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A Baby's Life Shouldn't Begin With Detox
When pregnant women take prescription medications, other drugs or alcohol, their babies may be born with Neonatal Abstinence Syndrome (NAS). These babies are born suffering from withdrawal symptoms such as fever, seizures, blotchy skin, incessant shrill cries, respiratory problems, and extreme sensitivity to sounds and light. In many cases, doctors and nurses give these newborns methadone, the same drug used to treat heroin addicts, and morphine to ease their constant pain.
Approximately 7 out of every 1,000 Floridian babies born in 2011 were diagnosed with NAS - and the epidemic is growing. In addition, newborns with NAS may require longer and more costly hospital stays, with treatments costing as much as ten times the amount of a healthy birth
But there is hope. There are many ways to help women of child-bearing age and expectant mothers decrease or eliminate drug withdrawal for their baby.
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About
"Born Drug Free Florida" is an initiative by the Florida Department of Children and Families, Florida Office of the Attorney General and the Florida Department of Health to raise awareness about babies being born exposed to prescription drugs. The campaign educates expectant mothers about the importance of discussing prescription drug abuse with their doctors and to offer assistance to the women.
Attorney General Pam Bondi worked with the Florida Legislature during the 2012 legislative session to create a Statewide Task Force on Prescription Drug Abuse and Newborns. She chaired the task force, which was charged with examining the scope of the problem of Neonatal Abstinence Syndrome, the costs associated with caring for babies with NAS, the long-term effects of NAS, and strategies for preventing prescription drug abuse by expectant mothers.
This initiative is one of the Prescription Drug Abuse and Newborns Task Force’s recommendations intended to end NAS in Florida’s newborns. The Department of Children and Families took the lead role in executing this educational initiative.
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Mothers
It is important to talk to a medical professional about all the medications you are taking, including prescription pain pills.
By talking to a medical professional before the pregnancy, you can reduce the chances of your baby being born with Neonatal Abstinence Syndrome (NAS).
Babies born with NAS suffer from withdrawal symptoms such as tremors, seizures, abdominal pain, incessant crying, and rapid breathing. In many cases, doctors and nurses give these newborns methadone, the same drug used to treat heroin addicts, and morphine to ease their constant pain.
If you are currently pregnant, there is still time to help the baby. The baby’s exposure to the drugs decreases the earlier a medical professional is involved. The severity and duration of drug withdrawal the baby experiences after birth can be significantly decreased.
If you do not currently see a medical practitioner, check out our map or call our Helpline at 1-888-233-5656 for medical contacts in your area.
Prescription Medications
There are a variety of reasons you may be taking prescription medications. However, these medications may have an impact on the development of your baby. Whether you take this medication with a prescription or for other reasons, it is important to be aware of the potential impact.
Have a conversation with your healthcare practitioner
If you are prescribed or taking one or more of the following prescription pain medications, talk to your healthcare practitioner about treatment or other alternatives:
Opioid pain medications including:
- Fentanyl (Duragesic®)
- Hydrocodone (Vicodin®)
- Oxycodone (OxyContin®)
- Oxymorphone (Opana®)
- Propoxyphene (Darvon®)
- Hydromorphone (Dilaudid®)
- Meperidine (Demerol®)
- Diphenoxylate (Lomotil®)
Central nervous system depressants including:
- Pentobarbital sodium (Nembutal®)
- Diazepam (Valium®)
- Alprazolam (Xanax®)
Stimulants including:
- Dextroamphetamine (Dexedrine®)
- Methylphenidate (Ritalin® and Concerta®)
- Amphetamines (Adderall®)
Alcohol and non-prescription drugs
If you are pregnant, or may become pregnant, your baby’s health is dependent on yours. When you use a drug or drink alcohol, it significantly impacts how your baby develops in the womb.
It is not too late. Contact your medical practitioner or view our map or call our helpline in order to give your baby a healthy start.
Screening Tools for Substance Use
CAGE
- C Have you ever felt you ought to cut down on your drinking or drug use?
- A Have people annoyed you by criticizing your drinking or drug use?
- G Have you ever felt bad or guilty about your drinking or drug use?
- E Eye-opener: Have you ever had a drink or drug first thing in the morning to steady your nerves or get rid of a hangover?
The CAGE can identify alcohol problems over the lifetime. Two positive responses are considered a positive test and indicate further assessment is warranted.
National Institute on Alcohol Abuse and Alcoholism
T-ACE
A score of 2 or more is considered positive. Affirmative answers to questions A, C, or E = 1 point each. Reporting tolerance to more than two drinks (the T question) = 2 points.
- T Tolerance: How many drinks does it take to make you feel high?
- A Have people annoyed you by criticizing your drinking or drug use?
