Prevalence of drug use in pregnant West Virginia patients.
Substance abuse in pregnancy is known to have deleterious effects on neonates. These effects differ with respect to the substance ingested and can include neonatal abstinence syndrome (NAS), low birth weight, intrauterine fetal demise, and structural abnormalities such as gastroschisis.
The substance abuse rates have been estimated to be between 2.8-19% (1,2,3) These reported rates vary based upon the population screened and the method of screening used.
The lowest number reported in the study by Ebrahim and Gfroerer utilized a population survey of the entire United States (1) while the highest rates reported (19%) by Azadi and Dildy utilized urine toxicology testing. (3) Chasnoff et al developed a screening tool that estimated that 15% of the population studied continued to use substances of abuse after becoming aware of the pregnancy. (2)
Recent work published by Montgomery et al compared the performance of meconium samples versus the testing of umbilical cord tissue. (4) This study showed concordance of the testing methods that correlated at or above 90% for all substances analyzed. Follow-up work included a study in which umbilical cord samples were collected and tested if high risk criteria for substance abuse were identified. Out of this cohort, 157 of 498 (32%) cords tested positive for substances of abuse. (5)
The number of newborns treated for neonatal abstinence syndrome (NAS) has increased dramatically in West Virginia. In data collected from the Cabell Huntington Hospital in Huntington, WV, the number of neonates treated for NAS increased from 25 in 2003 to 70 in 2007. (6) The cost difference in the care of an otherwise healthy neonate with NAS compared to a normal full-term healthy neonate was estimated to be $3,934 in the Cabell-Huntington cohort. Because of the added costs associated with the increased risk of prematurity, the average cost of all infants with NAS was $36,000 compared to $2,000 for a normal neonate. (6) Obviously any significant reduction in the number of neonates being treated for NAS can save significant amounts of money for the healthcare system.
In order to formulate public policy and to ensure that the proper maternal and neonatal medical services are available in West Virginia to prevent and to care for pregnancies complicated by substance abuse, an accurate determination of the rate of substance abuse during pregnancy as well as the substances involved is required. The objective of our study was to accurately determine the rate of substance abuse affecting pregnancy in West Virginia.
Materials and Methods
This study was conceived as an anonymous (no patient information collected) survey of normally discarded tissue (umbilical cord). As such, consent was waived and the study was approved by the institutional review boards at each of the eight participating hospitals. Hospitals were recruited with the goal having broad geographic distribution and collection of 1000 samples in one month.
Delivery staff in each hospital was instructed to collect a 6 to 9 inch segment of umbilical cord from as many deliveries as possible for the month of August (2009). Each sample was stripped of intravascular blood, rinsed in sterile saline, put in a separate sterile plastic specimen container and frozen for subsequent shipment to United States Drug Testing Laboratories (USDTL, Des Plaines, IL).
Eight drugs were selected for testing (Table 1). Commercially available enzyme linked immunoabsorbent (ELISA) kits, with confirmatory testing by gas chromatography/mass spectometry were used for 6 of the drugs. Buprenorphine was tested using liquid chromatography/ mass spectrometry (LCMSMS). Phosphatidylethanol (a metabolite of ethanol) testing was based on high pressure liquid chromatography/ mass spectrometry (HPLCMS).
Self reporting was assessed determining the prevalence of drug and alcohol use reported on birth certificate data as well as a nursing assessment tool used in West Virginia called the WV Birth Score as provided by the Office of Maternal Child and Family Health of the State of West Virginia.
Seven hundred fifty nine (759) samples were collected in one month and analyzed in batch form by USDTL. The participation by hospital is shown in Table 2. There were 142 (19.2%) cord specimens positive for drugs and/or alcohol (Table 3). Polypharmacy was common (Table 4), especially among those patients using benzodiazapines and methadone. There was also significant regional variation in drug and alcohol use (Table 5). Self reporting prevalence rates of drug and alcohol rates are compared to actual umbilical cord prevalence in Table 6.
