Substance Abuse and the Perinatal Period

1
Substance Abuse and the Perinatal Period
Colorado Perinatal Care Council August 3, 2012

• Kathryn Wells, MD, FAAP
• Medical Director, Denver Family Crisis Center
• Child Abuse Pediatrician, Denver Health
  Childrens Hospital Colorado
• Assistant Professor of Pediatrics, University of
  Colorado
• [phone]
• Kathryn.wells_at_dhha.org

Sharon Langendoerfer, MD, FAAP Associate Director
of Newborn Services, Denver Health Associate
Professor of Pediatrics, University of Colorado
School of Medicine [phone] Sharon.Langendoe
rfer_at_dhha.org
2
Objectives

• Discuss the relationship between substance abuse
  and child welfare
• List the harmful effects of drugs of abuse on the
  fetus
• Describe five points of intervention for the
  issue of perinatal substance abuse

3
Children in Substance-Abusing Homes
8.3 million (12 of U.S. children) live with
at least one parent who is alcoholic or in need
of substance abuse treatment National Survey on
Drug Use and Health Report, April 16, 2009
combined data from 2002-2007
4
Children of Parents with Substance Abuse Problems

• Have poorer developmental outcomes (physical,
  intellectual, social and emotional) than other
  children

• Are at (a three- to eight-fold) increased risk
  of substance abuse themselves

5
Substance Abuse Affects Parenting

• Impaired judgment and priorities
• Inability to provide the consistent care,
  supervision and guidance children need
• Substance abuse is a critical factor in child
  welfare

Blending Perspectives and Building Common
Ground, A Report to Congress on Substance Abuse
and Child Protection, April 1999
6
How Prevalent?

• Survey of 36 hospitals found an estimated 375,000
  infants exposed in utero to illegal drugs each
  year in the U.S., or 11 of all births
• (Chasnoff, 1989)
• The American Academy of Pediatrics estimates that
  1 in 10 newborns in the US have been exposed to
  an illicit drug
• (AAP, 1990)

7
How Prevalent? Natl Survey on Drug Use
Health 2008-09 (US Births 09 4,131,000)

• Substance 1st tri 2nd tri 3rd
  tri
• (past mo) (National Prevalence)
• Any Illicit 8.5 3.2
  2.3
• Alcohol 20.4 6.5
  3.5
• Binge Alc 11.9 0.9
  0.8
• Cigarettes 22.4 12.6
  11.6

SAMHSA, Office of Applied Studies, National
Survey on Drug Use and Health, 2007-2008,
http//oas.samhsa.gov/NSDUH/2K8NSDUH/tabs/Sect7peT
abs71to78.pdf
8
Obtaining Data Difficulties

• The unreliability of mothers self-reports
• The limitations of urine/mec toxicology
  techniques
• The nature of observable clinical conditions
• Lack of uniformity in hospital policies and
  procedures
• Drug-affected vs. drug-exposed

9
What are the Effects?

• Effects may be fetal, maternal or both
• Great variability in harm
• Problems with attention, self-regulation, and
  cognition
• Risk of maltreatment and impaired attachment
• Significant financial cost

10
What Drugs?

• Legal tobacco, alcohol, marijuana (?)
• Illegal LSD, (marijuana), etc, etc!
• Substances with recognized medical uses
  narcotics, barbiturates, cocaine and amphetamines

11
Indirect Maternal Effects

• Infections HIV, tuberculosis, hepatitis,
  syphilis, endocarditis, pulmonary infections
• Toxin-Induced nutritional deficiency (alcohol),
  cardiotoxins (cocaine, alcohol, amphetaminies),
  direct pulmonary effects (marijuana, tobacco),
  hepatotoxic (cirrhosis, solvent), nephropathy
  (heroin)

12
Obstetrical Complications

• Abortion
• Abruptio placenta
• Breech presentation
• Previous cesarean-section
• Chorioamnionitis
• Pre-eclampsia
• Eclampsia
• Gestational diabetes
• Placental insufficiency

• Intrauterine growth restriction
• Intrauterine death
• Post-partum hemorrhage
• Premature labor
• Premature rupture of membranes
• Septic thrombophlebitis

13
Fetal Effects altered by

• Route of intake (dose) and dosage interval
• Route of administration (IV, PO,SQ, inhaled)
• Rate of absorption
• Rate of elimination
• Lipid solubility
• Protein binding
• Concomitant maternal dz- renal, hepatic,etc
• Placental well-being
• Gestational age

