Substance Use Disorders in Pregnancy

Transcription

1 + Substance Use Disorders in Pregnancy Laura Lander, MSW, LICSW, Assistant Professor Emily Chilko, MSW, LICSW, Clinical Therapist Department of Behavioral Medicine and Psychiatry, WVU NASW Conference May 2018

2 + Overview of Today s Topics Brief Review of Emergence of Opioid Epidemic Brief Review of Diagnostic Criteria for SUDs Prevalence of Substance Use and SUDs During Pregnancy Impact of Substance Use on Developing Fetus Clinical Presentation of Pregnant Patients Unique Strengths of Pregnant Patients Unique Concerns in Treating Pregnant Patients A Review of Effective Treatment Models Stigma

3 + From Illness to Epidemic Substance Use Disorders in Today s Appalachia

4 + Overdose Deaths in 1999

5 + Overdose Deaths in 2014

6 + Central Appalachia in 1999

7 + Central Appalachia in 2014

8 + What Changed? Known Changes Radical shift in prescribing practices of Opioid pain pills Subsequent increased drug availability Pain as the 5 th vital sign Theorized Changes Increased Poverty and Despair resulting from increasing economic disparity between America s socioeconomic classes Increased incidences of Chronic Pain and Economic Decline in Post-Industrialized Regions of the U.S. Death of Community - decreasing attachment to religious and civic institutions Poverty of Spirit - resulting from unprecedented pressures of globalization Criminalization of Illness through changes in sentencing law and policy resulting in increased incarceration rates Healthcare as a Business offering access to quality prevention and treatment only for individuals who can afford to pay

9 + Understanding Diagnostic Criteria Knowing What SUD Is and Is Not

10 + What is Substance Use Disorder? Impaired Control 1. Using more or for longer than intended 2. Difficulty stopping 3. Significant time spent 4. Intense cravings Social Impairment 5. Continued use despite problems with role responsibilities 6. Strained relationships 7. Giving up previous sources of joy Risky Use 8. Using in ways that are dangerous 9. Continued use despite physical or mental problems Pharmacological Indicators 10. Tolerance 11. Withdrawal

11 + What do you notice is NOT included in the criteria?

12 + What is Substance Use Disorder? SUD Criteria does NOT include Type of Substance Used Quantity of Substance Used Frequency of Substance Used Whether Substance is legal/illegal These are still essential questions to ask, but are not necessarily indicative of a SUD diagnosis. Addiction is not what s in your blood stream, it s more about how well or poorly you re functioning in your life as a result of what s in your blood stream.

13 + Substance Use Disorders + Pregnancy How Significant is This Problem?

14 + Prevalence of the Problem NSDUH 2013 illicit drug use Pregnant women age % Pregnant women age % Pregnant women % Rates of heroin use increased 31% from Stitely, samples or chord blood taken for drugs or alcohol (19.2%) Over 1 million babies are born every year to mothers who abuse substances Over 4,000 in WV Treatment improves birth outcomes!

15 + Tobacco Use During Pregnancy WV Behavioral Health Epidemiological Profile, 2013 On Average, 30% of women who smoked 3 months before pregnancy quit before the last 3 months of pregnancy

16 + Tobacco Use During Pregnancy WV Behavioral Health Epidemiological Profile, 2013

17 + Risks of Tobacco Use in Pregnancy SIDS Prematurity Asthma Low birth weight Still birth ( greater risk, greater the heavier the use)

18 + Alcohol Use During Pregnancy WV Behavioral Health Epidemiological Profile, 2013 Nationally, in % of pregnant women reported current use of alcohol and 2.3% reported binge drinking (NSDUH, 2013) First trimester 19% Second trimester - %5 Third trimester - 4.4% In WV in 2010, 3.7% of women reported drinking alcohol the last three months of pregnancy. Pregnant women aged 35 and over had the highest percentage of drinking alcohol the last 3 months of pregnancy in West Virginia. In 2010, women with the lowest and highest income (< $10,000 and > $50,000) reported the highest use of alcohol in the last three months of pregnancy (PRAMS).

19 + Risks of Alcohol Use in Pregnancy Fetal Alcohol Syndrome 2-5% of live births in US Short stature Abnormal facial features Neurodevelopmental disability Cognitive impairment

20 + Cannabis Use During Pregnancy Most commonly abused drug among pregnant women 11.63% of pregnant women report cannabis use in the last year of pregnancy 7.47% age report use in the last month 2.12% age (Brown, 2017) Some doctors even support the use of cannabis in pregnancy to control symptoms of morning sickness In WV, there is a common perception that marijuana is not harmful or addictive.

