SUBSTANCE ABUSE SCREENING IN PREGNANCY

Presented by-

Debby Carapezza, RN, MSN

Nurse Consultant

Utah Department of Health

Reproductive Health Program

January 2004

The Problem:

While many providers know substance abuse during pregnancy is a problem, many assume:

-it only exists among the poor and

-it couldn’t possibly be a problem in their practice!

DATA BEG TO DIFFER!!

Maternal alcohol abuse during pregnancy is associated with:

Fetal Alcohol Syndrome (FAS)

Increased risk of spontaneous abortion

Alcohol-related neurodevelopmental disorder (ARND)

Alcohol-related birth defects (ARBD)

How Prevalent is FAS?

Prevalence varies by population studied & methods used

According to the CDC, rates vary from 0.2 to 1.5 cases per 1,000 live births in various areas of the US

FAS is one of the leading causes of preventable mental retardation

What about ARND & ARBD?

These conditions are believed to occur 3 times more often than FAS.

What about the $$$$$?

A North Dakota study found that if a prevention program prevents one new case of FAS/year, it would save that state:

$2,342 in the first year $128,810 after 10 years $491,820 after 20 years1

1. Klug, MG, Burd L. “Fetal alcohol syndrome prevention: annual and cumulative cost savings.” Neurotoxicology Teratology. (Nov-Dec. 2003). 25(6): 763-765.

But Isn’t Utah Different?

According to birth certificate data from 2002-

1% of women, or 514 women, experiencing a live birth in that year reported using alcohol while pregnant.

ILLICIT DRUGSThe National Survey on Drug Use & Health

During 2002, data were collected from 1,104 pregnant women aged 18-44 years of age2

2. Substance Abuse and Mental Health Services Administration. The National Survey on Drug Use and Health, “Pregnancy and Substance Use.” (Jan 2, 2004). Available at: http://oas.samhsa.gov/2k3/pregnancy/pregnancy.htm

Results:

9% of nonpregnant women ages 15 to 44 years reported use of illicit drugs in the month previous to the survey

3% of pregnant women reported use of illicit drugs in the month previous to the survey

Pregnant women aged 15 to 25 were more likely to use illicit drugs in the past month than pregnant women aged 26 to 44

Results continued:

Among pregnant women aged 15 to 44, approximately 6% of blacks, 4 % of whites and 2% of Hispanics used illicit drugs in the past month

Pregnant white & Hispanic women had lower rates of illicit drug use than nonpregnant women of the same age

Among pregnant, black women, the rate of past month illicit drug use was not statistically different from nonpregnant black women

Marijuana was the most widely used illicit drug among both pregnant and nonpregnant women

But Isn’t Utah Different?

During 2000, 13 well baby nurseries & during 2000-2001, 6 NICUs collected anonymous meconium samples on newborns3

Data were compared to results of a maternal substance abuse prevalence study conducted in the same geographic area in 1991.4

3. Buchi KF, Zone S, Langheinrich K, Varner MW. “Changing prevalence of prenatal substance abuse in Utah.” Obstetrics & Gynecology. (2003) Jul; 102(1): 27-30.

4. Buchi KF, Varner MW, Chase RA. “The prevalence of substance abuse among pregnant women in Utah.” Obstetrics & Gynecology. (1993) Feb; 81(2):239-42.

Results: THE GOOD!

No significant differences in the rates of positivity for methamphetamines and marijuana were noted between the 2 studies

Cocaine use had declined from 1.1% in 1991 to 0.3% in 2000/2001

Results: THE BAD & UGLY!

Positivity for methamphetamines, marijuana & cocaine was 4.7% among infants in NICUs

Positivity for those 3 drugs was 1.9% for infants in well baby nurseries

What is the Impact of Substance Use on the Fetus/Infant?

ALCOHOL USE

The Impact of Alcohol on the Infant

FAS ARND ARBD

Pre/postnatal growth retardation

Poor school performance

Heart defects

Facial anomalies Poor impulse control

Kidney problems

Microcephaly Hyperactivity Hearing problems

Joint Contractures

Mental retardation

How much alcohol does it take to produce FAS?

The exact levels are unknown. However the following is known:5

With intake of 4 drinks/day, the risk for FAS may be 20% With the intake of 5 drinks/day, the risk for FAS

increases to 30% With the intake of 6 drinks/day, the risk for FAS

increases to 40% Maternal binge drinking may also produce substantial

risk to the fetus5. The American College of Obstetrics & Gynecologists. Precis V: An Update in Obstetrics &

Gynecology.(1994). Washington DC. p. 140.

What is the Impact of Substance Use on the Fetus/Infant?

COCAINE

What about Cocaine?

A meta-analysis reviewed 33 studies of pregnancy outcomes among cocaine consuming women.6

Women were categorized into 4 groups by type of exposure:

– Mainly cocaine– Cocaine plus polydrug use– Polydrug use but no cocaine– No drug use

6. Addis A, Moretti ME, Syed FA, Einarson TR, Koren G. “Fetal effects of cocaine: an updated meta-analysis.” Reproductive Toxicology. (2001). Jul-Aug; 15(4):341-369.

Results

When cocaine exposed children were compared to those with no exposure, the cocaine exposed children had higher risks of:

-Major malformations -Low birth weights -Prematurity -Placental abruption -Premature rupture of membranes -Decreased length & head circumference

But…

Comparison of cocaine exposed children to children exposed to polydrug used without cocaine revealed-

-That only the risk of placental abruption and PROM were statistically associated with cocaine use

-That many adverse perinatal effects attributed to cocaine may be caused by multiple confounders

Recommendation by ACOG:

Substance abuse is one of the most important risks encountered in contemporary obstetrics. Therefore, all patients should be questioned thoroughly about substance abuse (including alcohol and tobacco) at the time of their first prenatal visit. (ACOG, 1994)

Not to worry! We all ask about drug & alcohol use – don’t we???