This anonymous sampling of umbilical cords involving 8 medical centers in West Virginia identified an overall prevalence of drug and alcohol use of almost 1 in 5 deliveries. There was a 10-19% prevalence of substance and 1-15% incidence of alcohol use in patients delivering during August 2009 with marked underreporting with standard data collection tools. There was a wide geographic variability in the prevalence of individual drugs and alcohol with one hospital reporting a 1 in 4 rate of drug and alcohol use! The lack of significant cocaine and methamphetamine use was surprising. Buprenorphine diversion has also been noted elsewhere but was not a significant contributor to the drug problem among these pregnancies.
Some limitations of this study should be noted. The hospitals were not selected at random. Rather they were selected to optimize the possibility of obtaining a large enough sample size (approximately 1000 deliveries) to be relevant and where possible to geographically cover the state of West Virginia. It includes the three tertiary care centers located in the state which could result in an overestimation of the prevalence as some out of state referrals may be included. However, the prevalence of drug exposure at these hospitals was comparable to the other hospitals in the study. Due to the anonymous nature of the sampling, it is impossible to analyze reasons for the wide geographic variations. While factors such as poverty, unemployment, and location of drug rehabilitation centers may play a role, definitive answers await a more comprehensive exploration of the problem. Finally, while there are some well known cross-reactivities on the ELISA screening tests used, each positive sample was confirmed using gas chromatography/mass spectroscopy which virtually rules out false positive results.
As noted earlier in the paper, the cost of drug addicted infants averages $36,000 per infant compared to $2,000 for non-affected infants (6), with multiple fetal effects contributing to this cost (Table 7). These findings sparked interest in possible detoxification or rehabilitation for patients who are using either illegal or non-prescribed substances or alcohol. The literature previously described the avoidance of detoxification during the second and third trimesters of pregnancy due to concerns about harms to the fetus. (7,8) Recent literature, however, does not substantiate these claims. (9,10,11) Luty studied 101 opiate dependent women who underwent a 21 day opiate withdrawal with no adverse effects found. (11) Opioid dependence, including methadone maintenance, has been linked to fetal death, growth restriction, pre-term birth, meconium aspiration, and neonatal abstinence syndrome. (7,12) Neonatal abstinence syndrome may be present in 60-90% of neonates exposed in-utero with up to 70% of affected neonates with central nervous system irritability that may progress to seizures. (13) Up to 50% may experience respiratory issues, feeding problems, and failure to thrive. (14) These issues are present as well in those infants whose mothers' are on methadone maintenance. (15) However, with methadone the onset of neonatal abstinence syndrome may be delayed for several weeks. (15) Some authors recommend 5-8 days of maternal hospitalization while their neonates' undergo observation for neonatal abstinence syndrome. (16) However, most insurance plans will not reimburse for the prolonged uncomplicated maternal stay.
The incidence of opioid relapse in pregnant opioid abusing women is very high with 41-96% relapsing. This mirrors the relapse rate of the general population at 1 month of 65-80%. (17,18) Over 90% of patients will relapse at 6 months after medication-assisted withdrawal. (19) Buprenorphine (Subutex[TM]) appears to have no difference in outcomes with regard to treatment of opiate addicted women. The same neonatal abstinence syndrome and neonatal effects are present. (20) Treatment of amphetamine abuse with fluoxetine and imipramine may be useful but is not a panacea for treatment. A recent review by the Cochrane Collaboration in 2001 (reissued in 2009) noted that medications are of limited use in treatment of amphetamine abuse. (21) They note that there are very limited trials at this time to be able to suggest what is the best way to treat amphetamine abuse. Benzodiazepine dependence and detoxification must be done gradually to reduce symptoms. Little has been written about benzodiazepine detoxification in pregnancy. Alcohol rehabilitation has had little written and until recently (as found in our paper) no ability to verify chronic use of alcohol due to its volatile nature and inability to test for its presence.