14
Relationship to Gestational Age

• (Malformations infrequent)
• First 6 weeks most severe malformations
• Up to 12 weeks malformations of the abdominal
  wall, gastrointestinal tract, reproductive system
  and urinary tract
• Second and third trimesters intrauterine growth
  restriction and vascular disruption syndromes

15
Neonatal Medical Complications

• Meconium aspiration
• Pneumonia
• Respiratory distress syndrome
• Septicemia
• HIV Infection
• Sudden infant death syndrome

• Hyperbilirubinemia
• Hypocalcemia
• Hypoglycemia
• Intracranial hemorrhage
• Intrauterine growth restriction
• Neonatal abstinence syndrome

16
Cocaine The Drug
17
Cocaine Effects on the Fetus

• Use occurs in about 1 of women rarely used
  alone
• Constricts blood vessels reducing blood flow to
  the fetus and diminishing oxygen supply and
  nutrients
• Fetal anomalies
• CNS abnormalities
• Intestinal abnormalities
• Urogenital system abnormalities
• Malformations of extremities
• May have periods of extreme heart rate variability

18
Cocaine Effects on Pregnancy and Delivery

• High rate of spontaneous abortion and placental
  abruption
• Increased rate of premature rupture of membranes,
  early onset of labor and preterm delivery
• Common knowledge on the streets may attempt
  self-induced abortions
• Birth outcomes improve if mother stops drug in
  the last 3 months of pregnancy damage to
  vessels is non-reversible

19
Cocaine Effects on the Newborn

• Increased risk for IUGR
• Neurobehavioral symptoms - jittery, high-pitched
  cry, startle at mild stimulation
• Abnormal sleep, poor feeding, tremors and
  increased muscle tone attributed to direct
  effects
• Deficits in ability to habituate or
  self-regulate, especially under stressful
  conditions
• May have increased risk for SIDS

20
Cocaine Effects on the Growing Child

• Behavior problems
• Small changes in IQ, language abilities,
  executive functioning, impulse control and
  attention

21
Cocaine Brain Effects

• Effects from direct effects on neurotransmitter
  systems, vasoconstrictive effects, and fetal
  programming (altered expression of genes and gene
  networks)
• MRI studies contributed to understanding of brain
  effects
• Longitudinal studies with careful control of
  other factors need to be done

22
Cocaine Effects on Breastfeeding

• May cause tremulousness, irritability, startle
  responses and other neurobehavioral abnormalities
• May even cause seizures

23
Methamphetamine The Drug
24
Overview Pregnancy and Methamphetamine

• Very little information
• Studies ongoing
• Similar to cocaine exposure
• Many challenges

25
Methamphetamine Use in Pregnancy

• Very similar to cocaine but not as studied
• Increased heart rate in fetus and constriction of
  blood vessels causing elevated blood pressure
• Increased maternal blood pressure resulting in
  premature delivery or spontaneous abortion
• Restriction of fetal development due to decreased
  blood flow

26
Methamphetamine Use in Pregnancy

• Considerable transfer of meth to fetal blood
  where it may remain in fetal circulation longer
  than in maternal blood
• Newborns may be sleepy and lethargic for the
  first few weeks, to the point of not waking to
  feed
• After the first few weeks, behave similar to
  cocaine-exposed infants
• Later on may have aggressive behavior and poor
  school performance by 7-8 years of age

27
Methamphetamine Use During Pregnancy

• Women who use methamphetamine and/or cocaine in
  the first trimester are more likely to use during
  the third trimester
• Nicotine use is universal among drug using
  pregnant women
• Marijuana and alcohol are secondary drugs, used
  in 60 of the group

(Source Dr. Rizwan Shah, Blank Childrens
Hospital, Des Moines, IA)
28
Use During Pregnancy IDEAL Study

• Further evaluation of study revealed that
  methamphetamine use does diminish during
  pregnancy
• However, a substantial proportion of users had
  consistently high or increasing use
• Those that decreased use had a higher incidence
  of polydrug use

29
Symptoms of Meth Exposed Infants and Children

• Newborn to 4 Weeks (I)
• (Dopamine Depletion Syndrome)
• Lethargic Excessive sleep period
• Poor suck and swallow coordination
• Sleep apnea
• Poor habituation

(Source Dr. Rizwan Shah, Blank Childrens
Hospital, Des Moines, IA)
30
Symptoms of Meth Exposed Infants and Children

• 4 weeks to 4 months (II)
• Symptoms of CNS immaturity effects on motor
  development
• Sensory integration problems tactile,
  defensive, texture issues
• Neurobehavioral symptoms interaction social
  development

