Transcript Community Approaches to Prevention and Early Intervention
Community Approaches to Prevention and Early Intervention Jan Campbell, R.N., B.S.N.
Sue Spooner, R.N., C.P.N.P.
January 2007
“Hand of Hope” The tiny hand of 21-week-old fetus Samuel Alexander Armas emerges from the mother’s uterus to grasp the finger of Dr. Joseph Bruner.
The Problem
Perinatal Substance Abuse
National Pregnancy and Health Survey
Illicit drugs
Cocaine
Marijuana
Alcohol
Tobacco 5.5% 1.9% 2.9% 20.4% 18.8%
CRT vs. SAMHSA Data: Substance Use in Pregnancy 25% 20% 15% 10% 5% CRT/4P's Plus SAMHSA 0% Alcohol Tobacco Illicit Drugs
Riverside County Substance-Exposed Babies
Preliminary data indicate 13% of women screen positive for substance use
In 2004, there were 29,545 births
Applying 13%, which is considered a low estimate, 3,841 babies were born exposed to drugs and/or alcohol
San Luis Obispo County Substance-Exposed Babies
•
Preliminary data indicate 38.5% of women screen positive for substance use
•
In 2005, there were 2,640 births
•
Applying 38.5% which is considered a low estimate, 1,016 babies were born exposed to drugs and/or alcohol
Substance Use Rates Across California Counties 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% M B SL SB V H A F R
Alcohol Use Patterns After Knowledge of Pregnancy: San Luis Obispo, Riverside vs. CA 0.7
0.6
0.5
0.4
0.3
0.2
0.1
0 SLO Riverside CA Daily 3-6d/wk 1-2d/wk <1d/wk
Predictors of Low Birth Weight Tobacco has a 3x greater impact than cocaine on predicting low birth weight
Tobacco
Decreases oxygen to fetus
Baby is born too early
Small babies (low birth weight)
Nicotine withdrawal
More likely to die from SIDS
Learning and behavioral problems
Marijuana
Right after birth
Hard time responding
Shakes
Hard time comforting
Long-term affects
Trouble paying attention
Aggressive behaviors
Baby Exposed to Cocaine
Cocaine, Methamphetamines, Heroin
Drugs can starve parts of the baby’s body and prevent it from growing
Can cause stroke or heart attack in the womb
Can cause miscarriage, early birth and nervous system problems
SIDS
Learning and behavioral problems
Alcohol
Low birth weight
Small brain with brain damage
Heart problems
Kidney problems
Malformations
Facial dysmorphology
Newborn baby boy with pronounced features of FAS and severe heart disease. Birth weight and length less than 5th percentile for gestational age.
Prenatal alcohol exposure is the leading preventable cause of birth defects, developmental disorders, and mental retardation in children Journal of the National Association of Neonatal Nurses 2005
Cause of FAS/FASD
The sole cause of FAS/FASD is women drinking alcoholic beverages during pregnancy.
Alcohol is a teratogen.
“ Of all the substances of abuse (including cocaine, heroin, and marijuana), alcohol produces by far the most serious neurobehavioral effect in the fetus” IOM report to Congress 1996
FASD Facts
100 percent preventable Leading cause of preventable mental retardation Not caused on purpose Can occur anywhere and anytime pregnant women drink Not caused by biologic father’s alcohol use Not a new disorder
FASD and the Brain
Prenatal alcohol exposure causes brain damage.
Effects of FASD last a lifetime.
People with an FASD can grow, improve, and function well in life with proper support.
FAS and the Brain
Effects of Alcohol on the Brain
FAS: CNS Effects
Mental retardation
Developmental delays
Hyperactivity
Behavior problems
Speech/language dysfunction
People with FASD have difficulty:
Following instructions Discerning the difference between truth and fiction Thinking about abstract concepts Organizing Storing and retrieving information Understanding social expectations Comprehending and responding to other people’s feelings Bonding or building personal attachment and trust
Alcohol Dose
1 drink/week
Hyperactive and aggressive behaviors
Moderate to heavy use
Delinquent behavior and overall problem behavior
Any alcohol use pregnancy
3.2 x risk for delinquent behavior
40000 35000 30000 25000 20000 15000 10000 5000 0 Comparing FASD to Other Birth Defects HIV MD Spina DS FAS FASD
Estimated Number of FAS
Fetal Alcohol Syndrome (FAS) 1 in 500 births
Combined estimated number of FASD 5 in 500 births Journal of the National Association of Neonatal Nurses 2005
Economic Cost of FAS
Cost the nation $5,400,000,000 in 2003.
Each individual with FAS will cost US $1,500,000 to $3,000,000 in his or her lifetime.
Message If you are pregnant or think you could be pregnant DO NOT USE ANY:
Alcohol (beer, wine, liquor)
Tobacco/Marijuana
Illicit drugs (methamphetemines, heroine, cocaine)
What Now?
Community Collaboration
Development of a Community Team
Who Should be on a Community Team?
People with passion Respected leaders in the community People with passion
People with the authority to commit resources and make decisions People with passion
Community Team Considerations
1.
2.
3.
4.
5.
6.
