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DATA ON PRESCRIPTION ABUSE DRUG TAKE-BACK EVENTS DRUG DROP-OFF LOCATIONS CAPSAT MEMBERS CAPSAT HOME PAGE GUIDELINES FOR THE SAFE USE OF OPIOIDS DRUG ABUSE IN PREGNANCY DRUG ABUSE TREATMENT RESOURCES PRESCRIPTION DRUGS AND THE LAW CAPSAT CONTACT INFORMATION
Substance Abuse during Pregnancy   Page Editor: Dr. Timmeni L. Harrison, D.O. Resident Physician   Dept. of Obstetrics and Gynecological Surgery OSU-Medical Center Tulsa, Oklahoma Substance use and abuse affects a large portion of the general population, with women representing 30% of the addicted population (Wendell, 2013). Research shows that 90% of women in the general population who abuse drugs are of childbearing age (French 2013). The results from the 2010 National Survey on Drug Use and Health reports that for pregnant women ages 15-44 years old, 5% were illicit drug users (SAMHSA, 2011). Current literature shows that the actual prevalence of substance use is underreported and therefore often undertreated. Although many women who use illicit drugs either decrease or abstain from use during pregnancy, many continue to use drugs throughout the gestational period (Sithisarn et al., 2012). The adverse impacts of substance use during pregnancy often become evident immediately following use. The risks for obstetric complications are increased substantially, including miscarriage, abruption, postpartum hemorrhage, poor nutrition, anemia, and urinary tract infections. Substance use during pregnancy as well as in the non-gravid condition also puts women at risk for sexually transmitted infections, hepatitis, and HIV. Some gestational effects on the infant can include, but are not limited to, an increased risk of prematurity, fetal growth restriction, low birth weight (less than 2500g), feeding problems, and respiratory distress syndrome (McLemore et al., 2013).  Fetal exposure to opioids increases the risk of stillbirth, SIDS death, and other congenital abnormalities such as gastroschisis, spina bifida, and congenital heart disease (Wendell, 2013). Other fetal effects of illicit drug exposure can include elevated blood pressure, changes to protein metabolism, cleft lip and palate, cancer, and even fetal death (Narcowicz et al., 2013). Fetal alcohol syndrome remains the leading cause of preventable birth defects in the United States (Wendell 2013). However, studies show a decline in the prevalence of alcohol as the drug of choice in substance abusing, pregnant women. Pregnant women reporting alcohol abuse (with or without concomitant drug abuse) has declined from 46.6% to 34.8% from 2000 to 2010. The shifts in the types of substances abused by pregnant women, as reported by Substance Abuse and Mental Health Services Administration (SAMHSA), show a decrease in alcohol and an increase in prescription drugs and other psychotherapeutics. Approximately one infant born per hour in the United States has signs of drug withdrawal (Patrick et al., 2012). Neonatal Abstinence Syndrome (NAS) is diagnosed when a newborn suffers withdrawal effects of a drug or drugs that they are exposed to in the womb. One recent population-based study in Washington State showed 18.9% of infants exposed to drugs in utero developed neonatal abstinence syndrome (NAS), (Creanga et al., 2012). Other studies have shown NAS to occur in 50% to 90% of neonates that were exposed to drugs in utero (Wendell, 2013).  Infants with NAS can exhibit high-pitched cries, hyperirritability, hypertonia, feeding intolerance, emesis, diarrhea, tremors, respiratory distress, tachypnea, seizures, and in severe cases death (McLemore et al., 2013). Effects of maternal substance abuse during pregnancy can be immediately apparent as obstetrical complications or subsequently affecting the infant at birth. Additionally, drug effects on the fetus are often seen long after parturition, and can accompany the exposed fetus long into adult life (Creanga et al. 2012, Wendell 2013, Narcowicz et al., 2013). Many individuals who suffered from fetal drug exposure have diminished IQs and adverse developmental sequela that follow them through childhood, adolescence, and even long into adulthood (Yang 2012). In addition to this, both maternal and fetal stress, as a