- C Have you ever felt you ought to cut down on your drinking or drug use?
- E Eye-opener: Have you ever had a drink or drug first thing in the morning to steady your nerves or get rid of a hangover?
Sockol RJ, et al. (1989) The T-ACE questions: Practical prenatal detection of risk drinking. AM Journal of Obstetrics and Gynecology. 160(4).
Chang G. (2001) Alcohol-Screening Instruments for Pregnant Women. Alcohol Research and Health, 25 (3), 204–209.
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Friends & Family
Most women stop using prescription pain medications, illegal drugs and alcohol during pregnancy. However, some may not know how dangerous continuing these drugs can be for their unborn baby.
People use substances for a variety of reasons. In the case of prescription drugs, this may be under the supervision of a physician. Other women may be using substances to help them cope with psychosocial stressors in her life.
In some situations, women may deny use of these substances, but there are warning signs friends and family members can look for.
Signs of drug use
Behavior Patterns
- Sedation
- Euphoria
- Agitation
- Aggression
- Increased physical activity
- Anxiety and nervousness
- Irritability
- Disorientation
- Prescription drug-seeking behavior
- Suicidal thoughts or attempts
- Sexual promiscuity
- Dishonesty
- Unreliability
Physical Findings
- Track marks and other evidence of intravenous drug use
- Alcohol on the breath
- Inflamed/eroded nasal mucus, nose bleeds
- Scars, injuries
- High blood pressure
- Tremors
- Slurred speech
- Self-neglect or poor hygiene
- Liver or renal disease
- Runny nose
- Chronic cough
- Nervous mannerisms, like frequently licking lips, jitters and foot tapping
- Pinpoint or dilated pupils
- Rapid eye movements
- Poor nutritional status
- Physical abuse
- Sexually transmitted disease
Psychological Problems
- Memory loss
- Depression
- Anxiety
- Panic
- Paranoia
- Unexplained mood swings
- Personality changes
- Intellectual changes
Medical History
- Frequent hospitalizations
- Gunshot/knife wound
- Unusual infections, like cellulitis, endocarditis, atypical pneumonias and HIV
- Liver problems
- Hepatitis
- Pancreatitis
- Diabetes
- Frequent falls/unexplained bruises
- Chronic mental illness
When a Woman Admits Use
The woman may go through many stages when admitting they are taking drugs. The Stages of Change model developed by Prochaska and DiClemente (1992) is one approach to understanding the steps to changing substance use during pregnancy.
Stages of Change:
- Pre-contemplation
- Contemplation
- Preparation
- Action
- Relapse
Pre-Contemplation
The woman is not considering change during the pre-contemplation stage.
- She may not believe it is necessary (examples: used during last pregnancy and nothing happened, or her mother used while pregnant with her and she is okay).
- She may not know or understand the risks involved.
- She has tried many times to quit without success, so she has given up and doesn’t want to try again.
- She has gone through withdrawal before and is fearful of the process or effects on her body.
- She feels strongly that no one should tell her what to do with her body.
- She has mental illness or developmental delay and does not have a good grasp of what using drugs and alcohol during pregnancy means—even when information is given to her.
- She has family members or a partner, whom she depends on, who use. She may not contemplate changing when everyone else continues to use.
The woman in pre-contemplation may present as resistant, reluctant, resigned, or rationalizing.
Resistant: “Don’t tell me what to do.”
Family Response: Work with the resistance.
Avoid confrontation and try to solicit her view of the situation. Ask her what concerns her about her use and ask permission to share what you know, and then ask her opinion of the information. Accept that this process of change is a gradual one, and it may require several conversations before she feels safe discussing her real fears. This often leads to a reduced level of resistance and allows for a more open dialogue. Try to accept her autonomy but make it clear that you would like to help her quit or reduce her use if she is willing.Reluctant: “I don’t want to change; there are reasons.”
Family Response: Empathize with the real or possible results of changing. It is possible to give strong advice to change and still be empathetic to possible negative outcomes to changing. Guide her problem solving.
Resigned: “I can’t change; I’ve tried.”
Family Response: Instill hope; explore barriers to change.
Rationalizing: “I don’t use that much.”
Family Response: Decrease discussion. Listen rather than respond to the rationalization. Respond to her by empathizing and reframing her comments to address the conflict of wanting a healthy baby and not knowing whether “using” is really causing harm.
Contemplation
The woman is ambivalent about changing her behavior. She can think of the positive reasons to change but also is very aware of the negative sides of change.
Family Response: Family and friends can share information on the health benefits of changing for the woman and foetus. The woman in contemplation will hear these benefits, and is very aware of the negative aspects of change on her life. Help her explore goals for a healthy pregnancy, and problem solve how to deal with the negative aspects of quitting alcohol and drug use and remaining abstinent.
