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Incorporating Screening for Substance Use into Routine Prenatal Care

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 10 th Street, F5102 Indianapolis, Indiana 46202

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Incorporating Screening for Substance Use into Routine Prenatal Care

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  1. 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@iupui.edu 1

  2. 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.

  3. 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, O’Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance and outcomes evaluation. JAMA, 2000;284:1689-1695.

  4. 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 4

  5. 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 STI’s combined. 5

  6. 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 1998;7:861-871 Universal Screeningmeans that every obstetrical patient is asked about substance use: At the first prenatal or intake visit, and At least once per trimester thereafter. 6

  7. 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. (p<0.0005) Peles E, Adelson M. Gender Differences and Pregnant Women in a Methadone Maintenance Treatment (MMT) Clinic. J Addictive Diseases 2006; 25: 39-45. 7

  8. 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! * NIDA’s National Pregnancy and Health Survey (1992/1993) 8

  9. 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.

  10. 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 10

  11. 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 • p<0.01 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.

  12. 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 1991;113:94-113. 12

  13. 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

  14. 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 – that’s 29 Million dollars just for the nursery LOS – Saving $140 million

  15. 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

  16. Screening Strategies and Interventions Attitude – Non Judgmental; Empathetic Motivational Empowerment Cognitive Behavioral Therapy 2 Item Screen 4 P’s Plus T-ACE – alcohol screen 5 A’s – tobacco brief intervention FRAMES – brief intervention for alcohol and drugs

  17. 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. 17

  18. 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? 18

  19. 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. 19

  20. 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 P’s Negative answers Low risk of addiction – send for routine prenatal care. Urine drug screen only if all patients get initial urine drug screen. 20

  21. Five P’s (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 P’s plus screen for substance use in pregnancy: clinical application and outcomes. J Pereinat 2005;25:368-374. 21

  22. Five P’s Plus Results A “yes” answer to any question was considered positive. The modified 5 P’s 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 P’s Plus. Chicago, IL: NTI Publishing; 1999. 22

  23. Negative AnswersTwo Item Screen and 4P’s Plus 23 • 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.

  24. The Role Of Urine Drug Screens (UDS) 24 • 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.

  25. 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. 25

  26. How Long is a Drug Detectable in Urine After Use? 26

  27. 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.

  28. Intervention Strategies • There are well recognized intervention strategies for specific drugs: • Alcohol: T-ACE; TWEAK • Tobacco: 5 A’s • Alcohol and Other Drugs – FRAMES • FRAMES is “generic intervention” and can be used for almost all substances and addictive behaviors.

  29. Positive Response with Respect to Alcohol 29 • 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.

  30. 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 30

  31. 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 > 14/drinks/week or > 4 drinks per occasion (men) Consumption is > 7/drinks/week or > 3 drinks per occasion (women) Document the consumption 31

  32. 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 32

  33. 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.) 33

  34. 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. 34

  35. Summary of Alcohol Screening • Get Consumption History • Assess with T-ACE • Use FRAMES intervention. • If continues to use – refer for treatment.

  36. The 5 A’s: 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. 36

  37. Example: Using the 5 A’s 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: Here’s 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.

  38. 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 baby’s 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) 38

  39. 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 1996;86:948-955. Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems: a review. Addiction 1993 Mar;88(3):315-35. 39

  40. 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 1993;88:315-335 40

  41. 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 I’m 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 41

  42. 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, “I’m proud of you for choosing to stop.” 42

  43. 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) 43

  44. FRAMES InterventionMenu 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. 44

  45. 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.” 45

  46. 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 46

  47. The Motivating Questions(to ask at every visit) “How will your life be better by not using (fill in with substance)?” I’ll be a better mother – of course you will. I’ll 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, “I’m proud of you.” 47

  48. 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 doesn’t work - ignoring the problem. 48

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