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Editor Joann Grayson, Ph.D. Editorial Director Ann Childress, MSW Sponsored by Editorial Assistant Wanda Baker Child Protective Computer Consultant Services Unit Phil Grayson, MFA Student Assistants Virginia Department Anthony Chhoun of Social Services Tigrai Harris Hayden Heath

Summer, 2016 Virginia Child Protection Newsletter Volume 106

SUBSTANCE USE IN PREGNANCY

compared to 14.5 million or 5.8% in 2007). Legal substances also impact pregnancy. Sandra grew up in a nice neighborhood, at- Della started abusing prescription pain Alcohol is a widely-used substance by wom- tended a private school, and graduated from medication and smoking marijuana in her en of child-bearing age. In a national sample, college. She had been dabbling in drugs teen years. She still functioned and was 17.9% of pregnant women were found to since high school but did not discover heroin employed. She quit illicit drug use during drink alcohol during the first trimester of until her senior year in college. After gradu- her first pregnancy. She relapsed and later pregnancy. The numbers drop to 4.2% in the ation, she relocated to a fast-paced city just discovered that she was pregnant again. This second trimester and 3.7% in the third tri- to be close to drug activity. She obtained time, she could not quit. mester (SAMHSA, 2013). Over 20% of the a good job but lost it within a year due to population smokes cigarettes. In a national absences and poor performance. When she sample, 18.9% of pregnant women were discovered that she was pregnant, she began smoking cigarettes (Havens et al., 2009). a methadone program and entered a sober Legally-prescribed substances and medi- home, but relapsed anyway. To avoid another cations can be misused or, even if taken as relapse, she entered a residential program prescribed, may affect the developing fetus. which was effective, along with the metha- Substance use in pregnancy has also done maintenance, in controlling her illicit changed over the past three decades. The drug use. Still, Sandra feels she has lost so incidence is believed to be increasing and the much of what she valued and she is worried substances used also change (Keegan et al., about maintaining abstinence and providing 2010). Each year in the United States, an es- for her baby when she leaves the hospital. timated 400,000 to 440,000 infants (10-11% Substance use in pregnancy can cause of all births) are affected by prenatal alcohol medical complications depending on how or illicit drug exposure (National Center on At 28 weeks pregnant, Tiffany presents to substances are administered. Pregnant wom- Substance Abuse and Child Welfare). Ac- a neighborhood health clinic with cramps. en who abuse substances, including legal cording to Young and Gardner (2007), more She has not started prenatal care and has a substances such as alcohol and nicotine, than 7 million children and youth under age 3-year-old with her. The fathers of both chil- have a greater-than-normal risk of medical 18 have been exposed prenatally if nicotine dren are in prison. Tiffany smokes 2 packs complications. These women should be and alcohol are included along with use of of cigarettes daily, drinks a six-pack of beer monitored regularly for signs of anemia, illicit substances and misuse of prescription several times a week, and occasionally uses poor nutrition, increased blood pressure, hy- medications. Most are not detected at birth cocaine. She grew up in foster care and has perglycemia, sexually transmitted diseases, and leave the hospital without any follow-up never had a fixed address. hepatitis, and preeclampsia. Infections such or services. as Hepatitis B and C, tetanus, and cellulitis About half of pregnancies in the Unit- can be profoundly harmful to both women ed States are unintended. Women who Josh is seven days old and weighs 5 pounds. and their fetuses, especially if unrecognized abuse substances are at even higher risk of He’s in the neonatal care unit experiencing and untreated (Treatment Improvement Pro- the symptoms of opioid withdrawal. His tocol Series, No. 43). mother, Mary, followed her doctor’s advice Illicit drug use in the United States is in- and took methadone during her pregnancy creasing, according to the National Institute instead of continuing heroin use. Now Josh on Drug Abuse (2015). In 2013, an estimated must be weaned from the methadone. Mary 24.6 million Americans aged 12 or older- understands his pain. Still, hearing his high- about 9.4% of the population- used an illicit pitched cries is agonizing. Josh is swaddled drug within the past month. In 2003, the and held in a spot with dim lights and gentle percentage was 8.3. The increase is mainly music. due to increased use of marijuana (19.8 mil- lion users- about 7.5% of those over age 12 continued on page 2 2 cellulitis and HIV which further complicate risk of serious infectious diseases, especially pregnancy (Keegans et al., 2010; Shan- if used intravenously. Individuals addicted to karan et al., 2004). Maternal nutrition and prescription opioid pain relievers sometimes health status affect the developing fetus and switch to heroin because it produces similar intersect with substance use as women who effects and may be cheaper and easier to are abusing substances may have nutritional obtain (Mactier, 2013; National Institute of deficiencies (Huestis & Choo, 2002). Drug Abuse). Substance use is associated with a According to a review by Wilder, Lewis number of other factors that can negatively & Winhusen (2015), the percentage of preg- affect maternal prenatal care. Mothers who nant women who use opioid drugs has tri- use substances have been found to be more pled in the ten years between 2002 and 2012 likely to have no partner, receive Medicaid, with 1.2% of all pregnant women reporting Substance Use in have lower SES, and have less education opioid use in 2012. Certain subgroups appear Pregnancy than abstainers. Substance-using women to be at higher risk. For example, a Canadian continued from page 1 may start prenatal care later and attend a study (Kelly et al., 2011) found 17.2% of lower percentage of prenatal visits (Nguyen neonates in their study of First Nations pop- unintended pregnancies (Grant et al., 2014). et al., 2010). ulation in Ontario were exposed to narcotics. Women who don’t plan on pregnancy may Exposure to substances in utero can affect According to Winklbaur et al. (2008), for be using alcohol or other substances during individuals across the lifespan (National illicit drug use in pregnancy, opiate use is the the early months of pregnancy without Institute on Drug Abuse, 2011). Estimat- second only to marijuana use and is almost realizing they are pregnant. The majority of ing the full extent of the consequences of four times greater than use of cocaine. women stop risky behaviors and substance maternal drug abuse is difficult for many Opiate-abusing mothers tend to have use as soon as they learn they are pregnant. reasons. According to the Centers for decreased health and poor nutrition, are Women who continue to use may be uned- Disease Control (2014), little is known less likely to obtain adequate prenatal care, ucated about the negative effects of sub- about the use of most medications during and are likely to abuse other substances stances on the fetus or they may be addicted pregnancy. Less is known about use of illicit (CRC Health Group, 2016). Poor obstetric and unable to quit use without additional substances. Factors that can determine the outcomes such as pregnancy complica- support and treatment (Virginia Department effects include: dose (how much is taken); tions, spontaneous abortions and premature of Behavioral Health & Developmental when during the pregnancy the substance is labor can be up to six times higher (600% Services, 2014). Pregnant women who are taken; the mother’s other health conditions; increase) if the mother is abusing opiates unemployed, unmarried and experiencing and other substances taken or used. As noted (CRC Health Group, 2016; studies reviewed current psychopathology are at greater risk above, multiple individual, family, and envi- in Holbrook & Nguyen, 2015; Keegan et of continued use of substances (Havens et ronmental factors (including but not limited al., 2010). For those using illicit intravenous al., 2009). to nutritional status; when prenatal care was heroin, risk of medical complications such as In 2012, the substance used by the largest begun; socioeconomic conditions) can make infectious diseases, abscesses and sexually number of pregnant women was tobacco, it difficult to tease out the effects of sub- transmitted diseases are increased (Winkl- followed by alcohol and then illicit drugs stances. Conversely, some effects from drug baur et al., 2008). (National Center on Substance Abuse and exposure are believed to be mitigated by Of the opiates, heroin has been the most Child Welfare). Changes in the type of sub- positive and supportive home environments frequently studied substance. It crosses stances used by pregnant women have been and quality parenting. the placenta readily and enters fetal tissues noted. The 2010 National Survey on Drug Even with challenges, there is some within an hour of maternal use. According Use and Health found decreasing numbers consensus about some of the possible effects to a National Public radio report (Tribble, of pregnant women abusing alcohol while of substance use in pregnancy. The projected 2016) a baby is born with Neonatal Absti- drug abuse increased (Virginia Department effects can differ by the type of substance, so nence Syndrome in the United States every of Health, Office of the Chief Medical Ex- the next sections will discuss findings about 25 minutes. Others offer a slightly higher aminer, 2015). A 2013 report by SAMHSA a particular substance or class of substances. figure of 27,000 cases in 2013 (Wilson & on trends in substance use among women Shiffman, 2015). pregnant at treatment entry documented Neonatal Abstinence Syndrome (NAS) a decrease in alcohol use (from 46.6 % in refers to situations in which newborns ex- 2000 to 34.8% in 2010) while the percentage perience a constellation of drug withdrawal reporting drug abuse but not alcohol abuse symptoms shortly after birth due to drug increased from 51.1% in 2000 to 63.8% exposure in utero. According to Newman in 2010. Non-pregnant women showed a (2013), it is important to note that no baby similar pattern. can be born “addicted” and physiologic Determining effects of substance use dependence is different than addiction. during pregnancy use is complicated. Addiction is a technical term that refers to Women who use one substance only may be compulsive behaviors that continue in spite less frequent than women who combine use of adverse consequences. of several substances. For example, women NAS is not inevitable if a woman is using who use opiates are likely to also use tobac- Opiates opiates. Studies cited in Keegan et al. (2010) co, alcohol, and cocaine, all of which also and by Mactier (2013) show between 45% have potentially negative effects on the fetus. Opiates include morphine, codeine, and 97% of infants exposed to heroin or to For women who use cocaine, the majority heroin, methadone, fentanyl, oxycodone, methadone maintenance will develop NAS. also use alcohol, tobacco and marijuana. and hydromorphone. The principal action of Similar estimates are cited by the National Sometimes one substance is mixed with opioid drugs is pain relief but euphoria and Center on Substance Abuse and Child Wel- another. For example, heroin may contain dissociation can also occur, promoting rec- fare (2012) and by Bandstra et al. (2010). amphetamine. Intravenous drug use is reational use. Common side effects include NAS can also be worsened by poly-sub- becoming more common and has additional sedation, respiratory depression and consti- stance use or smoking cigarettes (Jansson risk factors, for example infections such as pation. Use of opiates is linked to increased et al., 2012; Mactier, 2013). For example, 3 infants born to mothers on methadone during gestation who reported smoking 20 or more cigarettes a day had significantly higher peak SYMPTOMS OF NEONATAL NAS