PRAMS* asks new moms,

– “During your prenatal visits, did a doctor, nurse, or other health care worker talk with you about any of the things listed below?”

– “How drinking during pregnancy could affect your baby?”– “How using illegal drugs could affect your baby?”

*PRAMS is an ongoing, population-based risk factor surveillance system designed to identify and monitor selected maternal experiences that occur before and during pregnancy and experiences of the child’s early infancy.

And the results were…7

Only 55.4% of women reported discussion of the affects of alcohol on a baby

Only 47.6% of women reported discussion of how using illegal drugs affects a baby

Women receiving prenatal care through a private provider had the lowest rates of counseling

7. Utah Department of Health, Reproductive Health Program. “Prenatal Education in Utah.” PRAMS Perspectives: A Pregnancy Risk Assessment Monitoring System Quarterly Report. V.3 No. 1. p. 2-4.

SCREENING!

WHEN?

In a perfect world-

Preconceptionally during routine primary care visits

Preconceptionally during family planning visits

During pregnancy-

At the first prenatal visit

During each trimester

At the postpartum visit

More frequently if risk factors are present

I don’t screen all of my prenatal clients because…

I don’t want to offend anyone!

To avoid problems, before you start screening:

Train involved staff in interviewing techniques Train involved staff in use of the screening tool Assure a non-judgmental & supportive attitude Assure confidentiality to the extent permitted by law Involved staff should have an on-going relationship

with the client Screen all clients to decrease subjectivity & bias Screen in a language understood by the client

Remember:

Screening provides the opportunity to begin an open discussion of substance abuse!

During the screening whether the screening is positive or negative for substance abuse, the health implications of use and the benefits of reduction/abstinence should be stressed!

I don’t screen because…

in my busy office, I just don’t have time!

Most screening can be accomplished in a short time.

For the majority of clients, screening can take 30 seconds

For women with a problem, screening can often be accomplished in 5 to 10 minutes

Try these strategies for women with a positive screen:

Review for the client the information she has just reported to you

State your concern for both her & her baby’s health

State your belief that you know she want to have a healthy baby and that abstinence from alcohol & drugs will improve her baby’s health

Try these strategies for women with a positive screen:

State the need for her to stop using alcohol & drugs during pregnancy

Assure the client you will work with her to achieve a substance free pregnancy

Know your referral sources

Try these strategies for women with a positive screen:

Discuss possible strategies for her to stop:– Individual counseling

– 12-step programs

– Addiction treatment programs

Try these strategies for women with a positive screen:

Suggest referral source(s) for a more in-depth assessment by a specialist

If possible, make an appointment for her while in your office

Make a follow-up appointment to see the client after her assessment

Keep an on-going interest in her progress Praise any reported reduction in use Maintain communication with the treatment provider to

monitor progress

Emphasize to the client struggling with substance abuse…

The benefits will begin as soon as she reduces or stops her substance use – the earlier the better – but it is never too late!

The 4 Ps Screening Tool

A word (or 2) about the tool…

This tool has been chosen to screen for alcohol & drug use during pregnancy due to its brevity, validity, specificity and sensitivity.

It has been used with populations of pregnant women

It is public domain and may be copied without permission

And a few more words about the tool…

It has been recommended for use by the National Center for Education in Maternal & Child Health

Its screening questions can be included in other areas of the visit, i.e., in the family history review or when discussing the home environment

However, providers should select a tool with which they are comfortable and that fits their interview style

General Instructions on Use of the Tools:

Substance abuse screening should ideally occur face-to-face

Screening can be accomplished via a client completed questionnaire administered prior to the visit & reviewed with the woman during her intake & history

4Ps

Have you ever used drugs or alcohol during the Pregnancy?

Have you had a problem with drugs or alcohol in the Past?

Does your Partner have a problem with drugs or alcohol?

Do you consider one of your Parents to be an addict or alcoholic?

Any woman who answers yes to 1 or more questions should be referred for further assessment

Other screening tools are available.

You may also wish to consider the following:

– T-ACE– Tweak– TQDH– AUDIT

Resources:

For substance abuse: Utah Department of Human Services

– Division of Substance Abuse & Mental Health– 120 N 200 W– Salt Lake City, UT 84103– 801-58-4379– www.utahdsa.com

Substance Abuse Resources, continued

Substance Abuse & Mental Health Services Administration

Local treatment centers can be found by city, address or zip code at the following website:

http://findtreatment.samhsa.gov/facilitylocatordoc.htm

Mental Health Resources-

Mental Health Association in Utah 1800 S W Temple, Suite 501 Salt Lake City, UT 84115 801-569-3705 http://www.xmission.com/~mhaut/index.htm

Mental Health Resources, continued-

National Alliance for the Mentally Ill – Utah 309 E 100 S Salt Lake City, UT 84111 801-323-9900 Bridges Program, Kim Haws, Program Director Family to Family (provides support to

individuals coping with mentally ill family members)

Substance Abuse Resources, continued-

Medicaid Utah Department of Health Division of Health Care Financing PO Box 143106 Salt Lake City, UT 84114-3106 801-538-6155 Toll-free: 800-662-9651

In Summary:

All pregnant women should be screened for substance abuse at the first prenatal visit, every trimester thereafter and at the postpartum visit

Women with positive screens should be referred for more detailed assessment / treatment

Screening provides the opportunity to begin an open discussion of substance abuse!