Title : QGcover tip2 9-05-01v2ph.qxd (Page 2) Description : Keywords : Author : ----------------------------------------------- Quick Guide For Clinicians Based on TIP 2 Pregnant, Substance-Using Women ----------------------------------------------- Contents Why a Quick Guide? . . . . . . . . . . . . . . . . . . . 2 What is a TIP? . . . . . . . . . . . . . . . . . . . . . . . 3 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . 4 Medical Stabilization . . . . . . . . . . . . . . . . . . .7 Pregnant Women Using Alcohol . . . . . . . . .11 Opioid Stabilization . . . . . . . . . . . . . . . . . . 13 Pregnant Women and Cocaine . . . . . . . . . 16 Sedative-Hypnotics . . . . . . . . . . . . . . . . . . . 17 Postpartum Care . . . . . . . . . . . . . . . . . . . . 18 Nutritional Considerations . . . . . . . . . . . . . 19 Legal and Ethical Guidelines . . . . . . . . . . . 21 Child Protective Services . . . . . . . . . . . . . .23 Training Areas . . . . . . . . . . . . . . . . . . . . . . .24 Assessment Instruments . . . . . . . . . . . . . .27 ----------------------------------------------- Quick Guide For Clinicians This Quick Guide is based almost entirely on information con tained in TIP 2, published in 1993 and based on information updated through approximately 1991. No additional research has been conducted to update this topic since publication of the original TIP. Based on TIP 2 Pregnant, Substance-Using Women ----------------------------------------------- 2 Pregnant, Substance-Using Women WHY A QUICK GUIDE? This Quick Guide was developed to accompany Pregnant, Substance-Using Women, Number 2 in the Treatment Improvement Protocol (TIP) Series published by the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration. This Quick Guide is based entirely on TIP 2 and is designed to meet the needs of the busy clinician for concise, easily accessed "how-to" information. The Guide is divided into 12 sections (see Contents). For more information on the topics in this Quick Guide, readers are referred to TIP 2. ----------------------------------------------- What Is a TIP? 3 WHAT IS A TIP? The TIP series has been in production since 1991. This series provides the substance abuse treat ment and related fields with consensus-based, field-reviewed guidelines on substance abuse treatment topics of vital current interest. TIP 2, Pregnant, Substance-Using Women • Addresses concerns of a broad range of readers including clinicians, social workers, medical per sonnel, mental health workers, program admin istrators, and policymakers • Includes extensive research through 1992 • Lists numerous resources for further informa tion • Is a comprehensive reference for clinicians on substance abuse treatment for pregnant women See the inside back cover for information on how to order TIPs and other related products. ----------------------------------------------- 4 Pregnant, Substance-Using Women INTRODUCTION Evidence continues to accumulate that children exposed to drugs or alcohol in utero are at risk for developmental problems. Environmental risk fac tors, including homelessness, pregnancy, and domestic abuse, may interact with substance abuse to impact women and their families. The woman who is linked to appropriate resources can be effectively supported to recover and to manage her multiple roles. • Service providers need to be sensitive to the feelings and the cultural background of preg nant, substance abusing women and to offer care in an environment that is supportive, nur turing, and nonjudgmental. • Early intervention during the prenatal period is encouraged to improve the health of mothers and fetuses and to ensure that alcohol and other drug treatment is initiated. • Case management services are needed to ensure that a comprehensive and optimal level of care is available to and accessed by preg nant, substance abusing women and their fami lies. ----------------------------------------------- Introduction 5 Women in Public Programs Many women who seek treatment for their alcohol or illicit drug problems through publicly funded programs share the following characteristics: • Function as single parents and receive little or no financial support from the birth fathers • Lack employment skills and education and are unemployed or underemployed • Live in unstable or unsafe environments, includ ing households where others use alcohol and other drugs • Lack transportation and face extreme difficulty getting to and from treatment • Lack child care and baby-sitting options and are unable to enroll in treatment • Experience special therapeutic needs, including problems with codependency, incest, abuse, vic timization, sexuality, and relationships involving significant others • Experience special medical needs, including gynecological problems Preconception Counseling All women who receive alcohol or illicit drug treat ment services should receive counseling on the full range of reproductive options, including pre- ----------------------------------------------- 6 Pregnant, Substance-Using Women conception