Transcript Document 7330432

“Identifying and Treating Pregnant
Substance Users”
H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM
Director
Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
U.S. Department of Health & Human Services
National Summit on Substance Exposed
Newborns: Collaborative Approaches to a
Complex Issue
June 23, 2010  Alexandria, VA
“As a Nation, we must
work together to provide
access to effective
services that reduce
substance abuse and
promote healthy living.”
August 31, 2009
President Barack Obama
3
“At the Department of
Health and Human
Services we have a simple
mission: protect the
health of the American
people and provide
essential human services,
especially for those who
are least able to help
themselves.”
Kathleen Sebelius
Secretary
U.S. Department of Health & Human Services
May 5, 2009
4
SAMHSA: Key Messages
 Behavioral health is
essential to health
 Prevention works
 Treatment is effective
 People recover from
mental and substance use
disorders
Pamela S. Hyde, J.D.
Administrator, SAMHSA
5
Substance Abuse and Mental Health
Services Administration/CSAT
SAMHSA’s Mission:
 To reduce the impact of substance abuse and
mental illness on America’s communities
Center for Substance Abuse Treatment (CSAT) Mission:
 To improve the health of the nation by bringing
effective alcohol and drug treatment to every
community.
6
6
SAMHSA’s Role in Improving the Nation’s
Health
 Behavioral health services improve health status and reduce
health care and other costs to society.
 SAMHSA is charged with effectively targeting substance abuse
and mental health services to the people most in need and to
translate research in these areas more effectively and more
rapidly into the general health care system.
 Continued improvement in the delivery and financing of
prevention, treatment and recovery support services provides
a cost effective opportunity to advance and protect the
Nation’s health.
7
7
Female Past Month Alcohol Use
(Aged 12+) 2008

Any Use:
45.9%
Binge Use*:
15.4%
Heavy Use*:
3.4%
Among pregnant women aged 15 to 44, an estimated 10.6%
reported current alcohol use, 4.5% reported binge drinking,
and 0.8% reported heavy drinking. Binge drinking during the
first trimester of pregnancy was reported by 10.4 % of
pregnant women aged 15 to 44. This was up from 6.6%
reported in 2007.
* Binge Alcohol Use is defined as drinking 5 or more drinks on the same occasion on at least 1 day in the past 30 days. Heavy Alcohol Use is
defined as drinking 5 or more drinks on the same occasion on each of 5 or more days in the past 30 days; all heavy alcohol users are also
binge alcohol users.
Source: NSDUH 2008
8
Illicit Drug Use among Females
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
41.8% 42.9%
2007
2008
11.6% 12.2%
5.8%
Lifetime
Source: SAMHSA, Office of Applied Studies, NSDUH, 2008
Past Year
6.3%
Past Month
9
Substance Dependence or Abuse in the Past Year by
Gender: 2008
Substance Dependence or Abuse, Past Year
14%
12%
10%
8%
6%
4%
2%
0%
Female
Male
11.5%
9.7%
5.1%
2.2%
6.4%
3.4%
Illicit Drugs
Source: SAMHSA, Office of Applied Studies, NSDUH, 2008, Table 5.4B
Alcohol
Ilicit Drugs &
Alcohol
10
The Challenge
 Each year about 105,000
pregnant women need
substance abuse treatment.
 Poverty and limited access to health care contribute
to the pervasiveness of substance abuse among
pregnant women of low socioeconomic status.
 Many pregnant women who have substance abuse
problems do not seek prenatal care for fear of being
reported to law enforcement or social service
agencies.
Source: Andrulis & Hopkins (2001) and Funai, et al (2003) as cited in Walton-Moss, B. et al. (2009) Health status and birth outcomes
among pregnant women in substance abuse treatment. Women’s Health Issues 19: 167-175.
11
Pregnant
Past Month Binge* Alcohol Use:
Pregnant and Non-pregnant Women
Trimester 1
8.0%
Trimester 2
1.8%
Trimester 3
1.0%
Non-pregnant
No Child
32.6%
Child <3 mos.
10.0%
Child 3-5 mos.
15.5%
Child 6-8 mos.
14.6%
Child 9-11 mos.
16.9%
Child 12-14 mos.
17.6%
Child 15-17 mos.
16.8%
Child 18+ mos.
19.7%
0%
Source: NSDUH 2002-2007
5%
10%
15%
20%
25%
30%
* Binge alcohol use is defined as drinking 5 or more drinks at the same time or
within a couple of hours on at least 1 day in the past 30 days.
35%
12
Pregnant
Past Month Marijuana Use:
Pregnant and Non-pregnant Women
Trimester 1
4.6%
Trimester 2
2.9%
Trimester 3
1.4%
No Child
10.9%
Non-pregnant
Child <3 mos.
3.8%
Child 3-5 mos.
4.3%
Child 6-8 mos.
5.0%
Child 9-11 mos.
5.3%
Child 12-14 mos.
4.7%
Child 15-17 mos.
4.1%
Child 18+ mos.
3.8%
0%
Source: NSDUH 2002-2007
2%
4%
6%
8%
10%
12%
13
Resumption of Substance use among Recent
Mothers
 When compared with women in their third trimester,
mothers with children under 3 months old in the
household had much higher rates of:
• alcohol use (6.2% vs. 31.9%),
• binge alcohol use (1% vs. 10%),
• cigarette use (13.9% vs. 20.4%) and
• marijuana use (1.4% vs. 3.8%)
 The increase in rates of substance use among
parenting women tended to level off as the age of
the youngest child increased.
Source: NSDUH 2002-2007
14
Pregnant Women and Admission to Treatment
According to the Treatment Episode Data Set (TEDS),
approximately 4% of women reporting for substance abuse
treatment are pregnant at the time of admission.
• On average, 43% had no prior treatment episodes, 24%
had 1 prior admission, 13% had 2, 11% had 3 or 4 prior
admissions and 9% had 5 or more.
 In 2008, 32.9% of pregnant women admitted to treatment
were referred by the court or criminal justice system.
• This percentage has been steadily rising since 1992, when
it was 20.7%.

Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1998-2008
15
Primary Substance at Time of Admission –
Pregnant Women
Alcohol
Cocaine/Crack
Marijuana/Hashish
Heroin
Other Opiates & Synthetics
35%
30.9%
30%
25%
24.6%
22.3%
20%
18.6%
16.7%
16.6%
15%
13.3%
12.5%
10%
8.9%
5%
1.0%
0%
1998
1999
2000
2001
2002
2003
2004
Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1998-2008
2005
2006
2007
2008
16
Methadone-planned Treatment for Pregnant Women
Admitted to Treatment
Is the Use of Methadone Planned?
120%
Yes
No
100%
90.4%
80%
90.2%
91.2%
90.3%
89.7%
90.1%
88.7%
89.4% 89.0%
88.7% 87.7%
60%
40%
20%
0%
9.8%
9.6%
9.7%
9.9%
8.8%
10.3%
11.3%
10.6%
11.0%
11.3%
12.3%
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1998-2008
17
Age at Admission to Treatment: Pregnant Women
0.3%
3.7%
0.2%
5.0%
11.1%
30.0%
49.7%
Source: Treatment Episode Data Set -- Admissions (TEDS-A) -- Concatenated, 1998-2008
12-17
18-20
21-29
30-39
40-49
50-54
55 and Older
18
Treating Pregnant Substance Abusers – Barriers

Although there are many barriers felt by women who seek
treatment for substance use, those faced by pregnant women
can be even more serious. Among them:
• Guilt and shame brought about by societal attitudes
toward a pregnant woman’s substance use that may be
less understanding and more judgmental.
• The difficulty of navigating around a drug-using
boyfriend/partner/environment upon which the woman
may be dependent financially and emotionally.
• Stigma that results from negative reactions from the
treatment community itself.
• The perceived threat of losing child custody.
Source: Shannon, L. & Walker, R. (2008) Increasing the recognition of barriers for pregnant substance users seeking treatment.
[Commentary] Substance Use & Misuse. 43:1266-1267.
19
Gender-Informed Care

Health professionals need to be sensitive to the unique
challenges faced by women who enter treatment, and be
prepared to address them as part of their treatment program,
including:
• Trauma (past and present)
• The importance of relationships (healthy and unhealthy)
• The challenges faced by the increased number of female
veterans returning from Iraq and Afghanistan
• The treatment needs of females in the criminal justice
system. (Although more men go to prison, the number of
women entering prison is growing at a faster rate.)
20
The Impact of Relationships on Female Substance
Abuse
 Relationships play an important role in the initiation
of substance use among women.
 For women, initiation of substance use typically
begins after an introduction of the substance by a
significant relationship such as a boyfriend, partner,
or spouse.
 Some women continue using alcohol and illicit drugs
to have an activity in common with their partners or
to maintain the relationships. The man often supplies
drugs, and the woman becomes dependent on him
for drugs.
Source: TIP 51: Substance Abuse Treatment: Addressing the Specific Needs of Women: Chapter 2: Patterns of Use: From Initiation to
Treatment
21
Treating Pregnant Substance Abusers – The Impact of
Interdisciplinary Programs

Traditionally, pregnant women with substance abuse had to
attend a treatment program for their substance use disorder
and a separate medical clinic for their prenatal care.

Many times, these women would delay or totally avoid
prenatal care while in treatment.