result of substance abuse during pregnancy, can cause dysregulation of the fetal hypothalamic-pituitary-axis that can contribute to poor developmental outcomes (Sithisarn et al., 2012). Therefore, prevention through early screening, intervention, and treatment proves beneficial and often lessens the risk of adverse outcomes. Not only are the health consequences of maternal substance use significant, the additional cost incurred by complications stemming from maternal drug use can be substantially high. The increased cost of caring for an infant born after prenatal drug exposure is often significantly higher than the cost of caring for a non-exposed neonate. Patrick and colleagues, in a ten year study ending in 2009, reported the cost of caring for a newborn with NAS, from the time of birth to hospital discharge, exceeded $53,400 as opposed to $9,500 to care for a non- afflicted neonate (Patrick et al., 2012). Extended hospital stays and increases in related expenditures for health care are additional areas of concern on a global scheme. As the incidence of maternal drug use continues to rise across all populations, the impact on global health costs is astonishing. Patrick and colleagues also investigated 7.4 million weighted discharges from 4,121 hospitals in 44 states. The study showed that 60% of mothers using or dependent on opioids were covered by Medicaid as opposed to only 44.7% of mothers not using opioids were covered by Medicaid (Patrick et al., 2012).  In this same study, Medicaid was the primary payer for 77.6% of charges associated with Neonatal Abstinence Syndrome aggregate charges in 2009. Adding to the total cost of care for neonates affected by maternal drug use, the length of stay for infants diagnosed with NAS is, on average, sixteen days compared to an average of three days for all other hospital births (Patrick et al., 2012).  In light of the above information, one can infer that the early detection and successful treatment of maternal drug abuse could not only shorten the newborn's length of stay after delivery, but could also potentially ameliorate the increased health related cost incurred over the child's lifetime. The most critical time of pregnancy, concerning teratogenicity or ill effects on the growing fetus, is in the first trimester when organogenesis occurs. This places high priority on the importance of screening and diagnosis of substance use during early pregnancy. References Creanga AA, Sabel JC, Ko JY et al (2012) Maternal drug use and its effect on neonates: a population-based study in Washington State. Obstet Gynecol 119:924-933. French E (2013)Substance abuse in pregnancy: compassionate and competent care for the patient in labor. Clin Obstet Gynecol 56:173- 177. McLemore GL, Lewis T, Jones CH et al (2013) Novel pharmacotherapeutic strategies for treatment of opioid-induced neonatal abstinence syndrome. Semin Fetal Neonatal Med 18:35-41. Narkowicz S, P?otka J, Polkowska ? et al (2013) Prenatal exposure to substance of abuse: a worldwide problem. Environ Int 54:141-163. Patrick SW, Schumacher RE, Benneyworth BD et al (2012) Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009. JAMA 307:1934-1940.   Sithisarn T, Granger DT, Bada HS (2012) Consequences of prenatal substance use. Int J Adolesc Med Health 24:105-112.   Substance Abuse and Mental Health Services Administration, (SAMHSA) Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS. Publication No. (SMA) 12-4713. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012. Wendell AD (2013) Overview and epidemiology of substance abuse in pregnancy. Clin Obstet Gynecol 56:91-96. Yang SN (2012) Current status and future diagnostic trends of prenatal illicit drug exposure in the neonate. Pediatr Neonatol 53:81-82.
“NOW, THEREFORE, I, BARACK OBAMA, President of the United States of America, by virtue of the authority vested in me by the Constitution and the laws of the United States, do hereby proclaim September 18 through September 24, 2016, as Prescription Opioid and Heroin Epidemic Awareness Week. I call upon all Americans to observe this week with appropriate programs, ceremonies, and activities that raise awareness about the prescription opioid and heroin epidemic.” White House Press Release, 16 September 2016