IDENTIFICATION AND BRIEF INTERVENTION FOR SUBSTANCE USE DISORDERS

IDENTIFICATION AND BRIEF INTERVENTION FOR SUBSTANCE USE DISORDERS IN PREGNANCY Jaye M Shyken, MD St. Louis University School of Medicine October 4, 2018

OBJECTIVES Understand Screen Counsel about Be Know about Understand the epidemiology of substance use in pregnancy How to screen for Substance Use in pregnancy Be aware of the counseling about the impact of substance use on the fetus/neonate Be able to refer patients with known or suspected substance use for counseling and follow-up Know about current legislation as it relates to substance use in pregnancy in MO and IL

IMPORTANT CONCEPTS • Drug addiction is a disease • Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. • Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. • Not a character flaw

IMPORTANT CONCEPTS RISK FACTORS FOR ADDICTION • Addiction is not inevitable depends on a number of factors • Genetic • Biological factors • Age at first use • Psychological (personality) • Environmental factors (availability, family and peer dynamics, financial resources, cultural norms, stress, access to social support) • Higher risk • Co-occurring mental health problems • Genetic and molecular factors • Early life adverse events • Drug misuse in adolescence

FFR 1. 11 NUMBERS OF PAST MONTH ILLICIT DRUG USERS AMONG PEOPLE AGED 12 OR OLDER: 2017 Note: Estimated numbers of people refer to people aged 12 or older in the civilian, noninstitutionalized population in the United States. The numbers do not sum to the total population of the United States because the population for NSDUH does not include people aged 11 years or younger, people with no fixed household address (e. g. , homeless or transient people not in shelters), active-duty military personnel, and residents of institutional group quarters, such as correctional facilities, nursing homes, mental institutions, and long-term care hospitals. Note: The estimated numbers of current users of different illicit drugs are not mutually exclusive because people could have used or misused more than one type of illicit drug in the past month.

NATIONAL SURVEY OF DRUG USE AND HEALTH (NSDUH) 2012 -2013 PAST MONTH USE, WOMEN 15 -44 Pregnant Nonpregnant 5. 4% 11. 4% Tobacco 15. 4% 24. 0% Alcohol 9. 4% 55. 4% Binge Drinking 2. 3% 24. 6% Illicit Drugs MJ, Cocaine, Heroin, Halucinogens, inhalants, nonmedical use of pain relievers, tranquilizers, stimulants, sedatives http: //www. oas. samhsa. gov/nhsda. htm

PREVALENCE OF MARIJUANA USE NATIONAL SURVEY OF DRUG USE AND HEALTH, 2007 -2012 Ko JY, Farr SL, Rong VT, et al. Am J Obstet Gynecol 213; 201. e 1 -201. e 10 (Aug 2015)

PRESCRIPTION OPIOIDS: 1999 -2010 • 80% of the world’s oral opioids are used in the US CDC, MWWR 2011

HEROIN USE: 2002 -2013 80% of heroin users initially used Rx opioids

TRENDS IN HEROIN USE AND HEROIN DEATHS www. cdc. gov/vitalsigns/heroin/infographic. html#graphic, 2016

64, 400 overdose deaths in 2016 42, 249 with any opioid 15, 469 with heroin 33, 900 with natural and synthetic opioids (except methadone)

OPIOID USE DISORDER AT DELIVERY, 1999 -2014 Haight SC, Ko JY, et al. MMWR August 10, 2018; 67(31); 845 -9

2016 MO MEDICAID CLAIMS DATA FOR SUBSTANCE USE IN PREGNANCY, SUMMARY COUNTS Counts Total pregnant women % of Total Pregnant ♀ 60, 310 100 537 0. 89 1418 2. 35% Opioid dependence 990 1. 64% Opioid Use Disorder 945 1. 57% Other Substance Use Disorders 1732 2. 87% Any Substance Use Disorder 3707 6. 15% Any SUD, not OUD in same year 2223 3. 69% Any Opioid Use Disorder 1484 2. 4% Alcohol Use Disorder Cannabis Use Disorder Report Prepared by MO Dept Social Services, MO Healthnet Division, 2017

PATTERNS OF DRUG USE • Use • Sporadic consumption with no apparent consequences • Misuse • Sporadic or more frequent use, some consequences experienced by user • Physical dependence • Drug class-specific withdrawal syndrome produced by abrupt cessation or rapid dose reduction or by administration of an antagonist • Psychological dependence • Subjective sense of need, for positive effects or to avoid negative effects of abstinence • Addiction • Primary, chronic, neurobiologic disease. Characterized by impaired control over drug use, compulsive use, continued use despite harm, and craving

