Incorporating Screening for Substance Use into Routine Prenatal Care

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Incorporating Screening for Substance Use into
Routine Prenatal Care

• James J. Nocon, M.D., J.D.
• Chairman, Indiana Prenatal Substance Abuse
  Commission
• Director, Prenatal Recovery Clinic
• Wishard Memorial Hospital
• 1001 West 10th Street, F5102
• Indianapolis, Indiana 46202
• Substance Exposed Newborns June 23, 2010
• jnocon_at_iupui.edu

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Learning Objectives Screening for Substance Use
in Pregnancy

• Upon completion of this activity, participants
  will be able to
• Recognize the ethical and legal duty to screen
  for substance use in pregnancy.
• Understand the role of Urine Drug Screens.
• Understand basic screening strategies.
• Advocate detection and treatment of addiction
  during pregnancy.

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Addiction is a Chronic Relapsing Disease of the
Adult Brain

• Researchers have noted that
• Addiction is a chronic relapsing disease
• Successful treatment is comparable to, or better
  than, compliance with treatment plans for
  hypertension, diabetes and asthma
• And like diabetes and hypertension, addiction is
  an interaction between
• The substance alcohol, tobacco and other drugs
• The host genetics, vulnerabilities, co-morbid
  disorders
• The environment family, culture
• McLellen AT, Lewis, DC, OBrien CP, Kleber HD.
  Drug dependence, a chronic medical illness
  implications for treatment, insurance and
  outcomes evaluation. JAMA, 20002841689-1695.

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Universal Screening in Pregnancy is a Recognized
Standard of Care

• Hypertension 6-8 Prevalence
• BP and urine tests for proteinuria each visit
• History and simple tests will detect almost 100
• Diabetes 4-5
• Urine test for glucose each visit
• Glucola challenge 24-28 weeks
• History and simple tests will detect almost 100
• Sexually Transmitted Infections 4-5
• Everyone is tested rare exceptions
• Many state laws require STI testing

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Compare to Substance Use

• Prevalence estimated in Indiana 12-18
• But patients infrequently screened.
• Detection rates are less than 10.
• Drug use results in more fetal harm and preterm
  delivery than hypertension, diabetes and STIs
  combined.

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Ethical Duty To Screen all Pregnant and
Postpartum Women for Substance Use

• The American College of Obstetricians and
  Gynecologists (ACOG) Committee Opinion 422
  addresses the ethical rationale for universal
  screening for at-risk drinking and illicit drug
  use.
• American College of Obstetricians and
  Gynecologists. At-risk drinking and illicit drug
  use ethical issues in obstetric and gynecologic
  practice. ACOG Committee Opinion No. 422,
  December 2008.
• The American Medical Association also endorses
  universal screening.
• Blum LN, Nielson NH, Riggs, JA. Alcoholism and
  alcohol abuse among women report of the Counsel
  on Scientific Affairs. American Medical
  Association. J Womens Health 19987861-871
• Universal Screening means that every obstetrical
  patient is asked about substance use
• At the first prenatal or intake visit, and
• At least once per trimester thereafter.

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Why Universal Screening?Pregnancy Enhances
Recovery

• Pregnancy makes a difference in long-term
  recovery.
• After one year of treatment
• 65.7 of women who entered treatment while
  pregnant used no drugs, while
• Only 27.7 of non-pregnant women remained drug
  free. (plt0.0005)
• Peles E, Adelson M. Gender Differences and
  Pregnant Women in a Methadone Maintenance
  Treatment (MMT) Clinic. J Addictive Diseases
  2006 25 39-45.

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Why Universal Screening?Self Reporting Surveys
Inadequate

• In a national survey, 2.9 of patients admitted
  using marijuana in pregnancy
• Screening in Indiana indicate
• 29 tested positive for THC on the first prenatal
  visit in a major Southwestern Indiana Hospital
  (2006)
• 40 tested positive for THC in a Indianapolis
  (IUMG) center (2005)
• In both surveys, all patients were detected by a
  urine drug screen at the first prenatal visit.
• Self-reporting underestimates prevalence!
• NIDAs National Pregnancy and Health Survey
  (1992/1993)

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Compare Detection with Intervention

• Detection and Simple Intervention
• 274 patients 244 clean at delivery (85)
• 20 preterm delivery
• Detection with Only Routine Prenatal care
• 42 patients 23 clean at delivery (55)
• But, 33 preterm labor
• The process of detection is, in fact, an
  intervention.

