Prenatal Alcohol and Drug
Exposure:
Impact and Intervention
November 7, 2007
Conjoint 556
Addiction: Mechanisms, Prevention, Treatment
Therese Grant, Ph.D.
Director, Fetal Alcohol and Drug Unit
Associate Professor
Department of Psychiatry & Behavioral Sciences
University of Washington School of Medicine
Topics
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Teratogenic effects of alcohol and drugs
Fetal alcohol syndrome
Prevalence of prenatal alcohol use
Intervention and Prevention: ParentChild Assistance Program
• Challenges of conducting evidencebased community intervention
Teratogens
• Substances that have the potential to damage
the fetus when exposure occurs during
pregnancy (e.g., radiation, thalidomide,
alcohol).
• Degree of damage depends on timing and
dose of exposure.
• If timing and dose are below the teratogenic
threshold, some exposures have little risk of
causing malformation.
Prenatal Opiate Exposure
• Is not considered teratogenic; no known congenital
malformation is associated.
However:
• May affect prenatal growth due to maternal malnutrition
and co-morbid infections. LBW and intrauterine growth
retardation increase risk of preterm birth.
• Newborns of addicted women can suffer withdrawal. If
mother was IV drug user, children may be at increased
risk for HIV, Hepatitis B & C.
• It’s difficult to differentiate impact of prenatal heroin
exposure and poor postnatal environment on child longterm outcome.
Prenatal Marijuana Exposure
• There is no consistent link between prenatal
marijuana exposure and other adverse
pregnancy outcomes or congenital
malformation.
• Marijuana use during pregnancy may have a
modest effect on prenatal growth, but results
are inconsistent and diminish when potential
cofounders are controlled.
Prenatal Marijuana Exposure
• The principle psychoactive substance in
marijuana, -9-tetrahyrocannabinol (THC),
rapidly crosses the placenta and may remain
in the body for 30 days, thus prolonging
potential fetal exposure.
• Marijuana smoking produces higher levels of
carbon monoxide than tobacco, which may
be a potential mechanism of action of
marijuana’s impact on the developing fetus.
Prenatal Cocaine Exposure
• Cocaine and its metabolites readily cross the
placenta, concentrating in amniotic fluid, and
may produce direct neurotoxic effects,
disturb dopamine, norepinephrine, and
serotonin pathways, and cause vascularmediated damage.
Prenatal Cocaine Exposure
• Associated with obstetric complications: stillbirth,
placental abruption, premature rupture of
membranes, fetal distress, and preterm delivery.
• Growth restriction, but may require higher levels of
exposure and does not seem to persist after birth.
• The few available large, controlled, population-based
studies have reached contradictory conclusions.
CNS lesions (e.g., stroke, possible seizures), cardiac
defects, and genitourinary anomalies have been
reported.
Prenatal Methamphetamine
Exposure
• Impact of meth use during human pregnancy
is currently unknown.
• Animal studies have demonstrated
neurotoxic effects of amphetamines and
alteration of synaptic morphology in
response to prenatal methamphetamine
exposure.
Prenatal Methamphetamine
Exposure
• Women using meth during pregnancy may have an
increased rate of premature delivery and placental
abruption.
• Linked to fetal growth restriction and, occasionally,
withdrawal symptoms requiring pharmacologic
intervention at birth.
• Clefting, cardiac anomalies, and fetal growth reduction
have been described in infants and have been
reproduced in animal studies.
• Later effects on child health are unknown.
Prenatal Tobacco Exposure
• Associated with poor fetal growth; the most
important cause of LBW in developed
countries.
• Linked to myriad perinatal complications and
child health problems (along with
environmental smoke exposure, or ESE).
ESE is implicated in LBW, fetal death, and
preterm delivery.
• Implicated in a range of adverse behavioral
and cognitive outcomes.
Prenatal Tobacco Exposure
• Cigarette smoke contains tar, nicotine, and
carbon monoxide.
• Tar contains substances (lead, cyanide,
cadmium, and more) harmful to the fetus.
• Intrauterine hypoxia, mediated by carbon
monoxide and reduced uterine blood flow, is a
major mechanism of the growth impairment.
• Nicotine crosses the placenta and distributes
freely to the CNS, having direct and indirect
effects on neural development.
Prenatal Alcohol Exposure
Alcohol is a teratogen
Prenatal Alcohol Exposure
Effects have been demonstrated in animals
and humans
Neurobehavioral effects have been found to
be more injurious and long-lasting than
cocaine and other drugs abused prenatally.
