NATIONAL PERINATAL ASSOCIATION CONFERENCE 2014 - Treatment Programs HARPS Program (Helping At-Risk Pregnant Women Succeed) - Chris Cooper, MSN, NNP-CB, APRN and Dawn Forbes, MD

1. Substance
Dependence
During Pregnancy:
How Big is the
Problem?!?
K. Dawn Forbes, MD, MS, FAAP
Founder & Medical Director, HARPS
Program
Neonatologist, Kosair Children's Hospital
Neonatal Specialist

2. I have no known or
perceived financial or
professional conflict of
interest regarding this
presentation
All images of persons,
place or animal are either
purchased stock images
or personally
photographed images and
have no known affiliation
with drug use/abuse,
addiction, NAS or illicit
activity.

3.  What is Addiction?
 Review the epidemiology of
substance abuse
 Discuss the cost of
substance
abuse/dependence
 Discuss the pregnancy
specific cost and impact of
addiction/substance abuse
 Discuss recommendations
to decrease the impact of
addiction in pregnancy and
improve outcomes
OBJECTIVES

4. WHAT IS ADDICTION?

5. Definition of Addiction
 Addiction is complex disease, not just a choice
 Complex, chronic, relapsing disease of the
brain, characterized by craving & compulsive
drug seeking and use, despite harmful
consequences.
 Affects brain circuits involved in reward and
motivation, learning and memory, and
inhibitory control

6. Definition of Addiction
 The American Society of Addiction Medicine (ASAM), in April 2011, redefined addiction
 “Addiction is a primary, chronic disease of brain reward, motivation, memory and related
circuitry”.
 Affects neurotransmission such that addictive behaviors replace healthy, self-care related
behaviors.
 Genetics account for 50% of addiction development
 Significant self-deception
 Disruption of healthy social supports and problems in interpersonal relationships
 History of trauma or stressors that overwhelm an individual’s coping abilities
 The presence of co-occurring psychiatric illness
 Distortion in meaning, purpose and values that guide attitudes, thinking and
behavior
 The effects to the brain allow external cues to trigger craving and drug use
 Persistent risk of and/or recurrence of relapse
 Impaired executive function so that perception, learning, impulse control,
compulsivity and judgment are impaired

7. Why Do People Use/Abuse Drugs?
 Curiosity
 Peer Pressure
 To feed good
 Stimulants cause feelings of power, energy, and self-confidence
 Opiates cause relaxation & satisfaction
 To feel better
 Decrease social anxiety, stress & depression
 To do better
 Enhance cognitive or athletic ability
 Self medicate
 Undiagnosed/untreated mental illness
 Prescribed
 Post procedure or chronic pain

8. EPIDEMIOLOGY OF DRUG
ABUSE & ADDICTION

9. Substance Abuse and Mental Health Services
Administration:
Results from the 2013 National Survey on Drug
Use and Health: Summary of National Findings
NSDUH Series H-48, HHS Publication No. (SMA)
14-4863. Rockville, MD: Substance Abuse and
Mental Health Services Administration, 2014.

10. What's the most
commonly used drug
in pregnancy in the
US?
a. Marijuana
b. Opiates
c. Cocaine

11. Past month Illicit Drug Use Among Persons Aged 12 or Older: 2013
/9.4%
/7.5%
/4.5mil Pain Relievers
/1.7mil tranquilizers
/1.4 mil stimulants
/0.25mil sedatives
/2.5%

12. Trend In Past Month Use of Illicit Drugs
2002-2013

13. Trend In Past Month Non-Medical Use
of Psychotherapeutic Drugs 2002-2013

14. Past Month & Past Year Heroin Use:
2002-2013
60% increase
57% increase

15. Marijuana Use in 2013
 Marijuana continued to be the most commonly used
drug in 2013
 Use from 2007 to 2013 increased from 5.8% to
7.5%
 19.8 million reported past month use
 Of current drug users
 81% used THC
 65% used THC exclusively
 Average age of initiation of THC 18 yrs.