scores than when mothers were on ABSTINENCE SYNDROME methadone maintenance but did not smoke (Choo et al., 2004). • Persistent or prolonged high-pitched crying NAS is diagnosable and treatable. • Central nervous system hyper-irritability Symptoms of NAS can begin within 1 to • Gastrointestinal dysfunction (such as vomiting or diarrhea) 3 days after birth or may take 5-10 days to which can lead to weight loss appear. Babies who are born to opiate-abus- ing mothers can be very irritable with a • Excessive sucking reflex high-pitched cry, sneezing, restlessness and • Sleep problems poor sleep patterns. They have lower birth • Frequent yawning weights, diarrhea, tremors, and weight loss. • Nasal stuffiness or sneezing Feeding can be affected with frantic sucking. • Fever A smaller number of babies can be much • Sweating quieter with a reluctant feeding pattern • Rapid breathing (Mactier, 2013). They are at greater risk of • Feeding problems sudden infant death syndrome (SIDS). • Respiratory distress Sometimes, an infant’s withdrawal from opiates may be managed by simple measures • Dehydration such as swaddling, rocking, and minimizing • Tremors or seizures environmental stimulation (Mactier, 2013). However, treatment for NAS, a more ex- Source: March of Dimes Issue Brief treme form of withdrawal, can be expensive. According to sources cited by the Nation- were more likely to have neuro-developmen- to intrauterine fetal death and miscarriage al Center on Substance Abuse and Child tal impairments at 18 months and 3 years (CRC Health Group, 2016; studies cited in Welfare in 2009 the mean length of stay of age. The review by Holbrook & Nguyen Keegan et al., 2010). for infants with NAS was 16.1 days at an (2015) found lower cognitive and language Buprenorphine (Subutex or Suboxone) average cost of $53,000. Some infants may functioning, but no differences in execution treatment has also been used effectively need as long as 10 weeks in intensive care of motor and sensory tasks. to treat opiate addiction in pregnant wom- (Bhuvaneswar et al., 2008). Opioid-dependent women who are en (Newman, 2013). Large double-blind Breast feeding can reduce the sever- pregnant can be helped by methadone main- placebo-controlled trials of buprenorphine in ity of NAS and shorten the hospital stay tenance or buprenorphine treatment. It is general populations of addicts have shown (Mactier, 2013). Mothers are encouraged to considered safe for the baby, keeps the moth- reductions in opiate use comparable to use breastfeed, even though that option can be er free of withdrawal and offers an opportu- of methadone but with fewer withdrawal challenging due to symptoms of NAS such nity for the pregnant woman to take care of symptoms on discontinuation (McLellan et as uncoordinated sucking of the baby. Unless herself, and is shown to reduce risk-taking al., 2000). In one study (Jones et al., 2010), there are contraindications such as continued and criminal behavior. Higher doses of neonates exposed to buprenorphine required concomitant drug abuse, HIV positivity or methadone may reduce illicit opiate abuse significantly less morphine, had a signifi- use of certain psychoactive medications, the and possibly reduce use of other substances cantly shorter duration of treatment for NAS American Academy of Pediatrics recom- (Ebner et al., 2007; Davie-Gray et al., 2013; and required a shorter hospital stay com- mend that mothers in Medication Assisted Mactier, 2013). pared to neonates exposed to methadone. Treatment (MAT) be encouraged to breast- Methadone is currently the only medica- Preliminary studies of buprenorphine feed. The evidence suggests that only low tion approved for the addiction treatment of during pregnancy have shown the medication to be safe and effective for both mother and levels of methadone or buprenorphine are pregnant women who are dependent upon opiates (CRC Health Group, 2016). Metha- child. However, studies are not yet at a point transmitted to infants in breast milk (Hol- done is a long-lasting and stable opiate that where the U.S. Food and Drug Administra- brook & Nguyen, 2015). keeps blood serum levels at a constant level tion (FDA) will recommend buprenorphine. There is limited and conflicting data throughout the day. This stability keeps the A doctor may choose to prescribe it if meth- about longer-term effects of prenatal expo- fetus from experiencing withdrawal discom- adone is not available or the woman cannot sure to opioid drugs. There appears to be fort and therefore reduces stress on the fetus tolerate methadone, if the woman is already no evidence of congenital malformations (CRC Health Group, 2016). Women who taking buprenorphine or if the woman (Bandstra et al., 2010). Some sources indi- participate in MAT are more likely to receive refuses methadone. cate that infants may lag developmentally appropriate prenatal care and are more likely Because MAT has such strong evidence during the first year but are thought to have to maintain a healthy lifestyle (CRC Health for improved treatment outcomes, retaining normal development thereafter (CRC Health Group, 2016). Opioid therapy is associated pregnant women in MAT is perceived as crit- Group, 2016). According to the Nation- with longer gestation and higher infant birth ical (Wilder at al., 2015). One challenge in al Center on Substance Abuse and Child weight (Bandstra et al., 2010; studies cited in offering MAT is a limited number of clinics Welfare, several studies that have followed Gopman, 2014) and significantly decreases that accept Medicaid (nationwide, 35% of infants through age 5 have found that cog- the risk of spontaneous abortion (Holbrook clinics do not). Stressors increase after the nitive development in NAS infants is within & Nguyen, 2015). birth of a child. Coping with the needs of expected ranges. However, some analyses Withdrawal from methadone is viewed as an infant, often with limited family support, (studies cited in Mactier, 2013) suggested rarely appropriate during pregnancy. With- as well as managing increased financial and risk of cognitive and motor delay persisting drawal during pregnancy is associated with time constraints all are thought to contrib- at least to preschool years. For example, worse outcomes for the fetus overall (Bhu- ute to treatment drop-out for new mothers Hunt, Tzioumi, Collins and Jeffery (2008) vaneswar et al., 2008; Wilder et al., 2015). (Wilder et al., 2015). found children who were opiate-exposed Further, aggressive withdrawal could lead continued on page 4 4 coordination. The drug also increases heart rate, can harm the lungs, and can increase the risk of psychosis in those with underly- ing vulnerability. Studies indicated that 3% to 16% of all pregnant women use marijuana (studies Benzodiazepines cited in Keegan et al., 2010). More recent data from the 2007-2012 National Surveys Benzodiazepines are a type of medication on Drug Use and Health (NSDUH) shows commonly known as tranquilizers. Familiar 3.9% of pregnant women used marijuana names include Valium and Xanax. Benzo- within the past month and an additional diazepines are some of the most frequently Substance Use in 7.0% of pregnant women had used within prescribed medications in the United States the past year. More than 1 in 10 pregnant and are used to treat conditions such as Pregnancy women reported marijuana use in the past 12 anxiety and insomnia (Nordqvist, 2016). continued from page 3 months. A considerable percentage of those Abuse of benzodiazepines is becoming a serious public health issue (Nordqvist, An additional significant risk for pregnant who used marijuana (16.2%) reported daily 2016). Abusers are at risk for fatal over- women who are addicted to opioid drugs is use and 18.1% of users met criteria for abuse dose, confusion, slurred speech, seizures, the effects of tobacco. Akerman et al. (2015) or dependence (cited in Ko et al., 2015). severe drowsiness and weakness. Use of report that 88 to 95% of pregnant women It is hard to separate potential effects of benzodiazepines is often complicated by use receiving MAT for opioid use also smoke marijuana as users frequently use other illicit in combination with other drugs (Ogbru & cigarettes. This compares to a rate of 8 to drugs. Marijuana is not a pure substance and Marks, 2016). 16% reported in the general population of it varies in potency. Over 400 chemicals and While dated, Arria et al. (2005) found pregnant women (see below). The negative substances have been found to be mixed into that less than 1.0% of their sample of 1,632 effects from smoking, according to Akerman marijuana (Keegan et al., 2010). Women pregnant women used benzodiazepines. et al. are potentially more severe than the who are likely to continue to use marijuana However, Leppee et al. (2011) found Diaz- effects associated with opioid use. while pregnant are younger, have higher lev- epam ranked second among twenty most Pregnant women dependent on opioid els of depression, and are more likely to also frequently prescribed drugs in pregnancy. drugs require careful treatment to minimize smoke cigarettes and use alcohol. They also The risks for use in pregnancy include multi- harm to the fetus and neonate and improve continue to use marijuana when parenting ple anomalies including cleft lip and palate, maternal health. Applying multi-disciplinary children (National Institute of Drug Abuse, fetal growth restriction, and intrauterine fetal treatment as early as possible, allowing med- 2015). death (Bhuvaneswar et al., 2008; Keegan ication maintenance and regular monitoring According to studies reviewed by Keegan et al., 2010; Leppee et al., 2010). There are all can benefit mother and child (Davie-Gray et al. (2010) there is no known increase in risks for discontinuation during pregnancy et al., 2013; Winklbaur et al., 2008). pregnancy complications due to marijuana including withdrawal symptoms and recur- It is believed that many cases or even and there are no known increases in the risk rence of depression (Leppee et al.). the majority of cases are not reported to of congenital abnormalities, although there child protective services. Mothers who are may be fetal growth restriction as well as struggling with addiction may be unable to withdrawal symptoms in the baby. However, care properly for infants (Wilson & Shiff- Jaques et al. (2014) reviewed the literature man, 2015). The transition into parenthood and concluded that cannabis may adversely can be difficult (Davie-Gray et al., 2013) and affect the infant’s neurodevelopment, espe- some end in tragedy. For example, Reuters cially during periods of critical brain growth. identified 110 cases between 2010 and 2015 A review by Huizink (2014) noted incon- where babies of mothers addicted to opioid sistent findings but concluded there were drugs died preventable deaths (Wilson & negative effects on fetal growth and there Shiffman). may be subtle effects on specific cognitive and behavioral outcomes as well as executive functioning in adolescence. The National Institute on Drug Abuse (2011) information notes that effects on the baby can be subtle, but include low birth weight and impaired Amphetamines/Methamphetamine attention, language, and learning abilities, as well as behavioral problems. Low birth According to the National Institute on weight and growth restriction (which is Drug Abuse (2011), amphetamines are associated with many other problems) has powerful and addictive CNS stimulants that been a consistent finding for fetal exposure increase wakefulness and focus and can to cannabis/marijuana (Hurd et al., 2005; produce euphoria. The drug can cause high Marijuana Marroun et al., 2009). body temperature and lead to serious heart According to Budney et al. (2007) seven problems and seizures. Methamphetamine Marijuana is the most commonly abused published, randomized efficacy trials for (or “crystal meth”) is a derivative. Its effects illegal substance. The psychoactive sub- primary adult marijuana dependence have are particularly long-lasting and harmful stance is derived from the cannabis plant demonstrated that outpatient treatments can to the brain. The drug produces abnormal or created synthetically. The psychoactive reduce consumption and engender absti- brain