(Source Dr. Rizwan Shah, Blank Childrens
Hospital, Des Moines, IA)
31
Symptoms of Meth Exposed Infants and Children

• 6 months to 18 months (III)
• The Honeymoon Phase
• Symptom-free period

(Source Dr. Rizwan Shah, Blank Childrens
Hospital, Des Moines, IA)
32
Symptoms of Meth Exposed Infants and Children

• 18 months to 5 years (IV)
• Sensory integration deficit (same as II)
• Less focused attention
• Easily distracted
• Poor anger management
• Aggressive outbursts

(Source Dr. Rizwan Shah, Blank Childrens
Hospital, Des Moines, IA)
33
Methamphetamine Effects on the Growing Child

• Too early to know
• Behavior problems
• Small changes in IQ and language abilities
• Later on may have aggressive behavior and poor
  school performance by 7-8 years of age

34
Methamphetamine Brain Effects

• Only 3 MRI studies small sample sizes
• Studies suggest methamphetamine may have a
  neurotoxic effect on developing subcortical brain
  structures and prefrontal-striatal circuitry
  involved in attention and memory
• Very recent study suggests that striatal and
  limbic structures may be more vulnerable to
  prenatal methamphetamine than alcohol exposure
  and that more severe striatal damage is
  associated with more severe cognitive deficit

35
Methamphetamine Effects on Breastfeeding

• May cause tremulousness, irritability, startle
  responses and other neurobehavioral abnormalities
• May even cause seizures

36
Methamphetamine Effects on Breastfeeding

• Few cases reported in the media
• Arizona 2002 breastfeeding infant died from
  Methamphetamine overdose
• California 2003 breastfeeding infant
• California 2011 - current case - ? Breastfeeding
  infant

37
Meth Labs
38
Marijuana The Drug
39
Marijuana Use in Pregnancy

• Frequently used as part of a poly-drug regimen
• Studies are difficult to find on use of marijuana
  alone
• Pharmacology is worrisome because it can be
  stored for long periods of time in organs with
  high amounts of lipids (e.g. the brain)

40
Marijuana Effects on Pregnancy and Delivery

• May cause spontaneous abortions and stillbirths
• Readily crosses placenta higher in early
  pregnancy

41
Marijuana Effects on the Newborn

• Increased tremulousness, altered visual response
  patterns to light stimulus, and withdrawal-like
  crying
• Short-term effects are poor neurobehavioral
  organization poor state regulation
• Usually disappears in 30 days (?)
• Affects sleep and arousal patterns
• May have synergistic effect with alcohol and
  other substances

42
Marijuana Effects on the Growing Child

• Studies limited and inconsistent
• May be associated with deficits in short-term
  memory, verbal and abstract/visual reasoning, and
  executive functioning (complex tasks, sustained
  attention, hyperactivity, impulsivity and
  delinquency)

43
Marijuana Brain Effects

• Very little data
• Studies suggest relationship between prenatal MJ
  exposure and adol/young adult neural functioning
  during tasks requiring response inhibition and
  visuo-spatial working memory
• MRI studies suggest prenatal exposure may alter
  the lateralization and functional connectivity of
  multiple brain regions important in the
  performance of complex executive level
  functioning tasks

44
Marijuana Effects on Breastfeeding

• Rapidly transmitted into breast milk and remains
  there for longer time
• Breastfeeding not recommended for mothers who
  smoke marijuana and are not willing to give it up

45
Opiates (Heroin, Methadone, Morphine)
46
Opiate Use in Pregnancy

• Heroin, other street narcotics
• Low birth weight due to symmetric IUGR or
  prematurity
• Meconium aspiration fetal distress due to
  placental insufficiency
• Effects due to mothers behavior
• Lack of prenatal care
• Poor nutrition
• Medical problems
• Abuse of other drugs

47
Opiate Use in Pregnancy

• Methadone in a Treatment Program
• Eliminates most adverse maternal
  factors
• Usually normally grown
• Significant Neonatal Abstinence Syndr.

