The high prevalence of substance use in pregnant women highlights the importance of improving public education on the - - Risks of substance use in pregnancy - Increasing preventive services - Providing treatment for pregnant women who are in need

1. Topic-Substance use and
female reproductive health

2. Outlines-
 Introduction : Female reproductive health
 Female substance use: Etiology & Prevalence
 Substance Wise women reproductive health conditions
 Gender Responsive Services
 Interventions (Non pharmacological & Pharmacological)
 Critical comments on available literature
 Future directions

3. Introduction-
 Sexual and Reproductive Health (SRH) involves all sexual
and reproductive processes and functions of an individual,
in all stages of life and therefore consists of diverse
components -:
 Puberty
 Pregnancy
 Maternal care and delivery
 Family planning
 Sexually transmitted diseases, HIV/AIDS
 Abortion (safe) , infertility (Popin et.al; 1994)

4. Introduction-
 The high prevalence of substance use in pregnant women
highlights the importance of improving public education on
the -
 Risks of substance use in pregnancy
 Increasing preventive services
 Providing treatment for pregnant women who are in need

5. Introduction-
Normal Mammalian Puberty-
 The female reproductive system includes three basic
components:
Brain region (Hypothalamus)
Pituitary gland (Base of the brain)
Ovaries
(Molitch 1995)
 All three make up the female hypothalamic– pituitary–
gonadal (HPG) axis

6. Introduction-
In puberty hypothalamic
activation l/t episodic
secretion of luteinizing
hormone releasing hormone
(LHRH) –
Stimulates the pituitary for
secretion of LH and FSH
Which l/t maturation and
function of the ovaries
(Mauras et al. 1996)

7. Introduction-
 Puberty is also characterized by marked activation
processes of growth spurt – female growth hormone–
insulin-like growth factor (GH–IGF) axis
 GH regulated by interaction b/w hypothalamus, & other
organs, mainly the liver (Molitch 1995)
 Hypothalamus produces GRF and the hormone
Somatostatin (SS) in blood
 GRF stimulates GH synthesis and secretion
 SS inhibits GH synthesis

8. Despite negative feedback GH and IGF–1 both remain elevated is normal puberty.

9. Introduction-
In typical Menstrual cycle –
At day 12, estrogen levels surge –l/t
increase pituitary LH and FSH -
LH/FSH surge (day 14) results in
ovulation –
Sustained elevated estrogen, and
new increase in progesterone level
During (luteal phase) -prepare the
uterine wall for embryo
implantation and growth, for
pregnancy to occur

10. Introduction-
Pregnancy-
 In last three decades, medications use during pregnancy
has increased (80% reported in 1st TM) , a critical period of
organogenesis (Mitchell AA et.al;2011)
 Drugs that cross the placenta
 Direct toxic effect or a teratogenicity effect.
 Drugs that do not cross the placenta
 Constricting placental vessels and thus impairing gas and nutrient
exchange
 Producing severe uterine hypertonia that results in anoxic injury
 Altering maternal physiology (eg, causing hypotension)
 A drug’s effect on the fetus is determined largely by fetal
age at exposure, drug potency, and drug dosage.

11. Introduction-
• Drugs given at this time typically have an
all-or-nothing effect
• Teratogenesis is unlikely during this
stage
Before the 20th day
after fertilization
• Teratogenesis is most likely at this stage
• Spontaneous abortion and sub lethal
gross anatomic defect can occur
Organogenesis
(between 20 and 56
days after
fertilization)
• Teratogenesis is unlikely
• Drugs alter growth and function of
normally formed fetal organs and tissue
system and fetal toxicity
After organogenesis
(in the 2nd and 3rd
trimesters)

12. Female substance use
One out of three drug users is a woman, only one out of five drug users in
treatment is a woman

13. Female substance use
 1970’s – first focus was given on gender disparities
and women’s substance use issues
 90% of articles on gender published since 1990
(Back, 2007)
 24% of substance abuse treatment facilities now
provide specific programs or groups for women
(SAMHSA Facility Locator, 2007)