chemistry in all areas of the brain and ingredient (THC) induces a state of euphoria nence. Interventions that integrate MET can permanently change and damage blood and relaxation (Mactier, 2013). According (motivational enhancement therapy), CBT vessels in the brain (Otero, Boles, Young & to the National Institute on Drug Abuse, (cognitive-behavioral therapy) and CM (con- Dennis, 2006). marijuana impairs short-term memory and tingency management) were felt most likely Adderall, a treatment for attention-defi- learning, the ability to focus attention, and to produce positive outcomes. cit disorder is used frequently by women 5 of reproductive age. Amphetamine use is associated with risky sexual behaviors, teen pregnancy, and increased risk of sexual- ly-transmitted infections (Keegan et al., SCREENING 2010). A 2005 study (Arria et al.) found that 5.2% of their sample of 1,632 pregnant Although it is believed that substance use women used methamphetamine. during pregnancy is increasing, it often remains The effects of methamphetamine use undetected and undiagnosed (Keegan et al., during pregnancy have been less well-stud- 2010). Identifying substance use in pregnancy ied than the effects of opiates, alcohol or co- caine. In addition, women who use metham- can present significant clinical challenges. In phetamines frequently use tobacco, alcohol addition, there can be difficulty evaluating the effects of substance abuse and other drugs (Committee for Healthcare and predicting adverse outcomes. of Underserved Women, 2011). According to There are a variety of screening instruments that are reviewed on the the National Institute on Drug Abuse (2011), VCPN website. Screening should continue throughout the pregnancy and methamphetamine exposure in utero has into the postpartum period, at least once a trimester. In Virginia, the High been associated with fetal growth restriction, Risk Screening for Women of Childbearing Age is approved for reimburse- decreased arousal, and poor quality of move- ment in infants. For example, Smith et al. ment by DMAS (Department of Medical Assistance). The adapted tool was (2006) found infants who had been exposed created from several other measures. The Virginia Department of Behav- to methamphetamine were 3.5 times more ioral Health and Developmental Services has a website with additional likely to be small for gestational age. There information: are case studies suggesting an association of www.dbhds.virginia.gov/individuals-and-families/substance-abuse/sub- amphetamine use with congenital abnormal- stance-abuse-screening ities but consistent increase above popula- tion risk has not been shown (Keegan et al., 2010). A matched case prospective study of There are guidelines suggesting five procedures for service providers: 330 children (LaGasse et al., 2012) identified • ASK – Pick a tool that fits your setting and use it regularly. behavioral problems at age 5 associated with • ADVISE- Educate the woman and her partner about adverse effects prenatal methamphetamine exposure. and the benefits of quitting. Mothers using amphetamines should be • ASSESS- Determine the motivation to change. encouraged to stop as there are no detri- • ASSIST- Support and encourage the mother-to-be to seek services. mental effects associated with discontinued • ARRANGE- Learn about community resources and how to access use in pregnancy. Frequent ultrasounds are suggested to monitor fetal growth (Keegan them. Tailor referrals to the individual. et al., 2010). Mothers who are actively using methamphetamine should not breastfeed, as amphetamines purchased illegally often next “dose” which becomes the physiologic It should be noted that published studies contain a mixture of substances with unpre- priority for the user. “Crack” cocaine deliv- in the 1980’s and 1990’s included case dictable harmful effects on both the woman ers in one dose at least 10 times the amount reports and small samples. These early and her infant (Committee for Healthcare of of cocaine present in a “line” or a “hit.” Use studies suggested devastating conditions and Underserved Women, 2011). of cocaine can result in migraine headaches congenital anomalies of the brain and other Thus far, pharmacologic treatments and pulmonary problems (Bhuvaneswar et organs, hemorrhages and SIDS. Subsequent have not been effective in helping persons al., 2008). larger, better-designed studies have not discontinue use of methamphetamines. The Cocaine use has decreased in the last few confirmed these outcomes (Bandstra et al., American College of Obstetricians and Gy- years. Whereas there were over 2 million 2010). However, later studies have begun necologists (2011) recommends women seek users between 2002 and 2007, in 2013 the to document modest decrements in over- treatment voluntarily at a residential center. numbers had dropped to 1.5 million (Nation- all neurobehavioral function rather than a If outpatient treatment is used, starting with al Institute on Drug Abuse, 2015). VCPN specific pattern of deficits. The impact of three to five visits a week and continuing staff did not find recent estimates of cocaine these deficits on later functioning is unclear treatment for 90 days is recommended. use during pregnancy. (Bandstra et al.). The Matrix Model which includes behav- Cocaine rapidly crosses the placenta and According to reviews by Porter and ioral therapy, family education, individual higher concentrations occur in the fetus. Porter (2004) and by Keegan et al. (2010), counseling, 12-step support, and drug testing Maternal use of cocaine results in direct cocaine-exposed babies can be lethargic, is recommended along with Contingency toxic effects upon the fetal heart, brain unresponsive and disorganized in their sleep- Management interventions. chemistry and blood vessels (Mactier, 2013). ing and feeding patterns, and have seizures. Cocaine use in pregnancy can lead to spon- They are also prone to over-stimulation and Cocaine taneous abortion, preterm births, placental irritability. Studies of babies as they mature abruption, maternal seizures, and congenital suggest that areas of the brain that regulate Cocaine is a short-acting stimulant which abnormalities (Bhuvaneswar et al., 2008; attention and executive functioning may be can cause users to take the drug many times Keegan et al., 2010). Birth weight is sig- vulnerable to effects of cocaine exposure. in a short time period. Cocaine use can lead nificantly affected by the mother’s cocaine Regulatory functions such as arousal, sus- to severe medical consequences related to use, as is head size (Shankaran et al., 2007). taining attention and response inhibition may the heart, respiratory, nervous and diges- For example, Bauer et al. (2005) found on be adversely affected by prenatal cocaine tive systems (National Institute on Drug average that cocaine-exposed infants in their exposure (Behnke et al., 2013; Sheinkopf et Abuse, 2011). Following cocaine use, there sample were born 1.2 weeks earlier, weighed al., 2009; Schuetze, Eiden & Coles, 2007) is a 2-hour “high” and then a characteristic 536g less, measured 2.6 cm shorter, and had as well as behavioral problems through at “crash” with irritability, discomfort, and head circumferences 1.5 cm smaller than least age 7 (Bada et al., 2007). Studies of depression. This state leads to craving of the non-exposed infants. continued on page 6 6 end of this century. Fewer Americans are that most women who quit smoking during smoking cigarettes. In 2013, an estimated pregnancy do so between the first and second 55.8 million Americans 12 or older (21.3% trimesters. Therefore, approaching women of the population) were smokers, compared early in the pregnancy about smoking ces- to 26% in 2002. sation is indicated. Some research indicates According to literature reviewed by that stopping smoking is more crucial than Haug, Duffy, and McCaul (2014), an es- stopping illicit drug use and that ceasing timated 15.9% of pregnant women smoke smoking has a greater impact on birth weight cigarettes. The CDC offers a more modest than eliminating illicit drug use (Bailey, Substance Use in estimate, saying that the smoking rate at any McCook, Hodge & McGrady, 2012). given time during pregnancy was 8.4% in Pharmacologic agents approved by the Pregnancy 2014 (Curtin & Matthews, 2016). FDA for treatment of tobacco dependence continued from page 5 Carbon monoxide and nicotine from include Bupropion (Wellbutrin) and nicotine tobacco smoke can interfere with fetal replacement therapies in the form of gum, adolescents who were exposed to cocaine oxygen supply. Because nicotine crosses patch, nasal spray, and lozenge. These agents prenatally have shown higher rates of tobac- the placenta, it can reach concentrations in have success rates ranging from 8 to 46% in co, alcohol, marijuana and other drug use the fetus that are much higher than in the studies cited by Okuyemi, Nollen & Ahlu- than non-exposed adolescents (Minnes et al., mother. Nicotine concentrates in fetal blood, walia (2006). 2014). amniotic fluid, and breast milk, exposing One study suggested that contingen- Additionally, use of cocaine is associated both fetus and infant to toxic effects (NIDA, cy management (offering incentives for with inadequate prenatal care and frequent 2011). Ammonia, nitrogen oxide, cyanide, quitting) was most effective for women also concomitant use of tobacco and alcohol. Co- lead and other metals are present (Huizink addicted to narcotics with 31% achieving caine use may be accompanied by poverty, & Mulder, 2006). Exposure to tobacco abstinence within 12 weeks compared to 0% poor nutrition, stress, depression, lack of so- decreases the availability of nutrients such as in a non-contingent incentive group (Aker- man et al., 2015). cial support and sexually-transmitted infec- Vitamin B12, amino acids, vitamin C, folate, tions (Bhuvaneswar et al., 2008; Keegan et and zinc (Institute of Medicine Committee Much is known about who is at risk to al., 2010). Continued cocaine use following on Nutritional Status During Pregnancy and continue smoking throughout the pregnan- delivery has been related to insensitivity and Lactation, 1990). cy. Smoking rates are higher for women negative parenting behaviors. Mothers may Research dating to the 1960’s has shown with less than a high school education, who be less sensitive and stimulating and more a direct, causal link between smoking cig- initiate prenatal care later or not at all, who likely to disengage and terminate feeding arettes and suboptimal fetal outcomes due receive Medicaid insurance and who receive sessions and be impaired in play sessions. to teratogenic effects in early gestation and WIC benefits (Curtin & Mathews, 2014). Viewing prenatal cocaine exposure through abnormal growth and maturation of the fetus Women in these categories merit additional the lens of cumulative risk that includes in later gestation (Behnke et al., 2013; Curtin attention and support. Also, attention needs negative impact on parenting behaviors may & Mathews, 2016). There are increased to be paid to postpartum relapse. Between offer a useful conceptualization (Bandstra et risks for: spontaneous abortion/miscarriage, 45% and 70% of women who quit smoking al., 2010). ectopic pregnancy, placental insufficiency, during pregnancy relapse within one year Studies cited in McLellan et al. (2000) stillbirth; infant mortality; Sudden Infant after delivery (American College of Obstetri- show that treating pregnant women who Death Syndrome; preterm birth; childhood cians and Gynecologists, 2011). are using cocaine resulted in higher birth respiratory disease; slowed fetal growth weights of babies, fewer infants requir- and low birth weight. Low birth weight is ing intensive care, and considerable cost an important factor in later developmental savings. Mothers should not use stimulant delay. The more a mother smokes during drugs while breastfeeding (Mactier, 2013). pregnancy, the more infant birth weight is reduced. On average, infants born to women who smoke during pregnancy weigh 200 to 300 grams less than unexposed infants (Keegan et al., 2010). Smoking during preg- nancy can affect the infant’s cognition and is associated with behavioral problems at older ages (CDC, 2014; 2015; Keegan et al., 2010; NIDA, 2011). Alcohol Even second-hand exposure to cigarette smoke can cause problems for the devel- Alcohol use can damage the brain and oping fetus. According to the CDC (2015), most body organs. Areas of the brain most there is no safe level of breathing other likely affected are those controlling prob- people’s smoke. Strong associations have lem-solving and decision-making, memory Nicotine been found between second-hand smoke and learning, and movement coordination and low birth weight and premature birth. (National Institute on Drug Abuse, 2011). Nicotine is an addictive substance found Post-natal exposure to second-hand smoke Alcohol is one of the most widely in cigarettes and other forms of tobacco. has been associated with negative physical abused substances during pregnancy. In Tobacco smoke increases a user’s risk of health outcomes, including Sudden Infant their reproductive years, more than 50% of cancer, emphysema, bronchial disorders, Death Syndrome, respiratory illness (such American women use alcohol (Keegan et al., and cardiovascular disease. The mortality as asthma or bronchitis), ear infections, 2010). Women may not realize a pregnan- rate associated with tobacco addiction is cavities, and increased medical visits and cy has occurred and continue alcohol use. high. According to the National Institute on hospitalizations. Many women cease use of alcohol when Drug Abuse (NIDA) tobacco use killed 100 Pregnancy can be a significant motivator they are aware of the pregnancy but an million people during the 20th century and to stop or reduce smoking (Keegans et al., estimated 8.5% continue alcohol use, 2.7% is projected to kill one billion people by the 2010). Curtis and Mathews (2014) note report binge drinking and 0.3% report heavy 7 drinking (studies reviewed in Haug et al., 2014; SAMHSA, 2014). The development Resources of all fetal organ systems can be affected by alcohol in the early stages of pregnancy A Guide for Hospitals and Health Care Providers (Keegan et al., 2010). No level of alcohol Perinatal Substance Use: Promoting Healthy Outcomes use is safe (U.S. Department of Health and Human Services, 2012). Virginia Department of Social Services Alcohol is a teratogen and its effects 801 E. Main Street include spontaneous abortion, growth restric- Richmond, Virginia 23219 tion, birth defects, brain damage and intel- (804) 726-7555 lectual disability. For example, mothers who consumed alcohol while pregnant were 40% Available at: http://www.dss.virginia.gov/files/division/dfs/cps/intro_page/publications/ more likely to experience stillbirth compared general/B032-01-0037-eng.pdf with nondrinking mothers (Aliyu et al., 2008). Persons dependent on alcohol have The Perinatal Substance Use: Promoting Healthy Outcomes pamphlet was cre- a relatively low intake of proteins, essential ated to explain the Code of Virginia that promotes healthy maternal and infant outcomes. The fats, vitamins and minerals. Deficiencies of Code of Virginia established new screening and reporting requirements for health care provid- ers and hospitals. The brochure highlights legal requirements and implications, as well as top- nutrients may be a factor in alcohol-related ics to educate patients on how to reduce substance use during pregnancy. Health care providers effects on the fetus (Institute of Medicine can improve maternal and infant outcomes by providing prenatal education on: regular prenatal Committee on Nutritional Status During care, nutrition, and prevention of sexually transmitted infections (STI) and human immunodefi- Pregnancy and Lactation, 1990). ciency viruses (HIV). Additionally, the brochure offers information on the effects of substance When pregnant mothers drink alcohol, use on fetal development and provides substance use screening, brief intervention, referral for the effects on children may be life-long and substance abuse evaluation/treatment. State and internet resources are also identified. include physical, mental, behavioral, and learning disabilities. Babies may be born small, have problems eating and sleeping, Opioid Overdose Prevention Toolkit show difficulty with seeing and hearing, and have trouble paying attention and learn- The Association of State and Territorial Health Officials, in cooperation ing. They may have facial deformities and with Public Health Research Solutions, and U.S. Department of Health defects of the heart, kidneys and liver. There and Human Services (HHS), 23 pages. can be dental abnormalities and skeletal de- Substance Abuse and Mental Health Services Administration fects. Children with Fetal Alcohol Syndrome 5600 Fishers Lane (FAS) may need special teachers and schools Rockville, MD 20857 and need additional medical care throughout (877) 726-4727 (Publication Inquiries) their lives (Keegan et al., 2010; SAMHSA, 2014: U.S. Department of Health and Hu- Available at: man Services, 2007; 2012). https://store.samhsa.gov/shin/content/SMA13-4742/Overdose_Toolkit_2014_Jan.pdf After more than 35 years of research, there is consensus that prenatal alcohol SAMHSA’s Toolkit for opioid overdose prevention addresses precautions and procedures exposure is responsible not only for FAS but to reduce the risk of opioid overdose in a community setting. The Toolkit begins by identify- also for a spectrum of disorders. Criteria for ing opioids, how overdose occurs, and who is at risk for overdose, and then lists several strat- FAS include: 1) growth deficiency manifest- egies to prevent overdose-related death. A section of the Toolkit is dedicated to first respond- ed by small overall height and small head ers. This section offers the steps of obtaining help, identifying the possibility of a potential size; 2) central nervous system disorders opioid overdose, and immediate treatment to reduce the risk of fatality. This publication also including intellectual deficiency, and 3) a addresses the steps that healthcare professionals should take when treating patients who may distinct pattern of abnormal facial features. have overdosed on opioids, such as assessments, medications, and legal liability consider- FAS can be characterized by facial malfor- ations. The Toolkit concludes with safety advice for patients and family members who may mations, growth deficits, and developmental know someone who is at risk for overdose, and a guide to recovering from opioid overdose problems. Fetal Alcohol Spectrum Disorders with networks and resources for sustained recovery. (FASD) describes the spectrum of physical, mental, behavioral, and cognitive disabilities that can result from prenatal alcohol expo- National Center for Substance Abuse and Child Welfare sure. Children with lesser impairments might U.S. Department of Health and Human Services exhibit learning disabilities, poor impulse 200 Independence Avenue, S.W. control, memory problems, and poor atten- Washington, D.C. 20201 tion and concentration (U. S. Department of (866) 493-2758 Health and Human Services, 2009). Email: [email protected] The prevalence of FAS is estimated at 2 to 7 cases per thousand and the prevalence Website: https://www.ncsacw.samhsa.gov/ of FASD may be as high as 20-50 cases per As part of the Department of Health and Human Services, the National Center for 1,000 children. Both FAS and FASD have Substance Abuse and Child Welfare (NCSACW) is funded by the Substance Abuse lifelong health consequences. In many cases and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treat- people with FASD or FAS need lifelong ment (CSAT) and the Administration on Children, Youth and Families (ACYF), Children's assistance. They experience co-morbid Bureau's Office on Child Abuse and Neglect (OCAN).NCSACW focuses on families whose disorders at much higher rates (sometimes lives have been affected by substance abuse, mental health disorders, and child abuse/neglect. as much as a hundred times higher) than the By developing a new substance abuse and trauma care system, improving family roles and relations, and approving policies and procedures that follow research-supported practices, continued on page 8 NCSACW improves the safety and well-being of recovering parents and their families. 8 Child Welfare). Substance use has been (Keegan et al., 2010). Readers who are regarded as a significant factor in child interested in screening tools can check the maltreatment. Studies from the 1990’s VCPN website for details about instruments reported rates of child maltreatment were and where to obtain them. Prescription 10 to 15 times higher in families where monitoring programs (described elsewhere parents abused substances (Hogan, 1998). in this issue) can also serve as early warning More recently, the National Survey of Child for misuse of prescription drugs. Intensive and Adolescent Well-Being estimated that intervention such as a recovery coach for 61% of infants and 41% of older children women who have a substance-exposed infant in out-of-home care are from families with have had some positive impact on subse- active alcohol or drug abuse (Wulczyn, quent pregnancies (Ryan et al., 2008). Substance Use in Ernst & Fisher, 2011, cited in Child Welfare Certain populations of women appear Information Gateway, 2014). According to merit additional attention. For example, Pregnancy to the National Council on Child Abuse & adolescent mothers are thought to have an continued from page 7 Family Violence, substance abuse exists in increased prevalence of tobacco use and general population. A review by Popova et 40 to 80% of families in which children are substance use and high likelihood of later al. (2016) found the most frequent disorders, victims of abuse (2016). problematic substance use. The increase in experienced by 67 to 91% were: abnormal- Substance-exposed infants who show substance use after the baby’s birth empha- ities in peripheral nerves; conduct problems developmental lags can benefit from early sizes the need to incorporate substance use and disruptive behaviors and impulsivity; re- intervention services. These include Home prevention and education efforts into their ceptive language deficits, chronic, recurrent Visiting Programs, described in detail in Vol- care (studies reviewed in Chapman & Wu, ear infections; expressive language deficits; ume 98 of VCPN, as well as ‘Part C’ (federal 2013). refractive errors; intellectual and cognitive early intervention), early childhood edu- deficits; and speech and language delay. cation, Smart Beginnings, and the Virginia Concluding Thoughts FAS and FASD are best conceptualized as a Preschool Initiative (all described in detail in multifaceted spectrum of disorders. VCPN, volume 99). Substance-exposed infants pose signif- icant policy and practice challenges that Cumulative Effects Prevention impact many systems and disciplines. With comprehensive, coordinated efforts, states Many researchers note that women who Public education campaigns that em- can promote standardized practices such as abuse substances during pregnancy are likely phasize the potential harm of substance use screening and reporting procedures, offering to use a combination of substances. There is during pregnancy are felt to be effective. a cohesive, consistent, and equitable child some data that suggest that use of multi- Targeting women of childbearing age is cru- welfare response, and making treatment and ple substances and especially tobacco use cial in this effort (Young and Gardner, 2007). support services accessible. combined with other substances exacerbates Other cornerstones of prevention are early the negative effects on the developing fetus. detection and treatment (routine screening) References Available on the Website For example, Rivkin et al. (2008) in an MRI and education of women and their partners study of children’s brains concluded that cocaine, alcohol, marijuana and tobacco may act cumulatively during gestation to exert lasting effects on brain size and volume. CARING FOR SUBSTANCE-EXPOSED INFANTS Factors such as birth weight and environ- mental risks (both associated with substance use) may account for some risks. Substance exposure in utero is inextricably associated with environmental risks such as disruptions in care or low SES (Messinger et al., 2004).