counseling. Issues that should be thor oughly discussed include • The various methods of contraception and the attitudes of the woman, her significant others, and her community regarding their use • The impact on the woman and the fetus of alco hol and illicit drug use during pregnancy • The teratogenic (pertaining to a drug or other agent that causes abnormal fetal development) impact of prescribed medications, such as vari ous anticonvulsants and alternative medications with reduced or no teratogenic potential For more detailed information, see TIP 2, pp. 1–7. ----------------------------------------------- Medical Stabilization 7 MEDICAL STABILIZATION The initial stabilization as well as the medical withdrawal of pregnant women from their alcohol or drug(s) of abuse are recognized means of reducing the acute illness associated with the use of alcohol and illicit drugs. Medical and Obstetrical Assessment • Follow universal precautions for blood and body fluids. • Obtain a detailed history and comprehensive physical examination that includes an obstetri cal evaluation. • Conduct a laboratory evaluation, including sero- logical test for syphilis, and urine analysis. • Discuss HIV and document the discussion on the chart. • Obtain urine toxicologies or blood alcohol level tests as necessary. • Perform fetal assessment, including a baseline sonogram, non-stress tests, or biophysical pro files appropriate for gestational age, as neces sary. Alcohol and Illicit Drug Use Assessment 1.Obtain a history of alcohol and illicit drug use, covering legal and illegal drugs (prescription ----------------------------------------------- 8 Pregnant, Substance-Using Women drugs, over-the-counter drugs, cigarettes), that includes • Duration of use, including age of first use • Frequency, type, amount, and periods of abstinence • Routes of administration • Social context of use (when, where, and with whom the patient uses) • Past treatment history • Support group involvement 2.Determine the consequences of alcohol and illicit drug use for the patient (self-perceived and objective). 3.Identify relapse factors for the patient. 4.Obtain a family history of alcohol and illicit drug use. 5.Assess the patient's motivation for treatment, including self-perceived and objective difficulties in entering treatment. 6.Assess the patient's motivation for continued use of alcohol and illicit drugs. 7. Obtain urine and/or blood toxicologies as needed. ----------------------------------------------- Medical Stabilization 9 Psychosocial Assessment • Assess the patient's support systems, including her role in family and neighborhood support sys tems, and the stresses created by these sys tems. • Assess the patient's perception of her pregnan cy and pregnancy options. • Assess the patient's educational level. • Assess the patient's employment skills. • Assess abuse and neglect experienced by the patient as an adult and as a child, including sex ual abuse, physical abuse and neglect, and emotional abuse. • Assess legal considerations and problems. • Assess current crisis. • Assess the patient's current life and environ mental situation, including housing, transporta tion, child care, and monetary support and assistance. • Assess the patient's relationship to her other children. Mental disorders in pregnant, substance abusing women often go undetected by health care providers and alcohol and illicit drug treatment staff. It is essential that a dual diagnosis be made, when appropriate, and addressed in subse- ----------------------------------------------- 10 Pregnant, Substance-Using Women quent treatment planning. The complex combina tion of pregnancy, addiction, and mental illness requires a carefully coordinated approach. Mental Health Assessment Conduct a mental health evaluation that includes • Mental status examination • Psychiatric symptomatology • Past psychiatric history and treatment • Suicide risk • Family psychiatric history • Treatment recommendations Use standardized psychiatric evaluation tools in diagnosis and followup. Maintain liaison and ongoing contact with other members of the assessment and treatment team. For more detailed information, see TIP 2, pp. 13–26. ----------------------------------------------- Pregnant Women Using Alcohol 11 PREGNANT WOMEN USING ALCOHOL The sudden cessation of drinking can result in withdrawal symptoms, some of which may be threatening to the mother and the fetus. It is imperative that medical withdrawal of an alcohol- dependent, pregnant woman be conducted in an inpatient setting and under medical supervision that includes collaboration with an obstetrician. These conditions will ensure– • Close observation and monitoring of maternal alcohol withdrawal status • Continual monitoring of fetal well-being Maternal and Fetal Effects of Alcohol Alcohol use during pregnancy may be associated with a variety of serious health consequences for the woman, fetus, and subsequent infant. Possible maternal complications of excessive alco hol consumption • Nutritional deficiencies • Pancreatitis • Alcoholic ketoacidosis • Precipitate labor • Alcoholic hepatitis • Deficient milk ejection • Cirrhosis ----------------------------------------------- 12 Pregnant, Substance-Using Women Possible effects on the fetus • Fetal Alcohol Syndrome (prenatal/postnatal growth retardation, central nervous system deficits, facial feature abnormalities) • Fetal Alcohol Effects (cardiac abnormalities, neonatal irritability and hypotonia, hyperactivity, genitourinary abnormalities, skeletal and mus cular abnormalities, ocular problems, heman giomas) For more detailed information, see TIP 2, pp. 15–16. ----------------------------------------------- Opioid Stabilization 13 OPIOID STABILIZATION Maternal and Fetal Effects of Opioids These effects may be the result of concomitant (occurring together) maternal lifestyle factors rather than the direct result of drug use. Possible effects on the pregnancy • Toxemia • Intrauterine growth retardation • Miscarriage • Premature rupture of membranes • Infections • Breech presentation (abnormal presentation due to premature delivery) • Preterm labor Possible effects on the mother include • Poor nourishment, with vitamin deficiencies, iron deficiency anemia, and folic acid deficiency anemia • Medical complications from frequent use of dirty needles (abscesses, ulcers, throm bophlebitis, bacterial endocarditis, hepatitis, and urinary tract infection) • Sexually transmitted diseases ----------------------------------------------- 14 Pregnant, Substance-Using Women • Hypertensive disorder Possible effects on the fetus and newborn infant • Low birth weight • Prematurity • Neonatal abstinence syndrome • Stillbirth Guidelines for Methadone Maintenance Methadone maintenance is strongly encouraged for all pregnant, opioid-dependent women. It pro vides the following advantages: • Reduces illegal opioid use as well as use of other drugs • Helps to remove the opioid-dependent woman from the drug-seeking environment and elimi nates the necessary illegal behavior • Prevents fluctuations of the maternal drug level that may occur throughout the day • Improves maternal nutrition, increasing the weight of the newborn • Improves the woman's ability to participate in prenatal care and other rehabilitation efforts • Enhances the woman's ability to prepare for the birth of the infant and begin homemaking • Reduces obstetrical complications ----------------------------------------------- Opioid Stabilization 15 Guidelines for Medical Withdrawal from Methadone Medical withdrawal of the pregnant, opioid- dependent woman from methadone is not indicat ed or recommended. Few women will have the motivation or the psychosocial supports to accom plish and maintain total abstinence. The goal, therefore, is to achieve the best therapeutic dose with which the woman feels comfortable. The neonatal abstinence syndrome can be treated with minimal complications. For more detailed information, see TIP 2, pp. 19–21. ----------------------------------------------- 16 Pregnant, Substance-Using Women PREGNANT WOMEN AND COCAINE Maternal and Fetal/Infant Effects of Cocaine Possible effects of maternal cocaine use during pregnancy include • Intrauterine growth retardation (IUGR) • Abruptio placentae • Premature labor • Spontaneous abortion Possible effects on the fetus and newborn infant that have been reported • Increased congenital anomalies • Mild neurodysfunction • Transient electroencephalogram abnormalities • Cerebral infarction and seizures • Vascular disruption syndrome • Sudden infant death syndrome • Smaller head circumference For more detailed information, see TIP 2, p. 22. ----------------------------------------------- Sedative-Hypnotics 17 SEDATIVE-HYPNOTICS Inpatient medical withdrawal from barbiturates, benzodiazepines, and other sedative-hypnotic drugs is recommended because continual moni toring of the mother and the fetus is required. Drug doses must be tapered so that mother and fetus arrive at a drug-free state without experienc ing an uncontrolled withdrawal. Some considerations for withdrawal from sedative- hypnotic drugs during pregnancy • Severe withdrawal from barbiturates can pro duce status epilepticus and maternal and fetal respiratory arrest. Immediate obstetrical inter vention and hospitalization are warranted. • Use of dilantin and other anticonvulsants have been considered for a patient with a history of withdrawal seizures. However, these drugs have been associated with congenital anomalies. Therefore, their use in pregnancy must be based on an assessment of the risks versus the benefits. Although there are concerns of terato genicity regarding benzodiazepines and barbitu rates, these appear to have a lower risk versus benefit ratio. For more detailed information, see TIP 2, pp. 24–25. ----------------------------------------------- 18 Pregnant, Substance-Using Women POSTPARTUM CARE Permit Breast Feeding in Methadone- Maintained Patients A number of substance abusing women express a desire to breast feed their infants. Breast feeding is not contraindicated