Illicit Drug Abuse and Dependence in Women

1. Illicit Drug Abuse and Dependence in Women A Slide Lecture Presentation 409 12th Street, SW Washington DC 20024 202/638-5577 www.acog.org

2. Illicit Drug Abuse and Dependence in Women Ronald A. Chez, MD, FACOG University of South Florida, College of Medicine Robert L. Andres, MD, FACOG University of Texas Medical School, Houston Cynthia Chazotte, MD, FACOG Albert Einstein College of Medicine Frank W. Ling, MD, FACOG University of Tennessee, College of Medicine

3. This educational program was funded by the Physician Leadership on National Drug Policy at Brown University, Providence, Rhode Island. (www.plndp.org) The Physician Leadership on National Drug Policy project is supported through generous contributions from individuals and foundations, primarily the Robert Wood Johnson Foundation and the John D. and Catherine T. MacArthur Foundation.

4. Overview • Addiction to illegal drugs: • a major national problem • causes impaired health, harmful behaviors • creates major economic and social burdens • Treatment of drug addiction: • efficacy equivalent to other chronic conditions: • hypertension • asthma • diabetes mellitus

5. Prevalence and Incidence • Substance use varies among and within different cultural groups: • Present among all socioeconomic, cultural and ethnic groups • Descriptive categories of abusers do not represent distinct, homogenous groups

6. Prevalence and Incidence • 30 million Americans have used illegal substances: • 40% of 25-30 year olds • Adult monthly cocaine users: • 1.5 million abusers • 67% are employed full time • 53% of their fathers went to college • Age of first use is declining: • 23% high school seniors regularly use marijuana • 10% of all students have used an illicit drug

7. Prevalence and Incidence • 3.6 million Americans dependent on illicit drugs: • 50% have a co-morbid medical condition • 19,000 drug addiction deaths annually • $4.5 billion in health expenditures: • only 10% used for treatment of addiction • $44 billion productivity loss

8. Physician Barriers • Lack of training: • only 1/3 primary care physicians carefully screen for substance abuse • only 1/6 believe they are very prepared to spot illegal drug use • Most misunderstand: • chronic, relapsing nature of dependence • intensity of the urge to use • preoccupation with the substance

9. Physician Barriers • Lack of awareness: • pervasiveness throughout society • treatment options • community resources • Skepticism: • treatment for illegal drug abuse is not effective • patients lie about their substance abuse • Discomfort: • difficulty discussing potential of prescription drug abuse

10. Physician Barriers • Time constraints: • impediment to full discussion with patients • Fear of losing patients by asking: • resulting in patient fear, anger • Insurance coverage: • lack of reimbursement for time to screen • lack of reimbursement parity for treatment • denial of coverage for referrals

11. Physician Barriers • Physician as an enabler: • giving tacit approval of the abuse by not addressing the problem • providing patient excuses for work or school • providing prescriptions for inappropriate drugs and in excess quantity including refills • Physician may be a drug abuser

12. Patient Barriers • Reasons for lying to physician: • ashamed, afraid, do not want to stop • non-sympathetic, non-confidential setting • physician not knowledgeable, acting busy • Abusers’ attitudes toward physicians: • do not know how to detect addictions • prescribe potentially dangerous drugs • never diagnosed the abuse • knew about abuse but did nothing about it

13. Patient Barriers • Fear of government agencies • Loss of family role with legal and child-custody implications • Societal stigmata • Denial: • may be subconscious and unaware • a psychological defense against acknowledging the personal pain

14. Patient Barriers • Enabling by others reinforces patient denial: • covering at work or school • hiding the problem from superiors at work or school • minimizing or ignoring the substance abuse problem • providing drugs to avoid confrontation or unpleasantness

15. Diagnostic Criteria: Substance Abuse • A maladaptive pattern of substance use leading to clinically significant impairment or distress manifested by 1 or more of the following occurring within a 12 month period: • use results in failure to fulfill major role obligations: • work: absences, poor performance • school: absences, suspensions, expulsions • home: neglect of children or household • recurrent use in physically hazardous situations • recurrent substance-related legal problems • continued use despite resulting persistent or recurrent social or interpersonal problems

16. Diagnostic Criteria: Substance Dependence • A maladaptive pattern of substance use leading to clinically significant impairment or distress manifested by 3 or more of the following occurring at anytime within the same 12-month period: • tolerance of the substance: need for markedly increased amounts to achieve intoxication or the desired effect, or markedly diminished effect with continued use of the same amount • withdrawal: the characteristic withdrawal syndrome, or substance taken to relieve or avoid withdrawal symptoms

