Lessons from the 4P’s Plus

©

Substance Use in Pregnant Women

Anne Wells, PhD Samantha McCurties Ira J. Chasnoff, MD ©NTI Upstream 2007

Today’s Format

1.

2.

3.

4.

Research background of the 4P’s Plus

©

What do you predict?

What the data say Implications

©NTI Upstream 2007

Screening for Substance Use in Pregnancy

CAGE

Heavy alcohol X Light alcohol Illicit drugs Gender specific

NET T-ACE TWEAK AUDIT-C

X X X X X X

©NTI Upstream 2007

1. How often do you have a drink containing alcohol? 0 Never 1 2 3 4 Monthly or less 2– 4 times a month 2–3 times a week 4 or more times a week 2. How many drinks containing alcohol do you have on a typical day when you are drinking? 0 1 or 2 1 2 3 4 3 or 4 5 or 6 7–9 10 or more 3. How often do you have six or more drinks on one occasion? 0 Never 1 Less than monthly 2 Monthly AUDIT-C (+>4) 3 4 Weekly Daily or almost daily ©NTI Upstream 2007

Research Development of the 4P’s Plus



Medicaid-eligible women



Odds ratios



CART analysis

©NTI Upstream 2007

Risk for Drug/Alcohol Use

 Low (1) Never used alcohol and (2) did not smoke 3 or more cigarettes in the month before pregnancy <2% ©NTI Upstream 2007

Risk for Drug/Alcohol Use

 Average (1) Has used alcohol in the past, (2) did not smoke 3 or more cigarettes in the month before pregnancy, and (3) did not drink in the month before pregnancy 9.5% ©NTI Upstream 2007

Risk for Drug/Alcohol Use

 High Risk (1) Drank in the month before pregnancy or (2) smoked 3 or more cigarettes in the month before pregnancy 34% ©NTI Upstream 2007

Research Development of the 4P’s Plus



Medicaid-eligible women



Odds ratios



CART analysis



Clinical trials with focus groups

©NTI Upstream 2007

Research Development of the 4P’s Plus



Medicaid-eligible women



Odds ratios



CART analysis



Clinical trials with focus groups



Validity data

©NTI Upstream 2007

Validity Data for the 4P’s Plus

(N = 1,884) Screen is POSITIVE Screen is NEGATIVE Assessment is POSITIVE Assessment is NEGATIVE

310 65 395 1,204

©NTI Upstream 2007

Validity Data for the

4P’s Plus

Correct classification (1,514/1,884) Sensitivity (310/375) Specificity (1,204/1,509) Positive predictive validity (310/615) 80% 83% 80% 50% Negative predictive validity (1204/1269) 95% ©NTI Upstream 2007

Research Development of the 4P’s Plus

 Medicaid-eligible women  Odds ratios  CART analysis  Clinical trials  Validity data  Comparative trials vs. urine toxicologies ©NTI Upstream 2007

Urine Toxicology vs. 4P’s Plus in Southern Illinois

(N = 1,435) 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Urine done Urine Pos 4P's+ Pos Assmt Pos

©NTI Upstream 2007

The

SART

System



S

creening



A

ssessment



R

eferral



T

reatment

©NTI Upstream 2007

©NTI Upstream 2007

©NTI Upstream 2007

Today’s Dataset

 Information from 9 communities  Baton Rouge, LA         Butte, CA Madera, CA Riverside, CA San Luis Obispo, CA Shasta, CA Solano, CA Ventura, CA East St. Louis, IL ©NTI Upstream 2007

Today’s Dataset

   N = 23,122 Age (years)     Range = 9 to 48 M = 24.74

Median = 24.00

SD = 5.85

Ethnicity     Caucasian 19% Hispanic 59% African American 17% Other 6% ©NTI Upstream 2007

Today’s Dataset

   N = 23,122 Age (years)  Range  

M Median



SD

Ethnicity     Caucasian Hispanic African American Other 9 to 48 24.74

24.

5.85

19% 59% 17% 6% ©NTI Upstream 2007

Today’s Dataset

•

Primary Language

• • • • English 46.5% Spanish 54.8% English and Spanish 1.9% English and other language 0.1% ©NTI Upstream 2007

How many women have a positive

4 P’s Plus

© ?

Overall sample 27% ©NTI Upstream 2007

What patterns of perinatal substance use do you expect?

 Younger vs. older?

 Different ethnic groups?

 More educated vs. less educated  Poor vs. middle class?

 Relationship with domestic violence?

 Relationship with depression?

