Title: Pregnancy-Related Issues in the Management of Addictions
1Pregnancy-Related Issues in the Management of
Addictions
Train the Trainer Workshop Problematic Substance
Use in Pregnancy (PSUP) www.addictionpregnancy.ca
Last modified March 2008
2Conflict of Interest Disclosure
- Financial support for this workshop was provided
by Health Canada - Funding for the PRIMA Pocket Reference was
provided by the Lawson Foundation - No commercial sponsorship has been received to
support this program
3Pregnancy-Related Issues in the Management of
Addictions
4Key Concepts
5Addiction (dependence)
- Women using addictive substances find the effects
of the drug so pleasurable and reinforcing that
they have difficulty controlling their use of the
drug - Reinforcement may be small and multiple, e.g.,
nicotine, or large, e.g., heroin
6Many Substance Users are Survivors of Childhood
Trauma
- Women in substance abuse treatment report
- A lifetime history of trauma, most commonly
physical or sexual abuse - This ranges from 55 to 99 compared to women in
community samples (36-51) -
- Najavits et al, 1997
7Addictive Potential of Drugs
- Correlates with
- Rapid onset of action
- Potency at receptor site (euphoric effect)
- Short duration of action (contrast between
intoxication and sober state) - Tolerance (forces woman to escalate dose to
achieve same effect) - Withdrawal (forces woman to use drugs to avoid
withdrawal)
8Reward Pathway
- All drugs of abuse
- Increased dopamine receptor stimulation in
nucleus accumbens and medial forebrain bundle - Cocaine stimulates it directly
- Opioids, alcohol, nicotine stimulate it via
effects on other neurotransmitters
9Opiate Use is a Very Powerful self-medication for
- Blocking out intrusive thoughts, flashbacks and
nightmares - Numbing and avoiding feelings, thoughts, people
- Achieving sleep
10Tolerance
- Repeated administration alters
- Receptor numbers and sensitivity
- Levels of neurotransmitters
- Result decreased effect with same dose
- CNS develops resistance to drug effect
- Adaptive mechanism can function almost normally
despite very high doses
11Tolerance (2)
- Rate of development of tolerance depends on the
effects - For example, with opioids
- Analgesia - slow tolerance (months)
- Sedation rapid tolerance (days)
12Withdrawal
- On sudden cessation of drug, alterations in
receptors take days or weeks to normalize - Receptors that resist the drug are now
unopposed, leading to drug-opposite effects - Sedating drugs withdrawal -gt autonomic
hyperactivity - Symptoms appear when drug use decreases, forcing
woman to resume drug use
13Genetic Influences on Drug Dependence
- Positive family history increases risk of alcohol
dependence - Fewer adverse effects
- Greater tolerance
- More positive effects
14Sex and Gender Differences
- The Formative Years report from CASA demonstrates
that - Girls and young women use cigarettes, alcohol and
drugs for reasons different than boys - The signals and situations of high risk are
different - Girls are more vulnerable to substance use and
abuse and its consequences - Girls have incorrect knowledge and beliefs about
substances - Parents are often inattentive contd
- CASA. The Formative Years Pathways to Substance
Abuse Among Girls and Young Women Ages 8-22.