48
Opiate Use in PregnancyNeonatal Abstinence
Syndrome

• Occurs in 60-80 of heroin-exposed infants
• Onset within 70 hours of birth
• Lasts 2-3 weeks to 4-6 months, even as long as a
  year
• Involves central nervous system
• Irritability, hyperreflexia, abnormal suck, and
  poor feeding
• Seizures in 1 3
• GI symptoms include diarrhea and vomiting
• Respiratory signs include tachypnea, hyperpnea,
  and respiratory alkalosis
• Autonomic signs include sneezing, yawning,
  lacrimation, sweating and hyperpyrexia

49
Opiate Use in PregnancyDelayed Effects

• Subacute withdrawal with symptoms such as
  restlessness, agitation, irritability, and poor
  socialization that may persist for 4 6 months
• Association between SIDS and intrauterine
  exposure to opiates
• Delayed physical growth, neurologic performance,
  and cognitive development

50
Opiate Use in Pregnancy Delayed Effects (cont.)

• Poor weight gain during the first month of life
• Later in life have difficulties with decreased
  attention span
• Creates a vulnerability in infants that makes
  them more susceptible to poor environments, with
  subsequent poor developmental outcomes

51
Alcohol The Drug
52
Alcohol Exposure

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

Blending Perspectives and Building Common
Ground, A Report to Congress on Substance Abuse
and Child Protection, April 1999
53
Alcohol Use in Pregnancy

• Children with both FAS and FAE may exhibit a
  number of developmental delays, including
  hyperactivity, short attention spans, language
  dysfunctions, and delayed maturation
• Heavy alcohol consumption has been cited as
• The leading cause of mental retardation worldwide
  
• The oldest known cause of developmental
  disabilities (Bible)
• Only about 30 of children with FAS are in the
  care of their mothers through adolescence

54
Alcohol Mechanisms of Damage to the Fetus

• Alcohol and its primary metabolite acetaldehyde,
  are directly toxic to the developing embryo and
  fetus
• Interferes with the delivery of maternal
  nutrients
• Impairs supply of fetal oxygen
• Deranges protein synthesis and metabolism
• Stimulates excess production of certain hormones
  (prostaglandins) that modulate cellular functions
  of the body and could cause fetal malformations

55
Alcohol Effects During Pregnancy and Delivery

• Increased obstetrical complications vaginal
  bleeding, placental abruption, fetal distress
• Associated with high rates of spontaneous
  abortion, miscarriage, and stillbirth
• Risk for spontaneous abortion is dose related
• If averaging 3 or more drinks a day more than 3
  times more likely to miscarry than non-drinkers
• Even those who consume one or two drinks a day
  are at increased risk of miscarriage during the
  second trimester

56
Alcohol Effects on the Newborn

• Most consistent effects low birth-weight and
  intrauterine growth retardation (IUGR) more
  severe in women who drink heavily during the last
  3 months of pregnancy
• IUGR increases risks for infants early death and
  for respiratory difficulties, feeding problems,
  serious infections, and long-term developmental
  problems

57
Alcohol Effects on the Newborn

• Heavy drinking (avg of 5 drinks/day)
• Alcohol withdrawal tremors, abnormal muscle
  tension (hypertonia), restlessness, sleeping
  problems, inconsolable crying, and reflex
  abnormalities
• Decreased ability to tune out inappropriate
  stimuli
• Poor sucking abilities
• Disturbed patterns of sleep and wakefulness

58
Fetal Alcohol Spectrum Disorders (FASD)

• Umbrella term that describes the range of effects
  that can occur in an individual whose mother
  drank during pregnancy
• Effects may be lifelong
• Physical
• Mental
• Behavioral and/or
• Learning disabilities

(Source SAMHSA, Center for Excellence on Fetal
Alcohol Spectrum Disorder)
59
Fetal Alcohol Spectrum Disorders

• Not a diagnostic term used by clinicians
• Refers to
• Fetal alcohol syndrome (FSD) including partial
  FAS
• Fetal Alcohol Effects (FAE)
• Alcohol-related neurodevelopmental disorder
• Alcohol-related birth defects

(Source SAMHSA, Center for Excellence on Fetal
Alcohol Spectrum Disorder)
60
Alcohol Use in Pregnancy Alcohol Related Birth
Defects (ARBD)

• 1 in 200 births worldwide
• 5 of all congenital anomalies
• 10-20 of all cases of mental retardation
• U.S. ranks 15th in the world in alcohol
  consumption
• 5-10 of pregnant women are thought to drink at
  levels sufficient to place their fetuses at
  significant risk for ARBD

61
Alcohol Use in Pregnancy Fetal Alcohol
Syndrome (FAS)

• Described in 1973 by a group of scientists at the
  University of Washington in Seattle
• At least 5,000 infants are born with FAS annually
  
• 1-3 births per 1,000 live births

62
Fetal Alcohol SyndromeGuidelines for Diagnosis

• Prenatal maternal alcohol use
• Growth deficiency
• Central nervous system (CNS) abnormalities
• Structural
• Neurologic
• Functional
• Dysmorphic features

