5/7/05njm

**[Methamphetamine use in Indian Country: Discussion]{.underline}**

Below are some issues worth discussion about Methamphetamine use in
Indian Country. Let us here your thoughts on these, or other issues

 

-How common is meth use in your area?

-Should all mothers be screened at delivery for meth use or only if
medically indicated?

-What is the disposition of an infant born to a mother with known meth
use?

-Do you think this is or should be different than use of other drugs?

-What resources are available for teenagers and adults who are meth
users?

-What programs have shown success in treating meth addiction?

-Do you know of any successful prevention programs?

-In your tribal area are there laws that make meth production and use a
crime? Are there penalties for possession?

 

 

Here is a little background:

Methamphetamine (meth) has become an increasing drug of abuse in many
rural areas, including Indian reservations, in the past two years.
Primary care physicians see patients with meth issues in emergency
departments, clinics, delivery suites, domestic violence episodes and
child neglect cases. Diagnosis of meth abuse with the use of urine
toxicology screens is easy; successful treatment appears to be hard.

Clinicians need to be aware of this drug and its ramifications.

The two presentations below can serve as primers about methamphetamine
and as background for discussion.

The methamphetamine \"Word\" document was written by Thomas Drouhard,
MD, a longtime general surgeon at Tuba City. Possession and use of meth
is a federal crime and only recently became an illegal substance on the
Navajo Nation. This document was prepared as education for the Navajo
Nation tribal council which was drafting legislation to make meth
illegal.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/listservmethdocument.rtf>

 

This PowerPoint presentation was prepared by Drs. Harrison Alter of
emergency medicine and Diana Hu of pediatrics who also work in Tuba
City. Please feel free to use it for educational purposes for your staff
and community.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ListservMethPowerpoint.ppt>

 

A special thanks to Steve Holve MD for providing this material and
moderating this discussion

**Grenier, Denise (OIT-Tucson) \[Denise.Grenier@IHS.GOV\]**

**Thu 3/31/2005 7:53 AM**

In light of burn injuries associated with the production of
Methamphetamines (an interesting piece on this ran on NPR 03/30/05
citing an increase in visits to EDs and increased burn unit admissions
in Iowa due to burns received secondary to the production of
Methamphetamines), I wonder if we might also want to ask:

 

-Are you seeing an increase of burn injuries secondary to the production
of Methamphetamines? 

-Are victims of suspicious burn injuries being screened for meth use?

**Stuart, Peter \[Peter.Stuart@IHS.GOV\]**

**Fri 4/1/2005 5:01 PM**

Hard to know where to start but here's a mixed bag of responses and
questions -- first, while meth has 'arrived' on the res (at least here
in Navajo) and the alarm raised that does not equate in any manner or
form to the level of impact meth has had in many other communities -- we
still appear to be in the beginning stages of its distribution and
widespread use -- again referring to Navajo. Whether or not the
aggressive prevention and education efforts will save the day remains to
be seen but I think we need to be honest in how it is portrayed and
discussed. Alcohol still by far causes the most damage and disease and
should remain in the forefront of addiction prevention/treatment.

 

Second, many of the problems and violence related to meth use are
related to its manufacture and distribution and only partially due to
its direct effects as a drug. This will be an ongoing issue and begs the
question of whether a focus on closing down labs over targeting
individual users should be the strategy. Cleaning up lab sites,
preventing/reducing exposure of children and unwitting adults to the
toxic chemicals involved in manufacture and the manifold problems with
gang-based distribution chains (in a community with 50% unemployment
it's not a bad way to make some cash) will need ongoing attention
outside of standard prevention and treatment approaches. We do have
advantages out here because as compared to some rural parts of the
country setting up a lab in our remoter regions will be noticed by
someone -- because everyone is family. This may be an effective leverage
point in preventing long-term establishment of its manufacture here but
only with aggressive education and prosecution by local tribal police
and federal officers. Health care providers can assist in this process
by willingness where appropriate to get involved in the rough and tumble
of tribal politics.

 

Third, age-wise meth appears to have a more significant impact on our
local adolescent and young adult population -- related to its marketing
by pushers as a diet aid, wt loss agent, fatigue fighter etc. Alcohol is
perceived as the drug of the older generation and while used does not
have the cachet meth has with our teens. This has meant for us focusing
more attention on younger women as we have seen increasing numbers
becoming pregnant while on meth and who continue meth use during their
pregnancies. Drug screening in pregnancy and of newborn infants has
raised interesting issues about consent given the consequences of
positive screens (reporting to CPS, child removal, etc.). I personally
believe we need to move with great caution here making sure women in
crisis see us as supports and not as police agents while at the same
time not enabling continued drug use. Screening should be connected with
good, sound addiction treatment interventions and not done in isolation
-- and preferably with the full consent of the mother. The process also
needs to focus on the interaction part of the screening and assessment
process and not rely on urine screens as the sole indicators of risk.
Negative drug screens are not sensitive for the absence of a drug or
alcohol problem.

