Substance Use in Pregnancy A Clinician’s Toolkit for Screening, Counseling, Referral and Care Presented by: The Regional Perinatal Advisory Group (RPAG) June 2014 The toolkit online: www.baltimorecountymd.gov/go/perinatal RPAG Substance Use in Pregnancy A Clinicianʼs Toolkit for Screening, Counseling, Referral and Care For Maryland Prenatal Care Providers and Substance Use Disorder Treatment Providers Section.Page 1. Overview • Letter of Support .……………………………………… 1.1 • Introduction .…………………………………………… 1.2 • Scope of the Problem ………………………………….. 1.3 2. Screening, Counseling and Billing • Screening ………………………………………………. 2.1 • Screening Tools ..………………………………………. 2.3 • Negative Screening …………………………………….. 2 .13 • Positive Screening - Brief Intervention ………………... 2 .14 • Documentation ………………………………………… 2 .16 • Billing ………………………………………………….. 2.17 • Chart – Drink Equivalent ………………………………. 2.18 • Patient Drinking and Smoking Teaching Sheets ………. 2.19 3. Referral and Treatment • Referral for Substance Use Treatment …………………. 3.1 • Patient Self Referral Handout ………………………….. 3.2 • Substance Use Disorder Treatment in Pregnancy ……... 3.3 • Communication Between Providers …………………… 3.10 • Consent for Communication …………………………… 3.12 4. Effects of Substance Use on Mother, Fetus, Infant and Child • Overview …………………………………………….… 4.1 • Table of Substances and Their Effects ………………… 4.3 • Fetal Alcohol Spectrum Disorder ……………………… 4.28 • Neonatal Abstinence Syndrome ……………………….. 4.30 • Chart of Critical Periods in Gestational Development … 4.34 Regional Perinatal Advisory Group Substance Use in Pregnancy Toolkit 2014 Table of Contents Section.Page 5. Care of the Substance Using Pregnant Woman • Overview ………………………………………………. 5.1 • Special Considerations in Prenatal Care ……………….. 5.2 • Special Considerations in Postpartum Care …………… 5.6 • Special Considerations in Substance Treatment ……….. 5.7 6. Care of the Substance Exposed Infant • Breastfeeding …………………………………………... 6.1 • Therapeutic Handling ………………………………….. 6.5 7. Laws and Mandates • Resources Available for Substance Use Treatment ……. 7.1 • Substance Exposed Newborn ………………………….. 7.2 • Postpartum Resources …………………………………. 7.4 • Maternal/Child Health Funding Resources ……………. 7.4 • Health Services Required to be Paid by Insurances …… 7.6 • Affordable Care Act and Maternal/Child Health ……… 7.6 • Newborn Screening ……………………………………. 7.7 • Guide to Accessing Maryland Statutes ………………… 7.7 • Report of Substance-Exposed Newborn DHR/SSA……. 7.8 Form 2079 • Jurisdiction Departments of Social Services …………... 7.9 8. Perinatal Substance Treatment Programs in Maryland - Examples • Example One - CAP at Johns Hopkins Bayview ……… 8.1 • Example Two - SART in Carroll County ……………… 8.4 9. Resources • ACOG Committee Opinion: At-Risk Drinking and……. 9.1 Alcohol Dependence: Obstetric and Gynecological Implications August 2011 reaffirmed 2013 • ACOG Committee Opinion: Nonmedical Use of ……… 9.7 Prescription Drug October 2102 • ACOG Committee Opinion: Opioid Abuse, …...………. 9.13 Dependence, and Addiction in Pregnancy May 2012 Regional Perinatal Advisory Group Substance Use in Pregnancy Toolkit 2014 Table of Contents Section.Page 9. Resources (continued) • ACOG Committee Opinion: Smoking Cessation ……… 9.20 During Pregnancy Reaffirmed 2013 • ACOG Committee Opinion: Substance Abuse ………… 9.24 Reporting and Pregnancy: The Role of the Obstetrician-Gynecologist Reaffirmed 2012 • Pediatrics: Prenatal Substance Abuse: Short and ……... 9.26 Long Term Effects on the Exposed Fetus February 2013 • Pediatrics: The Transfer of Drugs and Therapeutics ….. 9.44 into Human Breast Milk August 2013 • Patient Materials ……………………………………….. 9.60 • Local Resources by Jurisdiction ………………………. 9.61 • Frequently Asked Questions - Laminated Sheet ………. Front flap • CD with Information and Patient Handouts …………… Front flap • HRSA Screening for Substance Abuse During ………... Back flap Pregnancy: Improving Care, Improving Health 1997 10. Addenda • Depression Screening and Mental Health Referral ……. 10.1 • Depression Screening Tool …………………………….. 10.2 • Mental Health Core Service Agencies ………………… 10.4 • HIV in Pregnancy ……………………………………… 10.5 • Intimate Partner Violence ……………………………… 10.10 • DHMH IPV Screening Tool ………………………….. 10.12 • IPV Resources …………………………………………. 