Perinatal Substance Abuse Program

Perinatal Substance Abuse ProgramDept of Alcohol and Drug Services (DADS)Presented by Lara WindettM.A., MFT, LPPC Certified Addiction Specialist (CAS)

1Please hold questions until after the presentation: I most likely will answer all questions you have as I go alongThe Department of Alcohol & Drug Services exists within the overall Santa Clara Valley Health & Hospital SystemDedicated to the health of the whole community regardless of ability to pay

2BackgroundPSAP was Brainchild of Anthony Puentes, MD, MPH, 1987Funding streamGoal of PSAP Program

3The Perinatal Substance Abuse Program of SCC was introduced in 1987 to address the growing need for appropriate and effective chemical dependency treatment for pregnant women.

Funding streams include:, Medical, Drug Medical, Medicare and other insurances (VHP, Valley Care), Calif State Department of Alcohol and Drug Programs, Perinatal Block Grant Funding SAPT (Substance Abuse Prevention and Treatment) which is federal allocations for DOA Tx, Prop 36, Self Pay, State general funds.

The goal of the program is to promote healthy mothers and healthy babies by providing the tools of recovery from alcohol, tobacco, and other drug addiction to mothers through treatment and education.

PSAP Keeps babies out of the NICUNICU costs ~$2,100 5000 per day2007 140 babies exposed, 30 in NICUAvg Length of Stay: 15 days

4Do the math (avg 3,550 per day) $1,597,500. PSAP Treatment Works!92% drug/alcohol free - neg tox screens

5PSAP provides treatment for $67.15 per client per day. This diverted babies who otherwise may have been admitted to VMCs NICU.Perinatal Drug Exposure Overview1992 StudyEstimated 15-18% of pregnant women use alcohol or drugs.PSAP Admission Statistics

6SCC 1992 Perinatal Substance Exposure Study in California 2 hospitals participated 9.8 % of babies born had alcohol or drugs in their systems (8 babies born per day).Women who drink alcohol/tobacco illicit drugs increase their risks for obstetrical complication and for premature labor and delivery (fetal loss, spontaneous abortion, miscarriages and stillbirths)Their addiction may result in other medical, social, legal, and family problems as they progress further in the disease of chemical dependency.On admission: 30-50% pregnant, 82% Methamphetamine users, 84% nicotine, 65% have between 1 and 3 children under 5 years of age.

PSAP = Empowerment ModelComprehensive Intensive Outpatient TreatmentMedically MonitoredMultidisciplinary ApproachDay Care for clients childrenTransportation

7Comprehensive Intensive Outpatient Treatment services to heroin/opiate addicted women and to women addicted to all other drugs or alcohol on and outpatient basis. Medically Monitored and supervised program. Multidisciplinary Approach to tx of chemically dependency and provide DOA as well as pregnancy, childbirth, parenting, relationship, trauma, and life skills education using SAMSHA and other guidelinesDay Care for clients childrenTransportation

PSAP Client EligibilityResident of Santa Clara CountyPregnant or Early Parenting Women 18 years or olderOn Methadone (MMT) or opiate dependentHx or DOA abuse or currently usingFamily Wellness Court ReferralsMedi-cal, Valley Care II, sliding scale fee, or other insurance (Kaiser)865 Maximum clients. Pregnant women and methadone and FWC are 1st priority (holding pen to get in is discovery group).Length of PSAP StayAssigned a Licensed Therapist, PSWCase ManagementIndividualized Tx PlanTypical Treatment Episode: 6-12 months9The client is assigned a counselor who will individualize her treatment plan and corroborate with the client, our PSAP Team the legal system, and or the MD regarding the length of time required to complete the program.StaffHCPM II3 Therapists (MFT) MDHealth Ed Specialist1 Health Services Representative3 day care aides (1/2 codes)1 Community Worker (van) (1/2 codes)Volunteers10Current PSAP Client Demographics~Capacity for 65+Women ages 19 to 43 years23% pregnant10 clients on Methadone (3 pregnant)30% Caucasian 33% Latina, 9 % Asian/Pacific Islander 18% Mixed Race 2% African American 8 % Declined to State 30% in THUsCPS Cases ~70% Prop 36 ~40%FWC 30%Probation Only - 20%DEJ 10%,