 

Finally, meth is an addiction plain and simple. Treatment success rates,
relapse rates, etc. are not dissimilar from the other drugs of abuse. It
is not thus per se more intractable or problematic than other addictions
such as our old friend alcohol. We should avoid thinking in rural areas
with limited resources and populations that we're somehow missing
treatment programs just because we don't have a "meth" program. What is
different with meth is that it's effect during intoxication are
different than alcohols, and it's delivery methods have their own
particular risks (HIV, endocarditis, etc.) that our local counselors
need to be aware of and educate clients on. But getting off of it
requires similar skills and approaches to those needed by people
struggling with alcohol dependence. Our message should be "If you're
addicted to meth -- there is help" not "oh my god you're on meth you're
doomed". Primary care providers have a role to play in that even fairly
simple interventions such as identifying use as a problem, discussing
consequences of use, and connecting patients to resources make a
difference. Asking about use regularly and predictably also sets the
stage for later revelations of use. Here in Chinle over the years I have
often noticed a general sense of despair when it comes to dealing with
addictions among primary care providers -- this is despite the fact that
more people here than elsewhere with histories of drinking problems end
up being teetotalers for the rest of their lives! That despair is
readily appreciated by our patients and no doubt contributes to a lack
of optimism by both providers and patients as it regards the patient's
addiction. This need not be -- **primary care level interventions can
and do make a difference!** -- but a long term and realistic perspective
definitely helps carry the provider through the inevitable valleys of
caring for patients with addictions. Motivational interviewing is a
technique readily learned and applied in the primary care setting and
has a good empirical base for interventions with drug and alcohol
dependencies.

 

We're working locally on helping the local tribal drug and alcohol
treatment program develop a "Matrix"-based treatment program. This is a
tested, manual based cognitive-behavioral treatment program that has
been used to treat both specifically meth dependent and alcohol
dependent patients and generally groups of patients with mixed drug and
alcohol dependencies. There is growing experience with NA/AN
populations.

More information is available at
[www.matrixinstitute.org](http://www.matrixinstitute.org/)

**Holve, Steve (TCRHCC)**

**Fri 4/1/2005 6:55 PM**

The issue of screening pregnant women is particularly difficult. Meth is
clearly a dangerous drug to use in pregnancy and likely has permanent
effects on offspring. On the other hand, given the potential legal and
social service ramifications of testing positive, do patients need
consent to be tested?

Will universal testing drive some women away from prenatal care?

How can we make testing a positive intervention?

What is done at the service unit level?

**N. Burton Attico, MD \[nbattico@POL.NET\]**

**Mon 4/4/2005 12:05 AM**

I do perinatal hospital reviews for an organization here, and have been
amazed in that usually we in OB seek consent for testing moms, but it is
rare for testing to ever be consented in the nursery, although the
newborn is in reality a proxy for the mom (and it is the mom who will be
the one reported to authorities). This has been considered an ethical
issue in ACOG\'s drug testing policy, but apparently does not carry over
to other disciplines. When I brought the issue up here, it even got to a
special committee at the Governor\'s Office.

**Matthew A. Clark, MD, FAAP**

**Thu 4/7/2005 7:38 PM**

Meth use is quite prevalent in the local community.  County Social
Services has noted an increase in child neglect referrals due to meth. 
Apparently the flow of meth from Mexico at low price has resulted in a
low number of \"meth houses\" for production locally.  One matter that
has arisen related to disposition of infants born to mothers with
suspected meth use is the fact\
that testing of the mother must follow a specific \"chain of custody\"
which requires a special lab procedure if the result is to be of benefit
to Social Services related to the child.  Our hospital has devised a
specific procedure for this.\
Internal Medicine/Pediatrics\
Southern Ute Health Center

**N. Burton Attico, MD \[nbattico@POL.NET\]**

**Fri 4/8/2005 2:17 AM**

This follows on my comments about ignoring the fact that testing of the
child is a proxy test of the mom, yet consent is never requested for
such testing. This is also the usual procedure with other drug testing,
and conflicts with ACOG\'s ethical guidelines on drug testing.