16. Daily THC use in past year & past Month
2002-2013

17. First Drug Associated with Initiation of Illicit Drug Use in 12 or older in 2013
6600 new
users/day
56.6% where
<18 yo
1600 new cocaine users/day
5500 new users/day
Avg age 22.4
7800 new users/day
463 new heroine users/day

18. Tobacco Product Use in 2013
 57.5 mil current cigarette users
 5753 new smokers/day in 2013
 50% of new smokers < 18 yo
 41.3% smoke 16 or more cigs/day

19. Prescription Drug Abuse
 Defined as the intentional use of medication
 Without a prescription
 In a way not prescribed
 For the “feeling” it invokes
 The US makes up 5% of the worlds
population & consumes 75% of prescription
drugs
 High prevalence caused by
 Misconceptions about safety
 Increasing motivations
“get high”
Counter anxiety, pain, insomnia
Improve performance or cognition
 Increasing availability
Prescriptions in millions between 1991-2010
250
200
150
100
50
0
Stimulants Opiates
1991
2010
NIH. Topics in Brief: Prescription Drug Abuse. December 2011.

20. Prescription Drug Use



 

21. DRUG USE &
DEPENDENCE
DURING
PREGNANCY

22. Substance Use In Pregnancy: 2000-
2010
Source: Treatment Episode Data Set (TEDS), 2000-2010

23. Drug Use In Pregnancy In 2013
 5.4% of pregnant women, 15-44, reported
current illicit drug use
 14.6% (18.3%) were 15-17 y.o. (20.9% in
2011)
 8.6% (9%) were 18-25 y.o. ( 8.2% in
2011)
 3.2 (3.4%) were 26-44 y.o. (2.2% in 2011)
 Of those using, 9% used in 1st trimester vs
2.4% in 3rd
 4.8% of women where pregnant at entry into
substance abuse treatment program
 1 in 6 pregnancy women (15.4%) smoked
cigarettes in past month

24. Past Month Cigarette Use in Pregnant
and Non Pregnant Women 2002-2013

25. Alcohol Use in Pregnancy in 2013
 19% of pregnant women used alcohol in 1st trimester
 9.4% pregnant women reported past month alcohol use
 2.3% reported binge drinking
 0.4% reported heavy drinking
 40K babies born with Fetal Alcohol Spectrum Disorder (FASD) in
2012

26. Cost of Addiction
Social
Economic
Criminal
Retail Morbidity
Health Care
Mortality

27. Retail Cost of Addiction
Street Drug Prices
 Amphetamine 10 mg $5
 Cocaine 1 gram $45
 Marijuana 1 gram $10
 Mushrooms 3.5 grams $25
 Oxycodone 60 mg $8
 Valium 7 mg $7
 Alcohol beer 6-pack 12 fl. Oz. $7.99
 Heroin 0.10 grams $25
 Ecstasy 100 mg $15
 Methamphetamines 20 mg $30
*Information provided by the DEA

28. Drug users in the United States have consistently spent >$100 billion annually on cocaine, heroin,
marijuana, and methamphetamine
 Compositional shifts
 Cocaine consumption decreased by about 50 %
 Marijuana consumption increased by about 40%
 Heroin consumption remained stable
What America’s Users Spend on Illegal Drugs: 2000-2010. February 2014. Office of National Drug Control Policy. Office of Research and Data Analysis.
Under HHS contract number: HHSP23320095649WC Contract Officer Representative: Michael Cala, PhD

29.  Heroine consumption has remained stable, $21-27 bil/year
 Majority of users are daily (>80-90%)

30. Cost of Addiction…Mortality
Cocaine
Heroine**`
**Likely increased heroine deaths since 2007:
 Increased availability
 Decreased price but increased purity
 Decreased prescription opiate availability

31. Rates of Prescription Painkiller Sales, Deaths and Substance Abuse
Treatment Admissions (1999-2010)
CDC. Vital Signs November 2011. Prescription Painkiller Overdoses in the US. http://www.cdc.gov/vital signs/pdf/2011-11-vital signs.pdf

32. Drug Overdose Death Rates by State Per 100,000 people (2008)
• Drug overdoses killed more than 38,000 people in 2010
(105 deaths per day)
• Prescription painkiller overdoses killed 16,500 people
• (45 deaths per day)
SOURCE: CDC. Vital Signs November 2011. Prescription Painkiller Overdoses in the US. http://www.cdc.gov/vital signs/pdf/2011-11-vital signs.pdf
National Vital Statistics System, 2008

