Illicit Drug Abuse and Dependence in Women A Slide Lecture Presentation

409 12 th Street, SW Washington DC 20024 202/638-5577 www.acog.org

Illicit Drug Abuse and Dependence in Women

Ronald A. Chez, MD, FACOG University of South Florida, College of Medicine Robert L. Andres, MD, FACOG University of Texas Medical School, Houston Cynthia Chazotte, MD, FACOG Albert Einstein College of Medicine Frank W. Ling, MD, FACOG University of Tennessee, College of Medicine

This educational program was funded by the Physician Leadership on National Drug Policy at Brown University, Providence, Rhode Island. ( www.plndp.org

) The Physician Leadership on National Drug Policy project is supported through generous contributions from individuals and foundations, primarily the Robert Wood Johnson Foundation and the John D. and Catherine T. MacArthur Foundation .

Overview

 Addiction to illegal drugs:  a major national problem  causes impaired health, harmful behaviors  creates major economic and social burdens  Treatment of drug addiction:  efficacy equivalent to other chronic conditions:  hypertension  asthma  diabetes mellitus

Prevalence and Incidence

 Substance use varies among and within different cultural groups:  Present among all socioeconomic, cultural and ethnic groups  Descriptive categories of abusers do not represent distinct, homogenous groups

Prevalence and Incidence

 30 million Americans have used illegal substances:  40% of 25-30 year olds  Adult monthly cocaine users:  1.5 million abusers  67% are employed full time  53% of their fathers went to college  Age of first use is declining:  23% high school seniors regularly use marijuana  10% of all students have used an illicit drug

Prevalence and Incidence

 3.6 million Americans dependent on illicit drugs:  50% have a co-morbid medical condition  19,000 drug addiction deaths annually  $4.5 billion in health expenditures:  only 10% used for treatment of addiction  $44 billion productivity loss

Physician Barriers

 Lack of training:  only 1/3 primary care physicians carefully screen for substance abuse  only 1/6 believe they are very prepared to spot illegal drug use  Most misunderstand:  chronic, relapsing nature of dependence  intensity of the urge to use  preoccupation with the substance

Physician Barriers

 Lack of awareness:  pervasiveness throughout society  treatment options  community resources  Skepticism:  treatment for illegal drug abuse is not effective  patients lie about their substance abuse  Discomfort:  difficulty discussing potential of prescription drug abuse

Physician Barriers

 Time constraints:  impediment to full discussion with patients  Fear of losing patients by asking:  resulting in patient fear, anger  Insurance coverage:  lack of reimbursement for time to screen  lack of reimbursement parity for treatment  denial of coverage for referrals

Physician Barriers

 Physician as an enabler:  giving tacit approval of the abuse by not addressing the problem  providing patient excuses for work or school  providing prescriptions for inappropriate drugs and in excess quantity including refills  Physician may be a drug abuser

Patient Barriers

 Reasons for lying to physician:  ashamed, afraid, do not want to stop  non-sympathetic, non-confidential setting  physician not knowledgeable, acting busy  Abusers’ attitudes toward physicians:  do not know how to detect addictions  prescribe potentially dangerous drugs  never diagnosed the abuse  knew about abuse but did nothing about it

Patient Barriers

 Fear of government agencies  Loss of family role with legal and child-custody implications  Societal stigmata  Denial:  may be subconscious and unaware  a psychological defense against acknowledging the personal pain

Patient Barriers

 Enabling by others reinforces patient denial:  covering at work or school  hiding the problem from superiors at work or school  minimizing or ignoring the substance abuse problem  providing drugs to avoid confrontation or unpleasantness

Diagnostic Criteria: Substance Abuse

 A maladaptive pattern of substance use leading to clinically significant impairment or distress manifested by 1 or more of the following occurring within a 12 month period: 1.

use results in failure to fulfill major role obligations:    work: absences, poor performance school: absences, suspensions, expulsions home: neglect of children or household 2.

3.

4.

recurrent use in physically hazardous situations recurrent substance-related legal problems continued use despite resulting persistent or recurrent social or interpersonal problems

Diagnostic Criteria: Substance Dependence

 1.

2.