Postpartum Concerns All infants born to drug-misusing women CASA of Arizona offers information about caring for substance- must be considered highly vulnerable, even exposed infants. CASA notes that the process can be difficult and demand- if they have not required treatment for NAS ing. These infants are more sensitive to light, sound, and external stimula- (Mactier, 2013). In substance-using preg- tion and may be in physical pain. nant women, there can be high incidence of • If the infant appears over-stimulated, the caretaker should decrease psychosocial problems that can complicate care for a newborn. According to Oei & Lui the stimuli. Signs of over-stimulation are yawns, sneezes, agitation, (2007) there is a high incidence of domes- color changes, and eye aversions. tic violence, poverty, child abuse, single • Don’t allow the infant to become frantic. parenthood and lack of community support • Lower light levels and noise levels if the infant is over-stimulated. among families affected by a drug-dependent • The modes of talking, touching, holding and looking should be tried mother. Mothers have a high incidence of individually at first. When the infant is comfortable, an additional psychiatric disorders such as depression, mode can be added. stress and even psychosis that impair par- enting ability. During pregnancy and prior • Swaddling and pacifiers can be helpful. to discharge from the hospital, the mother’s • Use up and down rocking rather than side to side rocking. ability to parent should be assessed. • Babies may be more willing to interact after being fed. Play when the Continuing substance abuse is a concern infant is ready, not when you want to play. (National Center on Substance Abuse and 9

VIRGINIA’S PICTURE

Trends in Substance Use recognize and respond to an opioid overdose Treatment Trends emergency with the administration of nalox- Data from SAMHSA for 2013-2014 one. Naloxone, a prescription medication, is In Virginia, treatment data are similar (National Survey on Drug Use and Health) an opioid antagonist that reverses the effects to national data. Of individuals needing show that in Virginia, 32.31% of youth ages that opioids have on the brain. When a person treatment for illicit drug dependence, only 18 to 25 used marijuana in the past year overdoses on opioids, the opioid overwhelms 18.8% (about 29,000 individuals) received and 19.84% used illicit drugs within the specific receptors in the brain, slowly decreas- treatment (SAMHSA, 2013). According to past month. Alcohol use was frequent (over ing respiration and heart rate before finally the ONDCP, between 1992 and 2011, use 62%). Over 37% used Tobacco products stopping it altogether. Naloxone has a very of marijuana was the most commonly cited within the past month. Dependence was also high affinity for these receptors and effective- drug among primary drug treatment admis- high with close to 19% considered depen- ly pushes the opioid off the brain receptor, sions in the commonwealth. From 2008 to dent on drugs or alcohol. allowing the body to resume respiration. One 2012, persons receiving methadone treat- An increase in the number of metham- dose lasts only minutes and may need to be ment rose from 3,743 to 5,140 and persons phetamine lab seizure incidents in Virginia readministered, so the Lay Rescuer must stay receiving buprenorphine treatment rose from is noted in data collected by the Office of with the victim and call 911. Naloxone has 382 to 1,230 (SAMSHA, 2013). National Drug Control Policy (ONDCP), no dangers if accidently administered to a rising from 19 seizure incidents in 2008 to person. It is thought that 26,463 lives have 201 seizure incidents in 2011. been saved nationwide since 1996 when the According to the Biennial Report on first Lay Rescuers were trained. Substance Abuse (Virginia Department of Recently, a new Virginia state law Behavioral Health and Developmental Ser- effective July 1, 2016 allows pharmacists to vices, 2015), in 2013 there were 912 deaths dispense naloxone under more lenient rules. in Virginia from drug-related causes. Deaths A pharmacist working with a prescriber due to heroin doubled from 2011 (87) to can collaborate on a “standing order” that 2013 (174). Another source from VDBHDS allows the pharmacist to dispense naloxone (2014) notes 49 deaths due to heroin use in without the patient seeing a doctor first. It is 2010 with a rise to 213 in 2013, an increase similar to the arrangement that allows people of 334%. to receive flu shots at drugstores without a Incidence of In Virginia, deaths from abuse of fentan- prescription. Pharmacists can also dispense Substance-Exposed Babies yl, hydrocodone, methadone, and oxycodone naloxone to persons not at risk of overdose According to the Virginia Department (referred to as FHMO) were 23 in 1999 and themselves but who worry that a friend or of Behavioral Health and Developmental increased 1,578% by 2013 with 386 deaths relative may overdose and who want to be Services, more than 10% of the 104,990 (REVIVE Newsletter, June 2015). Drug-re- able to save them if an overdose occurs. babies born in Virginia in 2008 were exposed lated deaths happen at a higher rate than More information is available from VD- to alcohol or drugs in utero. The Virginia deaths due to motor vehicle accidents. BHDS, (804) 786-3906 or on the website: Department of Health’s Pregnancy Risk Drug-related deaths in the commonwealth www.dbhds.virginia.gov/individuals-and- Assessment Monitoring System found that were higher in the Western portion of Vir- families/substance-abuse/revive 8.5% of women surveyed shortly after de- ginia in past years. However, currently, the livery in 2007-08 reported drinking alcohol prevalence of drug-related deaths is spread during their most recent pregnancy. evenly throughout the commonwealth. Pregnancy–Associated Deaths More recent data is limited. The Virginia Data for the first four months of 2016 from Drug Overdose Department of Health reports that there were from the Virginia Department of Health indi- 101,907 births in Virginia in 2014. Martha cates nearly 500 visits to hospital emergency Virginia’s Maternal Mortality Review Kurgans, LCSW, with the Virginia Depart- departments for unintentional heroin over- Team reviewed nearly 400 cases of pregnan- ment of Behavioral Health and Developmen- dose. That number is 2.5 times the number cy-associated deaths to Virginia residents tal Services notes that Virginia’s Community of ED visits for heroin overdose in the same that occurred between 1999 and 2007. These Services Boards (CSBs) reported contact time period in 2015 (Daily News Record, deaths occurred during pregnancy or within with 335 mothers referred postpartum by June 2, 2016). one year of the end of pregnancy. Slightly hospitals due to substance use. Mary Walter, more than 10% of the pregnancy-related MSW, CPS Policy Specialist with the Vir- REVIVE! deaths (41) were a direct result of drug ginia Department of Social Services report- overdoses, mostly accidents or suicides. ed that in state fiscal year 2015 (July 1, 2014 REVIVE! is the Opioid Overdose and Prescription medicines contributed to a through June 30, 2015) CPS received 1,099 Naloxone Education (ONE) program for majority of the deaths. View the full report reports of substance-exposed infants. the Commonwealth of Virginia, authorized at: http://www.dbhds.virginia.gov/library/ in 2013 in Virginia by the General Assem- substance%20abuse%20services/osas-hwc- bly. REVIVE! provides training on how to preg-assoc-deaths-overdose-report.pdf continued on page 10 10 Implications for Child Protective Services (CPS)

The primary role of CPS is to protect children who may be at risk for maltreat- ment by parents or caretakers. When CPS is notified of a substance-exposed infant, Hospital-based Services workers can assist families in accessing early intervention services and can monitor to Around 2009, staff at Winchester Medical Virginia’s’ Picture ensure the child’s safety. Center noticed an increase in substance-ex- continued from page 9 CPS units in Virginia are affected by the posed babies experiencing drug withdrawal. increased awareness of substance-exposed Teresa Clawson, MD, Medical Director of Legal Requirements in Virginia pregnancy and by the changes in patterns the NICU and employed by Mednax, initi- of substances used by pregnant women and ated the formation of a Perinatal Substance The Code of Virginia § 54.1-2403.1 spec- by parents. Winnie Mason, LCSW, is the Abuse Task Force. She invited social work- ifies that licensed practitioners should, as a Family Services Supervisor for Frederick ers, pharmacists, case managers, DSS, CPS, routine component of prenatal care, establish County Department of Social Services. Healthy Families, the Community Services and implement a medical history protocol to She is new to the position, having formerly Board and others to join her in an effort to screen all pregnant patients for substance use worked in Loudoun County Social Services. create a supportive system for substance-us- and determine the need for further evalua- Her predecessor, Craig T. Cline, compiled ing pregnant women and their babies. tion. Practitioners are required to counsel some statistics for the Frederick County DSS The Task Force formed in 2010-11. The all pregnant women with positive screens or about substance-exposed infant reports. members divided into three subgroups: substance abuse evaluations on the potential The numbers of substance-exposed in- Prenatal, Perinatal (hospital stay) and Dis- for poor birth outcomes and the appropriate- fants has been increasing. Frederick County charge/Post Partum. Dr. Clawson explains ness of treatment. Further, the law specifies had 26 reports in 2012, 45 reports in 2013, that each group created a “dream list” by that the results of the medical history screen 47 reports in 2014 and 61 in 2015. Children examining best practices and evidence-based or substance abuse evaluation shall not be entering foster care due to parental substance interventions. admissible in any criminal proceeding. use was 4 (of 14 total or 29%) in 2012 and One effort involved screening practices. Since a baby can contract HIV from the rose to 27 of 35 (77%) in 2015. Most of the By connecting at the first OB visit, a drug mother in utero, during childbirth, or through screen can identify women who need addi- parents were young. While the ages ranged breast-feeding, the law requires licensed tional attention. Dr. Clawson notes that the from 16 to 52, the average age of mothers practitioners, as a routine component of national average of substance-abusing preg- was 25 years and for fathers 27 years. prenatal care, to advise all pregnant patients nant women is 4%-5% while their local data As is noted in the literature, poly-sub- of the value of testing for HIV and request suggests that about 10% of pregnant women consent for testing. However, women have stance use accounts for about a third of are using substances. “The majority in our the right to refuse consent. cases. Opioid drugs and marijuana were area use Marijuana and these women may The Code of Virginia § 63.2-1509 the most likely substances of use. About also have mental health needs,” notes Dr. requires health care providers and others to half of mothers had a known history of Clawson. There is also a drug screen when report suspected child abuse and neglect to mental health services and about a third had women have outpatient procedures such as a local departments of social services or the a criminal history. Only 14% had a prior fetal stress test. Finally, everyone is screened state hotline when a child is exposed to alco- substance-exposed infant, suggesting that when admitted to the hospital for delivery. hol or controlled substances not prescribed screening methods are being successful in Maria DeLalla, Nurse Case Manager, by a physician. There are four specific early identification. Most identified cases notes that hospitals may not identify the circumstances that are reportable: positive were first births, and only 20% had a prior majority of substance-using women if they toxicology tests of an infant within 6 weeks history with CPS. don’t use a universal screening procedure. of birth; a finding that a child is dependent Mason laments the limited resources Winchester’s dedicated staff makes cer- on a controlled substance and experienc- available for intervention. CPS contracts out tain that all identified women are referred, ing withdrawal symptoms; a child has a drug screening. Workers do the safety plans including those who were using marijuana diagnosed medical condition attributed to with the identified cases. The local CSB prior to knowing about the pregnancy. in utero exposure; and any child diagnosed and three private providers are available for The result of screening is that staff at with fetal alcohol spectrum disorder, which intervention services. Mason notes that the Winchester Medical Center identifies babies includes Fetal Alcohol Syndrome. preference is to have the baby stay with the who are substance-exposed. “We