- Email: [email protected]
Substance abuse
International
Journal of Gynecology
& Obstetrics 47 (1994) 65-72
ACOG technical bulletin
Substance abuse Number 194 The obstetrician-gynecologist can play a role in substance abuse prevention and treatment. This role may include screening patients by use of questionnaires; providing education, treatment, and referral; guiding and referring high-risk patients; advising patients of social and support groups; practicing safe prescription writing; and addressing the needs of adolescents. Misuse of illegal and controlled drugs, alcohol, and tobacco constitutes a significant national health problem. Data from the most recent National Household Survey on Drug Abuse (1) indicate that 29% of Americans smoke cigarettes, up to 6.7% abuse beverage alcohol, 2% use psychotherapeutic drugs (eg. sedatives, tranquilizers, stimulants, and analgesics), and 7% use illicit drugs (eg, marijuana, cocaine, opioids). Of the nearly 60 million women of childbearing age (15-44 years), over 5 million (9%) have used marijuana or cocaine in the past month. Substance abuse is typified by a wide variety of use patterns, chronic relapsing patterns of dependence, and variation in individual responses and prognosis. Many of those who abuse substances use more than one substance-either an illicit substance or alcohol or tobacco. Typically with alcohol, a woman begins drinking in her teens with problem drinking beginning after 25 years of age. She is often introduced to alcohol or other drug abuse by a codependent male partner.
Subsbum
of Mum and Their Side Effects
Substance abuse can have serious implications for the health of women. Among them are adverse effects on reproductive function and pregnancy (2).
July 1994 In addition to the substance-specific effects described in this bulletin, there are also more generic risks of substance abuse. Abuse of substances is associated with unhealthy life styles. For example, the abuser may trade sex for drugs, exposing her to sexually transmitted diseases. Substance abusers are also at risk for malnutrition. Drug users who share needles are at risk of contracting blood-borne infections such as infection with human immunodeficiency virus or hepatitis B virus. Tobacco
Chronic cigarette smoking has been well documented to have a major adverse impact on women’s health (3). Nicotine is the most studied and most pharmacologically active substance found in cigarette smoke. It is readily inhaled into the lungs as particulate matter in smoke, and blood levels vary depending on the inhalation habits of the smoker, nicotine content of tobacco smoked, and presence or absence of filters. This waterand lipid-soluble substance is metabolized by the liver, kidneys, and lungs, with most eliminated from the body through urinary excretion within 2 hours of cigarette smoking. Coronary artery and peripheral vascular disease, respiratory illness (chronic obstructive lung disease), peptic ulcer disease, esophageal reflux, and cancer (lung, oropharynx, larynx, esophagus, bladder) are morbidities associated with chronic tobacco smoking. Marijuana
Marijuana is derived from the plant Cannabis sarivu. Its principal psychoactive ingredient is 1,Ptetrahydrocan-
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ACOG Technical Bulletin /Int. J. Gynecol. Obstet. 47 (1994) 65-72
nabinol, which is present in large quantities in each marijuana cigarette. This lipophilic substance accumulates in fatty tissues for days before being metabolized by the liver and eliminated in the feces. Marijuana smoking has been associated with tachycardia, exercise intolerance, bronchitis, sinusitis, andpharyngitis. Chronic consumption leads to anovulation and decreased sperm count and motility. Alcohol Beverage alcohol is a water-soluble compound that is readily distilled from a variety of plants. It undergoes first-order metabolism in the liver, and metabolic products are excreted by the kidneys. In 1984, alcohol abuse or dependence was the fourth most frequent psychiatric diagnosis in 18-24-year-old women (4). Approximately 100,000 deaths per year can be attributed to the misuse of alcohol (5). Alcohol use is associated with 50% of fatal automobile accidents, 68% of drownings, 54% of fires, and 48% of serious falls. Chronic alcohol consumption has multiple adverse health effects and is associated with a number of cancers. It is also linked to malnutrition, including deficiencies in thiamine, riboflavin, pyridoxine, niacin, and vitamin C. Cocaine Cocaine is a lipophilic alkaloid extracted from the leaves of Erythroxylon coca. It is generally consumed by snorting, “free-basing” (inhaling cocaine vapors combined with an organic solvent), or smoking the alkaloid itself as “crack.