11PSAP was nominated for the 2007 National Exemplary Award for Innovative Prevention Programs, Practices and Policies by the National Association of State Alcohol/Drug Abuse Directors (NASADAD)Out Patient Drug Treatment in Santa Clara County Including MethadoneOn the VMC campusReadily accessible - pregnant OPIOID DEPENDENT patients (Methadone candidates) are scheduled for admission the next business dayAll Patients can call Gateway 1-800-488-9919Providers can call Central Valley Clinic408 885-5400 Front Desk408 885-4064 PSAP Clerical

12Items to Remember if a Patient is in PSAP TreatmentWe ask for a verification of OB Care/complete the referral to VMC if no care is scheduled for pregnant people.We obtain a release to speak with the OB and all MDs in the patient's life.We obtain a release to Public Health.We obtain a release to the Pedi and we alert the Pedi (and OB) if the patient drops out of treatment.

13Overview of AOD Treatment/ConcernsRed flagsWhen interviewing/observing the patientWhen considering the historyRisks associated with various drugsTo the pregnancyTo the babySubstances to Be DiscussedOpioidsCigarettesAlcohol MarijuanaMethamphetamine

Amber32 y.o. Woman and the mother of an 8 y.o.Unplanned pregnancyUsing dailyHeroin by injection 2 grams/dayCocaineCigarettes 2 PPDSeeking admission to methadone program16AmberStealing to obtain drugsIsolated only living relative is maternal grandmother8 y.o. son is being raised by patients grandmotherFather of baby is using and at risk of deportation 17AmberMedically indigentHistory of depression and anxietyHistory of domestic violence (prior relationship)

18AmberFrustrated requested tubal ligation at 23Frightened concerned about damage already done to baby MotivatedRequests residential treatmentResolves to leave boyfriend if he will not get into treatment19Red Flags: Multiple & ObviousPatient volunteering history of substance abuse Physical exam remarkable for multiple tracks and physical withdrawalLife in disarrayChaotic and disrupted family relationships20Why Share this Story?Opioid dependence requires medical interventionPregnant patients need treatment to prevent adverse outcomes Women caring for infants need treatment to be functional mothers 21Pregnancy can be a Huge Motivation for Change: AmberStabilized on methadone maintenanceCompleted residential treatmentPermanently left the boyfriend who continued to useDelivered drug free

22A Sense of Hope:12 Years Later Amber isAbstinent and still in treatmentRaising her daughterWorking

23Prevalence of AOD Abuse in Pregnancy 2008 and 2009 data from the National Survey on Drug Use and Health found that among pregnant women ages 15 to 44, the youngest ones generally reported the greatest substance use. Also, pregnant women ages 15 to 17 had similar rates of illicit drug use (15.8 percent or 14,000 women) as women of the same age who were not pregnant (13.0 percent or 832,000 women).24BrendaReferred to treatment for history of methamphetamine abuseWorked as a medical assistant until about two years agoServed as caretaker for mother who died of breast cancerAfter mother died, dad was diagnosed with lung cancer; patient served as caretakerReported having a prescription for vicodin

25BrendaReported taking prescribed vicodin for chronic back pain (occasionally)Denied history of prescription opioid abuseWeekly u tox screens consistently positiveFor a variety of prescription opioidsNot just for vicodinEasy access to unlimited supply of prescription opioidsTransferred to methadone maintenance

2626Prescription Opioid Abuse May Not Be ObviousConsider the historyUnusual number of painful conditions for a young healthy patientMultiple opioid prescriptions during pregnancyMultiple ER visits for complaints of painMultiple care providers/no regular providerOpioids for unusual indications