don’t The Code of Virginia § 32.1-127 requires mother. If the mother cannot abstain from want them going home with unidentified hospitals to implement protocols for written drug use or if she has other challenges in NAS –neonatal abstinence syndrome- so we discharge plans for substance-abusing, post- caring for the child, she is encouraged to monitor for five days and allow ‘rooming in’ partum women and their infants. Appropriate suggest friends or relatives who can parent as much as possible,” notes Dr. Clawson. “If referrals must be made and documented the baby. If that effort is not successful, then normal comfort techniques aren’t effective, and to the extent possible, the child’s father foster care is available. The CPS unit works the baby can be cared for in the NICU.” and members of extended families shall be actively with probation and with the service To facilitate screening and referral, the involved. The hospital shall notify the local providers. Time frames of involvement are Task Force created a resource guide for their community services board (CSB) to appoint set by policy and whenever a child is consid- physicians so they know when and how to a discharge plan manager. ered to be safe, the case is closed. refer. They have provided training to key The Code of Virginia § 32.1-134.01 re- partners. They also use protocols for care of quires hospitals and licensed midwifes to in- Readers wanting more information or babies with NAS. form maternity patients about the incidence a chance to see the data from Frederick Through a partnership with Northwestern of postpartum blues and perinatal depression County can contact Winnie Mason, LCSW, Community Services Board, Amanda Judd, as well as educate about Abusive Head Trau- and (540) 665-5688, ext. 118 or by E-mail: MA, Infant, Youth and Family Services Li- ma and the dangers of shaking infants. [email protected] aison, is embedded in two OB/GYN offices 11 VIRGINIA’S PRESCRIPTION MONITORING PROGRAM (PMP) Virginia’s PMP is a secure, online system access 24/7. Ease of use and greater avail- Caroline Juran heads the Virginia Board that provides licensed healthcare practitioners ability prompted a huge growth in the pro- of Pharmacy. She spoke recently to VCPN access to a patient’s Schedule II through IV gram. By 2013, the program was processing staff. Juran notes that, in Virginia, deaths prescription history. The system allows a more than a million requests for the year. In due to drug overdose now outnumber practitioner to determine the patient’s treat- 2015, there were 4.8 million requests. motor vehicle fatalities. Virginia’s PMP is ment history concerning use of controlled The majority of states, including Vir- a tool to help practitioners determine that substances. That information can minimize ginia, require weekly data submission. The medication is being used appropriately. the risk of duplicating prescriptions and can law governing Virginia’s PMP is found in There is reason to be hopeful that PMP eliminate potential illegal activity. Chapter 25.2 of Title 54.1 of the Code of systems can be effective. Efforts to reduce Virginia’s PMP began in September, Virginia. Regulations governing the program the nonmedical use of prescription pain 2003 as a fax-based system covering only are found at 18 VAC 76-20-10 et seq. Ralph medications have shown some success, as Schedule II prescriptions in Virginia’s A. Orr, Director of Virginia’s PMP notes demonstrated by declines between 2009-10 southwest region. In 2006, Virginia’s PMP that new legislation that will be effective on and 2010-11 in nonmedical use by those was extended statewide and began using a January 1, 2017 changes the data submission ages 25 or younger (SAMHSA, 2013). web-based operation. In 2006, the require- requirement to reporting within 24 hours of Virginia’s PMP was selected to be part ment was reporting of all Schedule II, III, dispensing. of a 2013 National Governor’s Association and IV controlled substances dispensed by Orr relates that Virginia’s PMP is interop- Center for Best Practices Initiative for both resident and non-resident pharmacies erable with 19 of the 31 states that are cur- combating prescription drug abuse. as well as dispensing physicians. The sys- rently sharing PMP information across state tem was unavailable on evenings, nights, lines to aid in combating prescription drug For more information on Virginia’s and weekends. abuse. States that share with Virginia include PMP, contact Ralph Orr, Program Director In October, 2009, Virginia’s PMP began the border states of Tennessee, Kentucky, by E-mail: [email protected] or visit utilizing automated software that provided West Virginia, and Maryland. the website at: www.pmp.dhp.virginia.gov

Judd educates mothers-to-be about what home visiting service and teaches parenting to expect from CPS involvement. She helps skills. She notes that the vast majority of mothers-to-be prepare for their baby’s substance-exposed babies return home with treatment in the NICU. She also facilitates their mothers. One-third of DeLalla’s posi- bonding. Dr. Clawson explains that addiction tion as Perinatal Nurse Case Manager is “in changes the brain in ways that interfere with kind” to Healthy Families. bonding. When separation from the baby DeLalla explains that WMC screens also occurs due to the baby needing intensive 100% of all pregnant women to determine if and in the NICU at Winchester Medical care or due to the mother being discharged they are eligible for Healthy Families. “The Center several days a week. Judd arranges while the baby remains at the hospital, screening is a service in and of itself even referrals for treatment and facilitates care co- attachment is further disrupted. To counter- if some mothers do not qualify for in-home ordination with treating physicians. She also act these roadblocks, at Winchester Medical services. The mother may have unaddressed assists with linking pregnant women with a Center, every baby has its own room and PTSD or other mental health issues. They myriad of community services. every mother can stay. “Providing comfort may have experienced child abuse during Judd, a former CPS worker, is well- measures helps the baby with withdrawal their growing years. We may need referrals positioned to address high-risk parenting and simultaneously stimulates bonding,” to additional services,” she explains. In ad- behaviors. “Our biggest issue,” says Judd, “is explains Dr. Clawson. If parents are unable dition to referrals for mental health services, finding sufficient resources. We don’t have to provide comfort to their babies, trained Infant Toddler Connection can assess the many options, especially if mothers-to-be want volunteer ‘Cuddlers’ take on the task of pro- infant’s growth and development. Medication Assisted Treatment. There can be viding human contact to the babies. Dr. Clawson and her associates are doing delays of as long as three weeks.” Winchester Dr. Clawson is most concerned about a remarkable job of responding to the needs has only one methadone clinic, three Suboxone what happens after discharge. “We want of substance-exposed babies and their fami- providers and one Subutex provider. to ‘link arms’ and provide comprehensive lies. A two-page list of the accomplishments Judd talks about the mothers’ emotional services,” explains Dr. Clawson. “We have of the WMC Perinatal Substance Abuse Task state. “Many of the women are struggling with guilt. They have a tremendous sense of the babies for only a short time. Their long- Force from 2009 to present is available on fear and shame.” Judd notes that it is her role term environment is what is most important.” the VCPN website. to listen, to build a relationship, and to let The follow up is where Healthy Families can Readers who are interested in further the women know that they are deeply cared help. information can contact: about. “I let them know that there are people Maria DeLalla, RN BSN BA is a Nurse Maria DeLalla (540) 536-8490 or by who want to assist in their efforts to stop Case Manager and Resource Specialist E-mail: [email protected] using and to achieve their life goals. It is for Healthy Families. VCPN has reported Amanda Judd (540) 325-4358 or by through the woman’s willingness to partner frequently on the Healthy Families program E-mail: [email protected] and engage with community resources that and interested readers are referred to issues Teresa Clawson, MD (549) 536-7897 or by they can be successful.” 52 and 98. Healthy Families provides a E-mail: [email protected] 12 SPOTLIGHT ON The Hampton-Newport News Commu- nity Services Board offers a wide array of services for clients with substance use disorders. Six programs operate in collabora- tion to meet clients’ needs. Patricia Hartigan, Project LINK Partnerships MSW, Division Director of Substance Abuse Services, has been with the CSB for 20 Any woman seeking services for sub- In addition to the services at the CSB, years. She describes the overall services. stance abuse can be served by the Hamp- additional support is obtained from two drug ton-Newport News Community Service’s courts, the Hampton Drug Treatment Court Board’s Project LINK, whether or not she and the Newport News Adult Drug Court. is pregnant. This case management program Drug Courts seek to break the cycle of assists women and their children who have addiction through court-supervised treatment been affected by substance abuse. “Our that combines a problem-solving orientation Project LINK is more prevention-oriented, with techniques that promote accountability. integrating early intervention and substance For example, those accepted into the Hamp- abuse treatment with health care and support ton-Newport News Drug Court program are services,” explains Katalin Cannady, Project drug-tested every 48 hours. LINK coordinator. Sherry Glasgow, M. Ed.,CSAC is the Pro- Children are served up to age 8. Can- gram Administrator. She explained that their nady relates that about 112 women and 70 program works mainly with felons being children are seen each month. Most have released from incarceration. The program is co-occurring mental health diagnoses. About a minimum of 18 months and most individu- South-Eastern Family Project 70 children per month are screened with the als take two years to complete it. In order to Ages and Stages Questionnaire. Children are graduate, an individual must be drug-free at This project provides comprehensive res- tested every three months and the results are least a year. Since participants enter the program idential and day substance abuse treatment shared with the child’s medical provider. If for pregnant women. Mothers and newborns from incarceration, women entering are not indicated, referrals can be made to special- can remain together in a healthy, safe, and pregnant. However, sometimes they become ists. “We monitor immunizations, well child stable environment. Mothers receive clinical pregnant shortly after release. Glasgow said visits, sick child appointments and school help with addiction and mental health while she currently has two women enrolled who progress,” adds Cannady. The services are a learning daily living and parenting skills to are pregnant. “We immediately refer to Proj- foster healthy child development. Services mixture of community-based and home visit- ect LINK and to community referrals such as are provided by an array of professionals ing. Each of the six full-time case managers Healthy Families and Catholic Charities. We including physicians, nurses, case managers has a caseload of about 35. Project LINK make certain that the mother-to-be is attend- and therapists. Women can stay for 60 days provides only case management services. ing the prenatal appointments. If a pregnant post-partum and typically enter the program Treatment services are arranged through the woman is having difficulty remaining absti- while pregnant. other CSB components. nent, we can arrange for them to be in the Hartigan notes that in 1999 or 2000 a South-Eastern Family Project for residential woman had to be pregnant upon admission care,” she relates. but now the Project also accepts women after Partners in Recovery Glasgow continues, “Once the baby is birth. The facility is a large house in down- born we help the mothers apply for services, town Newport News with 8 or 9 bedrooms, including VIEW (Virginia Initiative for 6 bathrooms and a nursery area for infants. Individuals with serious psychiatric Employment Not Welfare). That program A total of 16 women and their infants can problems that co-occur with substance abuse pays for child care so there are no issues be accommodated. In 2013, 47 women were or dependence are the target of this program. with missed obligations due to caring for enrolled. In 2014 that number rose slightly Gracie Taylor, Clinical Manager, describes the baby.” The drug court program requires to 49 and in 2015, 35 women were served. a person-centered approach as the key to the women to obtain jobs within 60 days. “The Opiate dependence is the most frequent with trauma-informed service philosophy. A team goal of the drug court is to have participants 65% of the women in 2015 dependent upon approach to treatment integrates psycho- be productive,” states Glasgow, “and we be- opiates. therapy, medication management, crisis lieve that each of our participants can reach intervention, relapse prevention, and life that goal.” Hampton Roads Clinic skills training. The 12-step recovery model is The comprehensive model and partner- utilized in conjunction with other treatment ships operating in Hampton-Newport News This Opioid Treatment Program offers modalities to support participants in achiev- are impressive. For more information about unique and specialized services for adults ing their goals. “There is no wrong door the comprehensive services at Hampton- with dependence on opiates such as prescrip- when entering services,” comments Taylor. Newport News Community Services Board tion pain medications, heroin and morphine. “We have great community partnerships and and partners, readers can contact: The program offers a full range of outpatient referring agencies.” Patty Hartigan- (757) 788-0408 or services. The clinic offers MAT (Medication Other services include a Men’s Substance E-mail: [email protected] Assisted Treatment). A methadone clinic Abuse Case Management and Next Step, Katalin Cannady- (757) 788-0547 or is offered at Hampton Roads. Clients who a psychosocial rehabilitation program for E-mail: [email protected] prefer Suboxone can utilize the Norfolk CSB those with co-occurring substance abuse Gracie Taylor- (757) 788-0400 or regional clinic. “We inform clients about and mental health diagnoses. Peer Recovery E-mail: [email protected] their choices and help them create a plan that models are embedded into all of the pro- Sherry Glasgow- (757) 224-2378 or will be effective,” explains Hartigan. grams, according to Hartigan. E-mail: [email protected] 13