in a methadone-maintained patient if she is known to be free of other drug use and is known to be HIV-seronegative. If the mother is abusing multiple drugs that would expose the infant to diverse agents in varying lev els, then breast feeding may be contraindicated. Breast feeding is not recommended if the mother is HIV-infected. For more detailed information, see TIP 2, p. 42. ----------------------------------------------- Nutritional Considerations 19 NUTRITIONAL CONSIDERATIONS Cigarette Smoking Cigarette smoking may affect maternal nutrition and, consequently, fetal nutrition, in two important ways: • The increased metabolic rate in smokers can lead to lower availability of calories. • The exposure to tobacco may increase iron requirements and decrease the availability of certain nutrients such as vitamin B12, amino acids, vitamin C, folate, and zinc. In smokers, uteroplacental blood flow restricts nutrient and oxygen flow to the fetus. Alcohol Alcohol consumption may be related to decreased dietary intake, impaired metabolism and absorp tion of nutrients, and altered nutrient activation and utilization. Interactions between alcohol and deficiencies of such nutrients as protein and zinc may also play a role in the etiology of alcohol-relat ed effects on the fetus. Although there is no convincing evidence that nutritional supplementation will counteract the adverse effects of alcohol, standard prenatal vita- mins plus folate, B12, and iron supplementation ----------------------------------------------- 20 Pregnant, Substance-Using Women should be prescribed. However, since alcohol abuse has clearly been shown to be detrimental to the fetus, nutritional supplementation should not replace efforts to encourage women to limit or eliminate alcohol intake during pregnancy. Heroin The possible nutrition-related effects of heroin use include poor nourishment, with vitamin deficien cies, iron deficiency anemia, and folic acid defi ciency anemia. Many of the effects on pregnancy and the fetus can be mitigated in a comprehen sive methadone maintenance treatment program. Cocaine Cocaine's vasoconstrictive ability may lead to fetal hypoxia and reduced nutritional supply to the fetus. Since cocaine, like amphetamines, acts as an appetite suppressant, an inadequate maternal diet may play a role in retarding growth in fetuses of cocaine abusers. For more detailed information, see TIP 2, pp. 50–51. ----------------------------------------------- Legal and Ethical Guidelines 21 LEGAL AND ETHICAL GUIDELINES Caring for pregnant, substance abusing women and their infants can present complex legal and ethical issues concerning confidentiality, report ing, and the custody and protection of children. Service providers must understand and be pre pared to address all aspects of these issues. Impact of Confidentiality and Reporting Laws on Women State and local laws that require maternal alcohol and illicit drug use and fetal drug exposure to be reported to authorities have a significant impact on women and their children. These reports can be the impetus to remove children from their mothers' care and have them placed in protective custody or foster care. Knowing that such a report is in the offing, some women may forego their prenatal care or the fol lowup services they need. The closer communities move toward measures that detain pregnant, sub stance abusing women, the more punitive, detri mental, and potentially dangerous it becomes for these women and their children. ----------------------------------------------- 22 Pregnant, Substance-Using Women State Laws on Confidentiality of Alcohol and Illicit Drug Treatment Records A variety of State confidentiality laws may affect how services are provided to pregnant, substance abusing women. These laws may control the release of medical records; limit the ability of per sons to testify in court based on information obtained when providing professional services (testimonial privilege); or prohibit disclosure of information regarding specific diseases, such as HIV and drug use. Service providers and alcohol and illicit drug treat ment staff should consult with local counsel to determine which State confidentiality laws affect their practices, and protocols and training pro grams to help ensure that these laws are followed should be developed. For more detailed information, see TIP 2, pp. 54–56. ----------------------------------------------- Child Protective Services 23 CHILD PROTECTIVE SERVICES Child protective services agencies are mandated to help keep families together. Some women who enter alcohol or drug treatment programs will be in contact with their local child protective services agency. These women may not view this involve ment positively. In turn, many alcohol and drug treatment programs find it difficult to deal with child custody and placement issues. As a result, some treatment programs exclude women who are or could potentially be involved with a child protective services agency. Until this circumstance changes, the doors to alcohol and