33. Cost of Addiction…
Health Care Cost
 Health care costs continue to grow faster than the economy
 Health share of the Gross Domestic Product (GDP) reached 17.9% in 20111
 Aggregate cost for 39 million hospital stays totaled $387 billion in 20112
 2005, drug abuse was reported in 1.3 million hospital stays in the U.S. (3.3%) =
$9.9 bil in hospital costs
 2008, substance abuse (SA) disorders were the principal reason for 2.1% of
inpatient community hospital stays = $2.1 billion3
 Cost per stay $4600
 Cost per day $970
 Avg length of stay 4.8 days
 Drug abuse stays were six times more likely than typical stays to result in a
discharge against medical advice (6.2 percent versus 0.9 percent).
1 Centers for Medicare & Medicaid Services. National Health Expenditure Accounts. http://www.cms.gov/Research-Statistics-Data- and-Systems/Statistics-Trends-and-
Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html . Accessed July 17, 2013.)
2 Health Care Cost and Utilization Project, SB # 168, December 2013. Costs for Hospital Stays in the United States, 2011 Anne Pfuntner, Lauren M. Wier, M.P.H., and Claudia
Steiner, M.D., M.P .H.
3 Health Care Cost and Utilization Project, statistical brief 117; June 2011 State Variation in Inpatient Hospitalizations for Mental Health and Substance Abuse Conditions, 2002 2008
Elizabeth Stranges, M.S., Katharine Levit, Carol Stocks, R.N., M.H.S.A., Pat Santora, Ph.D.

34. Cost of Addiction…Health Care Admissions

35. Cost of Addiction…Health Care In-Patient
Hospital Inpatient Utilization Related to Opioid Overuse Among Adults,
1993-2012
Hospital Inpatient Utilization Related to Opioid Overuse Among Adults, 1993-2012. Pamela L Owens, Ph.D., Marguerite L. Barrett, M.S., Audrey J.
Weiss, Ph.D., Raynard E. Washington, Ph.D., and Richard Kronick, Ph.D.

36. Cost of Addiction…Fetal & Newborn
Morbidity & Mortality
 From Conception the pregnancy & fetus are at risk of
 Spontaneous abortion
 Fetal Hypoxia
 Preterm labor
 Preterm delivery
 Exposure to violence
 Exposure to infection
 In early Gestation some drugs can be teratogenic
 Alcohol
 After structural development is complete the fetus is at risk of:
 ?Alterations in neurotransmitters & receptors (GABA, Dopa, serotonin)
 ?Altered brain organization
 Placental insufficiency & poor maternal nutrition=IUGR/LBW

37. Cost of Addiction…Fetal & Newborn Morbidity & Mortality
Opiates THC Nicotine cocaine
NAS X ? X X
Withdrawal X ?
Toxicity X X
Learning Disabilities X X
Hyperactivity X X X X
Inattention X X X X
Impulsivity X X
Memory Problems X X X
Poor Language X X
Altered response to Visual
Stimuli
X
IUGR X X X
Low Birth Weight X X X
SIDS X X

38. Cost of Addiction…NAS from 2000-2009
 Maternal opiate use increased from 1.19 to 5.63/1000 live births
 NAS increased from 1.2 to 3.39/1000 live births
 NAS affected more than 13,539 infants in 2009
 1.5 infants born per hour with symptoms of withdrawal
 Total hospital charges for NAS increased from $190 million to $720
million
 Mean hospital charge per infant has increased from $39, 400 to
$53,400
 77.6% of charges attributed to State Medicaid
Neonatal Abstinence Syndrome and Associated Health Care Expenditures US 2000-2009.
SW Patrick et al; JAMA, May 9, 2012. Vol 307, No. 18

39. Cost of addiction…
In 2007, total cost of illicit drug use was
 Crime: $61,376,694
 Health Care $11, 416,232
 Productivity $120,304,004
Cost in Billions of Drug Misuse as Compared
$157 B
$174 B
0 100 200 300 400
Heart Disease
Obesity
Smoking
Diabetes
Drug Misuse
to Chronic Health Problems
$316 B
$147 B
$193 B
$193 Billion

40. Total Cost of Substance Abuse &
Addiction
Health Care Cost,
Billions
Total Cost,
Billions
Illicit Drugs $11 $193
Tobacco $96 $193
Alcohol $30 $235
Total Cost: $ 621 Billion

