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Course: Maternity Nursing

Topic: Substance Abuse and Pregnancy

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Module Goals

The learner will be able to:

Explain the health risks associated with alcohol, tobacco and illicit drugs.
Explain the pregnancy risks associated with alcohol, tobacco and illicit drugs.
Discuss the nursing care related to a pregnant woman who issuing tobacco alcohol or illicit drugs.
Discuss teaching needs associated with alcohol, tobacco and illicit drugs.

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Alcohol and Tobacco Use : Health Risks in General

Leads to major health problems when used alone or together:

Traumatic deaths and Injuries
Chronic liver diseases
Cancers (liver, lungs, mouth, tongue, throat)
Cardiovascular diseases
Alcohol toxicity
Psychosocial Problems: Homelessness,

court case, poor family support, and unemployment

National Institute on Alcohol Abuse and Alcoholism (2007)

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Either used alone together, alcohol, tobacco or drugs use may lead to major health problems.

The use of alcohol, drugs while driving can cause traumatic deaths and injuries due to crashes.
Alcohol is a contributing factor for liver diseases, cirrhosis, cancers, cardiovascular diseases, alcohol toxicity
Smoking tobacco is associated with lung disease, cancers, and cardiovascular disease
Chewing tobacco can cause oral and throat cancers
The risk of certain cancers increases if these substances are used in a combination form.

Cancers of the Mouth and Throat

People drinking and smoking are at the high risk of developing mouth, throat cancers and esophageal cancers.
Liver Cancer
Some studies reports that use of alcohol, tobacco, and drugs increases the risk of having liver cancers

Cardiovascular Disease

Tobacco use, drug use and alcohol consumption both are major risk factors for various forms of cardiovascular disease like heart attack, stroke, and hardening or narrowing of the arteries

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Illicit Drugs : Health Risks in General

Illicit drug: Drug illegal to possess or use, or legal drug used illegally¹
Examples²: Opioids, Methaphetamine, Cocaine, Heroin, Marijuana
Associated health risks are²:

Traumatic deaths and Injuries
Cardiovascular disease: stroke, cardiac arrest
Cancers and lung diseases
HIV/AIDS
Hepatitis B and C
Mental disorders
Psychosocial problems: Homelessness, legal issues, poor family support, and unemployment
Overdose and deaths

Australian Institute of Health and Welfare (2016)

National Institute on Drug Abuse (2020a)

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Illicit Drugs : Health Risks in General

Methamphetamine can cause severe dental problems
Opioids can lead to overdose and death
Drugs like inhalants, may damage/destroy nerve cells of brain or peripheral nervous system
Injectable drug users at risk of:

Blood borne infections like HIV/AIDS, Hepatitis C
Prone to have unsafe practices such as condom-less sex
Infection of skin, heart and its valves after exposure to bacteria

Mental disorders like anxiety, depression, schizophrenia can be associated with addiction

National Institute on Drug Abuse (2020)

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Alcohol, Tobacco, and Illicit Drugs :

Pregnancy Related Health Risks

Health risk to maternal health include:
Cigarette Smoking (Tobacco):

Risk of miscarriage
Placenta Previa
Uterine Infections
Preterm labor
Premature rupture of membrane

Alcohol:

Liver diseases
Miscarriages

Merk Manual (2021)

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Alcohol, Tobacco, and Illicit Drugs :

Pregnancy Related Health Risks

Illicit drugs use during pregnancy may cause:

Risk of infections (hepatitis and HIV/AIDS)
Preterm labor
Amphetamines: Causes defects in the developing fetus
Bath Salts: Placenta abruption, still birth, excessive bleeding
Cocaine: Miscarriage, placenta abruption, perterm birth
Hallucinogens: Miscariage, Preterm labour and delivery
Marijuana: Effects are unclear
Opioids: Dependency and addiction, miscarriage, abnormal fetal presentation, preterm delivery

Merk Manual, (2021)

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Cocaine during pregnancy: It constricts the blood vessels and narrows the blood vessel that carries blood to placenta which may result in miscarriage, preterm labor, placental abruption, still birth, growth restriction in fetus.

Hallucinogens dring pregnancy: Drugs like: Methylenedioxymethamphetamine (MDMA, or Ecstasy), rohypnol, methamphetamine may cause miscarriage, preterm labor and delivery, withdrawl syndrome in fetus or newborn.

Marijuana during pregnancy: The effect of marijuana during pregnancy is not established.