14. Female substance use
 National Survey on Drug Use & Health 2008-09 :
Substance 1st TM 2nd TM 3rd TM
(past month) (National Prevalence)
Any Illicit 8.5% 3.2% 2.3%
Alcohol 20.4% 6.5% 3.5%
Cigarettes 22.4% 12.6% 11.6%
(SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2007-2008),

15. Study (year) Summary Number Prevalence
1 Ray et.al;2004 National survey on
extent, pattern and
trends of drug abuse in
India
75 females
with SUD
Heroin (90.6%); SPV
(35%)Alcohol (33%);
tranquilizers (23%)
cannabis (11%)cough
syrup (15%)injecting
drugusers (40%)
2 Ray et.al;2004 Extent, pattern and
trends of drug abuse in
India (Rapid Assessment
Survey)
4648
substance
users
at 14 sites
About 8% users were
females.Heroin, alcohol,
and painkillers were
used substances
3 Ambekar et.
Al;2014
lDU Coming
to harm-reduction
Sites (Cross sectional
study)
M=202
F=98 IDU
Females: Ever use:
Heroin:85.7%
DPropoxyphene:58.2%
4 Chaturvedi et.
al; 2013
Correlates of opium use
in Arunachal Pradesh
n=3421
individuals
Opium use: Male -6.6%;
females -2.1%
Substance use prevalence (Indian studies)

16. FSU- Etiology
 Social dislocation/isolation
 Substance using partner
 Emotional problems e.g. marital disruption
 Poor treatment access: Stigma, lack of knowledge
 Role transition, ongoing stressors and life style
 Peers influence and drug availability
 High family loading
 Comorbid Psychiatric illness
 Substance using partner
 Women's with PMS* *(Tobin MB et.al; 1994)

17. FSU- Etiology
 Genetic factor & environmental factor influences:
Drug use across genders (Environmental factor > Genetic
factor )
(Jang KL et.al; 1997)
 Genetic factors are more for male then female (Male 33% and female
11%)
 Environmental factors are more for females
(Han c et.al; 1999)
 In women initiation of substance is shaped by environment
but genetic factors have greater impact on progression to
abuse or dependence (Kendler KS et.al; 1998)

18. Substances
Substances-
1. Alcohol
2. Tobacco
3. Cannabis
4. Cocaine
5. Opioids

19. 1. Alcohol
Non-pregnant Pregnant
 Women ages (14 to 44)
 55.5% reported alcohol use
 24.7% reported binge drinking
 5.2% reported binge drinking on at
least 5 days in the past month
 lower than in non-pregnant women
 8.5% reported alcohol use
 2.7% reported binge drinking
 0.3% reported binge drinking on at
least 5 of 30 days during pregnancy
 Among pregnant women ages 18 to
50, 3.6% met diagnostic criteria for
an alcohol use disorder
Prevalence – In 2012, 47.9% of women ages 12 years and over reported
current alcohol users
(NSDUH 2013) & (Vesga Lopez O et.al; 2008)

20. 1. Alcohol
Effects During Puberty, Pregnancy and Delivery :
 In puberty women have from irregular menstrual cycles to
absence of ovulation and infertility (Mello et.al; 1993)
 Increased obstetrical complications: vaginal bleeding, placental
abruption, fetal distress with high rates of spontaneous abortion,
miscarriage, and stillbirth
 Risk for spontaneous abortion is dose related:
 If average 3 or more drinks/day –3 times more likely to
miscarry
 Even with 1 or 2 drinks a day are at increased risk of
miscarriage during the 2nd TM

