Pregnancy-Related Issues in the Management of Addictions

1. Pregnancy-Related Issues in the Management of Addictions Train the Trainer Workshop Problematic Substance Use in Pregnancy (PSUP) www.addictionpregnancy.ca Last modified: March 2008

2. Conflict of Interest Disclosure • Financial support for this workshop was provided by Health Canada • Funding for the PRIMA Pocket Reference was provided by the Lawson Foundation • No commercial sponsorship has been received to support this program

3. Pregnancy-Related Issues in the Management of Addictions Overview of Addictions

4. Key Concepts

5. Addiction (dependence) • Women using addictive substances find the effects of the drug so pleasurable and reinforcing that they have difficulty controlling their use of the drug • Reinforcement may be small and multiple, e.g., nicotine, or large, e.g., heroin

6. Many Substance Users are Survivors of Childhood Trauma Women in substance abuse treatment report: • A lifetime history of trauma, most commonly physical or sexual abuse • This ranges from 55% to 99% compared to women in community samples (36-51%) Najavits et al, 1997

7. Addictive Potential of Drugs • Correlates with: • Rapid onset of action • Potency at receptor site (euphoric effect) • Short duration of action (contrast between intoxication and sober state) • Tolerance (forces woman to escalate dose to achieve same effect) • Withdrawal (forces woman to use drugs to avoid withdrawal)

8. Reward Pathway All drugs of abuse: • Increased dopamine receptor stimulation in nucleus accumbens and medial forebrain bundle • Cocaine stimulates it directly • Opioids, alcohol, nicotine stimulate it via effects on other neurotransmitters

9. Opiate Use is a Very Powerful self-medication for: • Blocking out intrusive thoughts, flashbacks and nightmares • Numbing and avoiding feelings, thoughts, people • Achieving sleep

10. Tolerance • Repeated administration alters: • Receptor numbers and sensitivity • Levels of neurotransmitters • Result: decreased effect with same dose • CNS develops ‘resistance’ to drug effect • Adaptive mechanism: can function almost normally despite very high doses

11. Tolerance (2) • Rate of development of tolerance depends on the effects • For example, with opioids: • Analgesia - slow tolerance (months) • Sedation – rapid tolerance (days)

12. Withdrawal • On sudden cessation of drug, alterations in receptors take days or weeks to normalize • Receptors that ‘resist’ the drug are now unopposed, leading to drug-opposite effects: • Sedating drugs: withdrawal -> autonomic hyperactivity • Symptoms appear when drug use decreases, forcing woman to resume drug use

13. Genetic Influences on Drug Dependence • Positive family history increases risk of alcohol dependence: • Fewer adverse effects • Greater tolerance • More positive effects

14. Sex and Gender Differences The Formative Years report from CASA demonstrates that: • Girls and young women use cigarettes, alcohol and drugs for reasons different than boys • The signals and situations of high risk are different • Girls are more vulnerable to substance use and abuse and its consequences • Girls have incorrect knowledge and beliefs about substances • Parents are often inattentive cont’d • CASA. The Formative Years: Pathways to Substance Abuse Among Girls and Young Women Ages 8-22. 2003. www.casacolumbia.org

15. Sex and Gender Differences (2) The Formative Yearsreport indicates that girls are influenced by: • Substance-using friends • Schools and communities that turn a blind eye • Physicians who are not vigilant to early warning signs • Exposure to entertainment media and alcohol and cigarette advertising, which bombard girls and young women with unhealthy and unrealistic messages about smoking, drinking and weight loss

16. Substance Use by Women • Substance use by women has been viewed by health professionals as more problematic • This has led to disparities in screening and access to care and treatment • Poor women, aboriginal women and women of colour are more frequently screened for substance use when accessing prenatal care than middle class and Caucasian women

17. Risks for Addiction Psychiatric Risk: • Mood disorders • Anxiety disorders, esp. post-traumatic stress disorder • Personality disorders that effect impulse control Social, Cultural: • Lack of meaningful work/school/relationships • Lack of social support • Cultural attitudes towards alcohol, drugs • Poverty

