# Presentation: 284687

## What We Did About Prenatal Substance AbuseSeptember 18, 2006

- Special Care Clinic

*What We Did About Prenatal Substance Abuse**September 18, 2006*

***Judy Whitecrane MSN, CNM***
***Director, Nurse-midwifery Service***
***Phoenix Indian Medical Center***

## Key Components-Prenatal Substance Program

- Obstetric provider (CNM, OB, FP)
- Behavioral Health Provider (SW, SAC, MHNP)
- Clinical setting for both providers together
- Gifts and Incentives (Nominal cost)
- Works well in a large or small setting

## Phoenix Indian Medical CenterObstetrics Department

- 850 deliveries per year
- 8 CNM’s & 8 MD’s
- Approx. 150 + UDS at birth
**Level II Nursery**
**Active Caseload-600 prenatal clients**
**30 (5%) in “Special Care Clinic”**
**Since 2003**
**Over 300 women enrolled in “Special Care Clinic”**

## How We Began

- Aware of increased meth use in pregnancy
- Variation in treating & referring
- Lack of knowledge of what works
- Strong desire to protect the unborn
- Feeling helpless, angry, frustrated...myriad of emotional responses

**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.

## What Drugs?

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

## The Most Dangerous Drug

_***Alcohol!!!***_

## What Stimulant Drugs Do

- Maternal Effects
- Fetal Effects
- Neonatal Effects

## Maternal Effects

**Tachycardia, Hypertension**
- Heart Attack, Stroke
**Cramping, Contractions**-
- First trimester- SAB
- Second & Third trimester
***Preterm to term labor***- often with tetanic contractions
_***Abruption***__-_
-  separation of placenta from uterus shortly after receiving amphetamines/cocaine/crack
_***Usually preceded by vaginal bleeding!!!!***_
***Potential death of mother and baby!!***

##  Maternal Behavioral Effects...

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

## Fetal Effects

**Intrauterine growth restriction (IUGR)**
- Caused by placental insufficiency
- Occurs in 30% of cocaine exposed fetuses (ACOG)
**Cardiovascular events**
- Fetal tachycardia
- Fetal hypertension/stroke
**Increase in birth defects**
- Neonatal asphyxia
- Cardiac, spina bifida, skeletal abnormalities, gastroschesis (hole in the abdominal wall)
- (Cocaine 4x’s, and Meth 6x’s)

## Neonatal Effects

**Preterm delivery**
- STAT C/Section for fetal distress common
- Transport to NICU
**Small for Gestational Age (SGA)**
- Small head circumference
- Learning disabilities,ADHD
- Developmental delays
**Neonatal Nursery**
- Lethargic, poor feeder, later irritability
- Neurobehavioral delays
- Methadone- neonatal withdrawal may take 2-3 months (hospitalized)

## Newborns and beyondNIDA study

**Howard, J., Tyler, R., Espinosa, M., & Beckwith, L. (1996****). Birth outcomes 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 **
**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 also have other environmental, medical, genetic causes
-  Labels follow the individual
-  Lower expectations may result

## 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)

## PIMC Contingency (Reward) System

- Stimulant users often respond well (TIP 33)
- (800)-729-6686
***Maternal instinct*** not to harm developing baby
***Rewards*** for drug abstinence
- Healthy baby
- Gifts
- Avoidance of CPS at birth
- Vouchers for retail outlets
- Sense of accomplishment
- Human warmth, bonds with staff

## 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..

## “Substance Abuse Workgroup” Began Meeting May 2003

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

## Clinic Development

- Evidence Based Care (SAMHSA, CSAT)
- Treatment Improvement protocols (TIP’s)
- Designated clinic-Thursdays
- Written Guidelines developed

## October 2003“Special Care Clinic”  begins

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

## Stages in Methamphetamine Treatment

**1.  Get started**
**2.  Get clean**
**3.  Stay clean**
**4.  Stay Healthy (Long-term abstinence support plan)**

## How are pregnant substance abusing women identified ?

- ER visits
- OB triage visits
- Women’s clinic, identified from
- Patient records
- Prenatal questionnaire
- Posters
- Family/friends/employees report

## Presenting Diagnosis

- 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”

## 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

## 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

## Coexisting Conditions

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

## 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

## PIMC Special Care clients

- 70% Substance abuse
- Often have coexisting conditions
- 30% Diagnosis of:
- Depression/Anxiety/Grief
- Domestic Violence
- Bipolar
- Schizophrenia
- Developmental delays-
- FAE, FAS

## 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...
- Incentives- gift card for retail outlet for 3 negative UDS

## 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 2-3 years
- Vaginal bleeding
- Preterm contractions
- Other children removed from home
- Obvious intoxication

## Urine Drug Screens

- Every 3 negative drug screens-rewarded with $15 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)

## Frequency of visits

- Heavy meth use- consider residential
- Rotted teeth		Sustained weight loss
- Emaciated looking	Sores
- Poor hygiene		Resistant to treatment/denial
- Positive UDS, weekly visits with midwife, and 2 or more visits with social worker/week
- When several drugs screens are negative, consider weekly visits, etc...

## Social Services/Substance abuse Counseling

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

## 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”

## “Drop in Deliveries”No prenatal care, + UDS

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

## Special Care ClinicPhase II

- Set up database of these patients
- Current address & phone number
- 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

- No prenatal care
- 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
- 6 months later- pregnant again & still using

## Patient #3- Common Scenario

- No prenatal care
- Estimated to be term
- “I’m in labor”
- Many contractions with late decels
- STAT C/Section
- UDS + Meth
- Social Services, CPS, Level II nursery

## Social Worker; Typical First Visit

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

## 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