41. How Do We Break the Cycle and Decrease the Cost
and Impact of Addiction & Substance abuse???

42. Emerging Trends of Substance Abuse among
Women 1
1. Gender gap is narrowing for substance use across ethnicities, particularly
among young women.
2. Women are more likely to be introduced to and initiate substance use
through significant relationships
 Boyfriend, family, or friend
 More likely to have partners who have substance use disorders 2
 Perceive shared drug use with their partner as a means of
connection or of maintaining the relationship
 Status change-death, divorce, separation
3. Women accelerate to injecting drugs at a faster rate than men
 High-risk behaviors with IV drug use influenced by relationships
4. Earlier age of initiation associated with higher risks for dependency
5. Women progress faster from initiation substance-related adverse
consequences 3
6. Women are more likely to alter pattern of use for caregiver
responsibilities
1 Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series, No. 51. HHS
Publication No. (SMA) 14- 4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.
2 Klein et al. 2003 Klein, H., Elifson, K.W., and Sterk, C.E. Perceived temptation to use drugs and actual drug use among women. Journal of Drug Issues 33(1):161–192, 2003.
3 Antai-Otong, D. Women and alcoholism: Gen der-related medical complications: Treat ment considerations. Journal of Addictions Nursing 17(1):33–45, 2006

43. Obstacles for Women in Engaging in Treatment
Services
 Poor availability of treatment centers
 Lack of collaboration among social service
systems
 Stigma of substance abuse & treatment
 Lack of culturally congruent programming
 Limited options for women who are pregnant
 Few resources for women with children
 Fear of loss of child custody
 Greater risk of history of abuse (sexual, physical,
psychological)
 Greater co-morbidity with depression, anxiety,
other mental illnesses
Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment
Improvement Protocol (TIP) Series, No. 51. HHS Publication No. (SMA) 14- 4426. Rockville, MD: Substance Abuse and Mental
Health Services Administration, 2009.

44. Mental Illness & Substance Abuse
 Of the 20.7 mil adults with substance use disorder (SUD)in 2012
 40.7% had co-occurring mental illness (AMI)
 12.6% had a serious mental illness (SMI)
 Those with an AMI & SUD were more likely:
 To have past month cigarette use
 To have past month binge or heavy alcohol use
 To be male (4.1 vs. 3.1%)
 To be American Indian or Alaska Native (14%)
 To not have graduated from college or HS
 To be unemployed
 To live below federal poverty line
 To be covered by Medicaid or CHIP

45. Maternal Treatment for Opioid Addiction
 Treatment is complex
 2012-23 mil needed treatment but only 2.5 mil received treatment*
 Effective treatment is multidimensional
 Medications, Counseling and Behavioral Therapies
 Medically assisted detoxification is only the first stage of treatment
 Extended treatment duration is critical
 Treatment must help one
 Stop using drugs
 Maintain a drug-free lifestyle
 Become functioning and productive in society
 Engage in healthy family and social relationships
 Address underlying triggers for use
 Most patients require long-term or recurrent treatment before sustained
abstinence and recovery

46. Maternal Treatment for Opioid Addiction
 Medications (Methadone, Buprenorphine)
Relieve withdrawal symptoms
Diminish cravings
Repair normal brain function
Decrease relapse
 Behavioral
Engages one in treatment
Modifies their attitudes about drug abuse
Increases healthy life skills
Enhances the effectiveness of medications
Keeps people in treatment compliant longer
NIDA. Info Facts. Treatment approaches for drug Addiction

47. Maternal Treatment for Opioid Addiction
 Methadone nor Buprenorphine are approved for use in pregnancy
 Methadone is the most commonly used maintenance treatment in
opioid dependent pregnant women
 Advantages of Methadone
 Reduces variation in serum opiate levels
 Protects fetus from in-utero withdrawal
 Decrease illicit opioid craving & use
 Blocks heroin induced euphoria
 Improves maternal physical and mental health
 Improves compliance with prenatal care and nutrition
 Improve obstetric outcomes
 Allows for anticipation of neonatal withdrawal
 Improve chances of stable postnatal environment for the infant

48. Maternal Treatment for Opioid Addiction
 Disadvantages of Methadone
Withdrawal can be harmful by
Increasing risk of fetal death
Increasing risk of illicit drug abuse
Risk of fetal dependence
Risk of NAS (60-90%)

49. Postpartum Period Triggers for Relapse in Drug
Dependent Mothers
 Pain/Pain medications
 Sleep deprivation
 Stress of caring for a newborn (+/- other children)
 Shifts in relationships with partners and family
 Interactions with child welfare agencies
 Court proceedings
 Temporary or permanent loss of custody
 Reunification after temporary loss of infant custody.
 Guilt and grief related to infant illness or death
 Added expense of newborn depleting funds for continued treatment
 Stressors of daily living
 Returning to activities abstained from during pregnancy
 Drinking
 Smoking
 Going out with friends (bars, clubs)
1 Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series, No. 51. HHS
Publication No. (SMA) 14- 4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.
2 Mullen, P.D. How can more smoking suspension during pregnancy become lifelong absti nence? Lessons learned about predictors, interventions, and gaps in our accumulated
knowledge. Nicotine & Tobacco Research 6(Suppl2):S217–S238, 2004.