Handle with C.A.R.E. Initiative

Virginia’s Handle with C.A.R.E. Ini- fall of 2014, Virginia applied for In Depth  Inform the Public–The public and tiative (Coordinating Access, Responding Technical Assistance (IDTA): Responses for non-traditional referral sources need to be Effectively to Maternal Substance Use) is an Substance Exposed Infants offered by the educated about the need. Success stories of interagency effort to identify a coordinated National Center for Substance Use and Child women in recovery could inspire those who state-level response to maternal substance Welfare (NCSACW). Kurgans related that are struggling to seek care. use. Pregnant and parenting women who use Virginia was awarded the grant. “We are one  Strengthen Legal Reporting substances often have complex, multi-fac- of six applications approved,” said Kurgans. Requirements–Clarifying CPS expectations eted challenges which bring them to the “The others are New Jersey, West Virginia, regarding services for substance-abusing attention of multiple agencies and systems. Kentucky, Connecticut, and a group of three mothers and substance-exposed infants could Women may be involved with health care, native tribes in Minnesota.” increase the consistency of response. Exist- child welfare, behavioral health and criminal In 2015 the workgroup convened and ing legislation can be reviewed to ensure that justice systems, for example. Identifying and considered barriers to identification and in- implementation is occurring and account- engaging these women in substance abuse tervention. In addition to seeking to develop ability is clear. Laws should meet treatment treatment can be difficult and efforts are a common vision and approach, The Handle needs and timelines. more effective when systems work together. with C.A.R.E. Initiative also identified op-  Incorporate Individual and Family Martha Kurgans, LCSW is the Women’s portunities for Virginia to improve response Support–Services such as childcare and Services Coordinator/Regional Behavioral to substance-using pregnant women. transportation may increase use of existing Health Consultant for the Department of Be-  Establish Statewide Standards of services. Service providers who are cultur- havioral Health and Developmental Services, Care– One opportunity is to establish clear ally competent with the populations needing Office of Behavioral Health. She explained standards for care that address screening, con- services can increase service use. how Virginia became involved in the Handle sistent procedures for follow up and referrals,  Increase Treatment Options and with C.A.R.E. Initiative. “Virginia has and liability and privacy protections for health Access–A continuum of treatment can allow care providers and patients. Kurgans offers been struggling with this issue for at least 16 referral sources to match the intensity of years,” Kurgans related. an example. “We are seeing a very dramatic need to treatment options. Expanded home Recognition of the challenges of serving increase in opiate use in pregnant women. visitation programs can assist women in fol- substance-exposed women led to a 1999 law This is a very new issue.” Kurgans explains low through with treatment options. Kurgans that required doctors and hospitals to report that most pregnant women cease substance notes that there are six residential substance substance-exposed infants to child protective use. “If a woman is pregnant and still using, services and refer their mothers to services. it is a sign of a more serious addiction, either abuse treatment programs in Virginia that “Far fewer babies than expected were iden- due to entrenched use or co-occurring mental accept pregnant women, however, only three tified,” states Kurgans. “Furthermore, of the health diagnoses,” she says. are approved for Medicaid reimbursement. known babies who were substance exposed, Kurgans adds, “We know there is a These are Bethany Hall in Roanoke, the only about a third of the babies were referred significant issue with the environment and Southeastern Family Project in Newport to a Community Services Board (CSB). care that these infants receive. They are News and New Generations in northern Knowing these statistics, we struggled with harder to soothe and it is harder to bond. The Virginia. Women who are pregnant may be how to work together.” baby is at increased risk if the mother is not reluctant to enter treatment far away from Kurgans explained that a child fatality stable and in treatment,” she explains. The their regular providers and also leave other report published by the Office of the Chief workgroup would like to create guidance children behind at home. There are 30 Opi- Medical Examiner (OCME) in 2014, Sleep for working with opiate-dependent pregnant ate Treatment Programs (OTP) in Virginia Related Infant Deaths, found that approxi- women and guidelines for plans of care for that provide methadone, a form of Medica- mately 20% of the children who died were substance-exposed children. tion Assisted Treatment (MAT). Virginia is substance-exposed, making substance abuse  Strengthen Community Collab- served by 40 Community Services Boards, a factor in many child fatality cases. Also, a orations–All Community Services Boards but only four of the OTPs are housed report on maternal fatality, Pregnancy- are required to provide services to pregnant within a CSB. A few additional CSBs have Associated Deaths from Drug Overdose women who are abusing substance and agreements with private Opiate Treatment in Virginia, 1999-2007: A Report from the they are required to do so within 48 hours. Providers to provide MAT. Virginia Maternal Mortality Review Team, Collaborative relationships between the local Kurgans explains that part of the difficul- found that substance misuse was a contribut- CSB, social services, health care providers, ty is funding. She says that the last increase ing factor in nearly one quarter (24.2% or 96 law enforcement, and community-based in funding for treating pregnant women cases) of all pregnancy-associated deaths in service providers can help identify women occurred in 1999 and costs of providing Virginia. Further, the report on sleep-related in need and refer them to the appropriate treatment keep rising. Even without funding infant deaths found that 95% were prevent- provider. Kurgans notes that substance-using increases, however, Kurgans believes that able and many were related to substance use pregnant women need more intense treat- there are methods to be more effective with by the parent or caretaker. ment and case management. They may need existing resources. In response to the concerns detailed in the basic resources such as housing and food. reports, Kurgans explains that an interagen-  Increase Educational Opportuni- More information is available at: cy workgroup was formed to try to create ties for Professionals– Once best practices www.dbhds.virginia.gov/individuals-and- a unified approach. Fortunately, there was are determined and guidelines are written, families/substance-abuse/handle-with-care technical assistance available and Virginia professionals in key positions will need to be Martha Kurgans, LCSW (804) 371-2184 or was invited to apply for the funding. In the educated. E-mail: [email protected] 14

Disability and local Social Services benefits. The majority of substance-abusing women have co-occurring mental health diagnoses, PROJECT LINK explains Ponton-Reid. In addition to concrete, practical interven- Project LINK provides intensive case schedule. A staff member individually reviews tions, Project LINK also teaches parenting management and home visiting services the packet with each pregnant woman. In FY skills and daily living skills such as shop- to pregnant and parenting women who are 2015, 186 women from five clinics received ping. For example, they partner with Child- abusing substances or who are at risk to the high-risk screening. Knight explained that ren’s Health Investment Program (CHIP) abuse substances. There are nine Virginia Project LINK generally screens around 300 of South Hampton Roads to complete a Project LINK sites. Each is affiliated with at women, but staff shortages last year reduced program called ‘Sleep Tight’ to educate least one Community Services Board (CSB) the number that could be reached. mothers about safe sleep for babies. Mothers which provides mental health and substance The direct service component includes who attend a 45-minute presentation receive abuse services. home visiting and case management, intakes, a free ‘Pak-n-Play.’ LINK also provides a  Roanoke (Blue Ridge CSB) parenting education groups and postpartum re- 7-week parenting class using a structured  Fredericksburg (Rappahannock Area ferrals. Knight is enthusiastic about the Nurtur- curriculum. It is free and open to the public. CSB) ing Program for Families in Substance Abuse “We have quite a few women with addi-  Charlottesville (Region 10 CSB) Treatment and Recovery. It is a 16-week tional children who often feel overwhelmed.  Newport News (Hampton-Newport evidence-based intervention. The program We perform most of our services in the home News CSB) also uses a Hazelden product for Life Skills and in the community. That allows us to  Virginia Beach (Virginia Beach CSB) education and budget planning. Workers can involve others such as fathers and grand-  Petersburg (District 19 CSB) assist with job searches and resume writing. parents. LINK also has a component called  Far Southwest Virginia Collabora- These interventions are designed to strengthen “Families Together” for children ages 0-7 tive (Cumberland Mountain CSB; the family unit. Knight said that 206 women who have been exposed to substance use. Dickenson CSB; Frontier Health/ received direct service during FY 2015. Ponton-Reid summarizes, “I have a Planning District One CSB) The third focus is community education passion for working with people who want and outreach. Knight did not know how to improve their life situation but may feel Project LINK sites provide intensive out- many women were served but said that the overwhelmed. They often have more power reach case management, home visitation, sup- program completed 281 home and office than they realize but need help to see the port services, and referral to women and their visits in FY 2015. Among the workshops positive in difficult situations.” families. Services coordinated through Project were several about Fetal Alcohol Syndrome Petersburg has a smaller Project LINK LINK include: substance abuse treatment; presented to female inmates at Rappahan- program, with a capacity of 15 women. family planning; prenatal care; well-baby care; nock Regional Jail. Presentations were also When interviewed in March, Shauna Chris- general health care; developmental screening, made to case managers and nursing staff at tian, CSAC, LPC, program coordinator, said assessment and intervention for the child; Spotsylvania Regional Medical Center. they were currently serving five women. In parenting education; and public education. Another example of a local program is addition to the usual services such as case Glenda Knight, MS, CSAC coordinates the Project LINK with Virginia Beach De- management, the