17. Substance Dependence (continued) • larger amounts of substance taken or over a longer period than was intended • persistent desire or unsuccessful efforts to cut down or control use • great deal of time spent in activities toobtain, use or recover from the substance’s effects • important social, occupational and recreational activities given up or reduced because of use • continued use despite knowledge of a persistent or recurrent psychological or physical problem likely to have been caused or exacerbated by use

18. Role of Ob/Gyn Physician • Screening, identifying and counseling women regarding substance use • Routine screening in history taking: • no physical symptoms in majority of abusers • screen everyone since no predictors • Know local community resources • Triage to community resources

19. Screening Questions • First, use ubiquity statements: • “Substance use is so common in our society that I now ask all my patients what, if any, substances they are using?” • Then, ask direct questions: • “Have you ever tried . . .?” • “How old were you when you first used . . .?” • “How often; what route; how much?” • “How much does your drug habit cost you?”

20. History: Red Flags • Maternal chaotic lifestyle: • psychosocial stresses • spouse/partner of an alcoholic or drug abuser • domestic violence, physical and sexual • Psychiatric diagnosis: • depressions, psychosis, anxiety, PTSD • lack of functional coping skills • unexplained mood swings, personality changes • Late or no prenatal care: • missed appointments and compliance problems • STDs, sexual promiscuity

21. Physical Examination Nothing unusual is the most frequent finding in users of illicit drugs.

22. Toxicology Testing: Principles • Random checks without clinical suspicion: • many consider this unethical • may be illegal in some locales • Nonemergency and competent patient: • verbally inform prior to testing • document permission in medical record • Test if necessary to direct immediate medical interventions

23. Toxicology Testing: Screening Panel • Usually urine: • major route of excretion and concentration • inexpensive and quick • Tests include: • enzyme multiplied immunoassay techniques • thin layer chromatography • Confirmatory tests: • gas chromatography, mass spectrometry

24. Toxicology Drug Screen: Urine • Time frame for drug or metabolite to be present: • marijuana, acute use 3 days • marijuana, chronic use 30 days • cocaine 1–3 days • heroin 1 day • methadone 3 days

25. Treatment: Principles • Drug addiction is a treatable disease • No single treatment is appropriate for all individuals • Recovery from drug addiction is a long-term process: • multiple treatment episodes with relapses • Effectiveness is dependent on remaining in treatment for a dedicated period of time • Matching multiple needs is critical: • medical, psychological, social, legal, vocational

26. Treatment: Cost Considerations Annual treatment costs for a drug addict:

27. Plan of Care • Establish a supportive relationship • Educate the patient: • ask the patient to describe her understanding of the situation and correct misunderstandings • link substance use to patient’s signs & symptoms • describe the importance of stopping or cutting down • explain consequences of continued use • Refer to specialists for assessment and initiation of a treatment plan

28. Treatment: Critical Components • Detoxification • Medications combined with counseling • Behavioral therapies: skill-building, problem-solving to prevent relapse • Assess for and treat coexisting conditions: • mental disorders • infectious diseases • family planning

29. Treatment: Behavioral Change • Prochaska’s stages of readiness: • assess the patient’s readiness for change and to accept treatment • match intervention strategies and goals to the patient’s stage • Stage = precontemplation • patient does not believe a problem exists • needs evidence of problem and its consequences

30. Treatment: Behavorial Change • Stage = contemplation • patient recognizes a problem exists: • is considering treatment • patient needs: • support/encouragement to initiate treatment • information on treatment options • referral to a specific treatment program

31. Treatment: Behavioral Change • Stage = action • patient begins treatment: • needs ongoing support • needs follow up to ensure success • Steps to break the cycle of recurrent binges or daily use: • weekly contact • peer support groups • family or group therapy • urine monitoring

32. Treatment: Behavioral Change • Intervention with family, close friends and co-workers: • group meets with patient • each group member states the effects of the patient’s substance use • consequences of not accepting treatment are stated: • loss of job; loss of family • legal consequences • potential of danger from drug access & presence • expressions of concern, support and love

33. Treatment: Behavioral Change • Stage = relapse • expected, not a failure • prevention is essential: • alter life style to reduce their influence • develop drug free socialization • identify social pressures that may predict use: • rehearse avoidance strategies • learn ways to deal with negative feelings: • identify ways to manage distorted thinking

34. Prevention: Stages • Primary prevention = use has not begun, or use is not problematic • Secondary prevention = treatment of problematic users • Tertiary prevention = preventing and treating complications of substance abuse

