substance use & abuse in pregnancy janet l. mitchell, m.d., m.p.h., f.a.c.o.g. consultant on...
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Substance Use & Abusein
PregnancyJanet L. Mitchell, M.D., M.P.H., F.A.C.O.G.
Consultant on Women’s Health
Addiction Research & Treatment Corporation
Brooklyn, NY
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"THE ALCOHOL OF GREAT BRITAIN AND TENNESSEE
AND THE TOBACCO OF KENTUCKY
UNDOUBTEDLY CREATE GREATER RATES OF MORBIDITY AND DEATH
THAN THE POPPY SEED OF TURKEY AND MEXICO”
BLINICK, ET AL., DRUG ADDICTION IN PREGNANCY AND THE NEONATEAMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGYVOL. 125, NO. 2, 1976
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Harlem Hospital’s Special Prenatal Program for Chemically
Dependent Women
• 1200 Pregnancies between 1988 - 1996
• 20% were HIV infected, 50% for those with a hx of IDU
• 4% 21 years of age - primary drug of use marijuana
• 80% listed crack and/or cocaine as their primary drug of choice
• Avg # of drugs used 3.5
• Higher rates of HCV then HBV
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ADDICTION
• Polydrug Abuse
• Poor Nutritional Status
• STD's
• Hepatitis
• HIV Infection
• Other Medical Problems
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ADDICTION and PREGNANCY
• Poor Dates
• Late Registration
• Inadequate Follow-up
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ADDICTION and PREGNANCYMATERNAL CONCERNS
• Poor Pregnancy Self-image
• Low Tolerance For Pain
• Poor Bonding
• Poor Parenting Skills
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ADDICTIONFETAL/NEONATAL CONCERNS
• Low Birth Weight
• Teratogenicity (Congenital Anomalies)
• SIDS
• Spontaneous Abortions
• Abstinence Syndromes
• Future Development
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ADDICTION
IS A
CHRONIC RELAPSINGRELAPSING,
MEDICAL DISEASE !!
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ALCOHOL
• CNS Depressant
• Known Teratogen
• Psychological and Physiological Dependence
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OTHER CNS DEPRESSANTS
• Barbiturates
• Benzodiazepines
• Methaqualone
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COCAINE
• CNS Stimulant
• Psychological Dependence
• ? Physiological Dependence
• ? Neonatal Abstinence Syndrome
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OTHER CNS STIMULANTS
• Amphetamines
• ‘Ice’
• Diet Pills
• Nicotine
• Caffeine
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COCAINEMATERNAL COMPLICATION
• Abruptio Placenta
• Preterm and/or Precipitous Labor
• Pre-eclamptic Like Syndrome
• Cardio-pulmonary problems
• Seizures
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COCAINEFETAL/NEONATAL COMPLICATION
• Low Birth Weight• Seizures• Intracranial Hemorrhage• ? Neonatal Abstinence Syndrome• Not a Teratogen
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OPIOIDS
• CNS Euphoria
• Not a Teratogen
• Psychological and Physiological Dependence
• Well Documented Neonatal Abstinence
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METHADONE MAINTENANCE
IS THE
TREATMENT OF CHOICE
DURING PREGNANCY!!
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METHADONE and PREGNANCYMATERNAL CONCERNS
• Inappropriate Medical Withdrawal
• Inadequate Dosage
• Chronic Constipation
• Pain Management
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METHADONE and PREGNANCYFETAL/NEONATAL CONCERNS
• Altered Antepartum Testing
• Neonatal Abstinence Syndrome
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METHADONE MAINTENANCE
IS THE
TREATMENT OF CHOICE
DURING PREGNANCY!!
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ADDICTION
IS A
CHRONIC RELAPSINGRELAPSING,
MEDICAL DISEASE !!
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CONCEPTS
• TREATMENT READINESS
• MOTIVATION TO TREATMENT
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DRUG DEPENDENCY AS DESCRIBED BY THE WORLD HEALTH ORGANIZATION (WHO):
“A BEHAVIORAL PATTERN IN WHICH THE USE OF A GIVEN PSYCHOACTIVE DRUG IS GIVEN A SHARPLY HIGHER PRIORITY OVER OTHER BEHAVIORS WHICH ONCE HAD A SIGNIFICANTLY HIGHER VALUE”
WHO, 1982
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STAGES TO SUCCESSFUL TREATMENT
• DENIAL
• NEGOTIATION
• ACCEPTANCE
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PRENATAL INTAKE PROTOCOL• Complete history, especially psychosocial & drug use• Complete physical examination focusing on the multiple
medical programs• Routine prenatal bloods + hepatitis screen for B & C• Tuberculin test • Counseling for HIV with strong recommendation for testing• Social service referral• Referral to therapeutic drug program• Methadone maintenance for opiod addiction• Establish rules, requirements and goals with patient and
significant others
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PRENATAL FOLLOW-UP PROTOCOL
• More frequent visits to identify medical and psychosocial problems early
• Random urine toxicologies
• Order and repeat appropriate tests as necessary
• Establish an ongoing relationship with the patient’s therapeutic drug program
• Establish an ongoing relationship with patient’s significant other(s)
• Began to discuss contraceptive methods
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LABOR AND DELIVERY PROTOCOLS
• Complete history and physical, especially recent drug history
• Repeat hepatitis screens and serological test for syphilis
• Urine toxicology• Alert pediatric and nursing staff• Alert social service• Pain management as appropriate• Method of delivery dependent on obstetrical
indications only
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POST PARTUM PROTOCOL
• Encourage continuation in a therapeutic drug program
• Encourage use of an appropriate contraceptive method
• Breastfeeding not contraindicated in methadone maintained women
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ADDICTION
IS A
CHRONIC RELAPSINGRELAPSING,
MEDICAL DISEASE !!
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TREATMENT IMPROVEMENT PROTOCALS (TIPS)FOR
PREGNANT, SUBSTANCE-USING WOMEN
Chair: Janet L Mitchell, MD, MPH, FACOG
The Centers for Substance Abuse Treatment (CSAT)Division for State Programs
Substance Abuse and Mental Health Services AdministrationSAMSA