What We Did About Prenatal Substance Abuse

1. What We Did About Prenatal Substance Abuse Judy Whitecrane MSN, CNM Director, Nurse-midwifery Service Kimberly A. Couch, CNM Phoenix Indian Medical Center

2. Phoenix Indian Medical CenterObstetrics Department 900 deliveries per year 8 CNM�s & 8 MD�s Approx. 150 + UDS at birth Level II Nursery Active Caseload-700 prenatal clients 625 CNM patients 75 MD (Hi risk) 30 (5%) in �Special Care Clinic�

3. Projected Deliveries 2007 Projected 168 positive Urine Drug Screens on admission. 168 babies potentially to be taken from their moms. 168 families, already struggling, to be fragmented and disrupted.

4. Data 3 years of operation Over 400 participants 70% substance abuse 30% �other diagnoses� Depression/Anxiety/Grief Domestic Violence Bipolar Schizophrenia Developmental delays FAS, FAE Homelessness

5. What Drugs? Methamphetamines Marijuana Cocaine/crack Alcohol- assume concurrent use? Narcotics- opioids

6. Maternal Effects Tachycardia, Hypertension, Muscular excitability Abruption- separation of placenta from uterus shortly after receiving amphetamines/cocaine Early in pregnancy- SAB Mid-late pregnancy-massive hemorrhage Potential death of mother and baby This is usually preceded by vaginal bleeding!!!!

7. Fetal Effects Intrauterine growth restriction (IUGR) 30% of cocaine exposed fetuses (ACOG) Placental insufficiency Fetal tachycardia, (?hypertension), fetal stroke Increase birth defects- Cardiac, spina bifida, skeletal abnormalities, gastroschesis (hole in the abdominal wall) (Cocaine 4x�s, and Meth 6x�s)

8. Neonatal Effects Preterm labor and delivery Small for Gestational Age (SGA) Small head circumference Learning disabilities ADHD Developmental delays, etc Neonatal Nursery Lethargic, poor feeder, later irritability Neurobehavioral delays

9. How We Began Staff concern Variation in treating patients Variation in referral practices Lack of knowledge of what or if anything works Strong desire to try to protect unborn Feeling helpless Although drug users may reveal nothing on history to suggest use, there are some �red flags� that raise the physician�s suspicion. These include a chaotic lifestyle, a peer group involved in drug use, easy access to a drug supply and domestic violence. Other �red flags� include patients who suffer from post-traumatic stress disorder (PTSD), have intellectual changes, memory loss, unexplained mood swings and personality changes, frequent missed appointments and problems with health-related compliance. Although drug users may reveal nothing on history to suggest use, there are some �red flags� that raise the physician�s suspicion. These include a chaotic lifestyle, a peer group involved in drug use, easy access to a drug supply and domestic violence. Other �red flags� include patients who suffer from post-traumatic stress disorder (PTSD), have intellectual changes, memory loss, unexplained mood swings and personality changes, frequent missed appointments and problems with health-related compliance.

10. Identifying pregnant SAW ER OB triage Women�s clinic Prenatal questionnaire, history, previous prenatal substance abuse Family/friends/staff refer

11. Why do they seek health care? Trauma Fell down, DV, Assault, Altercation Pelvic pain- STD�s- Chlamydia Vaginal bleeding Preterm contractions/labor No prenatal care + in labor Brought by concerned friend, family member Vague complaints, wants to �check my baby�

12. Began Meeting May 2003 Formed �Substance Abuse Workgroup� Nurses from OB ward Nurses from the Women�s Clinic Nurse-Midwives Social Workers Substance Abuse Counselors Public Health Nurse Case Management Pediatricians

13. Goals of our substance abuse workgroup To protect the unborn from toxic drug exposure To assist mother in successfully abstaining from drugs and alcohol To prevent repeat pregnancies with drug affected newborns

14. Clinic Development Evidence based care Treatment Improvement protocols Idea of incentives emerged Idea of designated clinic emerged Written Guidelines developed

15. Pregnancy �Pregnancy is a powerful motivator�.when you find people receptive to treatment� �If you are able to get away from it during your pregnancy, that can carry over to a time when you�re not pregnant� (Randy Stevens, MD,-addiction researcher)

16. Behavioral Risks Compulsive sexual behaviors Multiple partners Selling sex for drugs High rate of STD�s Chlamydia, HIV, AIDS, Gonorrhea, Syphilis, Hepatitis C and B Criminal behaviors Stealing for money to buy drugs Unintended Pregnancy!!!!