2727Patients Appearance on OpioidsNormalSedated with small pupilsSymptoms of withdrawalSweats/chills/goosefleshLacrimation/rhinorrheaYawning/sneezingIrritable/anxious/fidgetyVomiting

28Ask About Behaviors: Have you ever?Taken more than prescribed?Taken medication after the pain was gone?Gotten pills from a friend or relative?Bought pills on the street?Written or called in a prescription for yourself?Tried to stop and found you couldnt?29Ask about Reasons for UseManage emotions?Deal with stress?Feel high?Numb everything or go to sleep?

30Opioids: Three to Seven Times Higher Rates of Still birthFetal growth retardationLow birth weightSmall head circumferencePrematurityNeonatal mortality31Heroin: Medical Risks Associated With Injection CellulitisAbscessesEndocarditisHepatitisHIV infectionWound Botulism32Opioid Dependence in Pregnancy: TreatmentCurrently, methadone maintenance is the gold standardBuprenorphine maintenance looks promising and may be more available in the future (not FDA approved)A comfortable, stable mother increases the likelihood of a healthy, term delivery

33Impact of Methadone TreatmentReduced deathsReduced IVDUReduced HIV seroconversionReduced crime daysReduced relapse

Improved healthImproved relationshipsImproved productivityImproved social functioning

348-10 fold reduction in death rateThe rule of foursDemonstrated to improve pregnancy outcomeBenefits society as well as the individual drug addictAdditional Benefits During PregnancyIncreased participation in prenatal careReduced obstetrical complicationsImproved maternal nutritionDaily observation in clinic while dosing

35Therapeutic Dosing With MethadoneSuppresses opioid withdrawal symptomsReduces opioid cravingsProvides a stable opioid blood levelAllows a patient to concentrate on counseling/program to support recoveryMinimizes side effects; patient should not be sedated

36Methadone Withdrawal:Not Recommended During PregnancyThe relapse rate is high (80%) Risk of intrauterine demise Risk of premature labor/miscarriageWhat can you say to a patient wanting to Withdraw from MMT? Send them to their primary CSLR/the addiction MD to discuss

37Methadone Withdrawal:Not Recommended After Delivery?Like insulin, methadone stabilizes a chronic illnessThe normal brain has an endogenous opioid system that may never function properly in an opioid dependent patientVery high relapse rate when methadone treatment is discontinued

38Methadone: Effects on the BabyNo known birth defectsMore likely to be born at termLower birth weight/smaller head circumference at birth May experience developmental delay during the first year of lifeNot associated with learning difficultiesIncreased SIDS with opioid exposure

39Methadone and BreastfeedingNegligible amounts of methadone are passed in breast milkThe American Academy of Pediatrics considers methadone compatible with breastfeeding at any dose40Methadone: Neonatal WithdrawalSafer than heroin withdrawal in uteroExperienced by 60-80% of exposed babiesUsually occurs within the first 2-3 days of life; may occur within the first monthUsually treated with an opiate agonist Duration of treatment is days to monthsCan be life threatening without treatment

41Opiates: The Neonatal Abstinence SyndromeHigh-pitched cry, irritability Poor feeding, vomiting, diarrheaHyper tonicity (stiff muscles)TremorsSneezingSweatingOccasionally seizures42Symptoms of Opioid WithdrawalW = wakefulness I = irritabilityT = tremulousness, temperature variation, tachypneaH = hyperactivity, high-pitched persistent cry, hyperacusia, hyperreflexia, hypertonusD = diarrhea, diaphoresis, disorganized suckR = rub marks, respiratory distress, rhinorrheaA = apneic attacks, autonomic dysfunctionW = weight loss or failure to gain weightA = alkalosis (respiratory)L = lacrimation43Clarissa23 y.o.Pregnant with first childSmoking 1 - 2 PPD since late teensI will only quit if the doctor tells me my baby will die if I do not quit nowMy whole family smokes; I grew up with it; Ive been around it my whole life