©NTI Upstream 2007

Perinatal Substance Use as a Function of Age Use of Alcohol During Pregnancy Time 18 and younger

(

N

= 1182)

19 to 35

(

N

= 7663)

36 and older

(

N

= 494)

Before Known Pregnant 1 Since Known Pregnant 2 169 (14.3) 27 (18.6) 3 1063 (17.8) 218 (20.5) 49 (15.0) 11 (22.4)

Note.

1

X

2 (2) = 11.84,

p

= .003. 2

X

2 (2) = 0.42,

p

= .81. 3 Represents percent of non-missing data. ©NTI Upstream 2007

Perinatal Substance Use as a Function of Age Use of Marijuana During Pregnancy Time

(

18 and younger

N

= 1182)

19 to 35

(

N

= 7663)

174 (2.3) Before Known Pregnant 1 Since Known Pregnant 1 34 (2.9) 14 (48.3) 68 (49.6)

Note.

1

X

2 (2) = 20.67,

p

= .008. 2

X

2 (2) = 0.32,

p

= .85.

36 and older

(

N

= 494)

5 (1.0) 1 (33.3)

©NTI Upstream 2007

Perinatal Substance Use as a Function of Age Use of Other Illicit Drugs During Pregnancy Time

(

18 and younger

N

= 1182)

19 to 35

(

N

= 7663)

67 (0.9) Before Known Pregnant 1 Since Known Pregnant 2 18 (1.5) 6 (33.3)

Note.

1

X

2 (2) = 12.75,

p

= .12. 2

X

2 (2) = 0.67,

p

= .72.

25 (37.3) 36 and older

(

N

= 494)

1 (0.2) 0 (0.0)

©NTI Upstream 2007

Perinatal Substance Use as a Function of Ethnicity Use of Alcohol During Pregnancy Time Caucasians

(

N

= 2107)

Hispanics

(

N

= 6736)

African Americans

(

N

= 1921)

387 (20.1) Others

(

N

= 622)

137 (22.0) Before Known Pregnant 1 Since Known Pregnant 2 836 (39.7) 254 (38.1) 3 738 (11.0) 179 (29.4) 22 (7.6) 30 (24.4)

Note.

1

X

2 (3) =923.69,

p

<.001; 2

X

2 (3) =92.96,

p

<.001; 3 Represents percentage of non-missing data.

©NTI Upstream 2007

Perinatal Substance Use as a Function of Ethnicity Use of Marijuana During Pregnancy Time Caucasians

(

N

= 2107)

Hispanics

(

N

= 6736)

African Americans

(

N

= 1921)

Others

(

N

= 622)

26 (1.4) 57 (9.2) Before Known Pregnant 1 Since Known Pregnant 2 142 (6.7) 60 (50.8) 3 123 (1.8) 45 (61.6) 15 (57.7)

Note.

1

X

2 (12) =36.73,

p

data.

<. 001; 2

X

2 (12) =7.02,

p

=.07

; 3 Represents percentage of non-missing

15 (36.6)

©NTI Upstream 2007

Perinatal Substance Use as a Function of Ethnicity Use of Other Illicit Drugs During Pregnancy Time Caucasians

(

N

= 2107)

48 (2.3) Hispanics

(

N

= 6736)

61 (0.9) African Americans

(

N

= 1921)

Others

(

N

= 622)

6 (0.3) 9 (1.4) Before Known Pregnant 1 Since Known Pregnant 2 17 (35.4) 3 23 (37.7) 4 (66.7) 0 (0.0)

Note.

1

X

2 =20.20,

p

=.06; 2

X

2 =7.63,

p

=.05

; 3 Represents percentage of non-missing data.

©NTI Upstream 2007

County Perinatal Substance Use as a Function of Education Level

% Bachelor Degree or Higher 1

Substance Use Before Known (%) Substance After Known (%) Madera Shasta Riverside Butte San Luis Obispo Ventura 12.0

16.6

16.6

21.8

26.7

26.9

15.9

52.6

13.6

30.6

36.4

11.5

1.4

16.3

5.5

7.2

23.8

6.3

Note:

1 In population aged 25 years and older. Education data from U.S. Census Bureau, Census 2000 Summary File 3, Matrices P19, P36, P37, P38, PCT 24, and PCT 25.