21 + Risks of Cannabis Use in Pregnancy Low birth weight Still births 2.3x greater risk Smaller head circumference Poor cognitive functioning Hyperactivity Attentional issues

22 + Opioid Use During Pregnancy In a CDC study, 39% of women on Medicaid were prescribed opioids during their pregnancy , 28% or women with private insurance.

23 + Risks of Opioid Use in Pregnancy Preeclampsia Low birth weight Placental insufficiency and abruption Premature rupture of the membranes Preterm labor Neonatal Abstinence Syndrome Maternal infection associated with IV use (Hep C, HIV, Endocarditis)

24 + Neonatal Abstinence Syndrome Postnatal Withdrawal Syndrome 5-fold U.S. increase from CDC study of 28 states, , showed overall increase of ~300%, from 1.5 to 6.0/1,000 hospital births* in 2013, WV had 33.4 cases/1,000 hospital births = highest rate est. 80% of hospital costs for NAS covered by WV Medicaid *CDC. Incidence of Neonatal Abstinence Syndrome-28 States, MMWR August 12,2016; 65(31);

25 + Neonatal Abstinence Syndrome Symptoms of NAS Irritability excessive crying, difficult to console Feeding problems Sleep problems Excessive sucking Diarrhea Vomiting Exaggerated startle response Seizures (infrequent) Unknown long term impact

26 + Risks of Stimulant Use During Pregnancy Cocaine and Other Stimulants 25% increase chance of preterm labor Placental abruption Small head circumference Low birth weight Withdrawal when born Learning difficulties, cognitive deficits

27 + Risks of Benzodiazepine Use in Pregnancy Withdrawal, seizures for mother Cleft palate (small increased risk), data controversial Unknown long term effects

28 + Issues Unique to Pregnant Patients a Review of Strengths and Challenges Painting by Annie Preece; person in recovery

29 + Trends Among Pregnant SUD Patients Pregnant Patients Are often are highly motivated to change Can be less ambivalent about getting clean Tend to be younger Have a shorter progression of disease Can be emotionally labile Can be overwhelmed Often have family support Are hopeful about the future Have high level of willingness

30 + Treatment of SUDs in Pregnancy Access to treatment can be limited Coordination with Obstetrical Care is essential Participation in SUD treatment increases OBGYN care adherence Increased stigma vs. non-pregnant peers Treatment in all pregnancy treatment groups can reduce stigma and shame and increase social supports

31 + Unique Treatment Concerns Higher rates of domestic violence High levels of shame and guilt Fear of CPS intervention Women with addiction often do not have regular menses so may not realize they are pregnant right away Childcare issues Transportation issues Employment issues/financial limitations At risk for medial complications Need for discussions about contraceptive care post-delivery

32 + Post-Delivery Challenges Increased risk of relapse Increased risk of dropping out of treatment Post-partum depression Post-partum anxiety Negative family interactions Guilt and Shame

33 + Summary of Risks to Neonates Risks when Maternal SUDs are Untreated Obstetric/Pediatric complications Miscarriage Preeclampsia Preterm birth Operative deliveries Low birth weight Birth defects NICU admissions Sudden infant death syndrome Behavioral complications Poor infant self-regulation Insecure attachment developmental delays ADHD Anxiety disorders Conduct disorders It is very difficult to tease out effects of intrauterine drug exposure and environmental exposure post delivery.

34 + Maternal Effects on Disease Susceptibility

35 + Breastfeeding

36 + Breastfeeding WHO encourages breastfeeding for mothers including those receiving medication-assisted treatment as long as the mother is not using other substances. Research has shown breastfeeding improves outcomes for neonates. Skin-to-skin Bonding Protective benefits of breast milk The amount of MAT medication the babies get is minimal. Buprenorphine needs to be absorbed sublingually to get greatest benefit, when passed through the digestive system it is destroyed.

37 + Benefits of Breastfeeding For baby Reduced: allergies, asthma, obesity, celiac disease, SIDS, IBS, Childhood leukemia, ear infections Enhanced: mother/baby bonding, emotional security, increased IQ, financial security for family For mother Reduced: breast cancer, ovarian cancer, osteoporosis, diabetes, less work time missed, clean up Enhanced: sleep, financial savings, mothering skills and confidence

38 + Treatment Best Practices Comprehensive Opioid Addiction Treatment

39 + Treatment Options During Pregnancy Inpatient Detoxification Residential Treatment Programs Outpatient Therapy Outpatient Medication-Assisted Treatment (MAT) For Opioid Use Disorders Methadone Suboxone (Buprenorphine/Naloxone) Subutex (Buprenorphine)

40 + Medication-Assisted Treatment Methadone

41 + Medication-Assisted Treatment Buprenorphine (Subutex)

42 + Medication-Assisted Treatment Buprenorphine+Naloxone (Suboxone) Available in Tablets and Films

43 + Medication-Assisted Treatment

44 + Why put a pregnant patient on medication that may result in withdrawal for the baby?