FFR 1. 65 RECEIVED SPECIALTY SUBSTANCE USE TREATMENT IN THE PAST YEAR AMONG PEOPLE AGED 12 OR OLDER WHO NEEDED SUBSTANCE USE TREATMENT IN THE PAST YEAR, BY AGE GROUP: 2017 https: //www. samhsa. gov/data/report/slides-2017 -nsduh-annual-national-report

FFR 1. 66 PERCEIVED NEED FOR SUBSTANCE USE TREATMENT AMONG PEOPLE AGED 12 OR OLDER WHO NEEDED BUT DID NOT RECEIVE SPECIALTY SUBSTANCE USE TREATMENT IN THE PAST YEAR: 2017 https: //www. samhsa. gov/data/report/slides-2017 -nsduh-annual-national-report

FFR 1. 67 REASONS FOR NOT RECEIVING SUBSTANCE USE TREATMENT IN THE PAST YEAR AMONG PEOPLE AGED 12 OR OLDER WHO FELT THEY NEEDED TREATMENT IN THE PAST YEAR: PERCENTAGES, 2017 https: //www. samhsa. gov/data/report/slides-2017 -nsduh-annual-national-report Note: Respondents could indicate multiple reasons for not receiving substance use treatment; thus, these response categories are not mutually exclusive.

SBIRT Screening, Brief Intervention, and Referral for Treatment

SCREENING ASSESSES SUBSTANCE USE AND SEVERITY Chemical Screening Tools

URINE TESTING FOR DRUGS OF ABUSE Drug Duration in Urine False positives Amphetamines Methamphetamine 2 -3 d 3 -6 d Ephedrine, pseudoephedrine, phenylephrine, chlorpromazine, bupropion, amantadine, ranitidine, metformin, labetalol Barbiturates 2 -4 d Ibuprofen, naproxen Benzodiazepines Depends, 2 d to 6 wks Sertraline Cannabinoids 1 -7 d episodic 21 -30 d chronic Ibuprofen, naproxen, efavirenz, hemp seed oil Cocaine 2 -3 d Topical anesthetics containing cocaine Methadone 3 -4 d Doxylamine, diphenhydramine, quetiapine Opiates 1 -3 d Rifampin, fluoroquinolones, poppy seeds, quinine (tonic water), doxylamine Phencyclidine 7 -14 d Ketamine, dextromethorphan, diphenhydramine The Medical Letter 2002; 44: 71 -7

NEONATAL URINE TESTING FOR DRUGS OF ABUSE Drug Duration in Urine Amphetamines Methamphetamine 1 -2 d 1 -2 d Barbiturates 2 -6 weeks Benzodiazepines Moderate: 3 to 5 days Heavy: 3 to 6 weeks Cannabinoids One joint: 2 d 3 times per week: 2 weeks Daily: 3 to 6 weeks Cocaine 2 -4 d Methadone 2 -3 d Opiates 1 -2 d Phencyclidine 2 -8 d Moses S. Toxicology Screening, Urine Tox Screen. Family Practice Notebook; 2005 www. fpnotebook. com/Psych/Lab/Txclgy. Scrng. htm

TESTING OF MECONIUM AND UMBILICAL CORD TISSUE • Meconium • Reflects drug exposure over the last trimester in term infant • If specimen tests positive, reflex to confirmation with mass spectrometry • Umbilical cord tissue • Reflects drug exposure over approximately last trimester in term infant • Qualitative detection by mass spectrometry https: //arupconsult. com/content/newborn-drug-testing

URINE DRUG SCREENING BY RISK FACTORS • Obstetric History • No or scant prenatal care (< 3 visits) • Preterm labor, preterm delivery, premature rupture of the membranes • Placental abruption • Unexplained fetal demise • Unexplained elevated blood pressure AAP and ACOG (2017) Guidelines for Perinatal Care ACOG Committee Opinion #422, updated Apr 2012 Chasnoff IJ, Neuman K, Thornton C, et al. Am J Obstet Gynecol 2001; 184: 752 -8.