50. Factors that Encourage a Woman to Stay in
Treatment
 Supportive therapy
 Collaborative therapeutic alliance
 Onsite child care and children services
 Comprehensive treatment services
 Socio-demographics (income, age, safe home, transportation)
 Support and participation of significant others
 Having at least a high school education
 Criminal justice system or child protective service involvement (positive)
 Prior success in other life areas
 Confidence in the treatment process and outcome
 Pregnancy may motivate women in initiating treatment, BUT pregnant
women do not stay in treatment as long as non-pregnant women
Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series, No. 51. HHS
Publication No. (SMA) 14- 4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.

51. Services Needed in Women’s Substance Abuse
Treatment
 Medical Services
 Gynecological care
 Family planning
 Prenatal care
 Pediatric care
 HIV/AIDS services
 Treatment for infectious diseases
 Nicotine cessation services
 Health Promotion
 Nutrition
 Reproductive health
 Wellness programs
 Sleep and dental hygiene
 Preventive Education about STDs and other infectious diseases
 Preventative education on the effects of alcohol and drugs on
prenatal and child development
Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol
(TIP) Series, No. 51. HHS Publication No. (SMA) 14- 4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.

52. Services Needed in Women’s Substance Abuse
Treatment
 Gender-Specific Needs
 Women-only programming (same-sex versus mix-gender program due to
trauma history, pattern of withdrawal among men, and other issues?)
 Lesbian services
 Cultural and Language Needs (interpreter)
 Culturally appropriate programming
 Life Skills
 Money management/budgeting
 Stress reduction
 Coping skills
Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series, No. 51. HHS
Publication No. (SMA) 14- 4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.

53. Services Needed in Women’s Substance Abuse
Treatment
 Family and Child-Related Services
 Childcare services, including homework assistance, nurseries and
preschool programs
 Family treatment services including education re: addiction and its impact
on family function
 Couples counseling
 Parent/child services
 Age-appropriate programs
 Child safety education
 Parenting education
 Infant/child nutrition
 Children’s substance abuse prevention
 Children’s mental health needs
Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series, No. 51. HHS
Publication No. (SMA) 14- 4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.

54. Services Needed in Women’s Substance Abuse
Treatment
 Comprehensive Case Management
 Intensive case management, including case management for children
 Link to welfare system, employment opportunities, and housing
 Transportation
 Domestic violence services, including referral to safe houses
 Legal services
 Assistance for funding for treatment services
 Assistance in obtaining a GED/continued education
 Career counseling/vocational training/employment assistance
 Housing, including referral to transitional living or supervised housing
Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol
(TIP) Series, No. 51. HHS Publication No. (SMA) 14- 4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.

55. Services Needed in Women’s Substance Abuse
Treatment
 Mental Health Services
 Trauma-specific services
 Eating disorder and nutrition services
 Access to psychological and pharmacological treatments for depression,
mood/anxiety disorders, other mental illnesses
 Children’s mental health services
Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series, No. 51. HHS
Publication No. (SMA) 14- 4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.

56. Services Needed in Women’s Substance Abuse
Treatment
 Staff and Treatment Program Development
 Strong female role models in terms of both leadership and personal
recovery Peer support
 Adequate staffing to meet added program demands
 Staff training and gender-competence in working with women
 Staff training and program development centered upon incorporating
cultural and ethnic influences on parenting styles, attitudes toward
discipline, children’s diet, level of parenting supervision, and adherence to
medical treatment
 Flexible scheduling and staff coordination
 Adequate time for parent–child bonding and interactions
 Administrative commitment to addressing the unique needs of women in
treatment
 Staff training and administrative policies to support the integration of
treatment services with clients on methadone maintenance
 Culturally appropriate programming that matches specific socialization
and cultural practices for women
Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series, No. 51. HHS
Publication No. (SMA) 14- 4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.

57. THE END