45 + Risks and Benefits of MAT Benefits Prevents withdrawal Reduces cravings Blocks euphoric effects Enhances treatment retention Reduces relapse Reduces fetal exposure to illicit drugs Stabilized intrauterine environment Enhances involvement in prenatal care Reduced Costs Risks Risk of Neonatal abstinence syndrome Pain management issues Risk of abuse/diversion Familial conflict

46 + Detoxification alone does not work. Relapse rate is 90+%.

47 + Comprehensive Opioid Addiction Treatment The WV model Beginner 1-90 days abstinent Weekly group therapy Signed meeting lists Monthly individual therapy Intermediate days abstinent Bi-weekly group therapy Written report/no signatures required Monthly individual therapy Advanced >365 days Monthly group Mandatory meetings no longer required Monthly individual therapy no longer required

48 + Treatment Components In a beginner group Weekly medication management group with psychiatrist Weekly group therapy Random urine drug screens, can be observed Monthly individual therapy Participation in community based recovery meetings four times per week Work with a sponsor, recovery coach Open communication between our team and patient s OB Random pill counts Additional items at the team s discretion Requirements are less intensive as patients advance in program tiers.

49 + Therapeutic Considerations Establishing a trusting relationship and building rapport Psychoeducation about addiction Disease model, neurobiology of addiction Relapse prevention Stages of change, skills acquisition Managing Feelings Coping strategies Interpersonal relationships Impact on family Establishing social supports Self-help

50 + Compassion + Consequences Use a compassionate approach Addiction is a disease of the brain Link between trauma + SUDs Guilt and shame as relapse triggers Compassion is effective! (Especially when combined with clear expectations and consequences.) Hold patients accountable for their actions Every action will have a consequence. Expectations are clear and communicated at intake.

51 + The Value of Treatment Every dollar invested in addiction treatment programs yields a return of between $4 and $7 in reduced drugrelated crime, criminal justice costs, and theft. When savings related to healthcare are included, total savings can exceed costs by a ratio of 12 to 1. Drugabuse.gov

52 + Childhood Trauma + Addiction What We Learned from the ACEs Study

53 + The ACEs Study

54 + The ACEs Study

55 + What is the greatest barrier to treatment for pregnant women?

56 + STIGMA

57 + Video

58 + What is Stigma An attitude, behavior or condition that is socially discrediting Major influences regarding stigma are beliefs about cause and controllability Language and terminology strongly influence stigma Research shows that Addiction is the most stigmatized condition world wide (Room, 2005) Even among health care providers More stigmatized than other mental health conditions

59 + What factors influence stigma Cause Controllability Stigma It s not their fault. You don t choose to have a SUD They can t just stop. Quitting requires help. Decreases It is their fault. Their choices caused their addiction. They really can help it. They could stop if they really wanted to. Increases

60 + Beliefs about Causality Moral Model It s a lifestyle choice They choose to drink and use drugs Self-destructive, immoral, irresponsible, frustrating, revolting, lying, thieving, cheating, criminal, willful misanthropes Disease Model People have a disease Stress-induced defect in the midbrain s ability to properly perceive pleasure Craving is true suffering Bad People Sick People

61 + Drinking vs. Drunkenness Alcohol consumption begins to rise after the revolutionary war (1783), and surged in the 1830s Excessive Drinking initially considered a moral depravity The term alcoholism was introduced in 1849 by Swedish physician Magnus Huss, in the US the terms most common to describe alcoholism were dipsomania and inebriety. The term alcoholic began to be used by professionals in the early 1900s The term addiction began to be used in the professional literature in the mid 1890s

62 Dis-ease..Drunkenness resembles certain hereditary, family and contagious diseases.. Nearly all diseases have their predisposing causes including intemperate use of distilled spirits 1784 Dr. Benjamin Rush Father of American psychiatry

63 + Temperance Movement Temperance movement - moderation Fueled by public drunkenness Goal was moderation drinking Early efforts were to encourage whiskey drinkers to drink beer instead, but it did not work Temperance movement - abstinence Religiosity, Alcohol framed as evil Only solution is to abstain Let the drunkards die off The Stigma of Alcohol Use Disorders is born

64 + History of Self-Help Washingtonians First widely available mutual aid society Tried to reduce stigma Mid 1800s fraternal temperance societies and reform clubs 1935 Alcoholics Anonymous Narcotics Anonymous