Teratogenic Effects
of Prenatal Alcohol Exposure
• Direct toxic effect of alcohol on cells
• Hypoxia (inadequate oxygenation of blood) due to
impaired placental/fetal blood flow
• Effect on cell migration in the brain
• Effect on apoptosis (a natural process of
programmed cell death)
Fetal Alcohol Syndrome
• A permanent birth defect caused by maternal
alcohol use during pregnancy.
• The leading preventable cause of mental
retardation in the Western world.
• Annually: 40,000 infants born with FASD
(more common than Muscular Dystrophy,
Cystic Fibrosis, Downs Syndrome and
Spina Bifida combined).
Growth
Deficiency
FAS
Specific Pattern of
Facial Anomalies
Central Nervous System Dysfunction
Organic Brain Damage
• Hyperactivity, attention deficits
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Intellectual deficits, learning disorders
Problems with memory, language & judgment
Developmental delay, microcephaly
Fine & gross motor problems, seizure disorder
Mental retardation, structural brain damage
Fetal Alcohol Spectrum
Disorders (FASD)
can be
“Hidden Disabilities”
FAS Family Resource Institute
FASD
Central Nervous System Dysfunction
Organic Brain Damage
• Hyperactivity, attention deficits
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•
•
•
•
Intellectual deficits, learning disorders
Problems with memory, language & judgment
Developmental delay, microcephaly
Fine & gross motor problems, seizure disorder
Mental retardation, structural brain damage
FASD: Clinical Implications
Poor judgment ………… Easily victimized
Attention deficits ……… Unfocused / distractible
Arithmetic disability ….. Can’t handle money
Memory problems …..
Doesn’t learn from experience
Difficulty abstracting …. Doesn’t understand
consequences
Disoriented in …………. Fails to perceive social cues
time and space
Poor frustration ………... Quick to anger
tolerance
PREVALENCE OF SECONDARY DISABILITIES
Across the Life Span
100
Ages 6 - 51
Ages 21 - 51
90
80
70
%
60
50
40
30
20
10
Mental Health
Problems
Trouble With
the Law
Disrupted School
Experience
Inappropriate
Sexual Behavior
Confinement
Ages 6-51 (n=408-415)
Dependent
Living
Alcohol & Drug
Problems
Problems with
Employment
Ages 21-51 (n=89-90)
Alcohol Drinking
by Pregnant Women
Western WA: 1989-2004
We conducted three federally-funded
studies on problems associated with
prenatal substance abuse.
Study purposes varied, but all involved
screening hospitalized postpartum
women shortly after delivery for prenatal
alcohol and drug use.
Description of the Studies
Study 1:
Mar. 1989 – Apr. 1991 (N= 7,178)
Prospective study investigated neurodevelopmental
outcomes of children exposed to cocaine in utero
(Obstetrics and Gynecology (1994), 83(4), 524-531)
Study 2:
Jul. 1991 – Dec. 1992 (N=2,330)
Tested efficacy of a 3-year home visitation intervention
(Journal of Community Psychology (2003), 31(3), 211-222)
Study 3:
Jun. 2002 – Mar. 2004 (N=3,145)
Evaluated efficacy of a 12-month intervention program
using a randomized design FAS/ARBD Prevention:
Research to Practice
(APHA 133rd Annual Meeting. Dec. 2005. Philadelphia, PA)
Results
MONTH BEFORE
PREGNANCY
Any
Alcohol
STUDY 1
45%
Binge
Alcohol
DURING PREGNANCY
Any
Alcohol
Binge
Alcohol
9%
30%
3%
41%
10%
23%
4%
43%
14%
12%
1%
1989-1991
STUDY 2
1991-1992
STUDY 3
2002-2004
The Good News
Drinking during pregnancy decreased
between 1989 and 2004
• Public health messages about drinking
during pregnancy have clearly had an
impact.
• In general, when women know they are
pregnant, they decrease their alcohol
consumption.
Remaining Challenges
Binge drinking “pre-pregnancy” (or prior to
pregnancy recognition) has increased between
1989 and 2004
• Up to 60% of women don’t know they are pregnant in
early gestation and may unintentionally drink during
this vulnerable period
• Heavy drinking may lead to unexpected, unprotected
sexual activity
• More than half of all pregnancies in the U.S. are
unintended
February 21, 2005
U.S. Surgeon General Releases
Advisory on Alcohol Use in Pregnancy
Women who are pregnant or who may become
pregnant should abstain from alcohol
consumption in order to eliminate the
chance of giving birth to a baby with any of
the harmful effects of the Fetal Alcohol
Spectrum Disorders (FASD).