A maladaptive pattern of substance use leading to clinically significant impairment or distress manifested by 3 or more of the following occurring at anytime within the same 12-month period: tolerance of the substance: need for markedly increased amounts to achieve intoxication or the desired effect, or markedly diminished effect with continued use of the same amount withdrawal: the characteristic withdrawal syndrome, or substance taken to relieve or avoid withdrawal symptoms

Substance Dependence (continued)

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larger amounts of substance taken or over a longer period than was intended persistent desire or unsuccessful efforts to cut down or control use great deal of time spent in activities to obtain, use or recover from the substance’s effects important social, occupational and recreational activities given up or reduced because of use continued use despite knowledge of a persistent or recurrent psychological or physical problem likely to have been caused or exacerbated by use

Role of Ob/Gyn Physician

 Screening, identifying and counseling women regarding substance use  Routine screening in history taking:  no physical symptoms in majority of abusers  screen everyone since no predictors  Know local community resources  Triage to community resources

Screening Questions

 First, use ubiquity statements:  “Substance use is so common in our society that I now ask all my patients what, if any, substances they are using?”  Then, ask direct questions:  “Have you ever tried . . .?”    “How old were you when you first used . . .?” “How often; what route; how much?” “How much does your drug habit cost you?”

History: Red Flags

 Maternal chaotic lifestyle:  psychosocial stresses   spouse/partner of an alcoholic or drug abuser domestic violence, physical and sexual  Psychiatric diagnosis:  depressions, psychosis, anxiety, PTSD   lack of functional coping skills unexplained mood swings, personality changes  Late or no prenatal care:  missed appointments and compliance problems  STDs, sexual promiscuity

Physical Examination

Nothing unusual is the most frequent finding in users of illicit drugs.

Toxicology Testing: Principles

 Random checks without clinical suspicion:  many consider this unethical  may be illegal in some locales  Nonemergency and competent patient:  verbally inform prior to testing  document permission in medical record  Test if necessary to direct immediate medical interventions

Toxicology Testing: Screening Panel

 Usually urine:  major route of excretion and concentration  inexpensive and quick  Tests include:  enzyme multiplied immunoassay techniques  thin layer chromatography  Confirmatory tests:  gas chromatography, mass spectrometry

Toxicology Drug Screen: Urine

 Time frame for drug or metabolite to be present:  marijuana, acute use 3 days  marijuana, chronic use  cocaine 30 days 1 –3 days  heroin  methadone 1 day 3 days

Treatment: Principles

 Drug addiction is a treatable disease  No single treatment is appropriate for all individuals  Recovery from drug addiction is a long-term process:  multiple treatment episodes with relapses  Effectiveness is dependent on remaining in treatment for a dedicated period of time  Matching multiple needs is critical:  medical, psychological, social, legal, vocational

Treatment: Cost Considerations

Year in prison $53 -$71/day Annual treatment costs for a drug addict: Outpatient Intensive outpatient Methadone maintenance Short term residential treatment Long term residential treatment $15/day x 120 days 9 hours/wk + 6 months maintenance $13/day x 300 days $130/day x 30 days + $400 x 25 weeks $49/day x 140 days $25,900 $1,800 $2,500 $3,900 $4,400 $6,800

Plan of Care

 Establish a supportive relationship  Educate the patient:  ask the patient to describe her understanding of  the situation and correct misunderstandings link substance use to patient’s signs & symptoms  describe the importance of stopping or cutting down  explain consequences of continued use  Refer to specialists for assessment and initiation of a treatment plan

Treatment: Critical Components

 Detoxification  Medications combined with counseling  Behavioral therapies: skill-building, problem-solving to prevent relapse  Assess for and treat coexisting conditions:  mental disorders  infectious diseases  family planning

Treatment: Behavioral Change

 Prochaska’s stages of readiness:  assess the patient’s readiness for change and to accept treatment  match intervention strategies and goals to the patient’s stage  Stage = precontemplation  patient does not believe a problem exists  needs evidence of problem and its consequences

Treatment: Behavorial Change

 Stage = contemplation  patient recognizes a problem exists:  is considering treatment  patient needs:  support/encouragement to initiate treatment  information on treatment options  referral to a specific treatment program

Treatment: Behavioral Change

 Stage = action  patient begins treatment:  needs ongoing support  needs follow up to ensure success  Steps to break the cycle of recurrent binges or daily use:  weekly contact  peer support groups  family or group therapy  urine monitoring

Treatment: Behavioral Change

 Intervention with family, close friends and co-workers:  group meets with patient  each group member states the effects of the patient’s substance use  consequences of not accepting treatment are stated:  loss of job; loss of family  legal consequences  potential of danger from drug access & presence  expressions of concern, support and love

Treatment: Behavioral Change

 Stage = relapse  expected, not a failure  prevention is essential:  alter life style to reduce their influence  develop drug free socialization  identify social pressures that may predict use:  rehearse avoidance strategies  learn ways to deal with negative feelings:  identify ways to manage distorted thinking

Prevention: Stages

 Primary prevention = use has not begun, or use is not problematic  Secondary prevention = treatment of problematic users  Tertiary prevention = preventing and treating complications of substance abuse