URINE DRUG SCREENING BY RISK FACTORS: MEDICAL HISTORY • Sexually transmitted infections • Substance misuse history • HIV/AIDS • History of drug use in the past two years • Multiple STIs with current pregnancy • Positive drug screen in current pregnancy • Hepatitis • Enrolled in chemical dependency treatment (including methadone) • Gum or periodontal disease • Significant weight loss, low BMI, malnutrition • Sexual abuse • Psychiatric symptoms such as anxiety, panic, hallucinations and psychosis • Skin abscesses • Myocardial infarction without known etiology • Cerebrovascular accident without known etiology AAP and ACOG (2017) Guidelines for Perinatal Care ACOG Committee Opinion #422, updated Apr 2012 Chasnoff IJ, Neuman K, Thornton C, et al. Am J Obstet Gynecol 2001; 184: 752 -8.

PREVALENCE OF DRUG USE BY UNIVERSAL MATERNAL DRUG TESTING AT DELIVERY: PERFORMANCE OF SCREENING BASED ON RISK FACTORS Wexelblatt, SL, et al. J Pediatr 2015; 166: 582 -6.

WHY YOU SHOULD ASK • Begins the conversation • May identify drug use short of addiction • Allows an opportunity for intervention or to congratulate healthy behaviors • May make speaking about it in the future easier

BRIEF SCREENING TOOLS • NIDA Quick Screen • Validated for pregnancy • SURP-P • CRAFFT • WIDUS • 5 Ps • Missouri State Forms *****

PRINCIPLES OF SCREENING • Ask everyone! (“It is the standard of care that we ask all women about their history of medication, alcohol and tobacco use. ” “We ask these questions of everyone. ”) • Ask in private • Non-judgmental • Open-ended questions

PERINATAL RISK ASSESSMENT FOR SUBSTANCE USE FORM https: //health. mo. gov/living/wellness/tobacco/ato d/pdf/MCFH-4. pdf

PERINATAL RISK ASSESSMENT FOR SUBSTANCE USE FORM: TOBACCO https: //health. mo. gov/living/wellness/tobacco/atod/pdf/MCFH-4. pdf

PERINATAL RISK ASSESSMENT FOR SUBSTANCE USE FORM: ALCOHOL https: //health. mo. gov/living/wellness/tobacco/ato d/pdf/MCFH-4. pdf

PERINATAL RISK ASSESSMENT FOR SUBSTANCE USE FORM: OTHER DRUGS https: //health. mo. gov/living/wellness/tobacco/atod/pdf/MCFH 4. pdf

Wright TE, Terplan M, Ondersma SJ, et al. Am J Obstet Gynecol 2016; 215; 539 -47

CRITERIA FOR DIAGNOSING SUBSTANCE USE DISORDERS: DSM V • Increasing tolerance • Withdrawal symptoms • Using larger amounts or for longer than intended • Wanting to cut down or stop, but not managing to • Spending a lot of time to get, use or recover from drug use • Craving • Inability to manage commitments due to drug use < 2 = no disorder 2 -3 = mild disorder 4 -5 = moderate disorder > 6 = severe disorder • Continuing to use, even when it causes problems in relationships • Giving up important activities because of drug use • Continuing to use, even in dangerous situations • Continuing to use, even when physical or psychological problems may be made worse by drug use

BRIEF INTERVENTION Increase intrinsic motivation to affect behavioral change (reduce or stop drug use)

BRIEF INTERVENTION • 1 -5 patient-centered counseling sessions • Lasting < 15 minutes • Uses principles of motivational interviewing

Wright TE, Terplan M, Ondersma SJ, et al. Am J Obstet Gynecol 2016; 215; 539 -47

COMPLICATIONS FROM SUBSTANCE USE IN PREGNANCY Pregnancy Neonatal Cocaine Abruption, LBW, stillbirth, PTD, SGA, hypertension (mimicking preeclampsia) Increased sensitivity to CV toxicity State dysregulation, neonatal tremors, high-pitch cry, irritability, excess suck, hyperalert, abnormal MRI, transient abnormal EEG (Toxidrome) Long term outcome likely minimal effect except, possible attention and agression Amphetamines SGA, LBW, ? hypertension, PTD, abruption Neurobehavioral abnormalities (attention, verbal and spatial memory, ) Higher neonatal mortality Marijuana Small decrease in BW (100 g) Neurobehavioral effects (attention, visual problem solving) ? Association with small risk of ? Effect of confounders stillbirth (could not be adjusted for tobacco) LBW when smoke > 1 x/wk ACOG Committee Opinion #479, March 2011, reaffirmed 2017 ACOG Committee Opinion #722, October 2017 Conner SN, Bedell V, Lipsey K, et al. Obstet Gynecol 2016; 128: 713 -23 Gouin K, Murphy K, Shah PS, et al. Am J Obstet Gynecol 2011; 204: 340. e 1 -12

