Perinatal Substance Abuse Program

1. Perinatal Substance Abuse Program Dept of Alcohol and Drug Services (DADS) Presented by Lara Windett M.A., MFT, LPPC Certified Addiction Specialist (CAS)

2. The Department of Alcohol & Drug Services exists within the overall Santa Clara Valley Health & Hospital System Dedicated to the health of the whole community regardless of ability to pay

3. Background • PSAP was Brainchild of Anthony Puentes, MD, MPH, 1987 • Funding stream • Goal of PSAP Program

4. PSAP Keeps babies out of the NICU • NICU costs ~$2,100 – 5000 per day • 2007 140 babies exposed, 30 in NICU • Avg Length of Stay: 15 days

5. PSAP Treatment Works! • 92% drug/alcohol free - neg tox screens

6. Perinatal Drug Exposure Overview • 1992 Study • Estimated 15-18% of pregnant women use alcohol or drugs. • PSAP Admission Statistics

7. PSAP = Empowerment Model • Comprehensive Intensive Outpatient Treatment • Medically Monitored • Multidisciplinary Approach • Day Care for clients’ children • Transportation

8. PSAP Client Eligibility • Resident of Santa Clara County • Pregnant or Early Parenting Women • 18 years or older • On Methadone (MMT) or opiate dependent • Hx or DOA abuse or currently using • Family Wellness Court Referrals • Medi-cal, Valley Care II, sliding scale fee, or other insurance (Kaiser)

9. Length of PSAP Stay • Assigned a Licensed Therapist, PSW • Case Management • Individualized Tx Plan • Typical Treatment Episode: 6-12 months

10. Staff • HCPM II • 3 Therapists (MFT) • MD • Health Ed Specialist • 1 Health Services Representative • 3 day care aides (1/2 codes) • 1 Community Worker (van) (1/2 codes) • Volunteers

11. Current PSAP Client Demographics • ~Capacity for 65+ • Women ages 19 to 43 years • 23% pregnant • 10 clients on Methadone (3 pregnant) • 30% Caucasian 33% Latina, 9 % Asian/Pacific Islander 18% Mixed Race 2% African American 8 % Declined to State • 30% in THU’s • CPS Cases ~70% • Prop 36 ~40% • FWC 30% • Probation Only - 20% • DEJ – 10%,

12. Out Patient Drug Treatment in Santa Clara County – Including Methadone • On the VMC campus • Readily accessible - pregnant OPIOID DEPENDENT patients (Methadone candidates) are scheduled for admission the next business day • All Patients can call Gateway 1-800-488-9919 • Providers can call Central Valley Clinic • 408 885-5400 Front Desk • 408 885-4064 PSAP Clerical

13. Items to Remember if a Patient is in PSAP Treatment • We ask for a verification of OB Care/complete the referral to VMC if no care is scheduled for pregnant people. • We obtain a release to speak with the OB and all MDs in the patient's life. • We obtain a release to Public Health. • We obtain a release to the Pedi and we alert the Pedi (and OB) if the patient drops out of treatment.

14. Overview of AOD Treatment/Concerns • Red flags • When interviewing/observing the patient • When considering the history • Risks associated with various drugs • To the pregnancy • To the baby

15. Substances to Be Discussed • Opioids • Cigarettes • Alcohol • Marijuana • Methamphetamine

16. Amber • 32 y.o. Woman and the mother of an 8 y.o. • Unplanned pregnancy • Using daily • Heroin by injection 2 grams/day • Cocaine • Cigarettes 2 PPD • Seeking admission to methadone program

17. Amber • Stealing to obtain drugs • Isolated – only living relative is maternal grandmother • 8 y.o. son is being raised by patient’s grandmother • Father of baby is using and at risk of deportation

18. Amber • Medically indigent • History of depression and anxiety • History of domestic violence (prior relationship)

19. Amber • Frustrated – requested tubal ligation at 23 • Frightened – concerned about damage already done to baby • Motivated • Requests residential treatment • Resolves to leave boyfriend if he will not get into treatment

20. Red Flags: Multiple & Obvious • Patient volunteering history of substance abuse • Physical exam remarkable for multiple tracks and physical withdrawal • Life in disarray • Chaotic and disrupted family relationships

21. Why Share this Story? • Opioid dependence requires medical intervention • Pregnant patients need treatment to prevent adverse outcomes • Women caring for infants need treatment to be functional mothers

22. Pregnancy can be a Huge Motivation for Change: Amber • Stabilized on methadone maintenance • Completed residential treatment • Permanently left the boyfriend who continued to use • Delivered drug free

23. A Sense of Hope:12 Years Later Amber is… • Abstinent and still in treatment • Raising her daughter • Working

24. Prevalence of AOD Abuse in Pregnancy 2008 and 2009 data from the National Survey on Drug Use and Health found that among pregnant women ages 15 to 44, the youngest ones generally reported the greatest substance use. Also, pregnant women ages 15 to 17 had similar rates of illicit drug use (15.8 percent or 14,000 women) as women of the same age who were not pregnant (13.0 percent or 832,000 women).