Petersburg Project LINK the Project LINK program in the Rappa- partment of Human Services, Mental Health has an Intensive Outpatient Program (IOP) hannock area. She has spent eight years and Substance Abuse Division. Otelia Pon- available through their affiliated Community working with the program and is only the ton-Reid is the Team Leader for this Project Services Board (CSB). The twice-a-week third coordinator in the program’s 22 years. LINK. The four case managers and one par- program meets for 2 hours each session. She explains that the priority population is ent educator are currently working with 107 They also use the Hazelden materials for pregnant women who are diagnosed with a active clients. They serve not only Virginia the substance abuse treatment component. substance use disorder. The second priority Beach, but can also work with women from The IOP has two other components- Trauma is postpartum women who have delivered Portsmouth, Chesapeake, and Norfolk . Recovery and Parenting Education. Both a substance-exposed newborn. The third Ponton-Reid explained that the most components use evidence-based curricula. priority are parenting women with children typical substances used by pregnant women Similar to the other Project LINK programs under age seven who are diagnosed with a in their program are opiates, cocaine, and a interviewed, Christian has witnessed an substance use disorder. combination of alcohol and marijuana. Of increase in opioid and narcotics abuse. They Knight relates that Project LINK screens the 107 women being served, about 20 are can fund MAT (Medication Assisted Treat- women at five public health department still actively using substances while involved ment) and can refer to the Regional Perinatal maternity clinics. Women are screened not in treatment. Pregnant women who are still Program at Richmond Behavioral Health Au- only for substance use, but also for domestic using substances are referred to short-term thority for women who need residential care. violence and mental health risk factors. They inpatient treatment with the Mental Health Patricia Spangler, LPC is new on the job use the SBIRT (Screening, Brief Intervention and Substance Abuse Recovery Center or as Manager of the Project LINK at Blue and Referral to Treatment) model. SBIRT is women may choose to detox at a local hos- Ridge Behavioral Health Care in Roanoke. a comprehensive, integrated, public health pital. There are also longer-term treatment “I’m told that our Project LINK is different,” approach to the delivery of early intervention programs such as Boxwood available. Opiate she says. “Others do case management. We and treatment services for persons with sub- abuse is much more frequent now than in offer case management, but we also have an stance use disorders as well as those at risk the past and Medication Assisted Treatment Intensive Outpatient Treatment Program and for developing these disorders. Women who (MAT)(Suboxone; Methadone; Subutex) is Medication Assisted Treatment.” have risk factors are referred for services and available. Of the 107 current women being The LINK I program is for women who their nurse at the clinic is notified as well. served, 11 are receiving MAT. do not use opiates. The IOP is a 26-week Project LINK staff engages in prevention In addition to referrals, Project LINK program that meets three times a week. A activities. They give each woman a Prevention provides transportation (tickets or their trans- maximum of 12 women are in each IOP. The folder that has information on alcohol, tobac- portation unit or through Logisti Care) and group uses an evidence-based curriculum co, and illicit drugs. The packet also contains a assists with finding community resources. that covers substance abuse and parenting growth chart for the baby and an immunization They help women apply for Social Security topics. There are random drug screens. In 15 Governor’s Task Force on Prescription Drug order to graduate from the program women and Heroin Abuse must have consistent attendance, arrive on As of 2013, drug overdoses surpassed all Education Workgroup–Manz notes that other injuries as the leading cause of injury medical school and graduate programs in time to appointments, complete the therapeu- death in the United States, including injuries social work and psychology do not neces- tic homework assignments, create a relapse from motor vehicle collisions. That same sarily offer education about the recognition prevention plan, attend recovery-oriented year, Virginians died from drugs and poisons and treatment of addiction. First responders, activities, maintain sobriety as evidenced by more than any other injury, with an increase health care providers and behavioral health negative drug screens, meet regularly with of over 13% from just the prior year, 2012 providers need education and training. The the case manager, and participate in therapy. (Virginia State Fatality Review Team, 2015). public also need to be alerted about the When a woman does an intake and With the goal of improving public safety dangers of overuse or abuse of prescription requests MAT (Medication Assisted Treat- and public health, Governor McAuliffe signed drugs. ment), Project LINK can help a woman with Executive Order 29 in September, 2014 estab- Treatment Workgroup–“A treatment a history of opioid use by funding Suboxone lishing the Governor’s Task Force on Prescrip- structure is imperative,” states Manz. “Opioid or Subutex to aid in the process of recovery. tion Drug and Heroin Abuse. The Task Force addiction is a different sort of addiction and Acceptance into the program is decided by was created to recommend immediate steps to the workgroup learned that treatment is not the entire treatment team. LINK 2 Recovery address the growing and dangerous epidemic easily available.” She also notes that there is is divided into three phases. Approximately of prescription opioid and heroin abuse in a coverage gap as uninsured individuals may 10 women can be served in each phase. Virginia. lack the means to access treatment. The Treat- Spangler says that Phase I is a three times The Task Force was a multidisciplinary ment Workgroup has made recommendations a week treatment for 26 weeks. Medication team effort. It was co-chaired by the Secre- concerning treatment protocols and standards is dispensed daily. AA or NA groups are re- tary of Health and Human Resources and the for those offering treatment. According to quired twice a week. The program provides Secretary of Public Safety and Homeland Manz, there are currently 37 drug treatment child care and transportation. Spangler ex- Security. It included representatives from the courts operating in Virginia and there is need Office of the Attorney General, the legisla- for many more. plains that their prescriber is certified as both ture, judiciary, law enforcement, health and Data and Monitoring–“The impor- a psychiatrist and an OB-GYN. “She has an behavioral health professionals, providers, tance of accurate and timely data cannot be understanding of both fields.” community advocates, relevant state and understated,” declared Manz. Changes to the Phase II requires twice-a-week meetings local agencies, and individuals with personal Prescription Monitoring Program have been for 14 weeks plus a doctor’s group. Women experience with addiction. made to enhance its effectiveness as a tool for receive a week’s worth of medication at a Five work groups met for over a year. Jodi understanding prescribing practices and for time in this phase. Phase III is 12 weeks and Manz, MSW, Policy Advisor, Office of the monitoring trends in opioid use. people are followed once a month. Altogether, Secretary of Health and Human Resources, Storage and Disposal–Storing prescrip- the IOP takes a year. In order to move from provided coordination and support for the tion drugs in a secure manner and disposing one phase to the next, women must meet work. “We had a comprehensive approach. of them properly when no longer medically criteria. If women still need MAT after a year, Combating prescription drug abuse involves needed reduces opportunities for abuse or they can transition to a community provider. coordination of many systems. Those affected misuse and reduces potentially harmful ef- Spangler believes the IOP and MAT is are not just one population,” she emphasized. fects to the environment. Many communities effective. Women are with others in their ex- “Each task force spent considerable time and offer ‘take back’ events to encourage citizens act situation. The program offers child care effort in arriving at the recommendations that to relinquish unused medications to be prop- and transportation. She notes that hospitals were published in June, 2015. “ erly destroyed. Several pharmacies collect call them, as well as calling CPS, if a baby is The 51-page implementation plan, and destroy drugs as well. born positive for illicit drugs. Project LINK Recommendations of the Governor’s Task Enforcement–Law enforcement may be has a case manager assigned to the hospital. Force on Prescription Drug and Heroin the first on the scene of an overdose. Ongoing If a woman needs residential care, that can Abuse, is an impressive document. It is com- training is teaching law enforcement how prehensive and contains detailed recommen- to use naloxone (an overdose antagonist). be arranged as Project LINK has a memo- dations and action steps. Interested readers The workgroup explored viable options to randum of agreement with Bethany Hall. can find the document at: www.dhp.virginia. incarceration and the provision of treatment In the last six months of 2015, 129 cases gov/taskforce/minutes/20150630/TaskForce while incarcerated. The passage of Senate were opened. At any one time, they serve ImplementationPlan.pdf Bill 892/House Bill 1500 provides a ‘safe about 75 women. Not all are in the IOP. Manz notes that substance abuse by care- harbor’ alternative defense for individuals Project LINK at BRBH has partnered with takers is the main reason that children enter calling 911 or notifying emergency personnel Trish White of Choices to Recovery to en- foster care. CPS and foster care workers are in that someone in their presence has suffered an gage women and train them to become peer a position to recognize signs of addiction and overdose. support specialists after completion of the intervene by helping parents obtain treatment. The Implementation Plan is meant to be a program. The Choices to Recovery program She adds, “Addictions are not simply a medi- “living document” that will change as needs incorporates accountability, responsibility cal or health care problem.” Addictions affect and resources change. Attention is ongoing and service. It promotes personal empow- the entire community including the crime rate, and the Task Force intends to continue re- erment so the woman can become a func- lost work time, increased pressure on com- search and review of emerging best practices. tioning and contributing member of society. munity services boards to provide addiction Readers wanting additional information “Our hope is that those who have successful- treatment, and greater use of public health and may contact Jodi Manz, MSW by e-mail: ly completed the program can then sponsor Emergency Departments in hospitals. [email protected] or by others in the community,” explains Spangler. Workgroups have divided the task of con- phone: (804) 663-7447 sidering this complex problem. continued on page 16 16

Nonprofit Organization U.S. POSTAGE PAID Department of Harrisonburg, VA 22802 Psychology PERMIT NO. 4

91 E. Grace Street, MSC 7704 Harrisonburg, VA 22801 Attn: J. Grayson

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VCPN is on the web – Visit us at: http://psychweb.cisat.jmu.edu/graysojh/ continued from page 15 More information about Project LINK is available from: Martha Kurgans at (804) 371-2184 or E-mail: [email protected] Glenda Knight, at © Commonwealth of Virginia (540) 373-3223, Ext 3030 or Department of Social Services E-mail: [email protected] Check Our Otelia Ponton-Reid, at (757) 385-0818, VCPN is copyrighted but may be repro- E-mail: [email protected] duced or reprinted with permission. Website for: Shauna Christian at Write for “Request to Reprint” forms. (804) 862-6410, Extension 3191, Request or inquiry is addressed to: Joann v Opioid Use and Parenting E-mail: [email protected] Grayson, Ph.D., Department of Psychol- Patricia Spangler, at ogy, MSC 7704, James Madison Univer- (540) 266-9200, Extension 3223, sity, Harrisonburg, VA 22807, or call v Intervention and Treatment E-mail: [email protected] (540) 568-6482. E-mail: [email protected] v What We Know About Relapse v Reference List Special Thanks To….. v National Resources Robin J. Hamill-Ruth, MD Caroline D. Juran, RPh Go Green v Virginia Resources Courtney Lenard, MA Martha Kurgans, MSW If you prefer an electronic notice when Jodi Manz, MSW VCPN is published rather than a hard Carole Pratt, DDS copy, please e-mail your preference to Mary Walter, MSW Joann Grayson at [email protected]