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Why Universal Screening? Early Detection Leads
to Earlier Intervention

• Smoking cessation by 20 weeks
• Most or all of adverse effects of nicotine,
  cigarette smoke and additives avoided,
  specifically
• 20 of all low birth weight babies
• 8 of preterm babies
• 5 of all perinatal deaths
• Tobacco and Alcohol causes more fetal damage
  than all the other drugs combined.
• Cocaine cessation by 24 weeks
• Reduces prevalence of low birth weight and
  preterm labor

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Meconium Testing in 40 Term Newborns ofCocaine
Positive Mothers Treated 2002-2007

• All 40 tested positive for cocaine at first
  prenatal visit.
• 27 negative mean wt/gm 3253.55 s.d. 473.99
• 13 positive. mean wt/gm 2775.85 s.d. 466.68
• plt0.01
• It takes 10-14 weeks for the meconium to clear
  after cessation of cocaine use - mechanism is
  unclear.
• Thus, for a term newborn to be negative, the
  mother had to be drug free well before the third
  trimester.
• Early intervention clearly avoids the low birth
  weight effects of cocaine use in pregnancy.
• Strong and Nocon. Evaluation of a FRAMES-based
  Intervention for Pregnant Women Using Cocaine.
  Indiana University, School of Medicine.

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Universal Screening Is Highly Cost Effective

• When identified and treated
• Rate of abstinence increases.
• Maternal and fetal complications decrease.
• Less Preterm labor - 20 of treated mothers have
  preterm delivery
• Less Growth restriction
• Reducing preterm labor and low birth weight
  account for the largest savings.
• Preterm delivery accounts for the greatest amount
  of infant mortality, morbidity and medical costs
  in the first year of life.
• Hubbard RL, French MT. New perspectives on the
  benefit-cost and cost-effectiveness of drug abuse
  treatment. NIDA Res Monogram 199111394-113.

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Universal Screening Cost EffectiveReduction of
Preterm Labor

• About 89,000 deliveries in Indiana
• 51 funded by Medicaid 45,390
• 15 substance use - 6,808
• 95 are undetected - 6,468
• 35 Preterm delivery 2,263
• Mean nursery cost per preterm 75,000
• Total cost just for the nursery stay
• 169,725,000

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Savings If 50 of Medicaid Pregnant Substance
Users are Detected

• 3400 detected (D) 3400 undetected (U)
• 20 Preterm delivery D 680
• 35 Preterm delivery U 1190
• Total is 1870
• Difference from 95 U is 2263-1870 393
• At 75,000 per Premie nursery cost, detection of
  50 saves Medicaid at least
• 29,475,000.00 thats 29 Million dollars just
  for the nursery LOS Saving 140 million

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Take Home Message No. 1

• Universal Screening is a standard of care
• Endorsed by ACOG, AMA and CS
• Detection alone will result in 50-55 of patients
  using ATOD to stop using during the pregnancy.
• Simple follow-up can result in greater abstinence
  of longer duration.
• The failure to screen at the first prenatal visit
  deprives the patient of effective treatment.
• Is it malpractice?
• CS common sense

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Screening Strategies and Interventions

• Attitude Non Judgmental Empathetic
• Motivational Empowerment
• Cognitive Behavioral Therapy
• 2 Item Screen
• 4 Ps Plus
• T-ACE alcohol screen
• 5 As tobacco brief intervention
• FRAMES brief intervention for alcohol and drugs

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Note the Strong Link Between Alcohol/Nicotine Use
and Use of Illicit Drugs

• Among Women using BOTH Alcohol and Nicotine
• 20.4 used Marijuana
• 9.5 used Cocaine
• Women NOT using Alcohol or Nicotine
• 0.2 used Marijuana
• 0.1 used Cocaine
• Alcohol and nicotine use are markers for
  substance use.
• Alcohol and nicotine use cause more fetal damage
  than all the other drugs combined.