This updates a 1981 Surgeon General's Advisory.
If I’m Pregnant, Can I …
…Have a beer?
The Centers for Disease Control says “no level of
alcohol…has been determined safe,” but some
doctors feel limited drinking – no more than a
pint a day, suggests Dr. Gibb – after the first
trimester is okay.
- People Magazine, April 17, 2006, pp 102-107
What would a
cure for addiction
look like?
Community Intervention & Prevention:
Parent-Child Assistance Program (PCAP)
A 3-year intensive home visitation
intervention for high risk mothers
who abuse alcohol and/or drugs
during pregnancy
WHEN CASE MANAGEMENT
ISN’T ENOUGH
The Problem
Maternal alcohol and drug abuse puts
children at risk because of:
· possible effects of prenatal exposure on the
child’s health
· likelihood of a compromised home
environment
· likelihood that these mothers will have more
exposed, affected children
PCAP History
1991-present
• WA State locations: King, Pierce, Yakima, Grant,
Spokane, Cowlitz, Skagit Counties
• Replication sites: MN, NC, AK, TX, NV, LA, PA;
multiple sites in Canada
We thank our sponsors:
Substance Abuse and Mental health Services
Administration (SAMHSA)
WA State Dept. Social and Health Services
Division of Alcohol and Substance Abuse
March of Dimes
Nesholm Family Foundation
Private Philanthropy
Parent-Child Assistance Program
Primary Goal:
To prevent future births
of alcohol and drug exposed
children
Theoretical Framework of the
Intervention
Relational Theory
A woman’s sense of connectedness to
others is central to her growth,
development, definition of self
PCAP Intervention
Long term, positive interpersonal
relationship with case manager
Relational Theory
Consequences of alcohol and drug abuse differ among
women and men in terms of physiological effects and
social consequences.
Positive relationships within the intervention, treatment,
and recovery setting are critical.
The quality of interpersonal relationships:
• may determine whether or not a woman remains
in an intervention
• may be more important to improvement than
concrete services received
PCAP Case Managers
• Have experienced some of the same
types of adverse life circumstances as
clients, but seldom to same degree
• Have subsequently achieved success in
important ways
• Are positive role models and offer clients
hope and motivation from a realistic
perspective
Washington State PCAP
(2007 Annual Work Session)
Theoretical Framework
Stages of Change
Clients will be at different stages of readiness
for change. Motivation is a process for
change that occurs within the context of
interpersonal relationships.
PCAP Intervention
Motivational Interviewing
• acknowledge client’s perception of situation
• encourage her to explore + and – aspects
MOTIVATION
DECISION-MAKING
SELF-EFFICACY
CONTEMPLATION
PRE-CONTEMPLATION
PREPARATION
ACTION
MAINTENANCE
From Prochaska & DiClemente
Theoretical Framework
Harm Reduction
Addiction and associated risks are on a
continuum. The goal is to reduce
harmful consequences of the habit for
mother and her child.
PCAP Intervention
Any steps toward decreased risk are
steps in the right direction.
Characteristics of Effective Case Management
Community Providers
Bio
Mom
Schools
Job
Training
Family
Planning
Caretakers
Juvenile
Justice
Bio
Dad
Siblings
Extended
Family
Probation
Friends
Neighbors
Partners
Alc/Drug
Tx
Children
Health Care
Mental Health
TX
PCAP Case Managers:
• Work with a caseload of 16 families,
make home visits, transport
• Help client identify personal goals,
and teach “baby steps” to achieve
these goals
• Collaborate with network of service
providers to develop specific
plans with client input
• Connect clients with services, monitor
progress
The goal
is to help the client
move along a continuum,
from dependence on the case manager,
to interdependence with the case manager,
to independence and strength on her own.
