• Researchers are actually assessing the effects related to polysubstance exposure.

Possible Pregnancy-Related Effects of Prenatal Marijuana Use

• Decreased male fertility

• Decreased ovulation

• Altered hormones– Prolactin, follicle-stimulating hormone, luteinizing

hormone, and estrogen

• Altered oviductal transport, embryo implantation, and maintenance of pregnancy

Possible Pregnancy-Related Effects of Prenatal Marijuana Use

• Altered placental blood flow

• Intrauterine growth restriction

• Decreased gestational age

• Decreased birth weight

Neonatal Period

• No neonatal withdrawal syndrome identified

• Neurobehavior – no consistent results during first week of life

Minimal or No Effects on Child Development

• Minimal, inconsistent effect on general cognition

• Altered sleep patterns

• No effect on language

• Minimal effect on motor development

• Minimal effects on growth and pubertal development

Consistent Negative Effects on Child Development

• Poorer executive functioning skills and attention (ages 3 to 16)

– Attention, impulsivity, problem-solving, reasoning

• Increased conduct and behavior problems (ages 6 to 21)

– Greater risk of initiating cigarette smoking and marijuana use during adolescence

Key Points

• Pro-marijuana advocacy may result in an increase in the prevalence of marijuana use during pregnancy.

• Today’s marijuana is 6- to 7-times more potent than it just 20 years ago.

• Average marijuana consumption may be higher owing to the growing popularity of blunts compared to joints and pipes.

In the absence of strong public health messagesand the growing pro-marijuana movement,

marijuana use among pregnant women could increase in coming years.

This may be particularly true among young adolescents who already report the highest use

among all pregnant women.

Key Points

We Need to Get the Word Out

To date, the documented effects of prenatal marijuana exposure on fetal outcomes and child

development have been minimal.

However, given the increased potency and average use, the consequences of marijuana use

among pregnant women could be more significant and serious than in past decades.

Key Points

Key Points

• Intersecting political forces and medical issues mandate that physicians:

– Be knowledgeable about marijuana use by their patients and

– Be prepared to counsel their patients about the effects of prenatal marijuana use on fertility, pregnancy, and exposed offspring

• Kay, I created the following 2 slides based on the key points from our paper. I decided to simply the messages into the 3 “Key Points” slides. Keep or delete these – your choice!

Key Points

• Adverse fetal outcomes related to maternal marijuana use remain unclear.

• Associations have been found with:

– Infertility

– Placental complications

– Fetal growth restriction

Key Points

• Long-term effects of prenatal marijuana use on exposed offspring are difficult to ascertain because polysubstance abuse is the norm (cigarettes and alcohol).

Clinical Track:Maternal-Fetal Issues

for Physicians

Presenters:

• Scott L. Wexelblatt, MD, Regional Medical Director for Newborn Services, Cincinnati Children’s Hospital Medical Center

• Susan Ford, RN, BSN, BEACON Quality Improvement Coordinator, Ohio Perinatal Quality Collaborative

• Tamara D. Warner, PhD, Research Assistant Professor, Department of Pediatrics, University of Florida

• Kay Roussos-Ross, MD, Director of Women’s Health, UF Shands Medical Plaza

Moderator: Carla S. Saunders, NNP-BC, Advance Practice Coordinator, Pediatrix Medical Group, and Neonatal Nurse Practitioner, East TennesseeChildren’s Hospital, and Member, Rx Summit National Advisory Board

Rx15 clinical wed_430_1_wexelblatt-ford_2warner-roussosross

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