21. 1. Alcohol
1. Alcohol & metabolite
acetaldehyde directly
toxic to the embryo and
fetus
2. Interferes with
delivery of maternal
nutrients
3. Impairs supply of fetal
oxygen
4. Deranges protein
synthesis and
metabolism
5. Stimulates excess
production of
(prostaglandins) that
modulate cellular
functions cause fetal
malformations
Alcohol – Mechanisms of Damage to the Fetus :
(James R et.al;1994)

22. 1. Alcohol
Alcohol – Effects on the Newborn :
 Most consistent effects: LBW & IUGR – more severe in
women who drink heavily during the last TM of pregnancy
 IUGR l/t early death, respiratory difficulties, feeding
problems, serious infections, and developmental problems
Heavy drinking (average of 5 drinks/day)
 Alcohol withdrawal: tremors, hypertonia, restlessness,
sleeping problems, delayed crying, and abnormal reflex
 Decreased ability to tune out inappropriate stimuli
 Poor sucking abilities
 Disturbed patterns of sleep and wakefulness

23. 1. Alcohol
Fetal Alcohol Spectrum Disorders (FASD) :
 Umbrella term used to describes the effect of alcohol during
pregnancy. Effects may be lifelong: Physical, Mental
Behavioral and/or Learning disabilities-
 It refers to:
 Fetal alcohol syndrome (FAS)
 Partial Fetal Alcohol Syndrome (pFAS)
 Alcohol-related neurodevelopmental disorder (ARND)
 Alcohol-related birth defects (ARBD)
 Prevalence of FAS, ARND, and ARBD combined is at least
10 per 1,000 births, FASD affects nearly 40,000 newborns
each year. (May, P.A.et.al; 2001)
SAMHSA, Center for Excellence on Fetal Alcohol Spectrum Disorder 2015

24. 1. Alcohol
Alcohol Related Birth Defects (ARBD):
 1 in 200 births worldwide
 5% of all congenital anomalies
 10-20% of all cases of mental retardation

25. 1. Alcohol
FAS Guidelines for Diagnosis:
1. Prenatal maternal alcohol use
2. Growth deficiency
3. CNS abnormalities
- Structural
- Neurologic
- Functional
4. Dysmorphic features

26. 1. Alcohol
1. Prenatal
maternal alcohol
use
• Confirmed
• Unknown
2. Growth
deficiency
• Confirmed prenatal or postnatal height or weight, or
both, at or below the 10th percentile
• Adjusted for age, sex, gestational age, and race or
ethnicity

27. 1. Alcohol
3. Central nervous
system (CNS)
abnormalities
• Structural – HC at or below the 10th percentile
adjusted for age and sex or clinically significant
brain abnormalities observable in imaging
• Neurologic – Neurologic problems not due to
postnatal insult or fever
• Functional – Global cognitive or intellectual deficits
representing multiple domains of deficit
4. Dysmorphic
features
(must be +nt)
• Short palpebral fissures
• Indistinct philtrum
• Thin upper lip

28. 1. Alcohol

29. 1. Alcohol
Alcohol – Effects on Breastfeeding:
 Chronic exposure of alcohol is dangerous as infants oxidize
alcohol more slowly than adults
 Heavy drinking decreases milk supply - inhibits the milk-
ejection reflex
 Nursing babies of mothers who consume alcohol may be
irritable, drowsy and have abnormal weight gain

30. 1. Alcohol
 94% mental health problems.
 83% of adults experienced dependent living
 79% of employment problems
 60% had trouble with the law
 50% experienced inpatient treatment for mental health or
substance abuse problems or spent time in prison
 45% engaged in HRSB
 43% had disrupted school experiences
 35% overall had alcohol and drug problems
(Streissguth A.P et.al; 2004)
A study conducted by the University of Washington shows the
percentage of persons age 6 to 51 with an FASD who had
difficulties in the following areas:

31. Alcohol’s effect
 Menstrual irregularity
 Increased obstetrical complications (Abortion/Bleed)
 IUGR & LBW
 Fetal alcohol spectrum disorder (Malformation)
 Cognitive and behavior changes