**Neufeld, Brenda G (TUC) \[Neufeld@IHS.GOV\]**

**Fri 4/8/2005 12:28 PM**

As a family doctor doing prenatal care, I\'d like to echo Dr. Stuart\'s
comments. I feel that we should proceed very cautiously with drug
screens, although on occasion patients have readily agreed to them as an
adjunct to counseling, especially when CPS is already involved. Our
clinic is lucky to have a behavioral health counselor present in the
clinic on prenatal morning; all patients are encouraged to see her for
education and screening regarding substance abuse. Providers also screen
patients for substance abuse at the time of the first prenatal visit. We
have found it very helpful to use the ACOG database for prenatal visits
rather than the IHS form, as it has more space for additional comments.
We have made some stamps to add to the ACOG form so that we are certain
to ask additional questions about substance abuse, as well as about past
and present domestic violence, whether the pregnancy was planned,
educational level, etc.

**Bunt, Clayton \[Clayton.Bunt@IHS.GOV\]**

**Fri 4/8/2005 3:59 PM**

I\'ve got to admit I don\'t have a real sophisticated perspective on
this, but I really don\'t find the need to wring my hands over the
consent issue.

We need to remember that there is a child protection issue involved. 
Would you hesitate to order a skeletal survey if you suspect physical
abuse? I don\'t.

At our hospital, we set screening criteria such as less than 4 prenatal
visits, obvious clinical signs of intoxication, etc.  Those get at
minimum a meconium drug screen, and often a maternal urine screen in
labor.  I believe we wrote consent for testing into our admission
consent, although I don\'t have one handy to check.

 

If we get a positive, we then interview the mom.  Most, even if they
have previously denied drug use, then admit to using.  Social Services
are notified and we offer referrals to treatment.  This really can
become a positive therapeutic intervention if you approach it right.  I
find that reminding me of my own frailties and failings before
addressing the mom with a positive screen really helps in having a
successful interaction with her!!!

 

I don\'t have time in my practice to stew over the fine distinctions, so
I proceed from the premise I learned in the ER:  \"When in doubt,
Protect the Child\"

**Byron, Lori \[Lori.Byron@IHS.GOV\]**

**Sat 4/9/2005 10:28 PM**

I am only addressing the delivering mother's issue. Many years ago, we
adopted a policy in Crow Agency that all babies with s/s of possible
drug exposure would be screened and that INCLUDED poor prenatal care.
Jan Bays of Portland\'s research showed that poor prenatal care (defined
as 4 or fewer prenatal visits) was the number one indicator of drug
abuse in mothers. Our regional attorney approved our policy, i.e., we do
without parental consent, meconium and urine screens on infant and urine
on mother. Using those criteria alone, about 50% of our screens are
positive.

Disposition of a drug positive baby varies, unfortunately. Some are
allowed to go home with mom; others are placed with a relative. Most of
the mom\'s are then required to do drug assessment/treatment.

And meth is a bad problem here - is there anywhere that it is NOT
currently? Our child protection list seems full of meth+ parents. It is
not a crime on our res.

Lori Byron

17 years on the Crow Res, Southern Montana!

**Manning, Thomas \[tmanning@WSP.PORTLAND.IHS.GOV\]**

**Sun 4/10/2005 3:48 PM**

I think there would be great interest in the Crow policy that has passed
legal muster that allows screening of infants without having to obtain
parental consent.

**Holve, Steve (TCRHCC) \[steve.holve@TCIMC.IHS.GOV\]**

**Mon 4/11/2005 7:56 AM**

Yes, can you share with us your screening policy?

**Clark, Donald \[dclark@ABQ.IHS.GOV\]**

**Mon 4/11/2005 6:30 AM**

Only slightly off the subject:

Prenatals should have already been screened for domestic violence by
delivery. But if they haven\'t - or even if they have - \<4 prenatal
visits = (another) DV screen.

**Holve, Steve (TCRHCC) \[steve.holve@TCIMC.IHS.GOV\]**

**Mon 4/11/2005 7:54 AM**

An important point here is if screening is done, how to make sure that
the information is used in a positive way( intervention and treatment)
as opposed to purely punitive (arrest and jail time). A report to social
services is probably mandatory, does this lead unintentionally to
judicial proceedings in any tribal jurisdictions?

**Racehorse, Ann \[aracehorse@ABQ.IHS.GOV\]**

**Mon 4/11/2005 8:22 AM**

Is this why Dr. Hsi, a pediatrician, left Indian Health - there was no
real follow up and treatment for prenatal, women and infants for
substance abuse?  He is now at UNMH and has grants for programs such as
Milagro and Select which provide case management, treatment, residential
programs etc. for not only substance abuse but domestic violence as well
as other social issues that impact this client population. 

