SUBSTANCE ABUSE SCREENING IN PREGNANCY

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SUBSTANCE ABUSE SCREENING IN PREGNANCY

• Presented by-
• Debby Carapezza, RN, MSN
• Nurse Consultant
• Utah Department of Health
• Reproductive Health Program
• January 2004

2
The Problem

• While many providers know substance abuse during
  pregnancy is a problem, many assume
• -it only exists among the poor and
• -it couldnt possibly be a problem in their
  practice!
• DATA BEG TO DIFFER!!

3
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)

4
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

5
What about ARND ARBD?

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

6
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.

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But Isnt 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.

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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

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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

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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

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But Isnt 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
• Buchi KF, Zone S, Langheinrich K, Varner MW.
  Changing prevalence of prenatal substance abuse
  in Utah. Obstetrics Gynecology. (2003) Jul
  102(1) 27-30.
• Buchi KF, Varner MW, Chase RA. The prevalence of
  substance abuse among pregnant women in Utah.
  Obstetrics Gynecology. (1993) Feb 81(2)239-42.

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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

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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

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

• ALCOHOL USE

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The Impact of Alcohol on the Infant
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How much alcohol does it take to produce FAS?

• The exact levels are unknown. However the
  following is known5
• 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 fetus
• 5. The American College of Obstetrics
  Gynecologists. Precis V An Update in Obstetrics
  Gynecology.(1994). Washington DC. p. 140.

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

• COCAINE

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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.

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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

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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

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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)

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Not to worry! We all ask about drug alcohol
use dont 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 childs early infancy.

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And the results were7

• 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.

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SCREENING!

• WHEN?

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In a perfect world-

• Preconceptionally during routine primary care
  visits
• Preconceptionally during family planning visits

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During pregnancy-

• At the first prenatal visit
• During each trimester
• At the postpartum visit
• More frequently if risk factors are present

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I dont screen all of my prenatal clients because

• I dont want to offend anyone!

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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

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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!

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I dont screen because

• in my busy office, I just dont have time!

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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

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

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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

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Try these strategies for women with a positive
screen

• Discuss possible strategies for her to stop
• Individual counseling
• 12-step programs
• Addiction treatment programs

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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

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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!

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The 4 Ps Screening Tool
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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

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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

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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

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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

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Other screening tools are available.

• You may also wish to consider the following
• T-ACE
• Tweak
• TQDH
• AUDIT

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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

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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

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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

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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)

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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

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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!