44United States (1996-1998)National Household Survey on Drug Abuse (NHSDA)Survey of pregnant women CigarettesAlcoholAny Illicit Drug% using # fetuses/yr 20.3% 1.2 million 14.8% 0.8 million 2.8% 0.2 millionEbrahim, SH, Gfroerer, J. Pregnancy-related substance use in the United States during 1996-1998. Obstet Gynecol 2003; 101:374.45Cigarette SmokingSmoking during pregnancy is the most modifiable risk factor for poor birth outcomeIt is associated with 5% of infant deaths, 10% of preterm births, and 30% of small for gestational age infants

Trends in smoking before, during, and after pregnancy - Pregnancy Risk Assessment Monitoring System (PRAMS), MMWR Surveill Summ. 2009 May 29;58(4):1-29. 46There are a plethora of medical risks for pregnant and non-pregnant patientsPatients who smoke are more likely to relapse to other drugs of abuseCigarettes stimulate the same brain pathway as heroin and cocaine

Cigarettes in Pregnancy:Obstetric ComplicationsAdverse EventRelative RiskPlacental Abruption1.4-2.5 dose dependentPlacenta Previa1.4-4.4Stillbirth1.2-1.4 dose dependentPre-term PROM1.9-4.2Preterm Birth1.3-2.5Low Birth Weight1.3-10.0 dose dependent47Clinical Outcomes in PregnantWomen who Quit Smoking20% reduction in low birth weight babies17% decrease in pre-term birthsAverage increase in birth weight of 280g.Quitting before 30 weeks can still positively affect birth weight48Cigarette Smoking in Pregnancy & Other Drug Use10 times higher use of marijuana22 times higher use of cocaine21 times higher use of amphetamineVega, WA, Kolody, B, Hwang, J, Noble, A. Prevalence and magnitude of perinatal substance exposures in California. N Engl J Med 1993; 329:85049In Utero Cigarette Exposure:Congenital MalformationsMay contribute to anomalies associated with focal vascular disruptionCleft lip with or without cleft palateGastroschisisAnal atresiaTransverse limb reduction defectsRisk may be modified by genetic factors50In Utero Cigarette Exposure:Effects on the NewbornThere is a dose-response relationship between maternal cigarette use and infantStressHypertonicityExcitability and irritabilityMay be due to neurotoxicity or withdrawalWith second hand smoke exposure there is an increased risk of low birth weight51In Utero Cigarette Exposure: Postnatal MorbiditiesMorbidityNeonatal deathRR 1.2 - 1.4SIDSRR 2.0 7.2 Prenatal exposure a higher risk than postnatal 2nd hand exposureRespiratory infections, asthma, otitis media, infantile colic, bronchiolitis, short stature, childhood obesity, type 2 diabetes in adulthoodHeart disease and lung cancer in never smokersSecond-hand smoke increases risk by 20-30%5252In Utero Cigarette Exposure:Behavioral ProblemsToddlers (12-24 mo.s) showed a high and escalating pattern of disruptive behaviorChildren developed Oppositional Defiant Disorder at double the rate of controlsODD is a precursor of Conduct DisorderSeen in older children and adolescentsCharacterized by persistent antisocial behaviors (lying truancy, vandalism, aggression)NIDA Notes 2008: Vol.21 No. 653In Utero Cigarette Exposure:Cognitive Outcomes in 9-12 yr oldsIQ impacted (dose response effect)Poorer impulse controlMany individual WISC tests w/ significant dose response effectsPoorer performance on tests requiring visuoperceptual skills.Auditory memory particularly impactedWISC = Wechsler Intelligence Scale for Children54Medical Issues for the Children of SmokersIncreased incidence of smoking initiation20% higher if mom smoked up to 1PPD60% higher if mom smoked 1PPD or moreDiabetes mellitus Four times higher with more than 10 cigs/dayIncreased asthma in adult offspringDecreased sperm volume/count in adult male offspring

55Neonatal withdrawals are similar to opiate withdrawals less severeSIDS risk is significantdose response curveIncreased risk of asthma

Alcohol

Of all the substances of abuse (including cocaine, heroin, and marijuana), alcohol produces by far the most serious neurobehavioral effects in the fetus.