©NTI Upstream 2007

Perinatal Substance Use as a Function of Education Level County Shasta Butte San Luis Obispo Ventura Riverside Madera Infants Born to Parents with < 12 Years of Education (2003) Mothers:17.3% Fathers:13.2% Mothers:18.5% Fathers:17.8% Mothers:19.5% Fathers:19.6% Mothers:27.7% Fathers:27.4% Mothers:29.0% Fathers:28.3% Mothers:44.5% Fathers:44.9% Substance Use Before Known (%) 52.6

30.6

36.4

11.5

13.6

15.9

Note:

Education data from Children Now, California County Data Book 2005.

Substance After Known (%) 16.3

7.2

23.8

6.3

5.5

1.4

©NTI Upstream 2007

Perinatal Substance Use as a Function of Income County Ventura San Luis Obispo Riverside Shasta Madera Butte Median Income Level (2002) 57,052 43,456 42,929 35,374 34,432 32,124 Substance Use Before Known (%) 11.5

36.4

13.6

52.6

15.9

30.6

Note:

Income data from Children Now, California County Data Book 2005.

Substance After Known (%) 6.3

23.8

5.5

16.3

1.4

7.2

©NTI Upstream 2007

Perinatal Substance Use and Domestic Violence Domestic Violence 4Ps Plus Positive 4Ps Plus Negative Positive Negative 562 (48.7) 5676 (25.8) 593 (51.3) 16291 (74.2)

Note.

X

2 (1)=290.042,

p

<.001.

©NTI Upstream 2007

Perinatal Substance Use and Depression Depression Positive Negative 4Ps Plus Positive 252 (47.6) 5686 (26.5)

Note.

X

2 (1)=117.28, p

<

.001.

4Ps Plus Negative 277 (52.4) 16607 (73.5)

©NTI Upstream 2007

Domestic Violence and Depression Domestic Violence Depression Positive Depression Negative Positive Negative 169 (65.5) 360 (13.0) 89 (34.5) 2406 (87.0)

Note.

X 2

(1)=450.463, p =.000

©NTI Upstream 2007

Marijuana Use in Different States Marijuana Use Before Known Pregnant State California Louisiana Illinois Did not use any 7526 (92.3) Less than 1 day a week 183 (2.2) 702 (100.0) 2050 (88.3) 0 (0.0) 57 (2.5) 1 to 2 days a week 3 to 6 days a week Every day 144 (1.8) 87 (1.1) 211 (2.6) 0 (0.0) 66 (2.8) 0 (0.0) 44 (1.9) 0 (0.0) 104 (4.5)

Note: X

2 (8)= 113.5,

p

< .001.

©NTI Upstream 2007

Marijuana Use in Different States Marijuana Use Since Known Pregnant State California Louisiana Illinois Did not use any 7834 (96.3) 757 (100.0) 2197 (94.7) Less than 1 day a week 106 (1.3) 0 (0.0) 31 (1.3) 1 to 2 days a week 80 (1.0) 0 (0.0) 33 (1.4) 3 to 6 days a week 38 (0.5) 0 (0.0) 24 (1.0) Every day 73 (0.9) 0 (0.0) 36 (1.6)

Note: X

2 (8)= 54.07,

p

< .001.

©NTI Upstream 2007

Who are the perinatal substance users?

 Women who don’t know any better  Women who are addicted ©NTI Upstream 2007



In our dataset, what are the best predictors of women who continue to use alcohol throughout their pregnancy?

Possible predictors  Parents had substance abuse problem  Partner has a substance abuse problem  Has used substances before  Race (Caucasian, Hispanic, African American, Other)  Age ©NTI Upstream 2007



In our dataset, what are the best predictors of women who continue to use alcohol throughout their pregnancy?

Predictors not used  Depression and DV questions  Too much missing data  Used pills to solve problems  Too much missing data ©NTI Upstream 2007

In our dataset, what are the best predictors of women who continue to use alcohol throughout their pregnancy?

Canonical Variable X1 Z1 .16

Note: Standardized discriminant coefficients X2 -.091

X3 .95

X1 = parents substance problem X2 = partners substance problem X3 = used substances X4 = Caucasian X5 = Hispanic X6 = African American X7 = Age X4 .053

X5 .33

Eigen Value .035

% Contri bution 100.0

p

.000

X6 .15

X7 .37

©NTI Upstream 2007

In our dataset, what are the best predictors of women who continue to use alcohol throughout their pregnancy?

Structure Matrix Variable Used substances Correlation .878

Age .287

Parents substance problem .265

African American Caucasian Hispanic .070

.037

.006

Partner substance problem .000

©NTI Upstream 2007

Consequences of Findings

 Policymakers?

 Administrators?

 Providers?

 Researchers?

©NTI Upstream 2007