Knowledge Obstetrics Public Health Nursing Child Protective Services Mental Health Substance Abuse Treatment Healthy Start ( if it exists in the community) Community orientation Authority and influence Size Compatibility Consumer representation
Community Team Example
Director Maternal and Child Health Director Mental Health Director Substance Abuse Treatment Director Child Protective Services Director Healthy Start Public Health Nursing Obstetrician Pediatrician County Board of Supervisors Presiding Judge, Drug Dependency Court
The Community Team Considerations
Make sure there is representation from “the basic six” Recruit people with a community orientation Seek people who are respected in the community Invite those with authority of influence Keep the group a manageable size: 8-12 Make sure team members are compatible Involve consumers in a useful and respectful way
The Leadership Institute
A 3½ day learning and planning experience
Intended to give the team a shared understanding of the key issues in substance use among pregnant and parenting women
Designed to produce an initial plan for the team to use as the members return to their community
The Core Intervention
S creen Screen all pregnant women for substance use. Largely this is accomplished by making screening a fixed part of primary prenatal care.
A ssess Those women who screen positive are given a field assessment to determine if they are in fact using drugs. R efer T reat Those women who are found to be using drugs are referred to an appropriate type of drug treatment.
Those women who are referred to drug treatment receive quality, gender-specific drug treatment that is appropriate for their circumstances.
Where
Do
We Start?
Successful Implementation
of a Perinatal Screening, Assessment, Referral and Treatment Program
How Do We Begin?
Build your support services
Referral and treatment
Mental Health
Drug and Alcohol
Private psychologist and therapist
Training
It is important to train your provider prior to implementation of the SART Program
Dinner with providers and wives/husbands
Key note speaker - a physician knowledgeable and respected in the area of perinatal substance use
Establish a Good
Support System
Needs to be integrated as a routine part of prenatal care (not a psychosocial issue but a health issue)
This is a health issue for all pregnant women
Present the program as a complete package
Provide assessment forms Instructions/staff training (ongoing basis) Collection of Data Educational Materials
“I am concerned” brief intervention Pamphlets
Referral Process
Easy to use
Clear easy to use forms Minimal information to fill out Contact numbers answered by a person
Followed up in a timely manner
Contact clients within 2 to 3 days
Feedback to the physician
Respond back to referring physician regarding outcome of referral
Share Data
Give feedback on screening data to physician on a regular basis
Physician’s practice compared to overall county results
Value of Respect
Respect professionalism of OB providers by
Providing scientific proof
Best Practices Respect provider’s time by
Bringing all necessary materials Providing training and ongoing support Respect provider as a partner by
Visiting as often as necessary What can we do for you
Respect provider’s commitment to SART by
Acknowledging their contribution
Respect provider’s commitment to their patients’ means
Providing accurate and timely feedback
Respect provider’s interest in real results means
Working with other agencies to make sure referrals are acted upon
What does a screening program look like?
The
SART
System
S
creening
A
ssessment
R
eferral
T
reatment
P
arents
P
artner Screening Did either of your parents ever have a problem with alcohol or drugs?
Does your partner have a problem with alcohol or drugs?
Have you ever drunk alcohol?
P
ast
P
regnancy
In the month before you knew you were pregnant, how many cigarettes did you smoke?
In the month before you knew you were pregnant, how many beers did you drink?
In the month before you knew you were pregnant, how much marijuana did you smoke?
Assessment
What?
When?
How much?
Referral: A Brief Intervention
“I am concerned….” Abstain from drugs or alcohol “I see you are upset….” Come to consensus Refer: a “warm handoff ”
Treatment: Level of Care 4P’s+ neg pos
I
FA FA+
II “
handshake
”
brochure
IIIa
pretreatment
IIIb
group
IVb IVa
outpatient residential
The Perinatal Substance Abuse 4P’s Plus Assessment Program
Seeks to address the impact of alcohol, tobacco and illicit drug use during pregnancy and the benefits of early intervention
Works with prenatal providers on integrating substance abuse screening, assessment and referral as a routine part of prenatal care
Focuses on the education of the professional community and the community at large regarding the impact of alcohol, tobacco and illicit drugs during pregnancy and the benefits of early intervention
Funding
Helped fund Leadership Team
Funded 2 years of training and consultation with National Training Institute (Dr. Ira Chasnoff)
Provided funding for infrastructure for Beginnings
March of Dimes
Funded
Printing of brochures, posters
Trainings
Media campaigns
Maternal Child and Adolescent Heath Title V Funds
Licensure of 4P’s Plus assessment tool Purchase of “I am concerned” brief intervention books Printing of 4P’s Plus assessment tool Staff two positions for perinatal substance abuse program Educational materials
The California Endowment
Pamphlets Website Posters
Federal Grants
Healthy Start
Local Resources
Universities
Cal Poly San Luis Obispo
Graphic arts and photography for poster
Web design
Community Foundations
Preventive Health Grants
Hospitals
We Can Make A Difference
For more information… Please call for questions or additional information: Jan Campbell, MCAH Director, San Luis Obispo (805) 781-5592 Sue Spooner, MCAH Director, Riverside (951) 358-5192