Co-morbidities with multiple psychiatric issues in the patients with substance abuse issues must be considered. Many patients with substance dependence have affective disorders including: depression, mania, schizoaffective disorders, schizophrenia, borderline personality, and bipolar disorders. Therefore, many authors recently note that detoxification must be linked with a combination of behavioral therapy with contingency management therapy. (16,22,23) Behavioral therapy consists of the use of addictions counselors and counseling to assist substance and alcohol abusers to remain drug and alcohol free. A pilot program at Charleston Area Medical Center (CAMC) uses this approach with both individual and group therapy. Contingency management therapies are a type of psychosocial intervention where the clients receive rewards in the form of vouchers or prizes if they demonstrate changed behaviors. There seems to be data to support its use in cocaine and opioid abuse. (24,25) Due to the large number of patients affected in the State of West Virginia by both substance abuse and alcohol abuse, we suggest a programmatic approach with the use of both inpatient and outpatient therapy be used. Detoxification seems a reasonable approach with treatment of the psychological co-morbidities associated with substance use. Multidisciplinary clinics would appear the ideal solution with the combination of medical, psychiatric, counseling, and social support necessary to return healthy mothers with healthy drug-free neonates.
After completing this program, the reader will be able to quantify the rate of substance abuse during pregnancy in West Virginia and describe the maternal, fetal, neonatal and societal consequences of substance abuse during pregnancy.
(1.) Ebrahim SH, Gfroerer J. Pregnancy-related substance use in the United States during 1996-1998. Obstet Gynecol. 2003;101(2):374-9.
(2.) Chasnoff IJ, McGourty RF, Bailey GW, Hutchins E, Lightfoot SO, Pawson LL, Fahey C, May B, Brodie P, McCulley L, Campbell J. The 4P's Plus screen for substance use in pregnancy: clinical application and outcomes. J Perinatol. 2005;25(6):368-74.
(3.) Azadi A, Dildy GA 3rd. Universal screening for substance abuse at the time of parturition. Am J Obstet Gynecol. 2008;198(5):e30-2. Epub 2008 Feb 14.
(4.) Montgomery D, Plate C, Alder SC, Jones M, Jones J, Christensen RD. Testing for fetal exposure to illicit drugs using umbilical cord tissue vs meconium. J Perinatol. 2006;26(1):11-4.
(5.) Montgomery DP, Plate CA, Jones M, Jones J, Rios R, Lambert DK, Schumtz N, Wiedmeier SE, Burnett J, Ail S, Brandel D, Maichuck G, Durham CA, Henry E, Christensen RD. Using umbilical cord tissue to detect fetal exposure to illicit drugs: a multicentered study in Utah and New Jersey. J Perinatol. 2008;28(11):750-3. Epub 2008 Jul 3.
(6.) Baxter FR, Nerhood R, Chaffin D. Characterization of babies discharged from Cabell Huntington Hospital during the calendar year 2005 with the diagnoses of neonatal abstinence syndrome. WV Med J. 2009;105(2):16-21.
(7.) Rementeria JL, Nunag NN. Narcotic withdrawal in pregnancy. Am J Obstet Gynecol 1973;116:1152-1156.
(8.) Finnegan JP. Treatment issues for opioid dependent women during the perinatal period. J Psychoactive Drugs 1991;23:191-202
(9.) Jarvis MAE, Schnoll SH. Methadone maintenance and withdrawal in pregnant opioid addicts. In CN Chiang & LP Finnegan (eds). Medication development for the treatment of pregnant addicts and their infants. (pp 58-77). Washington, D.C.: US Department of Health and Human Services (NIDA Monograph 149).
(10.) Dashe JS, Jackson GL, Olscher DA, Zane EH, Wendel GD. Opioid detoxification in pregnancy. Obstet Gynecol 1998;92:854-58.
(11.) Luty J, Nikolaou V, Bearn J. Is opiate detoxification unsafe in pregnancy? J of Substance Abuse Treatment 2003;24:363-367.
(12.) Hoegerman G, Schnoll SH. Methadone maintenance and withdrawal in pregnant opioid addicts. Clinical Perinat 1991;18:51-76.