Interdisciplinary programs that simultaneously provide
prenatal care and substance abuse treatment result in
significantly higher infant birthweights or longer pregnancy
duration among participating women compared to those who
did not participate.
22
SAMHSA’s Pregnant and Post-Partum Women
(PPW) Program
SAMHSA’s Pregnant and Post-Partum Women (PPW) program
recognizes the importance of an interdisciplinary – or holistic –
treatment approach for pregnant and postpartum women
(postpartum refers to the period after childbirth up to 12
months) who suffer from alcohol and other drug problems, and
their minor children impacted by perinatal and environmental
effects of maternal substance use and abuse.
 The treatment services offered in the PPW program must be
coupled with access to primary health, mental health and social
services.
 PPW is a family-centered treatment approach that builds on the
strength and resources of the entire family, supports sustained
recovery for individual family members, and improves overall
family functioning.
23

Pregnant and Postpartum Women (PPW)
Program
The PPW program has proven successful in helping to
reach those in need of substance abuse services by:

Providing comprehensive services to women
during pregnancy significantly improves the lives
of women, children, and their families.

In 1992, in accordance with section 508 of the
Public Health Service Act, SAMHSA developed a
gender and culturally specific residential treatment
program for pregnant and postpartum women.
24
24
PPW: Program Purpose & Population of
Focus
 To expand availability of sustainable,
comprehensive,
quality residential treatment, recovery support, and
family services for pregnant and postpartum women
and their minor children impacted by perinatal and
environmental effects of substance abuse.
 Preserve and support
the family unit by including
fathers of the children, partners of the women, and
other extended family members in the treatment
program.
25
PPW: Outcomes

The PPW program has served 4,752 clients – 51.6% of whom
were pregnant at intake.
Of Clients who
reported…
At Intake
6-Month
Follow-up
Difference
No substance use
47.5%
90.9%
 91.5%
Being employed
9.2%
22.4%
 143.5%
No arrests
84.9%
97.7%
 15.1%
Being socially
connected
93.6%
96.3%

Source: SAIS data 2002 – 6/4/10
2.9%
26
PPW: Risk Behavior Outcomes
Of Clients who
reported…
At Intake
6-Month
Follow-up
Difference
Using Injection Drugs
8.6%
1.7%
 79.7%
Unprotected sexual
contact
88.7%
66.9%
 24.6%
Unprotected sexual
contact with IDU
Unprotected sexual
contact with indiv.
High on some
substance
8.3%
4.2%
 50.0%
27.1%
9.4%
65.4%
Source: SAIS data 2002 – 6/4/10
27
PPW: Mental Health Outcomes
Of Clients who
experienced…
At Intake
6-Month Follow-up Difference
Serious depression
52.0%
33.1%
 36.3%
Serious anxiety or tension
53.5%
39.8%
 25.6%
Hallucinations
3.1%
1.7%
 45.2%
Trouble understanding,
concentrating or
remembering
38.1%
26.9%
29.4%
Trouble controlling violent
behavior
10.2%
5.5%
46.1%
Attempted suicide
1.4%
0.3%
 78.6%
Source: SAIS data 2002 – 6/4/10
28
The National Center on Substance Abuse and Child
Welfare (NCSACW)
The NCSACW is a joint effort between CSAT and the
Administration on Children, Youth and Families
 The web site provides links to:

• Technical assistance,
• Tutorials and training, and
• Information about conferences.
An average of 500 people visit the web site each day –
a total of nearly 42,000 documents were downloaded
during the first quarter of FY 09.
 www.ncsacw.samhsa.gov

29
Treatment Improvement Protocols (TIPs)
 TIPs are best-practice
guidelines for the treatment of
substance abuse based on the experience and
knowledge of clinical, research, and administrative
experts. TIPs specific to treating women include:
• TIP 5 Improving Treatment for Drug-Exposed
Infants
• TIP 51: Substance Abuse Treatment: Addressing
the Specific Needs of Women
30
TIP 5: Improving Treatment for Drug-Exposed
Infants
 Primary focus of this TIP is the in utero exposure of
infants to illicit drugs.
 In utero exposure to cocaine and opiates, especially
heroin, is highlighted, and there is a brief discussion
of methadone.
 In addition, this TIP highlights medical and
psychosocial services for drug-exposed infants up to
18 months of age and their families.
 Concerns regarding older toddlers and children are
also mentioned.
31
Women’s Services Network
 CSAT has developed a Network of State Women’s
Services Coordinators
 The WSN has become a subcommittee of NASADAD’s
National Treatment Network
 The “Guidance to States: Treatment Standards for
Women with Substance Use Disorders,” was
released at the NASADAD National
meeting in June 2008.
32
Online Resources
Family-Centered Treatment for Women with Substance use
Disorders – History, Key Elements and Challenges
 A monograph introduces the concepts & evolution of
family-centered treatment approach – including key
principles, challenges, and solutions.
Funding Family-Centered Treatment for Women with Substance
Use Disorders
 Companion to the Family-Centered Treatment
monograph– helps treatment providers and
State substance abuse agencies to identify &
access potential funding sources.
33
Thank you.
34