32. 2. Tobacco
Prevalence:
 Cigarette smoking remains the m/c method of tobacco use
 20.9% of women aged 12 or more reported tobacco use
 >60% cigarette smokers are daily smokers
 >40% smoking a pack or more/day
 15.9% of Pregnant women between the ages of 15 and 44
reported smoking
(NSDUH 2013)

33. 2. Tobacco
Smoking and folliculogenesis :
 Smoking is a/w risk of 2 years early onset of menopause
(Jick & Porter et.al; 1977)
 Ovarian reserve lower in smokers (Freour et.al; 2008)
 Follicle loss reported at all stages-Primordial more sensitive
(Mulligan Tuttle et.al; 2009)
 Hyaluronic acid synthesis was diminished in the presence
of Cd & nicotine (Liu et.al; 2008)
 Isolated rat follicle growth decreased by 35% (15
cigarettes/day - 1.5 ng/ml of nicotine) (Neal et.al; 2007)

34. 2. Tobacco
Smoking and Steroidogenesis:
 Smoke compounds disrupt steroidogenesis, l/t decrease
synthesis of E2 and progesterone (Vidal et.al; 2006)
 Analysis of follicular fluid in smokers increased
androgen/estrogen ratio, l/t unfavorable androgenic
follicular environment – infertility
(Van et.al; 1996).

35. 2. Tobacco
Cigarette smoking and Fallopian tubes :
 Increased rate of ectopic pregnancies following exposure to
tobacco smoke (Karaer et.al; 2006)
 Smoke interfere with protein complexes involved in ciliary
mobility (axonemal and dynein) or calcium signaling and
protein kinase-mediated pathways which could all
contribute to impairment of ciliary activity
(Wyatt et.al; 2000)

36. 2. Tobacco
Smoking and embryo implantation:
 Implantation rates in smokers who underwent IVF (Using
human oocyte donation models) were lower in heavy smokers
(10 cigarettes/day) than control (25.8 and 32.3%,
respectively) (Soares et.al; 2007)

37. 2. Tobacco
Cardiovascular defects
• There is 9% increased
risk (P=0.009)
• least 1-year follow-up
• Strongest effect was
on VSD and ASD
Musculoskeletal defects
• 16% increase in risk by
maternal smoking
(P=0.002)
• Transverse &
longitudinal limb
reductions
• Cranio-synostosis and
digit anomaly also
found
Facial defects
• 19% increased risk of a
facial defect
(P=0.004)
• Orofacial clefts (cleft
lip, cleft palate)
• Eye defects
(anophthalmia,
microphthalmia,
eso/exotropia)
Systematic review of study published b/w 1959–2010-Maternal smoking & birth
defects (Allan hackshaw et.al; 2011)

38. 2. Tobacco
 CNS defects- Spina-bifida and anencephaly (the most
common CNS defects)
 Gastrointestinal defects- It include abdominal wall
defects & defect of the pharynx, oesophagus, intestine,
colon, bile ducts, gallbladder and liver
 Genitourinary system – malformation of genital organs,
urinary bladder, kidney, ureter and urethra

39. Tobacco’s Effects
 Decrease ovarian follicular growth & reserve/ infertility
 Ectopic pregnancy
 Early menopause
 Neonatal-
 LBW
 IUGR
 Congenital malformations
 Cognitive deficits

40. 3. Cannabis
Prevalence of Cannabis Use during Pregnancy:
 Cannabis is the most frequently used illicit drug during
pregnancy(Marijuana)
 5.2% of pregnant women aged 15-44 years reported past-
month cannabis use (slightly higher than previous)
(NSDUH, 2012)
 Highest use reported during the 1st TM (10.7%) as
compared to 2nd (2.8%) and 3rd (2.3%) TM
(SAMHSA, 2013)