COMPLICATIONS FROM SUBSTANCE USE IN PREGNANCY Pregnancy Neonatal Opioids (untreated heroin) IUGR, abruption, NAS fetal death, preterm labor, meconium Tobacco Miscarriage, stillbirth (dose. Increased irritability and hypertonicity, SIDS, asthma related), PPROM, LBW, abruption, placenta previa, Benzodiazepines Withdrawal Alcohol FASD, teratogenic, characteristic facial features, LBW, growth restriction, cardiac, skeletal, renal ocular anomalies Neurobehavioral impairment, hyperactivity, inattention, learning disability, seizures, deficits in memory and reasoning, poor executive function, poor school performance, conduct disorder, postnatal growth delay ACOG Committee Opinion #711, August 2017 Partnode CD, Henderson JT, Thompson JH, et al. Ann Intern Med 2015; 163: 608 -21 Pruett D, Waterman EH, Caugher AB. Obstt Gynecol Surv 2013; 68: 62 -9

NUTRITIONAL CONCERNS FOR SUBSTANCE USE IN PREGNANCY • Active addiction associated with poor quality diet • BMI • Vitamin deficiency (thiamine, vitamin D, B 12, folic acid) • Iron deficiency • Dental issues • Inflammatory state (immune function) • Recovery • Weight gain and obesity • Persistent of poor eating habits

REFERRAL FOR TREATMENT Provide to those identified to be at high risk (SUD) who are in need of specialty addiction care

REFERRAL FOR TREATMENT Behavioral therapy (chemical dependency treatment) MAT (now MT for OUD) Buprenorphine Methadone

BEHAVIORAL INTERVENTIONS FOR SUD • Contingency management (CM). Systematically use reinforcement techniques, usually monetary vouchers • Originally use for cocaine. Now for opioids, MJ, tobacco, alcohol, benzodiazepines, other • Motivational Interviewing (MI) • Patient-centered, collaborative, highly empathic counseling style to elicit behavior change • Helps patients explore and resolve ambivalence • Cognitive Behavioral Therapy (CBT) • Strategies to help patients understand situations that bring about undesirable thoughts, feelings or behaviors (to then avoid when possible) • Goal to break old patterns and replace with new ones Forray A. F 1000 Res. 2016; 5: F 1000 Faculty Rev-887

RESOURCES • SAMHSA (Substance Abuse and Mental Health Services Administration) Treatment Finder • Buprenorphine provider locator • https: //www. samhsa. gov/medication-assisted-treatment/physician-programdata/treatment-physician-locator • Missouri state resource • 800 -TEL-LINK (800 835 -5465)

RESOURCES

• Key screening conclusion by expert group • Screening for substance use should be done on all pregnant women at first prenatal visit and subsequently throughout pregnancy for those at high risk • Screening can be done using a validated instrument with follow-up by provider or by asking standardized questions during interview • Nonjudgmental • Open-ended questions • Urine toxicology should not be used in place of substance use screening questions Wright TE, Terplan M, Ondersma SJ, et al. Am J Obstet Gynecol 2016; 215; 539 -47

• Counsel pregnant women about the adverse effects of tobacco, alcohol and drugs REQUIREMENTS OF SB 190 (IMPLEMENTED JULY 1992) • Identify pregnancies at risk, provided for prevalence studies • Inform pregnant women of addiction services • Offer referrals to DHSS for service coordination • Immunity from civil liability for clinicians who comply with the requirements of SB 190

HOW MISSOURI/ILLINOIS HANDLES DRUG USE DURING PREGNANCY Missouri Illinois Substance use in pregnancy is a crime No No Prosecutions for drug use during pregnancy Yes Substance use in pregnancy is child abuse No specific law* Yes No No Health care workers must report drug use during pregnancy No specific law Yes Testing required if drug use during pregnancy is suspected No No Targeted program created Yes* Pregnant women given priority access for drug treatment Yes Pregnant women protected from discrimination in publicly funded programs Yes Substance use in pregnancy grounds for civil commitment Published on Guttmacher Institute (https: //www. Guttmacher. org) Date: 01 -Sep-2018

QUESTIONS?