Ann Racehorse, LMSW   

**Lindsey, Catharina \[Catharina.Lindsey@IHS.GOV\]**

**Tue 4/12/2005 10:43 AM**

I think that medical consent to procedures and basic medical ethics
might be a great topic for our next group forum. Practicing medicine on
the reservation does not give providers a license to practice
paternalism or disregard a client\'s basic rights. I wonder if we are
guilty of \'racial profiling\' in providing \'screening\' labs for our
own population.  Some of the comments voiced give me flashbacks to
Tuskegee and the eugenics movement. Is our assumption that the mother
has given consent simply by coming to our hospital? Do we reserve the
right to perform any procedures? I think that using \'poor prenatal
care\' (limited number of visits) in isolation when deciding if the
child should be screened for drug use when there are no other
indications for testing and the parent has not given consent is a
dangerous precedent.

 

Taking care of patients and client safety is certainly the central goal.
However, I am not sure if the current practice of taking children away
from parents and placing them in the care of social services crippled by
an overwhelming case load is the best answer to this issue.

 

I utterly agree with the provider who stated that we need to look at our
own motivations in providing care before providing care.

 

I work in Nevada on the Pyramid Lake Paiute Tribal Reservation. There is
no tribal code for meth use. I find the focus on punishment when
\'caught\' rather than on prevention or treatment very alarming.

Catharina

**Stuart, Peter \[Peter.Stuart@IHS.GOV\]**

**Tue 4/12/2005 1:40 PM**

Well said. I understand the sentiment behind the idea of uninformed drug
screening but I\'m not sure the evidence supports that it prevents what
it is intended to prevent. A very recent article (2005, Mar 31) in the
Journal of Pediatric Psychology at least suggests (though there are
different ways of interpreting the outcomes) that cocaine-exposed
children who are in foster care are more symptomatic than
cocaine-exposed children in maternal or relative care. Screening only to
have kids end up in problematic foster care settings is hardly a
solution. I believe a balance between informed consent and taking
appropriate action on the behalf of abused children is needed - and this
balance may vary due to prevailing concerns in specific localities. If
there was an excellent specialized foster care system in place, and if
there was active support for aggressive, outreach-oriented drug
treatment interventions (drug court, TX programs oriented to caring for
mothers with children, etc.) and if the intervention at the
hospital/clinic level was one of collaboration and support for pregnant
mother, or the new mother and her child(ren) then the downsides of
screening would be considerably less. Unfortunately, while most of us
may have one or sometimes two of the above, I would be surprised by
programs having all three.

 

The plus side of informed consent is that it is establishing an
atmosphere of trust and support between provider and patient - something
that may not pay off immediately but in our systems people are often
life-time members and the care they receive and how it is approached
will be remembered.

 

Finally, why not do informed consent? My experience is that if handled
appropriately most people consent anyway - and if they don\'t they are
deserving of increased attempts at outreach and support in many cases.
There is a cost to the system in time but the benefits of respectful
care are life long.

**Holve, Steve (TCRHCC) \[steve.holve@TCIMC.IHS.GOV\]**

**Tue 4/12/2005 11:43 AM**

How to best come down on the side of treatment as opposed to punishment?

How can we identify patients who are using meth and endangering
themselves and infants while not having a negative judicial outcome?

**Byron, Lori \[Lori.Byron@IHS.GOV\]**

**Mon 4/18/2005 1:11 PM**

I strongly disagree with any accusation of racial profiling.  Jan Bays
work was done on the Portland area folk, not related to Native American
or SES status.  When she looked at signs, symptoms, patient histories
obtained by various health care providers, etc., THE ITEM MOST LIKELY TO
INDICATE DRUG ABUSE WAS POOR PRENATAL CARE(because their patiuents
usually did not volunteer the info either!) We obviously have many
patients who have poor prenatal for other reasons, but 50% are drug
abusers.

 

The majority of our moms are NOT removed from their babies, but they are
monitored and offered/given services.  When I know a mom is positive and
the mom knows that I know that she is a drug user, we actually have a
more honest well child visit, and we can talk about the elephant in the
room;  if I did not know, she likely would not tell me, and we would
waste the visit on more mundane topics.

 

Most hospitals, ours included, do certain tests when signs/symptoms
point to an important problem, ie, doing a glucose as well as a drug
screen on a jittery baby, and talking to mom about the reasons/results
when you get the time.  The regional attorney (Gary Falstaff) for IHS
thought that with Jan\'s research, the meconium screens could be
obtained without parental permission (we do tell the families) in the
best interest of the child.