(13.) Briggs GG, Freeman RK, Yaffee SJ. Drugs in pregnancy and lactation. Williams and Wilkins, Baltimore, MD, 1994, pp 557-558,
(14.) Cooper JR, Altman F, Brown BS, Czechowicz D. (Eds1983). Research on the treatment of narcotic addiction: State of the art. (NIDA Research Monograph 83-1201). Rockville, MD: US Department of Health and Human Services.
(15.) Andres RL, Jones KL. Social and illicit drug use in pregnancy. In RK Creasy & R Resnick (eds). Maternal-Fetal Medicine (pp 191-192), 1994, Philadelphia, PA: Saunders.
(16.) Winklbaur B, Kopf N, Ebner N, Jung E, Thau K, Fischer G. Treating pregnant women dependent on opioids is not the same as treating pregnancy and opioid dependence: a knowledge synthesis for better treatment for women and neonates. Addiction 2008;103:1429-1440.
(17.) Chutuape MA, Jasinski DR, Fingerhood MI, Stitzer ML. One, three, and six month outcomes following brief inpatient opioid detoxification. Am J Drug Alcohol Abuse 2001;27:19-44.
19. Which of the following substances is associated with fetal growth abnormalities when ingested during pregnancy?
e. all the above
20. In the study population, the detection of alcohol ingestion was similar at all eight of the participating hospitals. True or False?
21. According to the study results, the most frequently abused substance (excluding tobacco) during pregnancy in West Virginia is:
Support provided by the West Virginia Department of Health and Human Resources, Bureau for Public Health, Office of Maternal, Child and Family Health with federal Maternal and Child Health Block Grant funds.
Michael L. Stitely, MD
Department of Obstetrics and Gynecology, West
Virginia University School of Medicine
Byron Calhoun, MD
Department of Obstetrics and Gynecology, West
Virginia University--Charleston Division
Stefan Maxwell, MD
Department of Neonatology, Charleston Area
Robert Nerhood, MD
Department of Obstetrics and Gynecology, Joan C.
Edwards School of Medicine at Marshall University
David Chaffin, MD
Department of Obstetrics and Gynecology, Joan C.
Edwards School of Medicine at Marshall University
Table 1. Umbilical cord drug profile. Drug Initial Test Cutoff Amphetamines ELISA 5.0ng/ml Cocaine ELISA 2.0ng/ml Opiates ELISA 2.0ng/ml Cannabinoids ELISA 100pg/ml Benzodiazapines ELISA 2.0ng/ml Methadone ELISA 2.0ng/ml Buprenorphine LCMSMS 2.0ng/ml Ethanol HPLCMS 20ng/ml Table 2. Distribution of sample collection by hospital. Hospital Number % of Total Bluefield Regional Medical Center BRMC 50 6.6 Raleigh General Hospital RGH 83 10.9 Thomas Memorial Hospital TMH 59 7.8 Charleston Area Medical Center CAMC 133 17.5 Cabell Huntington Hospital CHH 245 32.2 Ruby Memorial Hospital RMH 52 6.9 Wheeling Hospital WH 65 8.6 City Hospital CH 72 9.5 Table 3. Prevalence and distribution of drug use in umbilical cords. % of % of Drug Class Number Positives (146) population (759) Amphetamines 1 <l <<1 Cocaine 0 0 0 Opiates 41 28 5.4 Cannabinoids 58 40 7.6 Benzodiazapines 17 12 2.2 Methadone 14 10 1.8 Buprenorphine 0 0 0 Alcohol 39 27 5.1 Table 4. Polypharmacy in pregnant drug users. Of patients % also using: using: Opiates Cannabinoids Benzos Methadone Alcohol Opiates 12 12 7 7 Cannabinoids 8 5 3 7 Benzos 29 17 11 6 Methadone 21 14 14 14 Alcohol 7 10 2 5 Table 5. Regional variation in drug and alcohol use. Hospital Drugs % Alcohol % BRMC 14 4 RGH 19 2 TMH 10 8 CAMC 16 8 CHH 17 1 RMH 13 4 WH 12 15 CH 10 5 Table 6. Comparison of self-reporting tools and umbilical cord screening. Birth certificate/Birth Score reporting Hospital Total Reported Drug Reported alcohol (Total deliveries deliveries in Use in Aug use in Aug 2009 in Aug 2009) Aug 2009 2009 