illicit drug treatment will continue to close on pregnant, substance abusing women—the very women who need to be admitted. Women should not be barred from treatment or discriminated against because they are pregnant. It must be recognized that the family circum stances for women may be fluid, rather than stat ic. Children may be periodically absent and subse quently return to the home. Furthermore, alcohol and illicit drug use are chronic relapsing diseases. Relapse prevention must be an important part of any treatment approach. For more detailed information, see TIP 2, p. 58. ----------------------------------------------- 24 Pregnant, Substance-Using Women TRAINING AREAS Training for medical staff, alcohol and illicit drug treatment providers, and others serving pregnant, substance abusing women and their children should address these topics: Diagnosis and treatment • Medical guidelines • Treatment readiness in substance abusing women • Assessment instruments • Dual diagnosis • Women with positive toxicology screens in alco hol and illicit drug treatment programs • Followup care Federal/State guidelines and requirements • Federal and State guidelines for alcohol and illicit drug treatment • Confidentiality and reporting • Urine toxicology screening • Legal issues ----------------------------------------------- Training Areas 25 Population-specific issues • Child abuse and neglect • Noncompliant patients • Gender-specific treatment • Sociocultural sensitivity • Incest, adult, and child sexual abuse • Domestic violence • Habilitation and rehabilitation • Child development Case management • Coordinating medical and social services • Documentation • Ethics Community networking • Developing cooperative agreements among medical, alcohol and illicit drug treatment, and social service programs • Community services • Outreach Staff development • Multidisciplinary team approach • Staff development and burnout ----------------------------------------------- 26 Pregnant, Substance-Using Women Infectious diseases • HIV antibody counseling and testing • Infectious diseases of drug users For more detailed information, see TIP 2, pp. 64–65. ----------------------------------------------- Assessment Instruments 27 ASSESSMENT INSTRUMENTS Addiction Severity Index Pregnancy Status • This 22-question instrument was developed as an adjunct to the ASI. Available from SAMHSA's NCADI. Maternal Substance Use Survey • This 22-item survey covers a woman's health status, alcohol and illicit drug use, and family circumstances. A separate form captures the pattern of alcohol or illicit drug use prior to and during pregnancy. Available from SAMHSA's NCADI. Interagency Agreements In order for interagency collaboration and linkage to be successful, there must be a written docu ment that clearly delineates the responsibilities of the cooperating agencies. Interagency agree ments, at a minimum, should have these charac teristics: • Describe the services to be provided by each agency. • Describe the referral process to be used and the documentation requirements of each agency. • Establish a time frame for the review and possi ble revision of the agreement. ----------------------------------------------- 28 Pregnant, Substance-Using Women Examples of quality assurance monitoring activi ties are as follows • Monitor to ensure that the referring agency pro vided all appropriate and necessary patient information to the referral agency. • Monitor to ensure that there is documentation that the referral agency provided all agreed- upon services in a timely manner. • Monitor to ensure that the referral agency pro vided documentation to the referring agency of patient progress, continued need for services, or readiness for termination of services. For more detailed information, see TIP 2, pp. 66–75. For information on resources for pregnant and substance abusing women, refer to TIP 2, pp. 66–68. ----------------------------------------------- Ordering Information TIP 2 Pregnant, Substance-Using Women TIP 2-Related Products KAP Keys for Clinicians based on TIP 2 Do not reproduce or distribute this publication for a fee without spe cific, written authorization from the Office of Communications, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. Easy Ways to Obtain Free Copies of All TIP Products 1. Call SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI) at 800-729-6686, TDD (hearing impaired) 800-487-4889 2. Visit CSAT's Website at www.csat.samhsa.gov ----------------------------------------------- Other Treatment Improvement Protocols (TIPs) that are relevant to this Quick Guide: See the inside back cover for ordering information for all TIPs and related products. DHHS Publication No. (SMA) 01-3551 Printed 2001 TIP 5, Improving Treatment for Drug-Exposed Infants (1993) BKD110 TIP 25, Substance Abuse Treatment and Domestic Violence (1997) BKD239 TIP 27, Comprehensive Case Management for Substance Abuse Treatment (1998) BKD251 TIP 36, Substance Abuse Treatment for Persons With Child Abuse and Neglect Issues (2000) BKD343