41. Prenatal cannabis use: (findings are somewhat mixed)
 In the Generation R study, maternal (7,452 mothers)
cannabis use was associated with reduced fetal growth in
mid and late pregnancy as well as a LBW at term (P=.001)
(El Marroun et.al; 2009)
 A meta-analysis of 10 studies found only weak evidence
suggesting that any maternal use of cannabis during
pregnancy showed mixed result
(Holman& Bower et.al;1997)

42. 3. Cannabis
 Impaired performance in verbal and quantitative reasoning
and short-term memory found in children whose mothers
smoking 1/> marijuana cigarettes per day in pregnancy
(Goldschmidt et.al;2008)

43. Cannabis’s Effects
 Majority of the evidence supports minimal to no effects
associated with prenatal exposure to cannabis use and birth
outcomes
 ? Reduced fetal growth in mid and late pregnancy as well as
a LBW
 ?Impaired executive performance in verbal and
quantitative reasoning and short-term memory found in
children

44. 4. Cocaine
 2.4 million frequent (least twice weekly) users of cocaine
(NSDUH 2005)
 2.8% of women who used illicit drugs during pregnancy
10% used cocaine (It is difficult to determine how many pregnant women
use cocaine nationwide)
(Ebrahim et.al; 2003)

45. 4. Cocaine
Women compare to men:
 Take longer to feel its subjective effects, report less
euphoria
 Stronger cue associated craving
 Once addicted find it more difficult to quit
 Report shorter abstinence periods
 More likely relapse after stressful life events
 Females, estradiol has facilitator effects, progesterone
inhibits cocaine responses
 Response to cocaine is greater during the follicular(E2)
compared with the luteal phase (Evans et.al; 2007)

46. 4. Cocaine
Cocaine in Pregnancy l/t :
 Placental abruption
 Premature rupture of membranes
 Preterm labor & delivery
 Maternal seizures
 Migraine headaches, worsen during pregnancy
 Hemorrhagic and ischemic cerebrovascular accidents
 Hyperthermia (vasoconstriction and/or the hyper-metabolic state)
 Cocaine-induced hyperthermia l/t altered mental status in the
mother (Excited delirium) reactions are independent of amount,
route & metabolism of cocaine

47. 4. Cocaine
Fetal effects:
 Constricted blood vessels reduce blood, O2 &
nutrients supply to fetus
 Fetal anomalies
 CNS abnormalities
 Intestinal abnormalities
 Urogenital system abnormalities
 Malformations of extremities
 “Crack babies,” or babies born to mothers who abused
crack cocaine while pregnant severe and irreversible
damage
 “Crack lung” or Pneumonitis (fevers, pulmonary infiltrates,
and leukocytosis) l/t death (SIDS)

48. 4. Cocaine
Vasculopathy: (Due to prolonged vasoconstriction)
 Vasculopathy reduces the efficacy of the placental & fetal
blood-brain barrier, facilitate fetal exposure to teratogen
 Increased risk of infections/HIV via vertical transmission
due to cocaine-induced Vasculopathy
 Fetuses exposed to cocaine in utero Asymmetrical growth
retardation (Little et.al; 1991)

49. 4. Cocaine
 Benzodiazepines with cocaine increase the incidence of
malformations such as hydronephrosis, cryptorchidism,
and incomplete ossification of the skeleton. (Animal study)
(Mehanny et.al; 1991)
 Systematic review and meta-analyses (1966-2009)
antenatal cocaine exposure show LBW, shorter gestational
age at delivery (Gouin k et.al; 2011)

50. Cocaine’s Effects
Maternal :
 Preterm labor & delivery, PROM, P. abruption
 Worsening of Migraine headaches
 Hemorrhagic/ischemic cerebrovascular accidents
 Hyperthermia, Arrhythmia, Seizures
Fetal :
 Vasoconstriction reduce O2 & nutrients supply- IUGR
 Fetal malformations (CNS /Intestinal /Urogenital )
 Vasculopathy (risk of infections/vertical transmission)
 Pneumonitis (SIDS)