65 + The rise of drug addiction Incidence of opioid use disorders rose in the early 1900s and Medication-assisted treatment was available The Harrison Act of 1914 Criminalized drug use and addiction Criminalized the treatment of SUDs by physicians over 25,000 physicians indicted for treating individuals with SUDs Morphine maintenance clinics shut down Further Stigmatization of Substance Use Disorders

66 + 20 th Century th Amendment (National Prohibition) Repealed with the 21 st amendment in 1933 The Harrison Act and policies of Bureau of Narcotics pushed people with SUDs underground 1951 Boggs Act increased sentences for drug violations and mandatory minimum sentences 1956 Narcotic Control Act sentences for dug offences could include life sentenced or the death penalty Widely held belief that alcoholism and drug addiction were moral failings

67 + History of the Disease Model of Substance Use Disorders Early 1800 s awareness of alcoholism effecting liver, stomach, blood and nerves and delirium tremens as well as psychosis 1946 EM Jellinek progressive disease 1954 WHO recognizes Alcoholism as Disease 1956 AMA recognize Alcoholism as Disease 1960 Jellineck s Disease Concept of Alcoholism 1960 s Minnesota Model 28 day treatment

68 + Recent History political influence (anonymous people) 1960s and 70s 13 laws were passed to promote and develop a public health response to addiction and alcoholism, ground swell of community support and members of the recovery community testifying in the senate

69 + Criminalization of Substance Use Disorders Early 1970 s - Nixon Undercut this momentum drugs are public enemy #1 Penalties against the possession of a drug should not be more damaging to an individual than the use of the drug itself Jimmy Carter s - Reagan War on Drugs Return to criminalization of SUDs Crack epidemic From 1985 to today 80%+ of individuals who are incarcerated are there for nonviolent drug related crimes

70 +.Enter neuroscience and the understanding of the brain

71 + Nora Volkow on the science of addiction The Disease Model

72 + Science

73 + Impact of Stigma People fail to access or engage in treatment because of fear of what people might think; they don t want to be an addict Medical profession often fails to treat patients appropriately, like not using FDA-approved medications Mental health programs may exclude SUD patients Funding for SUD treatment is insufficient to meet the demand SUD patients are frequently sent to prison rather than treatment programs People in recovery are always under suspicion If patients have a criminal history because of their drug use, then this causes future stigma in terms of employment, housing & educational loans SOURCE: Dr. Richard Juman, The Deadly Stigma of Addiction, 12/05/12

74 + Why Reducing Stigma Matters World wide alcohol kills 3.3 million people a year, 350,000 die due to illicit drugs (WHO, 2015) 23 million people in the US have a substance use disorder Economic cost attributable to substance use disorders as a result of lost productivity, health care costs and criminal justice - $600 billion Despite 14,000 treatment facilities, 100,000 recovery support chapters meeting weekly in the US, only 10% of people receive help Main barrier to seeking and receiving help is stigma

75 + Reducing Stigma Stigma occurs at many levels Public Private Personal Stigma becomes a barrier to acknowledging the problem and accessing help and remaining in treatment Stigma about SUDs reinforces the misperceptions about cause and controllability

76 + Recommended Language Use person-first language & medically accurate terms

77 + The Role of Social Workers Social Workers can influence stigma With patients by Helping to reduce guilt and shame Offering moral support Respecting confidentiality Adopting a non-judgmental stance Treating the pregnant patient like any other patient with a chronic illness By advocating for patients who voice discrimination Other ways?

78 + The of Social Workers Social Workers can influence stigma With co-workers by Educating colleagues about SUDs being a brain disease Sharing stories of success Within ourselves by Being aware of your own biases Changing our language Finding support for transference issues we face Other ways?

79 + Instill Hope

80 + References Helmbrecht GD, Thiagarajah S. Management of addiction disorders in pregnancy. Journal of Addiction Medicine. 2008;(1):1-16. Jones HE, Martin PR, Heil SH, et.al. Treatment of opioid dependent pregnant women: clinical research issues. Journal of Substance Abuse Treatment. 2008;35(3): Stitely, Michael L.; Calhoun, Byron; Maxwell, Stefan; Nerhood, Robert; Chaffin, David. Prevalence of drug use in pregnant West Virginia patients. West Virginia Medical Journal. July Pritham, U. Breastfeeding Promotion for management neonatal abstinence syndrome. Journal of obstetric, gynecologic, and neonatal nursing. 2013;42, Jansson LM. AMB Clinical Protocol #21: Guidelines for breastfeeding and the drug dependent woman. Breastfeeding medicine. 2009; 4: Brown et al. Trends in Marijuana Use Among Pregnant and Nonpregnant reproductiveaged women. JAMA. 2017; 317(2): Room, R. Stigma, social inequality, alcohol problems and drug use. Drug and Alcohol Rev :