Prevention: Prescribing Guidelines

 Potentially addictive drugs:  assess option of alternative treatments:  nonpharmacological treatments  nonaddicting medications  determine risk of developing abuse or dependence  order an initial dose sufficient to provide analgesia, then taper to smallest effective dose

Prevention: Prescribing Guidelines

 Analgesics for acute pain symptoms:  short period of time for treatment  avoid more than one refill  avoid telephone refills  reassess at frequent intervals  prescribe on a fixed schedule vs. prn  taper, rather than discontinue if used long term  Write both number and word to minimize alteration

Prevention: Drug Seeking Clues

 Patient may be abusing psychoactive medication:  exaggerates or feigns symptoms  loses prescriptions or medications  runs out of medications ahead of time  obtains same prescription from multiple doctors  claims refill need but original doctor not available  insists that only one drug will work  demands an immediate prescription for a chronic illness  threatens when physician does not comply

Fertility

 Generic factors related to substance abuse:  men:  impotence  decreased semen quality  women:  alterations in ovulation  menstrual irregularity  libido:  variable effect

Pregnancy

 Prevalence and incidence:  no difference:  indigent/nonindigent patients  public and private clinics  ethnic groups  4 million women who gave birth:  757,000 drank alcohol products  820,000 smoked cigarettes  221,000 used illegal drugs

Pregnancy: Generic Issues

 Educate patient about adverse outcome effects  Screen for domestic violence  Screen for STDs, hepatitis B and C, TB  Co-manager or refer to multispecialty clinic  Refer to drug counseling program  Monitor with urine toxicology  Sequential antepartum assessment of growth  Refer newborn to pediatrics  Close postpartum follow up

Cocaine

 Alkaloid from leaves of

Erythroxylon coca

bush:  marketed as crystals, granules, white powder  routes:  intranasal, parenteral, oral, vaginal, rectal  decomposes with heating, melts at 195 o C  water soluble  Crack cocaine alkaloid is free base:  soluble in alcohol, oils, acetone, ether  colorless, odorless, transparent crystal  melts at 98 o C  not destroyed at higher temperatures

Cocaine

 Produces a dose dependent increase in:  heart rate and blood pressure  arousal, enhanced vigilance and alertness  sense of self confidence and well-being  Chronic, heavy use associated with:  pronounced irritability  paranoid ideations  increased risk of violence  reduced libido

Cocaine: Adverse Maternal Effects

 Possible systemic complications:  cardiovascular:  tachycardia and cardiac arrhythmias  vasoconstriction and hypertension  central nervous system:  hyperthermia  CVA  seizures

Cocaine: Adverse Fetal Effects

 Questionable Congenital anomalies:  published data are equivocal  reported anomalies include:  limb reduction defects  genitourinary tract malformations  congenital heart disease  central nervous system

Cocaine: Adverse Fetal Effects

 Impaired fetal growth:  decrease in mean birthweight  increase in low birthweight infants  increase in intrauterine growth restriction  significant correlation between cocaine metabolites in meconium and decreases in birth weight, birth length and head circumference.

Cocaine: Adverse Prenatal Effects

 Preterm labor and delivery:  no consensus among clinical studies:  Premature separation of the placenta:  most studies confirm  Premature rupture of the membranes:  controversial association

Cocaine: Adverse Neonatal Effects

 Initial neurologic findings:  coarse tremor  hypertonia  extensor leg posture  Increased risk of SIDS (4x)  Long-term consequences:  no consistent negative associations  developmental outcome similar to drug-free newborns

Cocaine: Treatment

 Goal = help patient resist the urge to restart compulsive cocaine use  Options according to personal characteristics:  group and individual drug counseling  cognitive behavioral therapy to prevent relapse:  ways to act and think in response to cues  avoid environmental/social pressures  practice drug refusal skills  medications

Opiates and Opioids

 Opiates (naturally occurring):  derived from the

Paper somniferum

poppy  examples: morphine, codeine  Opioids (synthetic):  examples: fentanyl, heroin, hydrocodone, hydromorphone, meperidine, methadone, and oxycodone

Heroin

 Routes:  inhaled, intranasal, IV, IM, SQ  lipid soluble, rapidly crosses the blood-brain barrier  Constant oscillation between feeling:  initial warmth, intense pleasure or rush  duration of high between 3-5 hours  followed by sedation and tranquility (on the nod)  symptoms of early withdrawal

Heroin: Maternal Adverse Effects

 Short-term adverse effects:  somnolence  altered mentation  cardiorespiratory arrest (overdose)  Long-term adverse effects:  physiologic withdrawal   hepatitis B and C STD’s, HIV  endocarditis  abscesses  pneumonia and tuberculosis

