5/10/2018 An Introduction to Substance Exposed Mothers and Infants Maridee Shogren DNP, CNM Region 8: Mountain Plains ATTC ATTC serves the United States through 10 regional offices and the Ukraine, Southeast Asia, Africa and Vietnam The Addiction Funded by U.S. Department of Health and Human Service (DHHS) Substance Abuse and Mental Health Service Administration Technology (SAMHSA) Region 8: Transfer Center Housed at UND‐NPCBR‐suite 220 Partners with University of Nevada‐Reno’s Center for the Network: Application of Substance Abuse Technologies (CASAT) Region 8: Serves six states: CO, ND, MT, SD, WY, UT Especially responsive to rural needs Mountain Plains People in MT (53%) ND (40%) SD (35%) and WY (57%) live at least 60 minutes from a city with at least 50,000 ATTC people (US Census data) 1 5/10/2018 Utilizes an array of technology strategies to accelerate diffusion of innovations regarding substance abuse treatment and recovery. Prepares addiction treatment providers and pre‐professionals to use evidence based practices in their current and future practice. Accelerate the adoption and implementation of promising addiction treatment and recovery‐oriented practices and services—offers training and technical assistance for providers using technology. Heighten the awareness, knowledge, and skills of the workforce to Goals of the address the needs of people with substance use or other behavioral ATTC health disorders. Fosters regional and national alliances among culturally diverse practitioners, researchers, policy makers, funders, and the recovery community. Improve treatment and recovery services in the region for people with addictive behaviors. Advances culturally and linguistically competent services. At the end of the presentation Participants will identify at least three potential consequences of maternal substance use disorder. Participants will identify at least five common symptoms of Objectives Neonatal Abstinence Syndrome Participants will identify at least three non‐pharmacological interventions for Neonatal Abstinence Syndrome Participants will recognize the need for a multidisciplinary approach to caring for substance exposed mothers and infants. 2 5/10/2018 Pregnancy is a relatively short, but important, period of time in a woman’s life: 40 weeks…10 lunar months…9 calendar months ~50% of pregnancies in US are unintended Rate is 2‐3 times higher among women with substance problems Pregnancy and (Terplan, 2015) Women are at highest risk for developing a Substance Use Substance Use Disorder (SUD) during reproductive years Fair to say that polysubstance use is common Still much stigma attached to substance use in pregnancy May be less likely to seek care OR may be more willing to seek/complete treatment Pregnancy may interrupt the pattern of substance use Substance use does still occur during pregnancy Tobacco: most common: 15.9% continue to smoke Alcohol: 8.5‐12% continue to drink Illicit drugs: 8.5% continue to use Pregnancy and 1‐2% use opiates, may be as high as 21% (Ettlinger, 2016) Nationally estimated that Substance Use 225,000‐380,000 babies born each year with prenatal drug exposure 550,000 are exposed to alcohol Over 1 million are exposed to tobacco in utero (Forray, 2015, Ettlinger, 2016) 3 5/10/2018 HOWEVER…. Many women with preconception risky or problem use ARE able to abstain temporarily during pregnancy and will quit or reduce after pregnancy is confirmed Percent of women who abstain: Pregnancy and 96% abstain from Alcohol Substance Use 78% abstain from Cannabis 73% abstain from Cocaine 32% abstain from Tobacco If they continue in pregnancy, they typically don’t understand the potential harm or CANNOT stop using on own (Klie, 2017) As a Result… postpartum relapse is another issue! Pregnancy and Substance Use Slide courtesy of Dr. Larry Burd, SMHS 4 5/10/2018 ALL women should be UNIVERSALLY screened for licit and illicit substance use in pregnancy Selective screening misses most with problematic use Prenatal Early identification is a must Common co‐occurring conditions with substance use: mental health, Screening DV, legal issues, social services Remember that the increase in co‐occurring conditions = increased risk for negative outcomes Patient history/self‐report (universal) Preferred for initial screening Maternal specimen testing (may be biased, not universal) Urine most common for ease but is not gold standard ; a negative test does not rule out sporadic use (ACOG, 2017) Prenatal Only detects recent use (past several days) May not detect synthetic opioids, some benzodiazepines Screening THC‐ excreted and testable for up to 10 days in maternal urine if mom is regular user, up to 30 days if chronic, heavy user