Opioids during pregnancy: Drug like heroin, morphine, methadone cause dependency and addiction. Causes miscarriage, abnormal presenting parts, preterm labor and delivery. Affects fetus; can have withdrawal symptoms in fetus, can cause small for gestational age infants.

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Alcohol, Tobacco, and Illicit Drugs :

Pregnancy Related Health Risks

Drugs used during Labor and Delivery

Drugs like local anaesthetics and opioids are used to relieve pain during labor and delivery

These usually cross the placenta and can affect the newborn

For example, may cause respiratory problems

Need to be given responsibly in smallest effect doses, if these drugs are needed during labor

Merk Manual, (2021)

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Critical Thinking Question/What Would a Nurse Do?:

A 28 years old female of 20 weeks of gestation is admitted to the unit with symptoms of Opium use. The next day she is complaining of having nausea, vomiting and is severe anxiety. She says “ I hate this pregnancy. It’s too difficult for me.” She said she does not believe that her nausea and vomiting are related to drugs. She is demanding to go home.

What would a nurse do?

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Barriers to Quitting Substance Abuse

National Institute of Drug Abuse (2020b)

Women are less likely to quit smoking
Relapse is common in women with heightened withdrawal and cravings around menstrual cycle
Nicotin-replacement options are not effective for women
Fear of weight gain

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Substance Use Disorder Treatment in Pregnancy/Breastfeeding

Pharmacotherapy:

Main effective treatment
Antipsychotics : Olanzapine, risperidone, haloperidol as standard treatment for managing symptoms
These medications restore the brain’s natural chemical balance, reducing or eliminating psychotic symptoms
May require several weeks to take effect

Intechopen (2018)

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Substance Use Disorder Treatment in Pregnancy/Breastfeeding

Pharmacotherapy:

Opioid Addiction: Methadone along with behavioural therapy
Tobacco Addiction: Tobacco replacement therapy, Bupropion, Varenicline along with behavioural therapy
Alcohol Addiction: Naltrexone, Acamprosate, Disulfiram along with behavioural therapy

National Institute on Drug Abuse (2018)

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Substance Use Disorder Treatment in Pregnancy/Breastfeeding

Behavioural Therapies

Provide incentives to remain abstinent, modify their attitudes and behaviors related to drug abuse
Increase life skills to handle stressors
Helps to deal with the stressor that may trigger intense craving for drugs
Prevents relapse or switching to other substance abuse products

National Institute on Drug Abuse (2018)

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Substance Use Disorder Treatment (Continuation)

Cognitive Behavioural Therapy:

Helps to identify and correct problematic behaviors via different skills
Enhance patients’ self-control by helping them develop effective coping strategies
Explores positive and negative consequences of continued drug use
Helps self-monitoring to recognize cravings early and identify situations that trigger the abuse
Helps to avoid high-risk situations
The effectiveness of the treatment remain even after the completion of treatment

National Institute on Drug Abuse (2018)

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Substance Use Disorder Treatment (Continuation)

Contingency Management Interventions/Motivational Incentives (Alcohol, Stimulants, Opioids, Marijuana, Nicotine)

A type of behavioural therapy
Giving patients tangible rewards to reinforce positive behaviors such as abstinence
Highly effective in increasing treatment retention and promoting abstinence from drugs
Can be voucher based or prize incentives

National Institute on Drug Abuse (2018)

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Substance Use Disorder Treatment (Continuation)

Community Reinforcement Approach Plus Vouchers (Alcohol, Cocaine, Opioids)

A type of behavioural therapy
A 24 week outpatient therapy for cocaine and alcohol addiction
Uses recreational, familial, social and vocational reinforcers
Goal is to maintain abstinence or reduction use of the substance and develop the coping strategies

National Institute on Drug Abuse (2018)

Image by Clipart Library

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Substance Use Disorder Treatment (Continuation)

Motivational Enhancement Therapy (MET):

Counseling approach aims to evoke rapid and internally motivated change
Uses motivational interviewing principles to strengthen motivation and build a plan for change
Coping strategies for high-risk situations are suggested, discussed with the patient
Monitors change, reviews cessation strategies being used
Continues encouraging commitment to change or sustained abstinence
May be used in combination with other cognitive behavioural therapy

National Institute on Drug Abuse (2018)

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Substance Use Disorder Treatment (Continuation)

National Institute on Drug Abuse (2018)