10.13 Regional Perinatal Advisory Group Substance Use in Pregnancy Toolkit 2014 Table of Contents 1.1 ACOG – Maryland Section Chair Jessica L. Bienstock, MD MPH 410.955.8487 [email protected] Dear Colleague: As the epidemic of drug and alcohol abuse continues unabated in the United States, the magnitude of impact on the health of the women we serve, as well as their infants, has also grown. This increase has largely been due to the explosion in misuse of legal opioid drugs as well as illicit opioids. Opioid overdose is now the leading cause of accidental death among adults, surpassing motor vehicle accidents, and approaching the number of HIV/AIDS-related deaths that occurred at the height of the HIV/AIDS epidemic. In addition, a 2012 JAMA study estimated that every hour, a baby is born in the United States with evidence of withdrawal from opiates (~13,500 infants per year). Unfortunately, Maryland statistics reflect these national trends. More than ever, women rely on us for generalized medical care beyond their gynecological and obstetric needs. Adequate screening for threats to the well-being of these women and their offspring has become an integral part of good care. Over the past several years, there have been significant changes in our recommendations for patient screening for depression, HIV, intimate partner violence, and substance misuse. In an effort to increase knowledge and improve practices among those providing obstetric care, as well as those providing substance abuse treatment to pregnant women, the Regional Perinatal Advisory Group (RPAG) has created Substance Use in Pregnancy: A Clinician’s Toolkit for Screening, Counseling, Referral, and Care. This toolkit will be distributed statewide to all sites/providers providing prenatal care and/or substance use disorder treatment, health departments, and hospitals providing obstetrical care. To provide comprehensive obstetric care, it is up to us to screen all of our patients for substance use and take appropriate actions, based on the results, in an unbiased manner. Indeed, we can make a difference in preventing or mitigating the harmful effects of substance use on our patients and their infants. I trust you will find this toolkit helpful and that it will encourage you to expand your screening for substance use to all your patients, as there is evidence that substance use disorder crosses all socio-economic borders. The Maryland Chapter of the American Congress of Obstetricians and Gynecologists Is committed to increasing the available information and tools regarding the problem of substance use in pregnancy in order for our members to continue to provide excellent care for their patients and families. Sincerely, Jessica L. Bienstock, MD MPH Chair – Maryland Section ACOG 1.2 Introduction This toolkit was created for obstetric care providers and substance use disorder treatment providers in order to: • Provide key information about the impact of legal and illegal substances on a woman’s pregnancy and on the unborn child. • Help professionals take better care of the pregnant woman who has been using or abusing substances. • Improve the collaboration between obstetric and substance use disorder treatment providers in the care of pregnant women who are misusing drugs or other substances. Use of legal and illegal substances occurs in all racial, ethnic and socio-economic groups. The use of tobacco and alcohol, misuse of prescription medications, as well as the use of illegal drugs contribute substantially to maternal, fetal, and neonatal morbidity and mortality. In addition, there is increasing evidence that use of some of these substances during pregnancy can have long-term impact on the child’s development and behavior. Pregnant women misusing substances are at greater risk for HIV infection and domestic violence than the general population. Misuse of legal and illegal drugs, alcohol, and tobacco often is not disclosed without specific questioning. Skillful screening for use, counseling about the risks associated with use, referral for treatment, and continuing collaboration between those offering treatment and those caring for the woman’s pregnancy are critical to providing optimum care. In order to give their infants the best chance in life, pregnant women are often more open to behavior change. They may be motivated to address substance use issues in an effort to protect their unborn infant. We hope this toolkit will help address the important problem of substance misuse and give you direction as you care for the pregnant woman and her unborn child. R egional Perinatal Advisory Group Substance Use in Pregnancy Toolkit 2014 Introduction 1.3 Scope of the Problem Tobacco Use Nationally • Cigarette smoking rates are lower in pregnant women aged 18 to 44 than their non- pregnant counterparts, but 22.7% of pregnant women aged 18 to 25 and 11.8% of 1 pregnant women aged 26 to 44 continue to smoke throughout pregnancy. • Tobacco use during pregnancy is associated with preterm labor, lower birth weights, fetal 2 deaths, and a variety of other pregnancy complications. • Tobacco use rates are especially high in adults who also abuse other drugs. Among adults in treatment for substance abuse, studies report as many as 80-98% also use 3 tobacco. • Maternal smoking during