 

Comparing this to sterilization is a little far-fetched.

 

Lori Byron

**Olson, Richard D. (HQE) \[Richard.Olson@IHS.GOV\]**

**Tue 4/12/2005 11:41 AM**

See attachment.  Meth use reported through RPMS by Area.

**Stuart, Peter \[Peter.Stuart@IHS.GOV\]**

**Tue 4/12/2005 3:16 PM**

These numbers should be used cautiously as they reflect things other
than actual incidence or prevalence. Some Areas report limited RPMS data
and are thus underrepresented in the numbers, others have more specific
treatment resources and thus may appear to have higher levels of
activity (i.e. one of the adolescent RTC\'s uses RPMS as an electronic
health record - and thus would regularly be entering visits with
\"methamphetamine dependence\" as the POV inflating the frequency of
meth POV\'s compared to areas who are not reporting RTC numbers).
Somewhat more representative numbers (though still not readily
interpretable without further information about reporting activity)
would be prevalence numbers - how many distinct patients were seen for a
POV of methamphetamine abuse, dependence or intoxication in the last
year.

**From Judy Thierry on Behalf of Suzan Murphy, PIMC Lactation
Consultant**

**Thu 4/14/2005 12:37 PM**

Meth pops in many conversations

We have a Pharm.D student addressing medications and drug exposure in
breastfeeding moms:

A format will be available at the breastfeeding web site -  user
friendly info,  categories for different issues like hypertension, dm,
mental health, colds/flu, gi distress, etc.  OTCs will be listed also
and the links to up-to-date and other resources.  [Hopefully she will
have a chance to do some in depth looking at street drugs.]{.underline}
The use of methamphetamines has increased in many communities - with not
clear guidelines on what/how/if with bf.  One of the local big hospital
groups now prevents moms from bf if they were UDS + for anything
(including marijuana) in the last 3 months of pregnancy or at delivery. 
We are planning to continue with case by case treatment. Info about
street drugs - esp. meth, will be helpful and time saving.

Dr. Hale et al have indicated that moms with a +UDS for meth at delivery
may still be able to breastfeed safely because the amount of meth that
gets into the colostrum is small, and the amount colostrum that the baby
receives is also small, making the meth dose negligible. Unfortunately,
as the baby grows, the subsequent use and feedings may be a problem.
There has been newspaper publicity about meth user's breastfeeding and
their babies dying. It is not yet a clearly understood issue.

**John Ratmeyer, GIMC**

**Fri 4/15/2005 2:32 PM**

What is fairly clear, however, is that breastfeeding is more than just
nutrition, something lost on those who would bar any woman from nursing
solely on the basis of a positive urine toxicology screen. 
Breastfeeding develops a bond between parent and child which may serve
as a motivator for positive change on the part of drug-abusing parents
while decreasing the risk of future child maltreatment.  That
information has to be considered along with concerns about the
likelihood and degree of drug exposure the newborn has if breastfed. 

If it\'s predetermined in whatever system one works that newborns will
be separated from their drug-abusing mothers, I would agree not to allow
breast-feeding to begin as a practical matter, but many social work
agencies are opting to send these infants home with their parents while
social work monitors the situation and puts a treatment plan in place. 
Those treatment plans include frequent visitation by SWer\'s, the
parent\'s attendance at 12-step programs, frequent parental urine drug
tests, and links with financial resources.  I think it\'s actually
fortunate when discharge disposition is not predictable.  That at least
suggests that some individualized care planning is possible.  I share
the concern that it may also mean that there is inconsistency within the
designated social service agency; that different workers approach
similar situations differently, with little or no supervisory oversight
to rectify these inconsistencies. 

We seem to have been spared the overwhelming problems meth has brought
to the reservation and remote rural areas.  As a border town, EtOH still
seems to be our drug of choice.  

 

Do I correctly understand that isolated poor prenatal care (defined as 4
or fewer visits) prompts urine drug screening of expectant or
newly-postpartum mothers in Crow Agency?  I don\'t believe we have a
written guideline used by our OB / CNM\'s, but I\'ll have to find out
what we\'re doing. 

What are other people doing? 

Do other people have written protocols/guidelines for such testing of
either mothers or their newborns?  Thanks!

 

John Ratmeyer, M.D., FAAP

Medical Consultant to the Child Protection Team

Gallup Indian Medical Center

Gallup, NM   

**Byron, Lori \[Lori.Byron@IHS.GOV\]**

**Mon 4/18/2005 12:01 PM**

John,

Poor prenatal care - the main identifiable risk factor for drug use in
pregnancy is used to obtain a meconiun drug screen.  Maternal and infant
urine drug screens are used when there are s/s of drug use/withdrawal.