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Start with the Two-Item Screen

• In the last year have you ever smoked cigarettes,
  drunk alcohol or used any drugs more than you
  meant to?
• Have you felt you wanted or needed to cut down on
  your smoking or drinking or drug use in the last
  year?

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Two Item Screen Results

• Two random samples of primary care patients (434
  and 702 participants) aged 18 to 59 had the
  following results
• No to each question 7.3 chance of a current
  substance use disorder
• 1 yes answer 36.5 chance
• 2 positive responses had a 72.4 chance
• Likelihood ratios were 0.27, 1.93, and 8.77
  respectively
• Source Journal of the American Board of Family
  Practice, May 2001. Reprint requests to Richard
  L. Brown, M.D., M.PH., Department of Family
  Medicine, University of Wisconsin Madison Medical
  School, 777 South Mills St., Madison, Wl 53715.

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Negative Answers on Two Item Screen

• If the patient states she does not use ATOD, she
  is at low risk for substance use.
• Proceed to 5 Ps
• Negative answers
• Low risk of addiction send for routine prenatal
  care.
• Urine drug screen only if all patients get
  initial urine drug screen.

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Five Ps (Modified) Screening

• Did either of your PARENTS have a problem with
  alcohol or drugs?
• Doe any of you PEERS have a problem with alcohol
  or drugs?
• Does your PARTNER have a problem with alcohol or
  drugs?
• Have you ever drunk beer, wine or liquor to
  excess in the PAST?
• (Modified) Have you smoked any cigarettes, used
  any alcohol or any drug at any time in this
  PREGNANCY?
• Morse B, Gehshan S, Hutchins E. Screening for
  substance abuse during pregnancy improving care,
  improving health. Washington, DC National Center
  for Education in Maternal and Child Health 1977.
• Chasnoff, et al. The four Ps plus screen for
  substance use in pregnancy clinical application
  and outcomes. J Pereinat 200525368-374.

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Five Ps Plus Results

• A yes answer to any question was considered
  positive.
• The modified 5 Ps Plus screen adds a question
  about the current pregnancy and a positive answer
  identifies 34 of drug and alcohol users.
• With a positive answer about partner, 65 were
  found to need drug treatment.
• Chasnoff IJ, Hung WC. The 4 Ps Plus. Chicago,
  IL NTI Publishing 1999.

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Negative AnswersTwo Item Screen and 4Ps Plus

• This is typical of 85 of your patients and you
  have just successfully accomplished universal
  screening in about 90 seconds.
• These women will be at a very low risk for
  addiction and should receive routine prenatal
  care for the remainder of the pregnancy.
• But, ask about ATOD use in each trimester.

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The Role Of Urine Drug Screens (UDS)

• Can be used to determine prevalence in a
  population
• consent not required
• both legal and ethical.
• Many providers use UDS as a routine prenatal test
  at the first visit this is highly recommended
• use opt out approach for informed consent
• UDS indicated for any positive answer on drug
  screens.

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OPT OUT Approach to Urine Drug Screens

• Inform patient about routine prenatal care and
  frequency of visits.
• Inform patient that a number of routine screening
  tests are done in pregnancy and include, blood
  tests, diabetes tests, genetic tests, tests for
  sexual infections, ultrasound, and urine tests
  for protein, sugar, infection and drugs.
• Inform patient that she may opt out of any
  test.
• If patient opts out of urine drug screen, inform
  her that pediatricians may order drug screens
  after baby is born.

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How Long is a Drug Detectable in Urine After Use?
Alcohol Alcohol 24 hrs
Amphetamines Amphetamines 48 hrs
Barbiturates Short acting 48 hrs
Barbiturates Long acting 7 days
Benzodiazepines Benzodiazepines 72 hrs
Cocaine Cocaine 72 hrs
Marijuana Single use 72 hrs.
Marijuana Chronic use 30-40 days
Opiates Morphine/Heroin 72 hrs
Opiates Methadone 96 hrs
Opiates Codeine Up to 10 days
Nicotine Nicotine 3-5 days from last use
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Urine Drug Screens Also Recommended

• At each prenatal visit for any patient identified
  as a substance user.
• Any history of drug use.
• Missing appointments.
• Late Prenatal Care.
• Preterm Labor.
• Third Trimester Bleeding Abruption.
• Growth restriction.
• Incarcerated patients.

