# Presentation: 043352

## What We Did About Prenatal Substance Abuse

- Special Care Clinic

*What We Did About Prenatal Substance Abuse*

***Judy Whitecrane MSN, CNM***
***Director, Nurse-midwifery Service***
***Kimberly A. Couch, CNM***
***Phoenix Indian Medical Center***

## Phoenix Indian Medical CenterObstetrics Department

- 990 deliveries per year
- 8 CNM’s & 8 MD’s
- Approx. 150 + UDS at birth
**Level II Nursery**
**Active Caseload-800+ prenatal clients**
**725 CNM patients**
**75 MD (Hi risk)**
**30 (5%) in “Special Care Clinic”**

## Projected Deliveries 2007

- Projected 168 positive Urine Drug Screens on admission.
- 168 babies potentially to be taken from their moms.
- 168 families, already struggling, to be fragmented and disrupted.

## Data

- 3 years of operation
- Over 400 participants
- 70% substance abuse
- 30% “other diagnoses”
**Depression/Anxiety/Grief**
**Domestic Violence**
**Bipolar**
**Schizophrenia**
**Developmental delays**
**FAS, FAE**
**Homelessness**

## What Drugs?

- Methamphetamines
- Marijuana
- Cocaine/crack
- Alcohol- assume concurrent use?
- Narcotics- opioids

## Maternal Effects

- Tachycardia, Hypertension, Muscular excitability
- Abruption- separation of placenta from uterus shortly after receiving amphetamines/cocaine
- Early in pregnancy- SAB
- Mid-late pregnancy-massive hemorrhage
- Potential death of mother and baby
_***This is usually preceded by vaginal bleeding!!!!***_

## Fetal Effects

- Intrauterine growth restriction (IUGR)
- 30% of cocaine exposed fetuses (ACOG)
- Placental insufficiency
- Fetal tachycardia, (?hypertension), fetal stroke
- Increase birth defects-
- Cardiac, spina bifida, skeletal abnormalities, gastroschesis (hole in the abdominal wall)
- (Cocaine 4x’s, and Meth 6x’s)

## Neonatal Effects

- Preterm labor and delivery
- Small for Gestational Age (SGA)
- Small head circumference
- Learning disabilities
- ADHD
- Developmental delays, etc
- Neonatal Nursery
- Lethargic, poor feeder, later irritability
- Neurobehavioral delays

## How We Began

- Staff concern
- Variation in treating patients
- Variation in referral practices
- Lack of knowledge of what or if anything works
- Strong desire to try to protect unborn
- Feeling helpless

**Notes:**
Although drug users may reveal nothing on history to suggest use, there are some “red flags” that raise the physician’s suspicion.  These include a chaotic lifestyle, a peer group involved in drug use, easy access to a drug supply and domestic violence.

Other “red flags” include patients who suffer from post-traumatic stress disorder (PTSD), have intellectual changes, memory loss, unexplained mood swings and personality changes, frequent missed appointments and problems with health-related compliance.

## Identifying pregnant SAW

- ER
- OB triage
- Women’s clinic
- Prenatal questionnaire, history, previous prenatal substance abuse
- Family/friends/staff refer

## Why do they seek health care?

- Trauma
- Fell down, DV, Assault, Altercation
- Pelvic pain-  STD’s- Chlamydia
- Vaginal bleeding
- Preterm contractions/labor
- No prenatal care + in labor
- Brought by concerned friend, family member
- Vague complaints, wants to “check my baby”

## Began Meeting May 2003

- Formed “Substance Abuse Workgroup”
- Nurses from OB ward
- Nurses from the Women’s Clinic
- Nurse-Midwives
- Social Workers
- Substance Abuse Counselors
- Public Health Nurse
- Case Management
- Pediatricians

## Goals of our substance abuse workgroup

- To protect the unborn from toxic drug exposure
- To assist mother in successfully abstaining from drugs and alcohol
- To prevent repeat pregnancies with drug affected newborns

## Clinic Development

- Evidence based care
- Treatment Improvement protocols
- Idea of incentives emerged
- Idea of designated clinic emerged
- Written Guidelines developed

## Pregnancy

- “Pregnancy is a powerful motivator....when you find people receptive to treatment”
- “If you are able to get away from it during your pregnancy, that can carry over to a time when you’re not pregnant”
- (Randy Stevens, MD,-addiction researcher)

## Behavioral Risks

- Compulsive sexual behaviors
- Multiple partners
- Selling sex for drugs
- High rate of STD’s
- Chlamydia, HIV, AIDS, Gonorrhea, Syphilis, Hepatitis C and B
- Criminal behaviors
- Stealing for money to buy drugs
_***Unintended Pregnancy!!!!***_

## Tragedies

- People with co-occurring MH and Addictive Disorders often seen in emergency rooms, jails, homeless shelters, on the streets, and in the obituaries.

## Support  Network

- Substance abusing women who are pregnant are viewed as the lowest, even less than criminals.
- They are cast aside by their families and society.
- Often their only support is the men who supply them with drugs because of the promiscuous sexual behavior they display.