 

Lori Byron, Crow Agency

**Murphy, Neil**

**Mon 4/18/2005 1:58 PM**

#1

I would like to welcome Andrew Hsi to the discussion. Dr Hsi has worked
in Indian Health and now is on staff at UNM in ABQ

"Good Evening, Neil,

Thanks for sending me the documents. I\'m on the road at the moment, but
from my first look, the documents have a wealth of information. I\'d be
happy to participate in the discussion on list serve. I told Judy that
the Abandoned Infants Assistance National Resource Center had identified
an expert on methamphetamine use and treatment, and I\'ll send the
contact information to her.

Looking forward to further communications, and thanks for including me,

Andrew Hsi, MD, MPH, FAAP

Professor

Director, Division of General Pediatrics UNM Health Sciences Center
phone (505) 272-3142 fax (505) 272-6847 "

#2

I think we may want to be a little clearer about the distinction between
'clinical testing' and 'screening'.  The following is an excerpt from
answer to the Frequently Asked Questions that I have posted on the MCH
website on this topic

"**Different indications for drug testing**

NB: Not all drug 'testing' is 'screening'

First, let us not confuse overlapping issues, e.g., there are at least
4-5 separate issues

A.) Clinically indicated drug testing of pregnant mother - this is not
drug 'screening', it is testing the mother because she bleeding,
changing her cervix, need to know for anesthesia and medications,
etc\....

B.) Targeted Drug testing - this is performed after the verbal 5 P's or
4 P's, IHS No. 866, or a CAGE-like screen. The verbal screens may be
confirmatory, qualitative, or quantitative. If the pregnant patient
answers yes to the questions, then you ask her to submit a biochemical
test.

If she says No, then you document that fact, as well.

C.) Universal screening - screening all pregnant patient based on some
common characteristic, e.g., all patients presenting to this clinic, or
that L/D unit.   This type of testing is reserved for areas where the
Native Board has approved it. As it is, exposures may be hidden, or
clinically obvious. This modality would only be indicated if there were
good treatment modalities and referral systems in place when one obtains
a positive result.

D.) Clinically indicated drug testing of an infant - this is not drug
screening of the infant; this is testing of an infant because he/she is
sick.   Yes this last method also secondarily implies something about
the mother, but the infant is a dependent individual and needs to be
tested be primarily for infant reasons.  Maternal autonomy is discussed
below. "

You may want to go to the following url because it contains the IHS
policy on this topic, several national benchmarks, Instructions on how
to receive a copy of a documentary about Methamphetamine use in Navajo
Country, what types of consent are suggested, and many more resources on
this topic

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DgSc41205.doc>

My own personal experience with tribal councils has only been positive.

Yes, it involves some time out of clinic, but many times if you have a
question about expanding your drug testing beyond just clinically
indicated testing, or whatever, the tribal councils are more often on
your side than not. 

In many cases your wish for the improved health among your drug abusing
patients is akin to returning to the natural harmony that many tribal
boards are seeking, as well.

It is worth the time is takes to talk it over with them.

Neil

**Murphy, Neil**

**Wed 4/20/2005 7:55 AM**

Four possible resources on this topic

#1

Here is DRAFT Neonatal Drug Screening **c**ourtesy of Lori Byron (also
attached as a Word document)

**DRAFT NURSING Guideline**

**PURPOSE:    ** To identify infants at risk for withdrawal and
teratogenic effects of illicit drugs used by pregnant women. Since drug
use during pregnancy places the infant at risk for abuse and neglect,
intervention strategies in the home can be initiated early if the
problem is identified.

**PATIENT POPULATION:     **

           

Neonates with the following signs/symptoms may have been affected by
maternal drug usage. If there is reason to suspect illicit drug usage
and the patient is symptomatic, sampling should be done in order to
optimize patient care.

The number one predictor of drug use during pregnancy is poor compliance
with

prenatal care (0-4 appointments kept).

**SIGNS / SYMPTOMS OF POSSIBLE DRUG EFFECTS:**

                        Hypoglycemia

                        Jitteriness

                        Lethargy

                        SGA    

                        Microcephaly  

                        Height for weight disproportion

                        Hypotonia

                        Hypertonia

                        Tremors

                        Seizures

                        Diarrhea

                        Sweating

**TREATMENT:**

1.  Withdrawal symptoms require close observation, hypoglycemia checks,
    and vital signs monitoring (as often as ordered by M.D.)