Preparation
The woman’s ambivalence is shifting toward changing her behavior. She is exploring options to assist her process. She may be experimenting by cutting down or has been able to quit for one or more days. Although her ambivalence is lessening, it is still present and may increase when she is challenged by those around her, triggered by the environment, or is under other types of stress she has handled by using in the past.
Family Response: Acknowledge strengths, anticipate problems and pitfalls to changing, and assist the woman in generating her own plan for obtaining abstinence. Problem solve with her regarding barriers to success. Work on plans for referral to treatment.
Action
The woman has stopped using drugs and/or alcohol.
Family Response: Acknowledge her success and how she is helping her infant and herself; have her share how she has succeeded and how she is coping with the challenges of not using. Offer to be available for assistance if she feels that she wants to use drugs/alcohol again. Provide assistance with treatment referrals: Discuss triggers and social pressures that may lead to relapse, and help the woman plan for them.
Relapse
The woman may relapse; incidence of relapse for those who are abusing or addicted is high.
Family Response: If relapse has occurred, guide the woman toward identifying what steps she used to quit before. Offer hope and encouragement, allow the woman to explore the negative side of quitting and what she can do to deal with those issues. (How did she deal with those issues in the past? Explore what worked and what didn’t work for her.) Offer to provide assistance in finding resources to help her return to abstinence.
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Practitioners
Opioid Abuse in Pregnancy: Guidelines for Health Care Practitioners
Effects on Pregnancy and the Child
- Chronic heroin abuse is associated with an increased risk of fetal growth restriction, abruption placentae, fetal death, preterm labor, and intrauterine passage of meconuim. These effects may be related to the repeated exposure of the fetus to opioid withdrawal and the effects of withdrawal on placental function and may also occur in other types of opioid abuse.
- First-trimester use of codeine has been associated with congenital heart defects in three of four case-control studies. No association has been described between the use of other opioids during pregnancy and an increased rate of birth defects.
- The lifestyle issues associated with illicit drug use put a pregnant woman at risk of engaging in activities such as prostitution, theft, or violence, to support herself and her addiction. The consequences of these activities pose a host of risks to the fetus.
- Neonatal abstinence syndrome (NAS):
- Occurs when newborns of opioid-abusing mothers are withdrawn from narcotic exposure. NAS usually manifests within hours to weeks of birth, when the child is separated from opioids in the mother’s body.
- Symptoms of NAS include hyperactivity of the central and autonomic nervous systems, uncoordinated sucking reflexes leading to poor feeding, increased irritability, and high-pitched crying.
- Long-term data for children with in-utero narcotic exposure is limited, but studies have not found significant decreases in cognitive development with maternal opioid abuse.
Screening for Abuse
- A urine drug screen is the single most useful test to determine if someone is abusing controlled substances.
- Before pregnancy and in early pregnancy, all women should be routinely asked about their use of alcohol and drugs, including prescription drugs. The patient should be informed that such questions are asked of all pregnant women to ensure they receive appropriate care and that all information will be kept confidential. Maintaining a caring and nonjudgmental approach will yield the most inclusive disclosure.
- Signs and symptoms suggestive of a substance abuse disorder:
- Seeking initial prenatal care late in pregnancy
- Poor adherence to appointments
- Poor weight gain
- Sedation, intoxication, or withdrawal symptoms
- Erratic behavior
- Multiple requests for early refills of a prescribed controlled substance
- Pressuring behaviors in the office, such as pleading for another prescription, excessively complimenting the prescribing practitioner, or threatening harm to self or others.
Validated screening tools for identifying prenatal substance abuse:
4P’s
- Parents: Did any of your parents have a problem with alcohol or drug use?
- Partner: Does your partner have a problem with alcohol or drug use?
- Past: In the past, have you had difficulties in your life because of alcohol or other drugs, including prescription medications?
- Present: In the past month, have you drunk any alcohol or used other drugs?
Any “yes” should trigger further assessment.
CRAFFT
(for women aged 26 and younger)
- Car: Have you ever ridden in a car driven by someone (including yourself) who was high or had been using alcohol or drugs?
- Relax: Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?
- Alone: Do you ever use alcohol or drugs while you are by yourself or alone?
- Forget: Do you ever forget things you did while using alcohol or drugs?
- Family: Do your family or friends ever tell you that you should cut down on your drinking or drug use?
- Trouble: Have you ever gotten in trouble while you were using alcohol or drugs?
Two or more “yes” answers should trigger further assessment.
Other questions to ask:
- In the past six months, have you taken any medications to help you calm down, keep from getting nervous or upset, raise your spirits, or make you feel better?
- Have you been taking any medication to help you sleep? Have you been using alcohol for this purpose?