The Matrix Model: A type of behavioural therapy

Provides structure to refrain and abstain from stimulants (methamphetamine and cocaine)
Receive direction and support from a trained therapist, and become familiar with self-help programs
Reinforce positive behaviour
Consists of individual sessions, family education groups, early recovery skills groups, relapse prevention groups, combined sessions, urine tests, 12-step programs, relapse analysis, and social support groups

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Substance Use Disorder Treatment (Continuation)

12-Step Facilitation Therapy (Alcohol, Stimulants, Opiates)

Facilitates substance abuser to become affiliated with and actively involved in 12-step self-help groups to promoting abstinence
Three key predominate ideas:

Acceptance: realize drug addiction as chronic, progressive disease, is detrimental to life, and overcome only with abstinence
Surrender: accepting fellowship and support structure of other recovering addicted individuals, and following the recovery activities of 12-step program
Active involvement in 12-steps meetings and related activities

National Institute on Drug Abuse (2018)

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Substance Use Disorder Treatment (Continuation)

National Institute on Drug Abuse (2018)

Family Behavior Therapy

A type of behavioural therapy
Very effective
Involves the patient with partner or significant other
Encourages to develop behavioural goals for preventing substance use
Goals are reviewed and rewarded

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Take a moment and think…..

What do you think are the roles of nurses in care of mothers with substance abuse problems?

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Role of Nurses in Substance Abuse Management

Careful history taking regarding substance abuse at the initial antenatal check-up

Family interview
Careful assessment for signs/symptoms of substance use
Careful assessment of risk behaviours

Discourage substance use during pregnancy
Assist in appropriate referral of mothers with substance abuse disorders to:

Substance abuse management programs
Community support groups, services

Provide patient/family education on detrimental effects of substance abuse to mother and fetus

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Role of Nurses While Treating Substance Abuse Patient:

Confront with non- judgmental attitude
Maintain therapeutic relation and strict self-discipline
Sets limits for inappropriate behavior
Provide options to deal with stressors
Teach coping strategies for stressors
Encourage joining support groups
Restrict the access of abusing substance
Show the patient a big picture ahead of her life
Watch for the symptoms of withdrawal or relapse
Provide the needed care, support needed
Encourage the patient to remain busy and active

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Red Flag

Pregnant woman with the needle marks on her arms: Drug abuse (injectable)
Physical withdrawal: Substance abuse/ Addiction
Unusual behaviours: Substance abuse/ Addiction
Loss of interest in life: Substance abuse/ Addiction
Evidence of lack of self-care
Pin Point Pupil: Use of narcotics
Bloodshot Eyes: Use of cannabis
Potential for child neglect or abuse

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References:

Australian Institute of Health and Welfare (2016). Illicit drug. Meteor. Retrieved on 26th of May 2021 from https://meteor.aihw.gov.au/content/index.phtml/itemId/413485

Gunatilake, R., & Patil, A. V. (2021). Women’s Health Issues: Drug during Pregnancy. Merk manual. Retrieved on 26th of May 2021 from https://www.merckmanuals.com/home/women-s-health-issues/drug-use-during-pregnancy/drug-use-during-pregnancy

Imkome, E. (June 27th 2018). Nursing Care for Persons with Drug Addiction, Drug Addiction, Fang Zhao and Meng Li, IntechOpen, DOI: 10.5772/intechopen.73334. Available from: https://www.intechopen.com/books/drug-addiction/nursing-care-for-persons-with-drug-addiction

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References:

National Institute on Alcohol Abuse and Alcoholism (2007). Alcohol Alert: Alcohol and Tobacco. Retrieved on 26th of May 2021 from https://pubs.niaaa.nih.gov/publications/aa71/aa71.htm

National Institute on Drug Abuse (2020a). Drugs, Brains, and Behavior: The Science of Addiction: Addiction and Health. Retrieved on 26th of May 2020 from https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/addiction-health

National Institute of Drug Abuse (2020b). Substance Use in Women Research Report: Sex and Gender Differences in Substance Use Disorder Treatment.

Accessed from : https://www.drugabuse.gov/publications/research-reports/substance-use-in-women/sex-gender-differences-in-substance-use-disorder-treatment

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References:

National Institute of Drug Abuse (2018). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). Accessed from: https://www.drugabuse.gov/download/675/principles-drug-addiction-treatment-research-based-guide-third-edition.pdf?v=74dad603627bab89b93193918330c223

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