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1.  Swaddling, pacifiers, and increased comforting may be required.
    Minimal noxious stimulations -- bright lights, unwrapping, bathing,
    may be indicated.

2.  Sedatives or anti-convulsants may be required (per M.D. order)

**MECONIUM TESTING:**

**           ** Procedure:  Meconium is collected and tested by gas
chromatography/mass spectrometry and immunoassay screening methods in a
testing lab. Testing can be done for amphetamines, cannabinoids
(marijuana), benzoylecogonine (cocaine), opiates (morphine), and PCP,
and reflects maternal usage for the 20 weeks preceding delivery. Stools
must be meconium stools. Discard first meconium stool and collect second
or third stool. To be accurate, stool should be collected within the
first 24 hours after birth.

**METHOD:**

1.  If ordered by physician, invert diaper or line diaper with plastic.

```{=html}
<!-- -->
```
1.  Transfer meconium (minimum 5 grams, or 5cc = 1 teaspoonful) with
    spatula into vial or cup.

2.  Affix specimen label.

3.  Place meconium vial in plastic bag.

4.  Refrigerate in lab until shipped.

5.  Enter "comprehensive meconium drug panel" on lab slip.

**BLOOD TESTING:**

            Purpose:  As meconium is much more accurate, blood or urine
testing should not be done for the drugs testable in meconium. As
alcohol usage cannot be detected in meconium, a STAT blood alcohol level
on the newborn immediately after birth should be obtained if the mother
is potentially intoxicated.

Procedure: 2cc whole blood via vein puncture is obtained immediately
after birth.

**ADD this paragraph to preprinted Infant orders**

**LABS:**

a.  Meconium Drug Screen on all infants born to mother with 4 or fewer
    prenatal visits.

```{=html}
<!-- -->
```
a.  Cord Blood:     \_\_\_\_\_\_\_ABG

> Type and Coombs
>
> Type and Screen

b.  IF ABO INCOMPATABILITY

> Total and indirect Bili at 12 hours of age. IF ≥ 10, call MD and begin
> phototherapy.

**Other resources**

#2

See this web based document for many other resources

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DgSc41205.doc>

#3

DRAFT Obstetrics Dept Guideline for Drug Testing

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ScrOBdraft.doc>

#4

## University of New Mexico Guidelines for obtaining maternal and neonatal UDM 

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/UNMScr.doc>

Let me know if you have questions

Thanks

Neil

**Masis, Kathleen (Billings)**

**Mon 5/2/2005 11:20 AM**

Some thoughts:

 

We don't always mean the same thing when we refer to "screening."  Nancy
Day at U Pitt said:  It's not an intervention unless the **interview**
is an intervention.  (Questioning a patient about alcohol/drug use has
to be seen as part of the clinical care---the need is not to come up
with the perfect set of questions, but to have a continuum of care for
addictions, and to be prepared to assess and refer at any point in the
woman's addiction.)  As in "no wrong door."   I think we need to have a
system of care for women and addictions, with pregnancy care as a
component in the system.

 

 Addiction is a co-occurring condition of some pregnancies.

We would not expect treatment of other co-occurring disorders to be very
successful if treatment were as inaccessible as addiction treatment
often is..

 

Compare addiction and exposure of the fetus to methamphetamine, for
example, to GDM.

The fetus is exposed to high blood sugar and high insulin levels.

This puts the fetus at high risk.

The care of the mother is not complicated (we hope) by stigma, with the
result that she is welcomed into care, and we assess needs that she
might have to help her follow the regimen that is prescribed.

Some women with GDM need a higher level of care than that provided by
primary care.  This is accessible to them.

 

Now let's look at use of methamphetamine in pregnancy.  There is a
continuum of use.  A 30 yo  pregnant woman injects meth,  has a positive
urine drug screen when she presents in the ER from trauma, and is found
to be pregnant (30 weeks, for example.)   She and her fetus are in need
of a high level of care. 

Which components of her care are available at our sites, and which
aren't?  Do urban sites have more accessibility to specialty care?  Is
Mental health assessment accessible?  Is her community chemical
dependency professional comfortable taking care of pregnant women?

 

A 20 yo primip uses meth via non-injection, on an intermittent basis. 
When asked if she uses drugs, she says "no."  She is employed.  She does
not have a positive drug screen. She comes in for prenatal care.  Her
delivery may or may not be uncomplicated, and the infant may or may not
have any problems. She may abuse tobacco as well.  Her infant may have a
positive drug screen if one is done. She needs a lower level of care,
but the need is just as great. 