## Maternal Coexisting conditions

- Methamphetamine Treatment Project (1999-2001) AJ of Addictions 2004
- Large multisite study (1016 meth users)
- High levels of psychiatric disease
- Depression/anxiety
- Attempted suicide
- Schizophrenia (10-65% use meth)
- Anger/assaultive behavior

## Urine Drug ScreensWritten policy

- No prenatal care
- Limited or late entry to care
- Weight loss, emaciation
- History of substance abuse (per records)
- Self-reported history (Clinic posters)
- +Prenatal questionnaire for drugs within last year
- Vaginal bleeding
- Preterm contractions
- Other children removed from home
- Obvious intoxication

## October 2003“Special Care Clinic”  begins

- One afternoon per week
- Longer appointments
- Social workers/substance abuse counselor in clinic to see patients

## Prenatal care-First visit

- Discuss presenting problem
- Routine prenatal workup, STD testing
- If substance abuse, discuss thoroughly and review drug contract and ask for signature
- UDS at each visit
- Can be refused, but...refusal is considered a positive test
- Slips happens

## Stages in Methamphetamine Treatment

**1.  Get started **
**agrees to participate in Special Care Clinic.**
**2.  Get clean**
**Counseling sessions, UDS, Gifts & Incentives**
**3.  Stay clean**
**Continue with above throughout pregnancy**
**4.  Stay Healthy (Long-term abstinence support plan)  -****We need a postpartum program!!!**
-                                      adapted from CSAT, 1999

## Special Care Clinic Agreement

- Date_________
- Name _______________________
- ____ I would like to participate in the Special Care Clinic Program. I know I will receive gifts at
- each visit for my baby and myself.
- ____I agree to see a social worker and work with her/him on a plan that will help me with this
- pregnancy and beyond.
_**Drug and Alcohol program**_
- _____I agree to urine drug testing whenever asked by my Nurse-Midwife or Physician.
- ____ I would like to participate in receiving gift certificates each time I have 3 negative drug
- tests **and have kept my counseling appointments**.
- Date_______Drug Screen _______    Date _______Drug Screen_________
- Date_______Drug Screen _______    Date _______Drug Screen_________
- Date_______Drug Screen _______    Date _______Drug Screen_________
- Date _______Drug Screen_______    Date _______Drug Screen_________
- Date _______Drug Screen_______    Date _______Drug Screen_________
- Date _______Drug Screen_______    Date _______Drug Screen_________
- Date _______Drug Screen_______    Date _______Drug Screen_________
- Gift certificate-Date______
- Gift certificate-Date______
- Gift certificate-Date______
- I agree to what is checked above:
- _________________________     Date_______
-          Signature

## Frequency of visit

- Heavy meth use- consider residential
- If + for drugs, weekly visits with midwife, and 2 or more visits with social worker/week
- When several drugs screens are negative, consider weekly visits, etc...

## Elk, R., Schmitz, J., Spiga, R., Rhoades, H., Andres, R., & Grabowski, J. (1995). Behavioral treatment of  cocaine-dependent pregnant women and TB-exposed patients. Addictive Behaviors, 20, 533–542.
This preliminary study examined the efficacy of a contingency management procedure (shaping) on decreasing cocaine use and increasing compliance with health regimens and pregnant substance abusers 
Pregnant substance abusers received monetary incentives for each successive decrease in the level of cocaine metabolite, cocaine-free specimens, or having all three specimens collected each week meet incentive criteria. 
All pregnant patients remained in treatment until delivery; mean treatment duration was 16 weeks. 
Compliance with prenatal care was high, with a mean rate of 72.5% of kept versus scheduled visits..  

- This preliminary study examined the efficacy of a _**contingency management procedure**_ (shaping) on decreasing cocaine use and increasing compliance with health regimens and pregnant substance abusers
- Pregnant substance abusers received monetary incentives for each successive decrease in the level of cocaine metabolite, cocaine-free specimens, or having all three specimens collected each week meet incentive criteria.
- All pregnant patients remained in treatment until delivery; mean treatment duration was 16 weeks.
- Compliance with prenatal care was high, with a mean rate of 72.5% of kept versus scheduled visits..

## PIMC Contingency (Reward) System

- Stimulant users often respond well (TIP 33)
- Maternal instinct not to harm developing baby
- Rewards for drug abstinence
- Healthy baby
- Gifts
- Helps with CPS at birth
- Vouchers for retail outlets
- Sense of accomplishment
- Human warmth, bonds with staff

## Urine Drug Screens

- Every 3 negative drug screens-rewarded with $10 gift certificate for Wal-Mart, target, or Food City
- Positive drug screens- non-punitive, just seen more frequently (2-3X’s weekly if methamphetamines or cocaine)

## Gifts & Incentives 

- Gift for self and gift for baby at each visit-
- Make-up, hair care products, jewelry, watches, lotions etc...
- Blankets, clothing, pacifiers, baby pictures frames...
- “Fetus” models; 11-12 week mini baby

## Social Services/Substance abuse Counseling

_***Makes it as accessible as possible!!!***_
- PIMC, next door the prenatal visit
- Don’t have to explain to clerk purpose of visit
- Same counselor each visit
- Female preferred