- Have you ever taken a medication to help you with a drug or alcohol problem?
- Have you ever taken a medication for a nervous stomach?
- Have you ever taken a medication to give you more energy or to cut down on your appetite?
- Have you ever taken over-the-counter cold preparations other than when you have had cold symptoms? Do you take over-the-counter diet pills?
- Positive answers to any of these questions warrant further investigation.
Look up each patient in E-FORSCE, Florida’s prescription drug monitoring program, to help determine if she is receiving controlled substances from other practitioners. Request an E-FORSCE account.
Do not use naloxone to diagnose opioid dependence in pregnancy women as opioid withdrawal may precipitate preterm labor or fetal distress.
Pseudoaddiction is a situation in which a patient’s legitimate chronic pain is undertreated with pain medication, leading the patient to act in a way that resembles addictive behavior. This condition usually arises when a clinician is reluctant to prescribe enough of a controlled drug to provide adequate symptom relief. It is important to carefully distinguish pseudoaddiction from true substance abuse.
Treatment
Comprehensive prenatal care and monitoring, chemical dependency counseling, and other psychosocial services for women with opioid dependence should be a part of any treatment plan.
- Methadone
- The rationale for opioid-assisted therapy during pregnancy is to prevent complications of illicit opioid use and opioid withdrawal, encourage prenatal care and drug treatment, reduce criminal activity, and avoid risks to the patient of associating with a drug culture. Comprehensive opioid-assisted therapy that includes prenatal care has been shown to reduce the risk of obstetric complications.
- Perinatal methadone dosages are managed by addiction treatment specialists within registered methadone treatment programs. A list of local treatment programs can be found at the federal Substance Abuse and Mental Health Services Administration.
- The severity of NAS does not appear to differ based on the maternal dosage of methadone treatment.
- Buprenorphine
- Buprenorphine is the only opioid which may be legally prescribed for the treatment of opioid dependence in an office-based setting. Physicians wishing to prescribe this medication must undergo specific credentialing.
- Advantages over methadone include a lower risk of overdose, fewer drug interactions, the ability to be treated on an outpatient basis without the need for daily visits to a methadone clinic, and evidence of less severe NAS.
- Disadvantages to buprenorphine include reports of hepatic dysfunction, lack of long-term data on infant and child effects, a clinically important patient dropout rate due to dissatisfaction with the drug, a more difficult induction with the potential risk of precipitated withdrawal, and an increased risk of diversion.
- The drug is available as a single agent or combined with naloxone, but the single agent is recommended during pregnancy. Although the single agent has a higher risk of abuse, it also has a reduced risk of exposing the fetus to naloxone which could lead to dangerous withdrawal symptoms.
- Medically-supervised withdrawal
- Not recommended because of its association with high relapse rates.
- If this is to be undertaken, however, supervised withdrawal should ideally occur during the second trimester and with the aid of a perinatal addiction specialist. If the only alternative to medically-supervised withdrawal is continued illicit drug use, the withdrawal should take place as soon as possible no matter the trimester.
Breastfeeding should be encouraged in both methadone and buprenorphine patients as minimal levels of these drugs are found in breast milk.
These guidelines are adapted from the American College of Obstetricians and Gynecologists’ Committee Opinion Number 524: Opioid Abuse, Dependence, and Addiction in Pregnancy and UpToDate’s Prescription Drug Abuse and Addiction: Prevention, Identification, and Management.
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Sites
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Florida Department of Children and Families, Office of Substance Abuse and Mental Health
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Zero Exposure Project, Healthy Start Coalition of Hillsborough County
- American Congress of Obstetricians and Gynecologists (quick guides): Drug Information | Teratology/Toxicology | Pregnancy
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Articles, reports and other useful information.
Topics in Brief: Prenatal Exposure to Drugs of Abuse, Drug Abuse among Pregnant Women in the U.S.
National Institute on Drug Abuse - Revised May 2011Prescription Drugs: Abuse and Addiction - Preventing and recognizing prescription drug abuse
National Institute on Drug Abuse - Updated October 2011Combating Misuse and Abuse of Prescription Drugs: Q&A with Michael Klein, Ph.D.
US Food and Drug Administration - Posted July 28, 2010Neonatal Abstinence Syndrome - What you need to know - Dartmouth-Hitchcock Medical Center
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Press Releases
- Attorney General Bondi, the Department of Children and Families and the Department of Health Announce “Born Drug Free Florida” Educational Campaign - Attorney General Pam Bondi News Release - 5/10/13
- Attorney General Pam Bondi, Department of Children and Families, and Department of Health, to Launch New Initiative Involving Prescription Drug Abuse and Newborns - Dept. of Children and Families Media Advisory - 5/9/13
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