 

The public health goal of reducing substance-exposure during pregnancy
(and safeguarding infants from abuse/neglect) is not likely to be
successful with critical deficiencies in the system of care.

 

We are all in a bind when appropriate clinical care calls for
identifying conditions for which treatment is not accessible to the
patient. 

 

Treatment for addiction may be available at a given location, (and in
fact some pregnant women are court-ordered to receive treatment,) but
the availability of non-pregnancy specific, and even non-gender specific
treatment does not translate into "accessibility" of the treatment of
choice for the pregnant, substance-abusing woman.

 

Recommendation:  each facility/location does an assessment of their
system of care for pregnancy and addiction, (Including postpartum and
family planning.)  Identify gaps.  Go from there.

 

A good background reference for the continuum of care is (free)
"Pregnant, Substance-Using Women" (1993) by  SAMHSA, available at NCADI
at 800 729-6686.

 

The American Society of Addiction Medicine Committee on Pregnancy and
Neonatal Addiction is available for specific case questions and for
broader questions. 
[www.asam.org](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.asam.org/)
or e-mail to peter_selby@camh.net

 

Other comments:

> The prognosis for a patient with an addictive disorder is related to
> several factors, including family (partner) support, employment, and
> cognitive factors.  When communities focus on the patients with the
> worst prognosis (who will often be the most "visible",) the benefit of
> intervention for the addiction often appears less "robust" than
> desired.
>
> (Compare:  if breast or cervical cancer were identified and
> intervention offered when the condition is most obvious, the poor
> prognosis of the group referred for treatment would be discouraging.)
>
>  
>
> Early intervention to prevent alcohol-exposed pregnancies can take
> several forms:
>
> Patient and partner education during first pregnancy.  The using
> population at age 18, for example, includes many women who have a
> better prognosis to change their behavior than they will 10-12 years
> later.  The pregnant woman who is 30 years old, who has several
> previous mildly affected children, (has lost custody of one or more,)
> is in an abusive relationship, has a poorer prognosis to stop
> drinking/using.  Intervention at this point is more costly.
>
>  
>
> Another "early" intervention is immediately following the birth of a
> child to a woman who used substances. A mentoring program for 3 years
> ("case management") This has been studied in Seattle, and is a "best
> practice."
>
>  
>
> The motivational interviewing/motivational enhancement model is useful
> for prenatal caregivers. 
>
>  
>
> Next week is the National Council on Alcoholism's "Alcohol and Other
> Drug-Related Birth Defects Awareness Week" May 8-13.  Info can be
> downloaded from their website.

 

> Another useful website is SAMHSA's FASD Center for Excellence.

         
[www.fascenter.samhsa.gov](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.fascenter.samhsa.gov/)

 

I know this was "all over the place."  Hope it is more useful than
confusing.

 

Kathy Masis MD\
Medical Officer for Behavioral Health\]

Billings Area I H S

406 247-7124

[**Stuart, Peter**](../Peter.Stuart@IHS.GOV)

**Mon 5/2/2005 12:32 PM**

Amen! If we can move to a position from where addictions/drug abuse are
not dealt with as moral issues (right/wrong) but rather as health
concerns (healthy/unhealthy) our chances of being as a source of support
and thus opening possible intervention opportunities increase
dramatically.  It is also true that the intervention begins in the
community with how our clinics/hospitals are perceived - a perception
that those who are identified or admit to drug use will be referred to
the authorities will mean more women and children presenting only in
extremis.\
\
Kathleen\'s point that all this revolves around having readily
accessible and friendly treatment resources is right on target.
Unfortunately it continues to be easier to access police interventions
than it is to access real and effective treatment. How do we get
appropriate resources focused on this issue? In way of example, our SU
has 4 OB/GYNs, 6 or 7 nurse midwives, an active nursery and inpatient
OCU, and outpatient pregnancy-related women\'s health programming -
conservatively amounting to 5 million annually for a SU user population
of 30K. Not even including neonatal intensive care . . . . In contrast,
we have an outpatient program staffed with 5 or 6 providers and
administrative support (budget maybe 400K) and an adolescent residential
program (budget about 1M) for people with substance abuse problems.
Imagine what the amount we spend on OB resources might mean in terms of
effective meth/alcohol/solvent/cannabis abuse programs? I\'m not at all
suggesting that we replace OB programs - but the system obviously values
OB care (or DM care . . . or MH care . . . or cardiac care etc) at a
higher level than substance abuse care if you follow the dollars.\
\
More coordination is good - but so would more dollars.