2003. www.casacolumbia.org
15Sex and Gender Differences (2)
- The Formative Years report indicates that girls
are influenced by -
- Substance-using friends
- Schools and communities that turn a blind eye
- Physicians who are not vigilant to early warning
signs - Exposure to entertainment media and alcohol and
cigarette advertising, which bombard girls and
young women with unhealthy and unrealistic
messages about smoking, drinking and weight loss
16Substance Use by Women
- Substance use by women has been viewed by health
professionals as more problematic - This has led to disparities in screening and
access to care and treatment - Poor women, aboriginal women and women of colour
are more frequently screened for substance use
when accessing prenatal care than middle class
and Caucasian women
17Risks for Addiction
- Psychiatric Risk
- Mood disorders
- Anxiety disorders, esp. post-traumatic stress
disorder - Personality disorders that effect impulse control
- Social, Cultural
- Lack of meaningful work/school/relationships
- Lack of social support
- Cultural attitudes towards alcohol, drugs
- Poverty
18Clinical Features
- Drug use becomes major focus of life and the
- addicted woman
- Neglects major responsibilities
- Continues to use despite knowledge of
consequences - Repeatedly tries to quit but relapses
- Develops tolerance and can go into withdrawal
- Experiences powerful urges to use (cravings)
19The 4 Cs of Addiction
- Continued use despite Consequences
- Unable to Cut down
- Cravings
- Compulsive drug use
20Classification of Drugs of Abuse
- Alcohol
- Benzodiazepines and other sedatives
- Opioids
- Stimulants cocaine, amphetamines
- Nicotine
- Cannabis
- Hallucinogens
21Psychological Treatment
- Natural Recovery
- Mutual Help Groups
- Outpatient Counseling
- Residential Treatment
- Minnesota model (28 or 21 day)
- Therapeutic community (months to years)
22Treatment of Substance Dependence Prognosis
- Approx. 30 abstinent one year post-treatment
- Prognosis worse if
- Older
- Longer drinking history
- Other substance use
- Untreated psychiatric disorder(s)
- Social instability
- Physicians warning associated with better
prognosis at 2 years - Treatment is cost-effective
23Success Rates of Formal Treatment (6 month
follow-up)Addiction Severity Index (ASI)
24Treatment for Women and Mothers
- When mothers and babies stay together in
treatment, women indicate that maintaining close
contact with their children was integral to their
recovery efforts. - Besinger, B.A. 2003. Mothers in addiction
treatment The role of onsite childcare.
University of Cincinnati, Cincinnati) - Women stayed in treatment longer, had less
depression and higher measures of self-esteem
than women separated from their infants. - Wobbie, K., Eyler F.D., 1997. Women and
Children in Residential Treatment Outcomes for
Mothers and their Infants. Journal of Drug
Issues, 27 (3), 585-607
25Cost-effectiveness of Treatment Matched
Case-control Study
- 300 reduction in health care costs in treated
group vs. waiting list controls - Holder HD, Blose JO. J Stud Alcohol 1992 53
293-302
26Role of the Health Care Providers
- Most substance users do not go to formal
treatment - BUT they make frequent use of health care
provider (HCP) services - Women often have considerable trust in their
nurse/midwife/physician - Health Care Providers should see women over long
periods of time and build therapeutic
relationships in order to effect long-term change - contd
27Role of Health Care Providers (2)
- Smoking cessation counselling one of the most
cost-effective interventions we can do - At-risk drinking often brief advice (5-15
minutes) is enough to get women to reduce
drinking to low-risk levels - Alcohol and drug dependence many women will
accept HCP advice to attend treatment program - contd
28Role of Health Care Providers (3)
- Treatment of withdrawal is first step to recovery
- Pharmacotherapy (methadone, bupropion, NRT, etc.)
greatly increases success rates of counselling
29Failure to Understand and Address Trauma Can Lead
to
- Retraumatization of the woman
- Increase in symptoms
- Increase in management problems
- Increase in relapse
- Withdrawal from service relationship
- (Finkelstein, 2006)
30Approach to the Woman who is Addicted to
Substance(s)
- Dos Like any other disease
- Express concern
- Review diagnosis and health effects
- Present range of treatment options
- Acknowledge womans efforts and successes
- Arrange follow-up
31Approach for Provider/Counselor and Woman
- Meet basic needs
- Build positive social network
- Advise group and individual support
- Teach techniques to avoid drugs and triggers for
substance use - Encourage to have a structured day, keep busy
32Pregnancy-Related Issues in the Management of
AddictionsSlide presentation developed by
members of the National PRIMA group
- Ron Abrahams
- Talar Boyajian
- Jennifer Boyd
- Wendy Burgoyne
- Katherine Cardinal
- Rosa Dragonetti
- Lisa Graves
- Phil Hall
- Samuel Harper
- Georgia Hunt
- Meldon Kahan
- Theresa Kim
- Lisa Lefebvre
- Nick Leyland
- Margaret Leslie
- Deana Midmer
- Stephanie Minorgan
- Pat Mousmanis
- Alice Ordean
- Sarah Payne
- Peter Selby
- Melanie Smith
- Ron Wilson
- Suzanne Wong
Principal Authors
Prima.medicine_at_utoronto.ca