25. Brenda • Referred to treatment for history of methamphetamine abuse • Worked as a medical assistant until about two years ago • Served as caretaker for mother who died of breast cancer • After mother died, dad was diagnosed with lung cancer; patient served as caretaker • Reported having a prescription for vicodin

26. Brenda • Reported taking prescribed vicodin for chronic back pain (occasionally) • Denied history of prescription opioid abuse • Weekly u tox screens consistently positive • For a variety of prescription opioids • Not just for vicodin • Easy access to unlimited supply of prescription opioids • Transferred to methadone maintenance

27. Prescription Opioid Abuse May Not Be Obvious • Consider the history • Unusual number of painful conditions for a young healthy patient • Multiple opioid prescriptions during pregnancy • Multiple ER visits for complaints of pain • Multiple care providers/no regular provider • Opioids for unusual indications

28. Patient’s Appearance on Opioids • Normal • Sedated with small pupils • Symptoms of withdrawal • Sweats/chills/gooseflesh • Lacrimation/rhinorrhea • Yawning/sneezing • Irritable/anxious/fidgety • Vomiting

29. Ask About Behaviors: Have you ever?… • Taken more than prescribed? • Taken medication after the pain was gone? • Gotten pills from a friend or relative? • Bought pills on the street? • Written or called in a prescription for yourself? • Tried to stop and found you couldn’t?

30. Ask about Reasons for Use • Manage emotions? • Deal with stress? • Feel high? • Numb everything or go to sleep?

31. Opioids: Three to Seven Times Higher Rates of… • Still birth • Fetal growth retardation • Low birth weight • Small head circumference • Prematurity • Neonatal mortality

32. Heroin: Medical Risks Associated With Injection • Cellulitis • Abscesses • Endocarditis • Hepatitis • HIV infection • Wound Botulism

33. Opioid Dependence in Pregnancy: Treatment • Currently, methadone maintenance is the gold standard • Buprenorphine maintenance looks promising and may be more available in the future (not FDA approved) • A comfortable, stable mother increases the likelihood of a healthy, term delivery

34. Reduced deaths Reduced IVDU Reduced HIV seroconversion Reduced crime days Reduced relapse Improved health Improved relationships Improved productivity Improved social functioning Impact of Methadone Treatment

35. Additional Benefits During Pregnancy • Increased participation in prenatal care • Reduced obstetrical complications • Improved maternal nutrition • Daily observation in clinic while dosing

36. Therapeutic Dosing With Methadone • Suppresses opioid withdrawal symptoms • Reduces opioid cravings • Provides a stable opioid blood level • Allows a patient to concentrate on counseling/program to support recovery • Minimizes side effects; patient should not be sedated

37. Methadone Withdrawal:Not Recommended During Pregnancy • The relapse rate is high (80%) • Risk of intrauterine demise • Risk of premature labor/miscarriage • What can you say to a patient wanting to Withdraw from MMT? • Send them to their primary CSLR/the addiction MD to discuss

38. Methadone Withdrawal:Not Recommended After Delivery? • Like insulin, methadone stabilizes a chronic illness • The normal brain has an endogenous opioid system that may never function properly in an opioid dependent patient • Very high relapse rate when methadone treatment is discontinued

39. Methadone: Effects on the Baby • No known birth defects • More likely to be born at term • Lower birth weight/smaller head circumference at birth • May experience developmental delay during the first year of life • Not associated with learning difficulties • Increased SIDS with opioid exposure

40. Methadone and Breastfeeding • Negligible amounts of methadone are passed in breast milk • The American Academy of Pediatrics considers methadone compatible with breastfeeding at any dose

41. Methadone: Neonatal Withdrawal • Safer than heroin withdrawal in utero • Experienced by 60-80% of exposed babies • Usually occurs within the first 2-3 days of life; may occur within the first month • Usually treated with an opiate agonist • Duration of treatment is days to months • Can be life threatening without treatment

42. Opiates: The Neonatal Abstinence Syndrome • High-pitched cry, irritability • Poor feeding, vomiting, diarrhea • Hyper tonicity (stiff muscles) • Tremors • Sneezing • Sweating • Occasionally seizures

43. Symptoms of Opioid Withdrawal • W = wakefulness • I = irritability • T = tremulousness, temperature variation, tachypnea • H = hyperactivity, high-pitched persistent cry, hyperacusia, hyperreflexia, hypertonus • D = diarrhea, diaphoresis, disorganized suck • R = rub marks, respiratory distress, rhinorrhea • A = apneic attacks, autonomic dysfunction • W = weight loss or failure to gain weight • A = alkalosis (respiratory) • L = lacrimation

44. Clarissa • 23 y.o. • Pregnant with first child • Smoking 1½ - 2 PPD since late teens • “I will only quit if the doctor tells me my baby will die if I do not quit now” • “My whole family smokes; I grew up with it; I’ve been around it my whole life”

45. United States (1996-1998) • National Household Survey on Drug Abuse (NHSDA) • Survey of pregnant women Ebrahim, SH, Gfroerer, J. Pregnancy-related substance use in the United States during 1996-1998. Obstet Gynecol 2003; 101:374.

46. Cigarette Smoking • Smoking during pregnancy is the most modifiable risk factor for poor birth outcome • It is associated with 5% of infant deaths, 10% of preterm births, and 30% of small for gestational age infants Trends in smoking before, during, and after pregnancy - Pregnancy Risk Assessment Monitoring System (PRAMS), MMWR Surveill Summ. 2009 May 29;58(4):1-29.

47. Cigarettes in Pregnancy:Obstetric Complications

48. Clinical Outcomes in PregnantWomen who Quit Smoking • 20% reduction in low birth weight babies • 17% decrease in pre-term births • Average increase in birth weight of 280g. • Quitting before 30 weeks can still positively affect birth weight

49. Cigarette Smoking in Pregnancy & Other Drug Use • 10 times higher use of marijuana • 22 times higher use of cocaine • 21 times higher use of amphetamine Vega, WA, Kolody, B, Hwang, J, Noble, A. Prevalence and magnitude of perinatal substance exposures in California. N Engl J Med 1993; 329:850

50. In Utero Cigarette Exposure:Congenital Malformations • May contribute to anomalies associated with focal vascular disruption • Cleft lip with or without cleft palate • Gastroschisis • Anal atresia • Transverse limb reduction defects • Risk may be modified by genetic factors