51. 5. Opioids
25% Currently
were heroin
users
18% Used
Dextro-
propoxyphene
11% Opioid
containing
cough syrups
7%
Buprenorphine
Rapid Assessment Surveys
A survey (1865 women drug users by 110 NGOs
across the country) revealed –
(Murthy P et.al; 2008)

53. 5. Opioids
 Opioid-containing medications are widely prescribed
among reproductive-aged women with either private
insurance or Medicaid
 Easy to obtain
 less social stigma
 less closely monitoring by law
 Non-medical prescription drugs later l/t development of a
substance use disorders (Heil et.al; 2011)
 The most frequently prescribed opioids among women is
hydrocodone, codeine, and oxycodone
(MMWR 2015)

54. 5. Opioids
 Women compare to men with age 12-17 years reports high
rate of dependence then 18-25 (Lowinson 5th ed.)
 Unintended pregnancy rate is 2–3 times then rate observed
in the general population (Mohllajee et.al; 2007)

55. 5. Opioids
Fetal effects:
 Opioids not categorized as a teratogen
 Low birth weight due to symmetric IUGR or prematurity
specially if exposed to Heroin
 Meconium aspiration – fetal respiratory distress due to
placental insufficiency
 Effects due to mother’s behavior
 Lack of prenatal care
 Poor nutrition
 Medical problems
 Abuse of other drugs (Lowinson 5th ed.)

56. 5. Opioids
Neonatal Abstinence Syndrome (NOWS):
 In the first few days (72 hours to 2 weeks) after delivery
 Affecting 55-94% of newborns born to opioid-dependent
mothers
CNS Respiratory GIT
Irritability, Hyperactive
reflexes, Altered sleep-
wake cycles, Tremors
Seizures, Fever
Autonomic (sweating)
Rapid respiration, nasal
stuffiness
Vomiting, Loose stools
Poor feeding, constant
sucking, Failure to thrive
Morphine sulfate (0.06 to 0.24 mg/kg/d) given if Finnegan score > 8 at 3
consecutive score/> 12 at 2 consecutive time (At 4 hours interval 2 hour after birth )

57. 5. Opioids
Indications for drug therapy in neonates with
confirmed in utero exposure to opioids:
 Seizures
 Poor feeding
 Diarrhea, Fever and vomiting (Unrelated to infection)
(American Academy of Pediatrics, 1998)
Buprenorphine v/s Methadone in neonatal withdrawal BPN
has :
 Shorter hospital stays
 Shorter duration of treatment
 Possible slower time to withdrawal (Jones et.al; 2010)

58. Opioids Effects
 LBW due to symmetric IUGR or prematurity
 Meconium aspiration (Respiratory distress)
 Neonatal opioid withdrawal syndrome

59. Need for Gender Responsive Services
Course of illness different than men:
Telescoping Efffects:
 Females advance more rapidly & escalate into addiction
faster.
 Physiological consequences sooner with less use &
Metabolic differences
 More medical, psychiatric and social consequences
 Treatment needs different & more complex than men
Convergence hypothesis:

60. Measurement Domains of Gender-Responsive
Treatment
SN. Domains Variables
1. Treatment
Orientation
Women as priority /target population, use of evidence-based
approaches, planned treatment duration
2. Administrator
and Staff
Program director’s gender, percent of female staff
3. Organizational
Characteristics
Type of setting (stand-alone /multimodality), referral etc.
4. Women’s Services Prenatal/postnatal services, women-only groups, parenting
training
5. General Services Gender-specific assessment, psychiatric consult, individual
counseling, family therapy, HIV education, employment
rehabilitation
6. Children’s
Services
On-site child care, live-in accommodations for children,
Child Welfare Services
7. Physical
Environment
Program environment, safety and security, child care area is
clean and well designed, spatial layout, recreational spaces,