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Intervention Strategies

• There are well recognized intervention strategies
  for specific drugs
• Alcohol T-ACE TWEAK
• Tobacco 5 As
• Alcohol and Other Drugs FRAMES
• FRAMES is generic intervention and can be used
  for almost all substances and addictive
  behaviors.

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Positive Response with Respect to Alcohol

• In the last year, have you ever drank, smoked
  cigarettes or used drugs more than you meant to?
• Yes
• Would you like to talk about that?
• Yes, I lost my job and I have been drinking a lot
  more beer than I usually do
• How much is a lot more?
• About 3 or 4 beers a night.

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Follow-up Questions About Alcohol Use In
Pregnancy

• Ask about most recent alcohol use
• Dates what did she use? how often?
• Type social? Binge?
• Document last use in record.
• Ask about consumption.
• Go to T-ACE
• If T-ACE score negative ask her to commit to
  stop using any alcohol in this pregnancy.
• If positive - Intervention

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Ask About Alcohol Consumption

• Consumption do you have more than 1 drink a
  day?
• Consumption do you have more than 3 drinks per
  social occasion?
• At risk consumption
• Consumption is gt 14/drinks/week or gt 4 drinks per
  occasion (men)
• Consumption is gt 7/drinks/week or gt 3 drinks
  per occasion (women)
• Document the consumption

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Alcohol Consumption Can Be Tricky

• A Standard Drink is defined as
• 12 ounces of beer,
• 5 ounces of wine, and
• 1.5 ounces of 80 proof distilled spirits
• In a study of pregnant drinkers, the median
  patient-defined drink size was
• 22 ounces of malt liquor, or
• 8 ounces of fortified (up to 20) wine, or
• 2 ounces of 100 proof spirits

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T-ACE A Screening Tool for Alcohol Use in
Pregnancy

• T Tolerance How many drinks does it take you to
  feel high?
• More than 2 drinks is a positive response score
  2 points
• A Annoyed Have people annoyed you by
  criticizing your drinking? (Yes score 1 point)
  
• C Cut down Have you ever felt you ought to cut
  down on your drinking? (Yes score 1 point)
• E Eye Opener Have you ever had a drink first
  thing in the morning to steady your nerves or get
  rid of a hangover? (Yes score 1 point.)

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T-ACE Scoring

• A score of 2 or more points indicates at-risk
  drinking in pregnancy.
• Intervention indicated and may need more
  aggressive referral
• Treatment center
• AA
• Sokol RJ Martier SS Ager JW.  The T-ACE
  questions Practical prenatal detection of risk
  drinking. American Journal of Obstetrics and
  Gynecology 160(4) 863-870, 1989.

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Summary of Alcohol Screening

• Get Consumption History
• Assess with T-ACE
• Use FRAMES intervention.
• If continues to use refer for treatment.

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The 5 As Tobacco Use

• ASK identify and document tobacco status for
  every patient at every visit
• ADVISE in a clear, strong and personalized
  manner, inform the patient of the effects of
  smoking
• ASSESS willingness to quit
• ASSIST refer to smoking cessation program if
  available and use nicotine patch or gum
• ARRANGE schedule follow up contact in one week
  after the quit date.

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Example Using the 5 As for Tobacco Use

• Ask How much do you smoke?
• Advise I want you to know that tobacco is the
  leading cause of low birth weight in the US. I
  advise that you cut down and stop.
• Assess Are you willing to stop? When?
• Assist Would you like to try a nicotine patch or
  gum?
• Arrange Heres a list of the smoking cessation
  programs which one will you go to this week?
• Thus, you will need to have a list of smoking
  cessation programs in your area.

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How to ASSESS the Willingness to Quit and Give
Feedback.