17. Tragedies People with co-occurring MH and Addictive Disorders often seen in emergency rooms, jails, homeless shelters, on the streets, and in the obituaries.

18. Support Network Substance abusing women who are pregnant are viewed as the lowest, even less than criminals. They are cast aside by their families and society. Often their only support is the men who supply them with drugs because of the promiscuous sexual behavior they display.

19. Maternal Coexisting conditions Methamphetamine Treatment Project (1999-2001) AJ of Addictions 2004 Large multisite study (1016 meth users) High levels of psychiatric disease Depression/anxiety Attempted suicide Schizophrenia (10-65% use meth) Anger/assaultive behavior

20. Urine Drug ScreensWritten policy No prenatal care Limited or late entry to care Weight loss, emaciation History of substance abuse (per records) Self-reported history (Clinic posters) +Prenatal questionnaire for drugs within last year Vaginal bleeding Preterm contractions Other children removed from home Obvious intoxication

21. October 2003�Special Care Clinic� begins One afternoon per week Longer appointments Social workers/substance abuse counselor in clinic to see patients

22. Prenatal care-First visit Discuss presenting problem Routine prenatal workup, STD testing If substance abuse, discuss thoroughly and review drug contract and ask for signature UDS at each visit Can be refused, but�refusal is considered a positive test Slips happens

23. Stages in Methamphetamine Treatment 1. Get started agrees to participate in Special Care Clinic. 2. Get clean Counseling sessions, UDS, Gifts & Incentives 3. Stay clean Continue with above throughout pregnancy 4. Stay Healthy (Long-term abstinence support plan) -We need a postpartum program!!! adapted from CSAT, 1999

24. Special Care Clinic Agreement Date_________ Name _______________________ ____ I would like to participate in the Special Care Clinic Program. I know I will receive gifts at each visit for my baby and myself. ____I agree to see a social worker and work with her/him on a plan that will help me with this pregnancy and beyond. Drug and Alcohol program _____I agree to urine drug testing whenever asked by my Nurse-Midwife or Physician. ____ I would like to participate in receiving gift certificates each time I have 3 negative drug tests and have kept my counseling appointments. Date_______Drug Screen _______ Date _______Drug Screen_________ Date_______Drug Screen _______ Date _______Drug Screen_________ Date_______Drug Screen _______ Date _______Drug Screen_________ Date _______Drug Screen_______ Date _______Drug Screen_________ Date _______Drug Screen_______ Date _______Drug Screen_________ Date _______Drug Screen_______ Date _______Drug Screen_________ Date _______Drug Screen_______ Date _______Drug Screen_________ Gift certificate-Date______ Gift certificate-Date______ Gift certificate-Date______ I agree to what is checked above: _________________________ Date_______ Signature

25. Frequency of visit Heavy meth use- consider residential If + for drugs, weekly visits with midwife, and 2 or more visits with social worker/week When several drugs screens are negative, consider weekly visits, etc�

26. Elk, R., Schmitz, J., Spiga, R., Rhoades, H., Andres, R., & Grabowski, J. (1995). Behavioral treatment of� cocaine-dependent pregnant women and TB-exposed patients. Addictive Behaviors, 20, 533�542. This preliminary study examined the efficacy of a contingency management procedure (shaping) on decreasing cocaine use and increasing compliance with health regimens and pregnant substance abusers Pregnant substance abusers received monetary incentives for each successive decrease in the level of cocaine metabolite, cocaine-free specimens, or having all three specimens collected each week meet incentive criteria. All pregnant patients remained in treatment until delivery; mean treatment duration was 16 weeks. Compliance with prenatal care was high, with a mean rate of 72.5% of kept versus scheduled visits..

27. PIMC Contingency (Reward) System Stimulant users often respond well (TIP 33) Maternal instinct not to harm developing baby Rewards for drug abstinence Healthy baby Gifts Helps with CPS at birth Vouchers for retail outlets Sense of accomplishment Human warmth, bonds with staff

28. Urine Drug Screens Every 3 negative drug screens-rewarded with $10 gift certificate for Wal-Mart, target, or Food City Positive drug screens- non-punitive, just seen more frequently (2-3X�s weekly if methamphetamines or cocaine)

29. Gifts & Incentives Gift for self and gift for baby at each visit- Make-up, hair care products, jewelry, watches, lotions etc� Blankets, clothing, pacifiers, baby pictures frames� �Fetus� models; 11-12 week mini baby

30. Social Services/Substance abuse Counseling Makes it as accessible as possible!!! PIMC, next door the prenatal visit Don�t have to explain to clerk purpose of visit Same counselor each visit Female preferred