N(%) N(%) Bluefield Regional 56 5(9) 1(2) Raleigh General 142 5(4) 2(1) Thomas Memorial 68 3(4) 1(1) CAMC 283 15(5) 2(<1) Cabell Huntington 251 7(3) 3(1) Ruby Memorial 119 4(3) 1(1) Wheeling Hospital 84 3(4) 1(1) City Hospital 71 3(4) 2(3) Total (1074) 1074 45(4) 13(1) Umbilical cord screening Hospital Cords Cords positive Cords positive (Total deliveries collected for drugs for alcohol in Aug 2009) N N(%) N(%) Bluefield Regional 50 7(14) 2(4) Raleigh General 83 16(19) 2(2) Thomas Memorial 59 6(10) 5(8) CAMC 133 21(15) 11(8) Cabell Huntington 245 43(18) 3(1) Ruby Memorial 52 7(13} 2(4) Wheeling Hospital 65 8(12} 10(15) City Hospital 72 7(10) 4(6) Total (1074) 759 115(15) 39(5) Table 7. Prenatal and neonatal effects of drugs of abuse. Marijuana Cocaine Possible Alters neurobehavioral Lower head circumference Physical performance IUGR Symptoms Lower gestational age at Abnormal fetal monitoring delivery and circulatory issues Increased risk of Higher heart rates prematurity Higher incidence of Reduction in the heart rate hypertension of the fetus Higher incidence of Growth Reduction respiratory distress syndrome Meconium staining Mai formations Neurodevelopmcnlal Possible Neurological symptoms Tremors and jitters Postnatal Hypertonicity High pitched cry Symptoms Irritability Excessive sucking Jitteriness Seizures Tachycardia Tachypnea Apnea Hyperirritabilily Issues at Late prenatal care Placental abruption delivery More often required NICU Premature ROM admission Pre term labor Less/late prenatal Premature Delivery/prematurity High risk of maternal death from intracerebral hemorrhage Stillbirth High risk of perinatal HIV Higher risk of syphilis Long Term First trimester exposure Higher infection rates Impacts affects child's depression Negative behavioral outcomes and anxiety symptoms at 3, 5 and 7 year Second trimester affects follow-up reading comprehension Lower IQ scores Speech and thought Higher risk of SLDS impairments Amphetamines Opiates/Methadone Possible SGA More feeding problems Physical Prematurity More likely tn require Symptoms IUGR resuscitation Smaller head circumference More feeding problems Lower birthweight Higher rates of prematurity, Transient bradycardia and SGAh, Methadone treatment tachycardia can cause bradycardia, Higher incidence of cleft tachycardia or an palate and cleft lip irregular heart rate Congenital detects, including limb anomalies and cardiac septal defects Possible Same as cocaine Symptoms of Neonatal Postnatal Tremors and jitters Abstinence Syndrome (NAS) Symptoms High-pitched cry Central nervous system Excessive sucking dysfunction Possible seizures Irritability Tachycardia Excessive crying Tachypnea Hyperactive reflexes Apnea Increased tone Hyperirritabilily Sleep disturbance Seizures Autonomic dysfunction Respiratory symptoms Issues at Higher incidence of Late prenatal care delivery stillbirth More often require NICU Poor prenatal care admission Sexually transmitted Antepartum hemorrhage diseases Increased risk of 1IIV Abruptio Placenta More likely to require Postpartum hemorrhage resuscitation Higher incidence of placental abruption Higher incidence of premature delivery Higher incidence of chorioamnionilis Higher rates of meconium staining Long Term Hyperactivity Higher incidence of SIDS Impacts Sleep disturbances Aggressiveness
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|Title Annotation:||Scientific Article: Special Issue|
|Author:||Stitely, Michael L.; Calhoun, Byron; Maxwell, Stefan; Nerhood, Robert; Chaffin, David|
|Publication:||West Virginia Medical Journal|
|Date:||Jul 1, 2010|
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