Heroin: Withdrawal Syndrome

 Symptoms:  drug craving  anorexia, nausea, abdominal cramping  increased sensitivity to pain  Signs:  hypertension, hyperventilation, tachycardia  lacrimation, mydriasis, rhinorrhea  yawning, sweating  vomiting, diarrhea  chills, flushing, muscle spasms  restlessness, tremors, and irritability  piloerection

Heroin: Adverse Pregnancy Effects

 Intrauterine growth restriction  Neonatal abstinence syndrome:  central nervous system:  hypertonia, hyperreflexia, tremors, convulsions  gastrointestinal system:  fist sucking, poor feeding, vomiting, diarrhea  respiratory system:  tachypnea, sneezing, yawning, hiccups  autonomic nervous system:  fever, vasomotor instability, sweating, tearing

Heroin: Treatment

 Principle = change from a short acting IV to long acting oral opioid to relieve drug craving and withdrawal  Methadone:  synthetic opioid blocks effect of heroin  long half life allows daily dosing  no euphoria, no interference with daily activities  New agents:  levomethadyl-acetate (LAAM)  buprenorphine (combined with naloxone)

Methadone: Perinatal Effects

 Pregnancy:  continuation of normal daily activities  decrease in associated maternal morbidity  Neonatal abstinence syndrome:  occurs on day 2-3 up to a week   similar to heroin withdrawal syndrome Naloxone (Narcan  ) contraindicated; severe withdrawal

Methadone: Treatment Protocol

 Initiation of treatment:  10-20 mg initial dose  next 24 hours: 5-10 mg every 6 hours per signs and symptoms of opiate withdrawal  daily maintenance dose 10-100 mg, qd or bid  Detoxification during pregnancy, controversial:  only if 30 mg/day is realistic goal  inpatient: 2 mg/day decrease in dose  outpatient: 5 -10 mg/week decrease in dose

Methadone: Maintenance Programs

 State and federal regulations restrict prescribing:  who enters the program  daily dosing schedule  location of clinic sites  specially licensed physicians

Marijuana

 Active ingredient = tetrahydrocannabinol (THC):  derived from

Cannabis sativa

 lipophilic with accumulation in fatty tissues  metabolized by liver and eliminated in feces  effects:  onset within 30-60 minutes  3-5 hour duration

Marijuana: Adverse Maternal Effects

 CNS depression  May act as a cardiovascular stimulant:  tachycardia, hypotension  Respiratory problems similar to tobacco smokers:  bronchitis, sinusitis, pharyngitis  Learning & social behavior:  changes in attention, memory, information processing

Marijuana: Adverse Perinatal Effects

 Controversial or no clear association:  no evidence of congenital anomalies  doubt decrease in birth weight  doubt increase in preterm birth  no evidence of long term infant-child neurodevelopmental sequela  THC is present in breast milk

Pregnancy: Ethical Issues

 Maternal autonomy:  the pregnant woman’s right to choose or refuse recommended therapy  fetal interests do not have to be abandoned  If conflict between maternal and fetal interests:   urge the woman to seek consultation refer to institution’s ethics committee  document in detail in medical chart  Court orders for treatment can be destructive to:  the woman’s autonomy  the physician-patient relationship

Summary

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Drug dependence is a chronic, relapsing medical illness.

The etiology and course of the disease is influenced by genetic heritability, personal choice and environmental factors.

Drug dependence produces lasting change in brain chemistry and function.

Effective medications are available to treat opiate dependence and achieve abstinence.

Long-term care strategies produce lasting benefits for the patient who can live normal, productive lives.

Sources of Learning Materials

 American College of Obstetricians and Gynecologists  202-638-5577  American Society of Addiction Medicine  301-656-3920  March of Dimes Birth Defects Foundation  800-367-6630  National Clearinghouse for Alcohol & Drug Information  800-729-6686 or 301-468-2600  National Institute on Drug Abuse  301-443-1124  Physician Leadership on National Drug Policy  401-444-1816

Internet Resources

 Association for Medical Education & Research in Substance Abuse  http://www.amersa.org

 Center for Alcohol & Addiction Studies, Brown University  http://www.caas.brown.edu

 Center for Substance Abuse Treatment (DHHS)  http://www.samhsa.gov/csat  Narcotics Anonymous  http://www.na.org/index.htm

Internet Resources (continued)

 National Advisory Council on Drug Abuse, National Institute on Drug Abuse (NIDA)  http://www.drugabuse.gov

 National Clearinghouse for Alcohol & Drug Information  http://www.health.org

 Physician Leadership on National Drug Policy  http://www.plndp.org

 US Department of Justice, Drug Enforcement Admin.

 http://www.usdoj.gov/dea