61. Barriers to Treatment
Systemic Barriers Structural Barriers Social, Cultural, &
Personal Barriers
Lack of decision-making
power
Limited awareness of gender
differences
Lack of knowledge of women
with SUD & their treatment
needs
Lack of low-cost, evidence-
based treatment models
Differences in funding of
health services
Childcare
Transportation
Services for pregnant
women
Location & cost of
treatment programs
Rigid program schedules
Service coordination
Fear of leaving children
Lack of support from
family /partners
Substance use perceived
as solution, not problem
Stigma, shame, & guilt
Lack of confidence in the
effectiveness of treatment

62. Steps of Intervention
1. Screening and assessment
2. Non-pharmacological approach
3. Substance specific pharmacological approach

63. 1. Screening and Assessment
Screen high risk:
 Adolescents with indicators of substance use
 Commercial sex workers
 Spouses of substance user
How to screen?
 Open-ended, non-judgemental questioning-brief interventional techniques
 Women of childbearing age should be screened periodically for
alcohol, tobacco, and prescription and illicit drug use
 When clinically indicated, urine drug screening is the preferred
method. (Informed consent should obtained from the woman)
 Liaison with obstetrics and pediatric care for management of
complications in substance using mother and newborn.
(Hinderliter SA et.al; 1993)

64. 1. Screening and Assessment
T-ACE and TWEAK questionnaires were developed for screening at-risk perinatal alcohol use
T-ACE
• T Tolerance A Have people annoyed you by criticizing your drinking?
• C Cut down on your drinking?
• E (Eye-opener)
• Scoring: T: 2 points if > 3 drinks; A,C,E: 1 point for each yes answer
• A total 2 or more indicates an alcohol problem.
TWEAK
• T Tolerance W Have friends or relatives complained about your drinking? (Worried)
• E Eye-opener A Has a friend or family member ever told you about things you said or
did while you were drinking that you could not remember? (Amnesia or black-out)
• K Cut-down
• Scoring: T: 2 points if > 3 drinks; W, E, A, K: 1 point for each yes answer
• A total of 3 or more risk drinking
(Chang G et.al; 1998)

65. Non Pharmacological approach
 Establishing confidentiality & rapport on being non
judgmental
 Assessment of the severity of the problems
 Comorbid problems should be assessed
 Educate about ill effects to patient and family

66. Non Pharmacological approach
CBT/Relapse Prevention Motivational Enhancement
Interventions
Contingency Management
Teaching skills for relapse
prevention
BCT (Behavioral Couples
Therapy )
Women with co-
occurring SUD and PD
:
1. Dialectical Behavior
Therapy (DBT)
2. Dual Focused Schema
Therapy (DFST)
To increase the
individual’s awareness of
their substance
To build upon the specific
coping styles more
emotionally focused reliant
upon religious or spiritual
coping than those of men
Pregnancy “window of
opportunity” during which
women are more receptive
to motivation
Effect enhance when the
woman’s partner
participate
Contingency management
approaches employ a
schedule of rewards to
“Strengthen the practice of
desired behaviors” (e.g.,
abstinence) based on the
duration of abstinence
attained
(SARC Supplement 5, 2008)

67. Pharmacological management
Opioids: Methadone
Buprenorphine
Methadone maintenance in pregnancy
superior outcomes compared with not
being in treatment (Ward et al, 1998)
Not increasing the risk of congenital
abnormalities in the fetus
Should be started as soon as possible
after confirmation of pregnancy
(maintenance should be continued)
The metabolism of methadone is
increased by pregnancy age
(Wittman & Segal, 1991)
Placental transfer of buprenorphine
may be less than that of methadone,
there by low incidence of NAS (Fischer et
al, 2000)
No adequate follow-up periods to
demonstrate its safety during pregnancy
and breastfeeding
(Dunlop et al, 2003)
Naltrexone (opioid antagonist)
No obstetric complications were
observed, high drop-out (dysphoria)