(Source SAMHSA, Center for Excellence on Fetal
Alcohol Spectrum Disorder)
63
Fetal Alcohol SyndromeGuidelines for Diagnosis

• Prenatal maternal alcohol use
• Confirmed
• Unknown

(Source SAMHSA, Center for Excellence on Fetal
Alcohol Spectrum Disorder)
64
Fetal Alcohol SyndromeGuidelines for Diagnosis

• Growth deficiency
• Confirmed prenatal or postnatal height or weight,
  or both, at or below the 10th percentile
• Documented at any one point in time
• Adjusted for age, sex, gestational age, and race
  or ethnicity

(Source SAMHSA, Center for Excellence on Fetal
Alcohol Spectrum Disorder)
65
Fetal Alcohol SyndromeGuidelines for Diagnosis

• Central nervous system (CNS) abnormalities
• Structural head circumference at or below the
  10th percentile adjusted for age and sex or
  clinically significant brain abnormalities
  observable through imaging
• Neurologic neurologic problems not due to
  postnatal insult or fever or other soft
  neurologic signs outside normal limits
• Functional global cognitive or intellectual
  defecits representing multiple domains of deficit

(Source SAMHSA, Center for Excellence on Fetal
Alcohol Spectrum Disorder)
66
Fetal Alcohol SyndromeGuidelines for Diagnosis

• Dysmorphic features all 3 features must be
  present
• Short palpebral fissures
• Indistinct philtrum
• Thin upper lip

(Source SAMHSA, Center for Excellence on Fetal
Alcohol Spectrum Disorder)
67
Fetal Alcohol Syndrome
(Journal Alcohol Health and Research World, Vol.
18, No. 4, 1994)
68
Fetal Alcohol SyndromeFacial Characteristics

• Abnormally small head
• Low nasal bridge
• Abnormally small eyes
• Flat midface
• Short nose
• Thin upper lip

69
Fetal Alcohol Syndrome Other Physical
Characteristics

• Permanent brain damage
• Growth problems
• Underweight
• Small head
• Heart and kidney defects
• Long-term behavior problems

70
Alcohol Use in Pregnancy Fetal Alcohol Effect
(FAE)

• At least 50,000 infants annually (3-5 in 1,000)
• Includes the behavioral and developmental
  problems without the facial features

71
Alcohol Effects on Breastfeeding

• Same concentration in breast milk as in blood -
  rapidly transmitted but is diluted with body
  water
• Infants blood alcohol content is usually much
  lower than moms

72
Alcohol Effects on Breastfeeding

• Chronic exposure to high doses of alcohol is
  potentially dangerous as infants oxidize alcohol
  more slowly than adults
• Heavy drinking decreases milk supply and inhibits
  the milk-ejection reflex
• Nursing babies of mothers who regularly consume
  alcohol may be irritable, drowsy and have
  abnormal weight gain

73
All Exposures Increased Infant Mortality

• Associated increased risk of SIDS (?)
• Associated risk of positional overlay
• Associated risk of very premature birth and
  severe complications

74
The Facts

• Infants born to women with addictions are at
  risk for birth defects, premature birth, and
  complications after birth such as withdrawal. In
  addition, these infants display a higher
  incidence of child abuse and neglect.

75
Prenatal Exposure to Drugs and Alcohol

• Small proportion of the children affected and
  potentially endangered by substance abuse
• Not identified - fear of prosecution or losing
  their children

76
FEBRUARY 3, 1997 VOL. 149 NO. 5
SPECIAL REPORT FERTILE MINDS FROM BIRTH, A
BABY'S BRAIN CELLS PROLIFERATE WILDLY, MAKING
CONNECTIONS THAT MAY SHAPE A LIFETIME OF
EXPERIENCE. THE FIRST THREE YEARS ARE CRITICAL
BY J. MADELEINE NASH  
77
What We Dont Know

• Effect of other factors
• Other exposures
• Environment
• Brain effects
• Labs
• Long-term outcomes
• Most effective approach

78
What Happens Next?

• Most go home 75-90 of substance-exposed
  infants go home undetected
• Why?
• Many hospitals dont screen or test or dont
  systematically refer to CPS
• State law may not require report or referral
• Urine test only detects very recent use

(Source S Gardner, N Young, National Center on
Substance Abuse and Child Welfare)
79
No One AgencyIssue Demands

• Comprehensive services
• Provided along a continuum of prevention,
  intervention and treatment
• At different developmental stages in the life of
  the child and family
• NO single agency can deliver all of these

(Source S Gardner, N Young, National Center on
Substance Abuse and Child Welfare)
80
Needed Partners