• Use this formula Data Feeling Opinion Want
• Example tobacco use
• The data is that you are smoking a pack a day
• I am afraid that this may affect you babys
  growth
• My opinion is that almost all women can quit or
  cut down significantly
• I want you to quit smoking
• Then ask
• Are you willing to do so?
• When will you stop? (get a date)

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FRAMES Intervention

• FRAMES was used in a World Health Organization
  study to assess brief interventions. The study
  evaluated heavy male drinkers from 12 countries
  with obvious cultural differences in alcohol use.
  
• A brief intervention resulted in a decrease in
  alcohol use of 27, compared to 7 among
  controls, still present 9 months after the
  intervention.
• FRAMES also works well with other drug use.
• World Health Organization Brief Intervention
  Study Group. A cross national trial of brief
  interventions with heavy drinkers. Am J Public
  Health 199686948-955.
• Bien TH, Miller WR, Tonigan JS. Brief
  interventions for alcohol problems a review.
  Addiction 1993 Mar88(3)315-35.

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FRAMES A Brief Intervention

• F - Feedback about the adverse effects of drugs
  or alcohol
• R - Responsibility for a change in behavior
• A - Advise to reduce or stop use
• M - Menu of options treatment medications
• E - Empathy is central to the intervention.
• S - Self-empowerment You can change.
• Bien TH, Miller WR, Tonigan JS. Brief
  interventions for alcohol problems a review.
  Addiction 199388315-335

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FRAMES InterventionFeedback

• F - Feedback
• About the adverse effects of Cocaine
• Specific feedback for specific drug
• Use Formula Data-Feeling-Opinion-Want
• Example
• The data is your urine screen was positive for
  cocaine
• Im afraid that if you are positive at delivery,
  CPS will investigate and may put the baby in
  foster care
• My opinion is that you can stop using
• I want you to stop using now

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FRAMES InterventionResponsibility

• R - Responsibility for a change in behavior two
  simple statements
• Only you can decide that you want to stop
  using.
• Are you willing to stop using now?
• You may add, Im proud of you for choosing to
  stop.

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FRAMES InterventionAdvise

• A - Advise to reduce or stop use
• "For the next week, will you cut down your use of
  cocaine by 2 times per week. Can you make that
  stretch?
• Set up a win-win for the patient, that is,
  challenge her to do something she can do.
• This is called a stretch.
• It builds self-esteem.
• And it works.
• Since cocaine costs you 40 dollars a hit, that
  means you will have 80 dollars more.
• I want you to buy something for yourself with the
  money. What will you buy? (reward success)

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FRAMES Intervention Menu of options

• "If you find that cutting back for the next week
  is impossible, then we should consider other
  options.
• Or, You may need additional support for your
  choice to stop using
• For example
• Referral to counseling services/social services
• Adjunct medications
• Support Groups AA, NA, Smoking cessation groups
• Inpatient treatment.

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FRAMES Intervention Empathy and Self Empowerment

• Empathy is central to the intervention.
• I realize this must be real hard to do.
• I am proud of you for considering a change.
• I am proud of you for being honest with me.
• Self-empowerment
• I am proud of you for agreeing to cut back.
• You will find that you can succeed.
• I am glad that you continue to come for prenatal
  care.

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FRAMES is a Motivational Empowerment Approach

• Less emphasis on diagnostic label alcoholic
  addict.
• Reduces risk of shaming
• Motivation empowers patient to make choices and
  take action we call this accountability.
• Emphasizes personal accountability to change.
• Remember to order a UDS for each prenatal visit
• Document the date of the negative test
• Tell her you are proud of her for getting clean
• This is very powerful reinforcement

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The Motivating Questions(to ask at every visit)

• How will your life be better by not using (fill
  in with substance)?
• Ill be a better mother of course you will.
• Ill have more money how much more?
• I have a safer house what do you need to be
  safe?
• When she is clean ask, How is your life better
  now that you are not using (substance)?
• Record specific answers
• Say, Im proud of you.

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Take Home Message Number 2

• What works - just about anything
• Identifying the problem at least 50 will
  abstain
• Motivating the patient 80-85 will abstain
• What doesnt work - ignoring the problem.

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