## Social Worker; Typical First Visit

- Develop trust
- Encourage participation
- Discuss Special Care Clinic-
- “Why are you here?”
- Participation is voluntary
- Identify their strengths
- Mini-psychosocial assessment

## Newborns and beyondNIDA study

**Howard, J., Tyler, R., Espinosa, M., & Beckwith, L. (1996). Birth outcome in cocaine- abusing women following three months of drug treatment. In L. S. Harris (Ed.), *****Problems of drug dependence, 1995: Proceedings of the 57th Annual Scientific Meeting. *****National Institute on Drug Abuse.**
- Polydrug-using (cocaine plus other drugs) pregnant women (*N* = 72) participated in a drug treatment program including regular urine toxicology testing.
_**Women who decreased their drug use at least 50% from intake gave birth to infants with longer gestational periods, higher birth weights, and larger head circumferences**_.

**Notes:**
Chemical used to make these drugs are explosive

## Meth Baby Myth

- No identified syndrome attributable to meth
- LD, ADHD, Conduct disorders may have environmental cause
-  Labels follow the individual
-  Lower expectations may result

## Breastfeeding and Meth

- Infant deaths reported after meth using mom breastfeeds
- Institutional policies often prohibit
- Benefits
- Fewer colds, flu, etc...
- Less obesity
- Less diabetes
- Bonding/attachment issues

## “Reasoned Approach”

- Explain and document risk.
- Maintained abstinence during pregnancy after entering SCC
- Breastfeeding hotline info
- What to do if slip occurs- no breastfeeding for 3 days, call hotline & counselor, etc....

## Patient evaluations

- Some still lost to follow-up
- 50% have four or more visits- some as many as ten visits
- Good rapport with patients
- Many are drug free- others with occasional usage.  Often self-report lapses

## Comments from patients

- I can’t believe I have done this!!- (gone without drugs)
- “It helped me realize I’m gonna be a mother. Also how to take care of myself & child”
- “Helped me to quit and not use when pregnant”
- “It helped the most to be screened and drug tested”

##  Comments from patients

- “It helped by not judging me”
- “The social worker and the OB people & the Drs.  They all helped me want to change my life for the better.  Thank you for helping me want to stay clean”
- “Kept me clean by encouragement”

## Phase II –drop in deliveries+ UDS

- Reported to CPS
- If baby is also +, increases level of concern
- Baby may be placed in foster care
- Extremely emotional event
- Mother may plunge deeper into drugs

## Phase IIDrop in deliveries with + drug screens

- Set up database of these patients
- Nurse-midwife as Case manager
- Encourage contraception, treatment
- Prevent another substance exposed infant next year

## Patient #1 Meth Death

- Multigravida
- Class B DM
- Two other children alive and well; received prenatal care with them
- Began using meth 2 years ago
- Unplanned pregnancy
- No prenatal care

## Meth Death

- Presents to ER
- IUFD
- Ketoacidosois
- Sepsis, Fever 103
- Dies in ER

## Patient #2 Near Miss

- Limited prenatal care- no records
- Vaginal bleeding all night-
- FOB brings patients in- he is extremely agitated-worried about “her”
- Patient Reports bleeding, “not that bad”
- Can’t lay down in bed-has to sit up to get her breath
- Looks pale

## Near Miss Cont’d

- EFM- contractions with late decels
- Estimated at 34 weeks
- STAT C/S
- Baby survives
- Admission Maternal Hg- 3.0
- Transfused in OR
- Patient Survives

## Patient #3

- No prenatal care, G8P6sab1, Two previous C/S, 4VBAC
- Estimated to be term, admits to Meth use that morning.
- “My water broke this morning, I’m in labor”
-  No FHT’s, IUFD (pt. reports last fetal movement within the hour.)
- Delivers a few hours later with pitocin augmentation of labor.  The infant is in an advanced state of decomposition.  Death probably occurred days prior.

## Patient #3 Postpartum

- Profuse bleeding and retained placenta
- To the OR, 100 feet away from the delivery room, this patient lost 2500cc of blood. She lost another 2000cc during the procedure.
- Stat Hysterectomy and massive blood replacement.

## Patient #4

- 30 week IUP
- No prenatal care
- Contracting
- 3/-1/80%
- BP 160/99
- Maternal HR 130’s
- Vaginal bleeding off and on

## Patient #4 treatment

- Tocolysis-MgSO4-6 Gram bolus, 2 Grams per hour  (Avoid terbutaline)
- CBC, Type and screen (cross)
- UDS
- Large bore IV (2)
- Prepare for transport
- Betamethasone 12 mg IM (24-34 weeks-ACOG)
- 2 doses 12 hr apart
- Apresoline 5-10 mg IV- give in small doses

## Future plans

- On site GED program
- On site support group (substance using women)
- Native parenting program
- After care groups
- Graduate continue to be involved and mentor others

## Summary

- Form a multidisciplinary team
- Use known treatment protocols
- Market your program to all departments, members of your organization
- Use non-punitive, non-judgmental approaches
- Use pregnancy as a motivator
- Celebrate every success