• Hospitals
• Private physicians
• Health care management plans
• Maternal and child health
• Childrens and adult mental health
• Domestic violence agencies
• Child welfare
• Drug and alcohol prevention, treatment, and
  aftercare

• Developmental disabilities agencies
• Schools and special education
• Family/dependency courts
• Child care and development
• Employment and family support agencies
• And more

(Source S Gardner, N Young, National Center on
Substance Abuse and Child Welfare)
81
Emerging Issues

• Increasing number of pregnant women and children
  affected by maternal use of methamphetamine
• Advancing research on fetal alcohol spectrum
  disorders and Alcohol-related Neurodevelopmental
  Disorders
• Renewed proposals of State legislation aimed at
  both fetal alcohol exposure and maternal abuse of
  illegal drugs
• Child Abuse Prevention and Treatment Act (CAPTA)
  amendments of 2003 and 2010

(Source S Gardner, N Young, National Center on
Substance Abuse and Child Welfare)
82
Child Abuse Prevention and Treatment Act (CAPTA)

• Reauthorized in 2003
• Established new legislative responsibilities
  regarding prenatally exposed infants

83
Child Abuse Prevention and Treatment Act (CAPTA)

• Stated that states must have in place
• 106(b)(2)(A)(ii) Policies and procedures
  (including appropriate referrals to child
  protection service systems and for other
  appropriate services) to address the needs of
  infants born and identified as affected by
  illegal substance abuse or withdrawal symptoms
  resulting from prenatal drug exposure,

84
Child Abuse Prevention and Treatment Act (CAPTA)

• (ii) including a requirement that health care
  providers involved in the delivery or care of
  such infants notify the child protection services
  system of the occurrence of such condition in
  such infants,

85
Child Abuse Prevention and Treatment Act (CAPTA)

• (ii) except that such notification shall not be
  construed to
• (I) Establish a definition under Federal law that
  constitutes child abuse or
• (II) Require prosecution for any illegal action

86
Child Abuse Prevention and Treatment Act (CAPTA)

• (iii) The development of a plan of safe care for
  the infant born and identified as being affected
  by illegal substance abuse or withdrawal
  symptoms

87
Defining the Problem

• Little data exists on the extent of the problem
  and successful approaches to address it
• Need early identification to reduce risks to the
  infant and enhance success
• Potential for criminal prosecution reduces
  utilization of medical and treatment resources

88
Underlying Common Themes

• Addressing the issue of the continuum
• Better relationships are needed (Legal Community,
  DHS, Treatment, Medical Providers)
• Education is critical
• Supporting and enhancing treatment is imperitive

89
Five Points of Intervention

1. Pre-Pregnancy
2. Prenatal Screening and Services
3. Screening and Testing at Birth
4. Post-Natal Services to Infants and Children
5. Post-Natal Services to Parents

(Source S Gardner, N Young, National Center on
Substance Abuse and Child Welfare)
90
Five Points of Intervention

• Pre-pregnancy awareness of
• substance use effects

2. Prenatal screening and assessment
Initiate enhanced prenatal services
3. Identification At Birth
Parent
Child
4. Ensure infants safety and Respond to
infants needs
Respond to parents needs
System Linkages
5. Identify and respond to the needs
of infant/preschooler child/adolescent
Identify and respond to parents needs
System Linkages
91
1. Pre-Pregnancy

• Public education campaigns
• Warning signs at points of sale
• Warning signs at other venues
• Work with institutions of higher education to
  disseminate the message
• Studies suggest that message is not getting to
  critical group of pregnant women

(Source S Gardner, N Young, National Center on
Substance Abuse and Child Welfare)
92
Five Points of Intervention

• Pre-Pregnancy
• Prenatal Screening and Services
• Screening and Testing at Birth
• Post-Natal Services to Infants and Children
• Post-Natal Services to Parents

(Source S Gardner, N Young, National Center on
Substance Abuse and Child Welfare)
93
2. Prenatal Screening and Services

• Prenatal screening - standardize
• No states require prenatal screening for
  substance abuse
• Consider prenatal testing as standard of care
• Give pregnant women priority status in entering
  treatment, in accord with Federal requirements

(Source S Gardner, N Young, National Center on
Substance Abuse and Child Welfare)
94
2. Prenatal Screening and Services

• Referrals of pregnant women to treatment and
  progress in treatment are not monitored on a
  Statewide basis
• Extensive wait lists in some states, especially
  for residential care
• Admissions of pregnant women are a very small
  percentage of total admissions

