Thursday, September 26, 2013

Pregnancy and Post Partum Addiction

Dr. Shimi Kang
-Faculty UBC Addiction Psychiatry

I'd heard from Dr. Shaila Misri, world renowned psychiatric authority on Pregnancy and Psychiatric Disorder, that Dr. Shimi Kang was a remarkable addiction psychiatrist who'd been doing incredibly fine work at the BC Women's Hospital.  I was thoroughly delighted to hear her presentation. It was extraordinary. She's an amazing speaker and communicator with tremendous academic and scientific knowledge coupled with obvious clinical experience and skill.  One of the finest presentations I've ever heard, reminiscent, really, of those great presentations I heard by Dr. Misri , beginning decades ago, when she was making the most telling breakthroughs in helping pregnant women. Now here was Dr. Shimi Kang going forward with addressing this 'taboo' subject of addiction and pregnancy with the same deep concern and marvellous clinical acumen. 

I apologize that my rough notes don't do justice to this superb presentation but hopefully they will help someone and should they need more I would most strongly recommend they contact Dr. Shimi Kang or the UBC Department of Addiction Psychiatry. 

Pregnancy and Post Partum Addiction 

Women who use substances have 70% chance of concurrent psychiatric diagnosis
  • often trauma and chronic pain are complicating factors

Concern now with pregnancy that women who have alcohol abuse problems are switching to marijuana in pregnancy because they say it helps with nausea and eating.

Presented a case of a woman who drank heavily in pregnancy and gave birth to a child with Fetal Alcohol Syndrome - she was an internist and the issue of alcohol was never raised in her pregnancy.  Dr. Kang - “I want to bust the Stigma - I work with all kinds of women with addiction issues.

Used of mood altering substances has been an accepted feature of human society for thousands of years

Alcohol Use and Binge Drinking among pregnant women
7.6% of pregnant women reported drinking in the last 30 days - 10 % of these women are college graduates. they report starting drinking in college
1.4% of pregnant women reported binge drinking in the last 30 days

Showed slide of twins - mother drank 10 beer a day in pregnancy - one child appears normal, other appears obviously with fascies of Fetal Alcohol Syndrome.  - same womb, same mother, same amount of alcohol but one thoroughly affected and the other not

Younger population is at higher risk

If a woman is smoking in pregnancy - red flag - likely woman is using another substance

My concern stated, Dr. Kang, is not just addiction in pregnancy but ‘concurrent disorders’.  
Biopsychosocial risk factors for mental illness and addiction run in parallel

Concurrent disorders in Pregnancy - 35% to 60% of patients 

Mood disorder, Mania, Depression, Panic, Agaraphobia, Generalized anxiety,

Opioid prescriptions are going up and up in women - young people
Used to be stimulants
Women present in pain with oxycontin - often with having all kinds of prescriptions from having all kinds of procedures
Prescription use and chronic 

Concurrent Disorders - more relapse - outcomes far worse

Women are different from Men
  • Global context -gender based violence, low income, unremitting responsibility for care of others, socioeconomic disadvantage, 
  • over and over again I see women who can have services but cant take them because they are caring for a mother or children or someone

Women are more likely to use pharmaceutical drugs
May become dependent on some illicity substance faster
greater rates of concurrent mental health problems
More likely to have suffered sexual and/or physical abuse
May engage in more HIV risk behavior
Higher mortality and advances to AIDS from HIV
Poly-substance use is often present

Freeze, Flight or Fight - depression/addiction/acting out - I explain your brain grew up with adrenaline - when you grew up with trauma - cortisol is linked
I give this explanation so they know there is a biology as well as a psychology
It is normal to be anxious to being chased by axe murderer but not to go to buy milk

Women are more stigmatized and less likely to be acknowledged
More severe problems at start of treatment
More likely to be introduced to and carry on using with partner
Less resources (education,employment,income)
Care for dependent children

Women versus men
  • more concurrent diagnosis
  • more rates of violence
  • more difficulty accessing treatment

75% of women in treatment for addiction report childhood sexual abuse
Severity of SUD related to trauma

Menstrual cycle, fertility and substance use
  • substance disrupt menstrual cycle
  • asking about pms and relapse and craving - looking for patterns 
-Fertility -substances can effect fertility, cocaine and opioids cause secondary amenorrhea and risk of unplanned pregnancy
-can have no period but still be ovulating

Risk factors for substance use in pregnancy and postpartum
-past history Substance Use Disorder

Pregnancy red flags
  • missed or inadequate prenatal care
  • recurrent somatic complaints
  • psychiatric condition
  • trauam
  • nicotine and /or alcohol
  • failure to gain adequate weight
  • intra-uterine growth delay/retardation
  • withdrawal signs (eg. delivery)

Window of Opportunity
-for many women first time in health care system
in prenatal period women more liekly to engage with care and abstain or reduce their substance use, without treatment will relapse

****90% of those who remain abstinent for 2 years will be substance free for at 10 years******NIDA 1995- Vaillant et al 1988

-requires integrated approach to treatment of mental health and substance use disorder

Perinatal consequences of Substance Use
In general - LBW (less than 2500 g), prematurity, small head circumference, poor nutritional status, infections, withdrawal issues
Substance specific
-Alcohol - fetal alcohol syndrome/effects
-Marijuana - behavioural problems - impaired decision making, memory and attentiveness, tremors and altered visual responsiveness

Breast Feeing
-active substance use - eg heroin, cocaine
-breast pump 

Child protection
-professional responsibility
  • encourage self - referral
  • physical harm, sexual abuse or exploitation, emotional harm, deprivation, parental refusal of needed treatment, death and abandonment, 

Female vs Mixed Gender Services
  • treament engagement and adherences
  • children are 5x less likely to be put in care if woman goes to gender specific service

Motivational Therapy
Importance Confidence Ruler
  • smoking woman
  • on scale 1-10 if you could wish on a star what would be number
  • in general we get, 7-8 10
  • in general women don’t want to be using in pregnancy

Next question
On same scale , how confident are you you can quit smoking today
-tends to be 2 or 3

I then say I don’t need to tell you the risk, you’re there - importance , and we can shift to building confidence 
‘Ask how do we build your confidence?”

if they say 3
Then ask why did you say 3 instead of 1
Then they will give you reasons to quit
  • i quit before, ministry on my back
  • we are evoking their reasons to quit

-Methadone Prescriber
dilemna prescribing SSRI’s and Antipsychotics
-half of doctors are saying don’t prescribe i npregnancy
-I say to women you don’t want to take anything in pregnancy - say this is tough - I don’t like prescribing to women - our principal is not prescribing and if we do we use lowest dose - then we said all associations, pediatricians, obstetricians, family physicians - got to gether and said - maternal health must be guiding principal - so we prescribe medication for asthma and diabetes despite those medications having risks in pregnancy
  • I give them the risks and ‘
  • I tell them risks of treatment and the risks of not being treated
  • I say what can happen to you - when you last quit smoking you relapsed to cocaine because of anxiety

If all else is equal we go with SERTRALINE for anxiety and depression
For schizoprhenia SEROQUEL

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