35. Prevention: Prescribing Guidelines • Potentially addictive drugs: • assess option of alternative treatments: • nonpharmacological treatments • nonaddicting medications • determine risk of developing abuse or dependence • order an initial dose sufficient to provide analgesia, then taper to smallest effective dose

36. Prevention: Prescribing Guidelines • Analgesics for acute pain symptoms: • short period of time for treatment • avoid more than one refill • avoid telephone refills • reassess at frequent intervals • prescribe on a fixed schedule vs. prn • taper, rather than discontinue if used long term • Write both number and word to minimize alteration

37. Prevention: Drug Seeking Clues • Patient may be abusing psychoactive medication: • exaggerates or feigns symptoms • loses prescriptions or medications • runs out of medications ahead of time • obtains same prescription from multiple doctors • claims refill need but original doctor not available • insists that only one drug will work • demands an immediate prescription for a chronic illness • threatens when physician does not comply

38. Fertility • Generic factors related to substance abuse: • men: • impotence • decreased semen quality • women: • alterations in ovulation • menstrual irregularity • libido: • variable effect

39. Pregnancy • Prevalence and incidence: • no difference: • indigent/nonindigent patients • public and private clinics • ethnic groups • 4 million women who gave birth: • 757,000 drank alcohol products • 820,000 smoked cigarettes • 221,000 used illegal drugs

40. Pregnancy: Generic Issues • Educate patient about adverse outcome effects • Screen for domestic violence • Screen for STDs, hepatitis B and C, TB • Co-manager or refer to multispecialty clinic • Refer to drug counseling program • Monitor with urine toxicology • Sequential antepartum assessment of growth • Refer newborn to pediatrics • Close postpartum follow up

41. Cocaine • Alkaloid from leaves of Erythroxyloncoca bush: • marketed as crystals, granules, white powder • routes: • intranasal, parenteral, oral, vaginal, rectal • decomposes with heating, melts at 195oC • water soluble • Crack cocaine alkaloid is free base: • soluble in alcohol, oils, acetone, ether • colorless, odorless, transparent crystal • melts at 98oC • not destroyed at higher temperatures

42. Cocaine • Produces a dose dependent increase in: • heart rate and blood pressure • arousal, enhanced vigilance and alertness • sense of self confidence and well-being • Chronic, heavy use associated with: • pronounced irritability • paranoid ideations • increased risk of violence • reduced libido

43. Cocaine: Adverse Maternal Effects • Possible systemic complications: • cardiovascular: • tachycardia and cardiac arrhythmias • vasoconstriction and hypertension • central nervous system: • hyperthermia • CVA • seizures

44. Cocaine: Adverse Fetal Effects • Questionable Congenital anomalies: • published data are equivocal • reported anomalies include: • limb reduction defects • genitourinary tract malformations • congenital heart disease • central nervous system

45. Cocaine: Adverse Fetal Effects • Impaired fetal growth: • decrease in mean birthweight • increase in low birthweight infants • increase in intrauterine growth restriction • significant correlation between cocaine metabolites in meconium and decreases in birth weight, birth length and head circumference.

46. Cocaine: Adverse Prenatal Effects • Preterm labor and delivery: • no consensus among clinical studies: • Premature separation of the placenta: • most studies confirm • Premature rupture of the membranes: • controversial association

47. Cocaine: Adverse Neonatal Effects • Initial neurologic findings: • coarse tremor • hypertonia • extensor leg posture • Increased risk of SIDS (4x) • Long-term consequences: • no consistent negative associations • developmental outcome similar to drug-free newborns

48. Cocaine: Treatment • Goal = help patient resist the urge to restart compulsive cocaine use • Options according to personal characteristics: • group and individual drug counseling • cognitive behavioral therapy to prevent relapse: • ways to act and think in response to cues • avoid environmental/social pressures • practice drug refusal skills • medications

49. Opiates and Opioids • Opiates (naturally occurring): • derived from the Paper somniferum poppy • examples: morphine, codeine • Opioids (synthetic): • examples: fentanyl, heroin, hydrocodone, hydromorphone, meperidine, methadone, and oxycodone

50. Heroin • Routes: • inhaled, intranasal, IV, IM, SQ • lipid soluble, rapidly crosses the blood-brain barrier • Constant oscillation between feeling: • initial warmth, intense pleasure or rush • duration of high between 3-5 hours • followed by sedation and tranquility (on the nod) • symptoms of early withdrawal