18. Clinical Features Drug use becomes major focus of life and the addicted woman: • Neglects major responsibilities • Continues to use despite knowledge of consequences • Repeatedly tries to quit but relapses • Develops tolerance and can go into withdrawal • Experiences powerful urges to use (cravings)

19. The 4 C’s of Addiction • Continued use despiteConsequences • Unable to Cut down • Cravings • Compulsive drug use

20. Classification of Drugs of Abuse • Alcohol • Benzodiazepines and other sedatives • Opioids • Stimulants: cocaine, amphetamines • Nicotine • Cannabis • Hallucinogens

21. PsychologicalTreatment • Natural Recovery • Mutual Help Groups • Outpatient Counseling • Residential Treatment • Minnesota model (28 or 21 day) • Therapeutic community (months to years)

22. Treatment of Substance Dependence: Prognosis • Approx. 30% abstinent one year post-treatment • Prognosis worse if: • Older • Longer drinking history • Other substance use • Untreated psychiatric disorder(s) • Social instability • Physician’s warning associated with better prognosis at 2 years • Treatment is cost-effective

23. Success Rates of Formal Treatment (6 month follow-up)Addiction Severity Index (ASI)

24. Treatment for Women and Mothers • When mothers and babies stay together in treatment, women indicate that maintaining close contact with their children was integral to their recovery efforts. Besinger, B.A. 2003. Mothers in addiction treatment: The role of onsite childcare. University of Cincinnati, Cincinnati) • Women stayed in treatment longer, had less depression and higher measures of self-esteem than women separated from their infants. Wobbie, K., & Eyler F.D., 1997. Women and Children in Residential Treatment: Outcomes for Mothers and their Infants.Journal of Drug Issues, 27 (3), 585-607

25. Cost-effectiveness of Treatment: Matched Case-control Study • 300% reduction in health care costs in treated group vs. waiting list controls Holder HD, Blose JO. J Stud Alcohol 1992; 53: 293-302

26. Role of the Health Care Providers • Most substance users do not go to formal treatment • BUT they make frequent use of health care provider (HCP) services • Women often have considerable trust in their nurse/midwife/physician • Health Care Providers should see women over long periods of time and build therapeutic relationships in order to effect long-term change cont’d

27. Role of Health Care Providers (2) • Smoking cessation counselling: one of the most cost-effective interventions we can do • At-risk drinking: often brief advice (5-15 minutes) is enough to get women to reduce drinking to low-risk levels • Alcohol and drug dependence: many women will accept HCP advice to attend treatment program cont’d

28. Role of Health Care Providers (3) • Treatment of withdrawal is first step to recovery • Pharmacotherapy (methadone, bupropion, NRT, etc.) greatly increases success rates of counselling

29. Failure to Understand and Address Trauma Can Lead to: • Retraumatization of the woman • Increase in symptoms • Increase in management problems • Increase in relapse • Withdrawal from service relationship (Finkelstein, 2006)

30. Approach to the Woman who is Addicted to Substance(s) Do’s: Like any other disease… • Express concern • Review diagnosis and health effects • Present range of treatment options • Acknowledge woman’s efforts and successes • Arrange follow-up

31. Approach for Provider/Counselor and Woman • Meet basic needs • Build positive social network • Advise group and individual support • Teach techniques to avoid drugs and triggers for substance use • Encourage to have a structured day, keep busy

32. Pregnancy-Related Issues in the Management of AddictionsSlide presentation developed by members of the National PRIMA group: Ron Abrahams* Talar Boyajian Jennifer Boyd Wendy Burgoyne Katherine Cardinal Rosa Dragonetti Lisa Graves* Phil Hall • Samuel Harper • Georgia Hunt* • Meldon Kahan • Theresa Kim • Lisa Lefebvre • Nick Leyland • Margaret Leslie • Deana Midmer* • Stephanie Minorgan* • Pat Mousmanis* • Alice Ordean* • Sarah Payne* • Peter Selby • Melanie Smith • Ron Wilson • Suzanne Wong *Principal Authors Prima.medicine@utoronto.ca