IOM Report to Congress, 199656A look at Denial/Pre-Contemplation: Denise28 y.o. pregnant woman and the mother of 7 and 3 y.o. boysPregnant for the 5th timeHistory of two 2nd trimester miscarriagesStarted drinking at 23 (not pregnant)

57DeniseDrinking 1-2 shots of peppermint schnapps daily until about 1 yr agoQuit drinking when learned was pregnant with second child, now age 3GA ~ 9wks when quitGrowth and development of this child appear normal58DeniseDrinking 5 shots of peppermint schnapps daily for the past yearDrinking this pregnancy until GA ~33 wksNot worried about the baby becauseLast baby was okayU/S during this pregnancy looks normal59Alcohol Use During Pregnancy:Obstetrical Complications Increased risk of second-trimester abortion50% increase in fetal mortalityInfant withdrawal (3-12 hrs after delivery)Fetal Alcohol Spectrum Disorders

60Alcohol is a Teratogen that Freely Passes the PlacentaTeratogen: a substance that causes abnormal physical developmentBehavior teratogen: a substance that causes impaired cognitive, affective, social, reproductive, and/or sensorimotor behavior, even in the absence of obvious physical problems61Prenatal Alcohol Exposure Can Cause:DeathMalformationGrowth deficiencyFunctional deficits62Teratogenic Effects Depend On:Dose of alcoholPattern of exposure (binge vs. chronic)Developmental timing of exposureSusceptibility (genotype of mother and fetus)Synergistic reactions with other drugsInteraction with nutritional variables63Dose-Response EffectsHigher maximum blood alcohol levels result in more severe neurotoxicityBinge drinking is particularly dangerousMales appear to be more susceptible than females64SOME CREDIBLE INCREDIBLE WEBSITES!(Thanks Mark Stanford, PhD)Addiction Technology Transfer Centerhttp://www.nattc.org/asme.aspBrookhaven Addiction Research. Center for Translational Neuroimaginghttp://www.bnl.gov/CTN/addiction.aspNational Institute of Drug Abuse (NIDA). Medical and Health Professionals http://www.nida.nih.gov/medstaff.htmlMoyers On Addiction: Addiction As A Diseasehttp://www.pbs.org/wnet/closetohome/science/The Institute of Medicine. Marijuana and Medicine: Assessing the Science Basehttp://www.nap.edu/readingroom/books/marimed/index.htmlNIDA Science & Practice Perspectiveshttp://www.drugabuse.gov/Perspectives/National Institute of Mental Health (NIMH). Medicationshttp://www.nimh.nih.gov/health/publications/medications/complete-publication.shtmlUCLA Addiction Clinichttp://www.uclaisap.org/addclinic/University of Utah. Genetic Science Learning Centerhttp://learn.genetics.utah.edu/units/addiction/issues/treatments.cfmCounselor Magazine for Addiction Professionalshttp://www.counselormagazine.com/component/option,com_magazine/Itemid,1/Society of Neuroscience. Advancing the Understanding of the Brain and Nervous Systemhttp://www.sfn.org/DADS:Sccdads.org

Please ask me for more or e-mail me!!!

65Content Provided by:Deborah Stephenson, MD, MPH Dept of Alcohol & Drug ServicesSanta Clara Valley Health & Hospital System

Mark Stanford, PhDDept of Alcohol & Drug ServicesSanta Clara Valley Health & Hospital System

Margaret Williams, M.S., RD, H.E.S.Dept of Alcohol & Drug ServicesSanta Clara Valley Health & Hospital System

Thank you!

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