68. Pharmacological management
Detoxification Preventing or minimizing relapse
Benzodiazepines remain a first-line
therapy for alcohol withdrawal
(William et.al; 2001)
1. Disulfiram (FDA 1952) Nonspecific
fetal abnormalities have been
reported with first trimester
exposure (Reitnauer et.al; 1997)
2. Naltrexone did not detect any gross
abnormalities in fetal development
(Hulse et.al;2001)
3. Acamprosate (not much used in
pregnant women)
Alcohol: It is an established human teratogen and there is no clear safe level
of consumption during pregnancy

69. Pharmacological management
Cocaine:
 No one drug has been found to be unequivocally effective.
 Withdrawal symptoms on abrupt cessation of cocaine during
pregnancy reduced with short-term use of BDZs
 Combination of symptomatic interventions and psychosocial
interventions may be effective
 Naltrexone outcomes are not as favorable
 Bupropion outcomes are not as favorable
 Baclofen may be more effective in reducing cocaine use (Lowinson 5thed)
Cannabis:
 Currently, there are no pharmacotherapies for cannabis
dependence.

70. Pharmacological management
Nicotine:
 Approved medications for smoking cessation include several
nicotine replacement therapies (gum, transdermal patch, lozenge, inhaler,
and nasal spray) and an antidepressant bupropion
 Smoking cessation counseling should be considered as a first-
line intervention for pregnant
 NRT can be considered if counseling is not successful
 NRT combined with CBT, results higher quit rates than
counseling alone
(Pollak et.al; 2007)

71. TREATMENT OUTCOMES IN
GENDER-SPECIFIC PROGRAMS(GSP) FOR WOMEN
 Entrance in (women only programme) WOP at their earlier
addiction careers
 Women with female therapist retained in treatment for a
longer time
 Women in GSPs had more severe problems before
treatment entry but were twice as likely to complete
treatment as women in mixed-gender treatment programs

72. TREATMENT OUTCOMES IN
GENDER-SPECIFIC PROGRAMS FOR WOMEN
 Provided more comprehensive services, including those that
addressed family, parenting, and mental health needs
 Better drug and legal outcomes at follow-up
 Greater satisfaction with treatment particularly when services
are matched with their needs
 Better outcomes in psychological well-being, attitudes and
beliefs, and HIV risk reduction
 Cost-benefit analyses have shown favorable results

73. Critical comments
 Western countries have recognized the need to study and
address the issues pertaining to FSUs
 Most of the literature is from the Western developed
countries with data from developing countries like India
being sparse
 Most studies are based on case-reports & retrospective data
 Only few studies are longitudinal observational studies with
large sample sizes

74. Critical comments
 India, there is still a lack of research-based information on all
aspects of women’s substance use and related problems
including :
Prevalence, Pattern of use, Physiological and psychosocial effects
and consequences characteristics of women with SU problems,
Treatment experiences
 Women’s approach to formal services, and relatively less
support from their families to seek treatment for substance use
related problems are not well addressed
 Limited Consultation- liaison services b/w obstetrical inpatient
& psychiatric and substance-use consultation

75. Future directions
 More sensitivity- sensitive to gender perspectives of
women using drugs will help in evolving effective
communication for prevention and early intervention
 More evidence- Drug abuse among women needs to be
studied in a more systematic fashion using both qualitative
and quantitative methods of research and through
multi-centered studies
 Better interventions- Drug abuse among women a
growing global concern- interventions to target causes and
consequences

76. Future directions
 Greater Collaboration- Interdisciplinary relationships
and consultation among primary care, obstetric, family
medicine, and midwife practices with psychiatric and
substance-use consultation
 Preventive measures-
 IEC regarding consequence of substance use in pregnancy
 FASD is 100% preventable
 Prenatal serum/urine toxicology should include drugs of abuse
 Reduce unnecessary prescribing and use of opioid-containing
medications

77. Thank you…