(Source S Gardner, N Young, National Center on
Substance Abuse and Child Welfare)
95
2. Prenatal Screening and Services

• Special Connections Program only 7 referred
  from medical community
• Women in the criminal justice system
• Encourage prenatal medical care
• Consider a public health outreach approach to
  pregnant women in need of treatment

96
2. Prenatal Screening and Services

• CO HB12-1100 !!! reduces risk of prosecution of
  pregnant women
• No information relating to substance use not
  otherwise required to be reported pursuant to
  C.R.S. 19-3-304, obtained as a part of a
  screening test for purposes of prenatal care, of
  a woman who is pregnant or determining if she is
  pregnant, shall be admissible in any criminal
  proceeding. Nothing in this section should be
  interpreted to prohibit prosecution of any claim
  or action related to such substance use based on
  independently obtained evidence.
• CO HB12-1100 signed 3/9/12!!

97
ACOG Resources

• http//www.womenandalcohol.org/
• Alcohol screening and brief intervention at a
  glance Pocket card
• Tips for working with women who drink
• iPhone app for identifying and intervening with
  women who drink at risk levels
• ACOG Committee Opinion At risk drinking and
  alcohol dependence Obstetric and gynecologic
  implications
• Additional clinician resources
• Community resources

98
Five Points of Intervention

• Pre-Pregnancy
• Prenatal Screening and Services
• Screening and Testing at Birth
• Post-Natal Services to Infants and Children
• Post-Natal Services to Parents

(Source S Gardner, N Young, National Center on
Substance Abuse and Child Welfare)
99
3. Screening and Testing at Birth

• Policies on screening at birth are not at State
  level local hospital policy
• Hospital policies vary widely, with few
  standardized protocols that are consistently
  implemented
• Reporting requirements recent legislation
• Defining substance exposure as evidence of abuse
  or neglect

(Source S Gardner, N Young, National Center on
Substance Abuse and Child Welfare)
100
Colorado Law

• Title 19 Childrens Code
• 19-1-103. Definitions
• (1)(a) Abuse or child abuse or neglect
  means an act or omission in the following
  categories that threatens the health or welfare
  of a child
• (VII) Any case in which a child tests positive
  at birth for either a schedule-I or schedule-II
  controlled substance unless the child tests
  positive for a schedule-II controlled substance
  as a result of the mothers lawful intake of such
  substance as prescribed

101
3. Screening and Testing at Birth

• States do not monitor screening and referrals
• Detection of and response to FAS and FASD is
  inconsistent with policy and practice
• Fear of prosecution and child welfare involvement

(Source S Gardner, N Young, National Center on
Substance Abuse and Child Welfare)
102
Screening (verbal) should be routine!

• Screen for tobacco and alcohol as well as illicit
  drugs
• Need to use a standardized tool and follow an
  objective protocol
• SBIRT model (Screening, Brief Intervention,
  Referral to Treatment) www.healthteamworks.com
  (billing codes, trainings)
• Great potential for preventing negative outcomes
  if identified early

103
Testing

• Infant vs mother
• Need to follow an objective protocol
• Universal vs. targeted testing
• Reliability and fairness
• Cost from financial or civil rights perspective
• Dont miss the big picture

104
Urine Testing

• Rapid Drug Screening
• Pros Inexpensive, fast, sensitive
• Cons Cross-reactivity, false positives
• Needs confirmation
• Gas Chromatography/Mass Spectroscopy
• Confirmation
• Sensitive and specific
• Lower limits
• May be send-out

105
Duration of Positive Tests (Urine)

• Amphetamines
• Alcohol
• Barbiturates
• Valium
• Cocaine
• Heroin
• Marijuana
• Methadone

• 48 hours
• 12 hours
• 10 30 days
• 4 5 days
• 24 72 hours
• 24 hours
• 3 30 days (rare)
• 3 days

(USDHHS, SAMHSA, CSAT TIP 5, 1993)
106
Urine Screening - Opiates

• Most detect Morphine, Codeine,
  6-monoacetylmorphine, Hydrocodone
• Most will NOT detect Methadone, Hyrdopmorphone,
  Oxycodone, Fentanyl, Propoxyphene, Buprenorphine

107
Meconium Testing

• High sensitivity not for meth
• Easy collection
• Detects illicit drug use from 24 weeks gestation
  until birth

108
Other Testing Methods

• Hair
• 3rd trimester
• May stay positive for 3 months after birth
• Umbilical cord
• Newer
• Looks close to meconium in sensitivity
• Serum
• Better for medications that require levels
• Alcohols
• Better dose-response curve