31. Social Worker; Typical First Visit Develop trust Encourage participation Discuss Special Care Clinic- �Why are you here?� Participation is voluntary Identify their strengths Mini-psychosocial assessment

32. Newborns and beyondNIDA study Howard, J., Tyler, R., Espinosa, M., & Beckwith, L. (1996). Birth outcome in cocaine- abusing women following three months of drug treatment. In L. S. Harris (Ed.), Problems of drug dependence, 1995: Proceedings of the 57th Annual Scientific Meeting. National Institute on Drug Abuse. Polydrug-using (cocaine plus other drugs) pregnant women (N = 72) participated in a drug treatment program including regular urine toxicology testing. Women who decreased their drug use at least 50% from intake gave birth to infants with longer gestational periods, higher birth weights, and larger head circumferences. Chemical used to make these drugs are explosiveChemical used to make these drugs are explosive

33. Meth Baby Myth No identified syndrome attributable to meth LD, ADHD, Conduct disorders may have environmental cause Labels follow the individual Lower expectations may result

34. Breastfeeding and Meth Infant deaths reported after meth using mom breastfeeds Institutional policies often prohibit Benefits Fewer colds, flu, etc� Less obesity Less diabetes Bonding/attachment issues

35. �Reasoned Approach� Explain and document risk. Maintained abstinence during pregnancy after entering SCC Breastfeeding hotline info What to do if slip occurs- no breastfeeding for 3 days, call hotline & counselor, etc�.

36. Patient evaluations Some still lost to follow-up 50% have four or more visits- some as many as ten visits Good rapport with patients Many are drug free- others with occasional usage. Often self-report lapses

37. Comments from patients I can�t believe I have done this!!- (gone without drugs) �It helped me realize I�m gonna be a mother. Also how to take care of myself & child� �Helped me to quit and not use when pregnant� �It helped the most to be screened and drug tested�

38. Comments from patients �It helped by not judging me� �The social worker and the OB people & the Drs. They all helped me want to change my life for the better. Thank you for helping me want to stay clean� �Kept me clean by encouragement�

39. Phase II �drop in deliveries+ UDS Reported to CPS If baby is also +, increases level of concern Baby may be placed in foster care Extremely emotional event Mother may plunge deeper into drugs

40. Phase IIDrop in deliveries with + drug screens Set up database of these patients Nurse-midwife as Case manager Encourage contraception, treatment Prevent another substance exposed infant next year

41. Patient #1 Meth Death Multigravida Class B DM Two other children alive and well; received prenatal care with them Began using meth 2 years ago Unplanned pregnancy No prenatal care

42. Meth Death Presents to ER IUFD Ketoacidosois Sepsis, Fever 103 Dies in ER

43. Patient #2 Near Miss Limited prenatal care- no records Vaginal bleeding all night- FOB brings patients in- he is extremely agitated-worried about �her� Patient Reports bleeding, �not that bad� Can�t lay down in bed-has to sit up to get her breath Looks pale

44. Near Miss Cont�d EFM- contractions with late decels Estimated at 34 weeks STAT C/S Baby survives Admission Maternal Hg- 3.0 Transfused in OR Patient Survives

45. Patient #3 No prenatal care, G8P6sab1, Two previous C/S, 4VBAC Estimated to be term, admits to Meth use that morning. �My water broke this morning, I�m in labor� No FHT�s, IUFD (pt. reports last fetal movement within the hour.) Delivers a few hours later with pitocin augmentation of labor. The infant is in an advanced state of decomposition. Death probably occurred days prior.

46. Patient #3 Postpartum Profuse bleeding and retained placenta To the OR, 100 feet away from the delivery room, this patient lost 2500cc of blood. She lost another 2000cc during the procedure. Stat Hysterectomy and massive blood replacement.

47. Patient #4 30 week IUP No prenatal care Contracting 3/-1/80% BP 160/99 Maternal HR 130�s Vaginal bleeding off and on

48. Patient #4 treatment Tocolysis-MgSO4-6 Gram bolus, 2 Grams per hour (Avoid terbutaline) CBC, Type and screen (cross) UDS Large bore IV (2) Prepare for transport Betamethasone 12 mg IM (24-34 weeks-ACOG) 2 doses 12 hr apart Apresoline 5-10 mg IV- give in small doses

49. Future plans On site GED program On site support group (substance using women) Native parenting program After care groups Graduate continue to be involved and mentor others

50. Summary Form a multidisciplinary team Use known treatment protocols Market your program to all departments, members of your organization Use non-punitive, non-judgmental approaches Use pregnancy as a motivator Celebrate every success