Alcohol, nicotine, opiates, cocaine and amphetamines (Behnke, 2013) Hair Drugs trap in hair, may reflect longer period of time Nicotine, opiates, cocaine, amphetamines 5 5/10/2018 Continued observation/screening during pregnancy a must… Screen in first trimester and at least every trimester for women who screen positive OR Screen at first and every prenatal visit Prenatal DON’T forget postpartum! (ACOG, 2017; Forray et al, 2015; WHO, 2014) Screening ALSO…Concurrent infectious disease screening, psychosocial assessment, contraception needs post‐pregnancy (NIDA, 2012) No single best screening tool for self‐report or as part of patient interview. Many options! Alcohol: NIAAA Single Question AUDIT AUDIT‐C Screening T‐ACE TWEAK Tools in MAST Pregnancy Both Alcohol and other substances DAST 4Ps Plus CRAFFT/CRAFFT 2.0 (pregnant adolescents) CAGE‐AID SBIRT model encouraged: Screening, Brief Intervention, Referral to Treatment 6 5/10/2018 7 5/10/2018 Substance use in pregnancy connected to many complications/negative health outcomes for mom/baby dyad Consequences Indirectly linked to of Substance Lack of nutrition (mom and fetus/infant) Domestic violence (mom and fetus/infant) Use in Increased risk of mental illness/infection Pregnancy Any substance has potential to cross over to the fetus Maternal / fetal transfer of licit/illicit drugs BBB Google images, 2017 8 5/10/2018 Generally, substances can be teratogenic in: Maternal / Embryonic Stage and/or Fetal Transfer Fetal Period Impact abnormal growth, alteration in of Licit and neurotransmitters/receptors, brain organization Illicit Drugs placental insufficiency National Organization on Fetal Alcohol Syndrome (NOFAS). (Coles, 1994) (2004; adapted from Moore, 1993). 9 5/10/2018 Absorption Alcohol enters stomach where absorption and metabolism occur rapidly Blood ethanol concentrations peak in ~1hour **Women attain consistently greater blood ethanol levels than men with equal consumption Distribution and Placental effects Alcohol Alcohol readily passes into fetal blood Once in fetal blood, alcohol reaches concentrations similar to mom Embryo has limited ability to metabolize alcohol, mostly because liver is immature and lacks enzymes to do so, alcohol passed back to mom for metabolism This takes time! Alcohol levels may remain higher in embryo for longer periods of time which increases risk of exposure (Behnke, 2013, Brimacombe et al, 2009) No area of the brain is resistant to the effects of fetal alcohol exposure Alcohol can cause thinning or absence of the corpus callosum leading to deficits in attention, intellectual function, reading, learning, verbal memory, and executive and psychosocial Neuromorphol functioning. ogical Birth Preterm delivery Craniofacial abnormalities Defects Impaired motor development Growth deficiencies (Behnke, 2013; Brimacombe, 2009; Brown, 2016) 10 5/10/2018 Mattson, S.N. et al. 1994; Brimacombe, 2009 Non-alcohol effected vs. Profoundly Alcohol-effected Brain Brimacombe, 2009 (Clarren , 1994) 11 5/10/2018 Cigarette Smoking: Tobacco / Nicotine Retrieved from: http://sites.psu.edu/krfaustnutr/2015/10/28/smoking‐pregnancy‐psa/ Fetus exposed to over 4000 compounds through cigarette smoking ~ 30 compounds linked to adverse outcomes Nicotine Concentration higher in placenta, amniotic fluid, fetal blood than in maternal serum Cigarette May cause alterations in brain metabolism and abnormal brain development Smoking: Believed to cause hypoxia Tobacco / LBW, IUGR, prematurity Increased risk of SIDS Nicotine Potential for placental abruption Weakly associated with oral facial clefts 1.8‐2.8x greater risk of stillbirth Passive exposure‐2.1x greater risk of stillbirth No particular neonatal withdrawal syndrome noted (Behnke, 2013, NIDA, 2016) 12 5/10/2018 Interesting fact: Among women using BOTH Alcohol and Nicotine in the pregnancy 20.4% also used Marijuana 9.5% also used Cocaine Women NOT using Alcohol or Nicotine FYI 0.2% used Marijuana 0.1% used Cocaine Alcohol and Nicotine CO‐USE is a marker for other drug use. (Burd, 2017) Cannabis https://www.google.com/search?q=photo+image+marijuana&tbm=isch&tbo=u&source=univ&sa=X&ved=0ahUKEwiLmffIjf3VAhUp5IMKHV_bAyMQsAQILg&biw=1920&bih=924#i mgdii=SS0oE8TPbBHI4M:&imgrc=8qcNmFE4OuWV4M: 13 5/10/2018 Cannabis 7.5% of pregnant women 18‐25y use cannabis, 4% in all pregnant women (Forray, 2015; Grant et al, 2017; Klie, 2017) Expectant mothers might use for N/V of pregnancy Weight gain (increase appetite) Depression/Stress/Anxiety General discomforts of pregnancy Fun Cannabis Insomnia Marijuana use in pregnancy associated with Increased risk of dysfunctional labor Precipitous labor Meconium stained amniotic fluid (Grant, 2017; Klie,2017) Legalization continually