109
What Happens Next?

• Referral for services/report to DHS
• Care plan established
• Support services
• Monitoring of progress

110
Five Points of Intervention

• Pre-Pregnancy
• Prenatal Screening and Services
• Screening and Testing at Birth
• Post-Natal Services to Infants and Children
• Post-Natal Services to Parents

(Source S Gardner, N Young, National Center on
Substance Abuse and Child Welfare)
111
4. Post-Natal Services to Infants and Children

• Early intervention policies and process for
  referrals
• Child welfare developmental assessments of
  substance-exposed infants or older children just
  entering the system

(Source S Gardner, N Young, National Center on
Substance Abuse and Child Welfare)
112
Treatment of Drug Exposed Infants and Children

• Symptoms may vary
• Diagnosis based on a detailed evaluation
  including a detailed history of drug/alcohol use
  during pregnancy
• Treatment based on symptoms that the infant/child
  is exhibiting, not solely on the history of
  drug/alcohol exposure
• Not all drug/alcohol exposed infants and children
  will have problems

(Source Dr. Rizwan Shah, Blank Childrens
Hospital, Des Moines, IA)
113
5. Post-Natal Services to Parents

• Consider setting aside supplemental federal
  funding for treatment for pregnant and parenting
  women
• Family-centered services
• Significant gaps
• Capacity of programs not sufficient to serve all
  those in need of treatment

(Source S Gardner, N Young, National Center on
Substance Abuse and Child Welfare)
114
ASAM (American Society on Addiction Medicine)

• Released July 2011
• Public policy statement on women, alcohol and
  other drugs, and pregnancy
• Addresses three aspects
• Harms that alcohol and other drugs may cause to
  the woman and her developing fetus
• Provides policy recommendations
• Summary statement regarding the use of alcohol
  during pregnancy
• http//www.asam.org/docs/publicy-policy-statements
  /1womenandpregnancy_7-11.pdf

115
Colorado State Meth Task Force SEN Subcommittee

• Began in September 2009
• Multiple disciplines including healthcare
  providers, substance treatment, mental health,
  child welfare and criminal justice
• Finalizing recommendations for policy and
  practice www.coloradodec.org/substanceexposednew
  borns.html

116
Pregnancy Is Only A Part.

• Factors in the postnatal environment mediate
  prenatal factors in predicting developmental
  outcomes

117
The Solution?

• Treatment is needed for mothers who choose to use
  drugs during pregnancy
• Criminalizing this activity will not solve the
  problem and will likely result in avoiding
  prenatal care
• Helping these mothers access treatment is a
  better solution than criminalization

118
Womens Treatment

• Addressing more than substance abuse alone
• mental illness
• domestic violence
• HIV/AIDS
• low incomes
• inadequate or unsafe housing
• Must remove all barriers to successful treatment
  and recovery
• Recovery will only be successful to the extent
  that the issues which precipitate it are also
  ameliorated

119
Successful Treatment Programs for Women

• Removed barriers to attendance
• allowing children
• transportation
• Addressed childrens emotional and behavioral
  problems
• therapeutic child care
• childrens social skills training
• substance abuse education for the children
• Provide parent support services
• Parenting classes
• Home visitation
• Job skills training

120
Motherhood as Incentive

• Motherhood is often the only legitimate social
  role valued by drug dependent women
• Most women in treatment are very concerned about
  how their substance abuse had affected their
  children

• Pregnancy and motherhood are times of
  increased motivation for treatment

121
Drug Treatment

• Treatment for drug (including methamphetamine)
  addiction is effective
• Important component in order to break the cycle
• Involved professionals can influence a parents
  desire to participate in treatment
• Addiction is not a moral failing but rather a
  brain disease
• Every child deserves a parent whose abilities are
  not hampered by substance abuse or addiction

122
Family Drug Courts?

• Offers the client the opportunity to contract
  with the court to seek treatment instead of
  potentially losing their child
• Referred through the countys regular judicial
  system, the department of health or other
  governmental agency
• One- to two-year process of outpatient treatment
  and aftercare, culminating with educational,
  job-training or work programs
• Report to case manager and judge on a regular
  basis
• Drug tested at least once a week

123
Recovery

• Recovery is a lifetime journey, not an event

124
Building a Stronger Continuum of Interventions

• Strengthened partnerships between multiple
  agencies are key to many of these innovations
• Possible with little or no additional
  expenditures
• Compromise on a unified plan

125
Drug Exposed Children

• NOT doomed for life!
• Need
• Patience
• Consistency
• Love
• Hope

126
THANK YOU!
Questions?
127
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