PCAP Enrollment Criteria
1) Currently pregnant or up to six
months postpartum
2) Used alcohol/drugs heavily during
pregnancy
3) Not effectively connected with
community resources
- OR Have delivered a child with a diagnosis of
FAS/FASD
The Formula for Preventing
Alcohol/Drug Exposed Births
• Motivate women to stop drinking
or using drugs before and
during pregnancy
• Help women who can’t stop
drinking or using drugs to
avoid becoming pregnant
Blended Evaluation Design
1. Original Demonstration Cohort (1991 – 1995)
Quasi-experimental, non-randomized comparison group,
pretest-posttest
2. Post-Program Follow-Up Cohort (1997 – 1998)
Follow-up interview 2.5 yrs after PCAP exit
3. Seattle and Tacoma Replication Cohorts (1996 - 2003)
Study compared pretest/posttest outcomes across 3
sites: OD, SR, TR; no comparison group
PCAP Outcomes at 36 Months
Current Outcomes
N = 403
Inpatient or Outpatient Treatment Completed
or in Progress
89%
Clean & Sober > 6 months at exit
41%
Clean & Sober > 1 yr during program
56%
Received Mental Health Services
70%
In Permanent, Stable Housing
67%
Drug-free Housing/Treatment
7%
PCAP Outcomes at 36 Months
Current Outcomes
N = 403
Regular Family Planning
60%
More Reliable Method
46%
Any Subsequent Birth
Any exposed subsequent birth
25%
14%
Custody of Target Child
Bio Mom
61%
Other Family
17%
Foster Care
12%
Adopted
8%
Systems Working Together
Good things happen
when communities
implement effective
programs and states
implement strong
policy.
Systems Working Together
Substance Abuse Treatment
WA State Division of Alcohol & Substance Abuse
(DASA) increased treatment beds for women:
55 to 153 (1991 - 2007)
Systems Working Together
Family Planning
DSHS “Take Charge” program (1989-present)
• Developed to help low income pregnant
women obtain services
• Recent development:
Free family planning supplies for women
and men at 200% below FPL
Preventing Future Exposed Births
At PCAP replication sites, 78 women were binge drinkers
(>5 drinks/occasion) during the index pregnancy.
At PCAP exit, 51 (66%) were no longer at present risk of
having another alcohol exposed pregnancy:
• 24 (31%) using reliable contraception;
• 18 (23%) abstinent from alcohol/drugs
>= 6 months;
• 9 (12%) both reliable contraceptive and
abstinent.
Preventing Future Exposed Births
Without PCAP about 30% (or 23) of 78 drinking mothers
would have had another highly exposed birth;
We reduced that by 66%, preventing about 15 alcoholexposed births;
Incidence of FAS is estimated at 4.7% to 21% among
heavy drinkers;
Therefore we estimate PCAP prevented at least one and
up to 3 new cases of FAS.
Cost Savings
The average lifetime cost for an individual with FAS
is $1.5 million.
PCAP costs about $15,000/ client for 3-years
(intervention, administration, evaluation).
If we prevented just one new case of FAS, the
estimated lifetime cost savings = cost of PCAP
for 102 women.
Benefits and Costs of Prevention and Early
Intervention Programs for Youth
* Home Visiting Programs
for At-Risk Mothers and Children
Benefits
Costs
Benefits
per
Dollar of
Cost
$11,089
$4,892
$2.27
Benefits
Minus
Costs
$6,197
Washington State Institute for Public Policy, July 2004 found an
average net benefit of $6197 per client among selected
well-researched home visiting programs, including PCAP.*
www.wsipp.wa.gov
Challenges of Practicing Good Science In
Community Intervention Studies
• Randomized trial:
may be perceived as unethical
(solution: one health care provider training
project uses a “wait list” control group)
• “Treatment as usual” problem:
standard treatment or control condition may
vary in multi-site studies
• Meeting study recruitment goals:
may require multiple strategies
Challenges of Practicing Good Science In
Community Intervention Studies
• Measuring exposure:
High-risk women may not present
prenatally, and postnatal assessment may be
biased
• Measuring fidelity of the intervention
• Standardize intervention:
Describe in detail so it can be replicated for
research, clinical purposes
True or False?
• The global war on drugs can be won.
• We can reduce the demand for drugs.
• Reducing the supply of drugs is the
answer.
• U.S. drug policy is the world’s drug
policy.
• Legalization is the best approach.
• Legalization will never happen.
True or False?
Legalization would result in….
• purity assurance under FDA regulation
• labeled concentration of the product (to avoid
overdose)
• obliteration of vigorous marketing (“pushers”)
• obliteration of drug crime and reduction of theft crime
• savings in expensive enforcement
• significant tax revenues
Effort and funds can then be directed to educating
the public about the hazards of all drugs.