“Cocaine’s major site of action is at the nerve terminal, where it inhibits dopamine, norepinephrine, and serotonin uptake. This results in intense vasoconstriction, arrhythmia, and a concomitant rise in blood pressure (6). Other adverse consequences are seizures, cerebrovascular accidents, psychosis, nasal septal perforation, malnutrition, and hyperthermia. Some cocaine users may trade sex for drugs, resulting in a higher incidence of infectious disease complications, including but not limited to syphilis, hepatitis, and acquired immunodeficiency syndrome (AIDS). Opioids Opioids are a class of drugs derived from opium and synthetic compounds with similar actions. The proto-
typical opioid is morphine. Heroin (diacetylmorphine) is more potent on a gram-for-gram basis but is believed to exert its effects chiefly by being metabolized to morphine. Codeine is methylated morphine and is also metabolized to the parent compound. Other opioids, such as meperidine (Demerol), methadone (Dolophine), and oxycodone (Percodan), are structurally dissimilar to morphine but share its pharmacologic properties, probably by stimulating the same receptors. These agents produce euphoria, somnolence, and decreased sensitivity to pain. Adverse effects of opioid use include constipation, nephrotic syndrome, and overdose. Inhalants Use of inhalants (“glue sniffing,” solvent abuse) tends to be limited to adolescents. These substances are lipophilic and readily pass through the respiratory tract. Their use may be accompanied by arrhythmias leading to sudden death. They may also cause bone marrow toxicity, liver damage, renal failure, peripheral neuropathy, atrophy, parethesias, cerebellar signs, and organic brain syndrome. Hallucinogens Phencyclidine (PCP, “angel dust”) is an amphetaminelikecompound. Lysergic aciddiethylamide (LSD) shares many similar properties. Both of these agents are thought to aggravate latent schizophrenia. Their use may lead to chronic psychosis, flashbacks, and violent behavior. Amphetamines and Barbiturates Abuse of medications may occur alone or in combination with other substances to reduce the uncomfortable side effects of polydmg abuse. Use of amphetamines (“uppers”) may be accompanied or followed by use of barbiturates (“downers”); benzodiazepines may be taken with cocaine (“moon-walking”). Repeated ingestion of these central nervous system stimulants and depressants may lead to cognitive impairment and psychologic depression.
Prevention Obstetrician-gynecologists have important opportunities for prevention of substance abuse. Three of the key areas in which they can make an impact are prescribing
ACOG Technical Bulletin /Int. J. Gynecol. Obstet. 47 (1994) 65-72
appropriately, encouraging healthy behaviors through providing appropriate information and education, and identifying and referring patients already abusing drugs. Several occasions for substance abuse screening and prevention exist in daily practice. Pregnancy and visits for medical problems which may be exacerbated by substance abuse are two examples. Awareness of populations that may be at higher risk for substance abuse can aid clinicians in their prevention efforts: ??Biological daughter of alcoholic or drug-abusing parent(s) ??Spouse of an alcoholic or drug abuser ?? Women who have recently experienced a traumatic life event -Divorce or separation -Death of spouse or significant other -Job loss -Retirement -Rape or sexual abuse -Witness to a traumatic event ?? Women with a physical handicap or disability ?? Health care professionals ?? Women who have a psychiatric disorder (eg, depression, psychosis, anxiety, hyperactivity) When prescribing potentially addictive substances, the clinician should carefully assess the risks of drug treatment and should consider nonpharmacologic treatments or nonaddicting medications whenever possible (7). Potentially addictive drugs should be initially prescribed at a dose adequate to relieve symptoms and then be reduced gradually to the smallest effective dose. Use of the following guidelines may be helpful: ?? Take a thorough history of current and past prescription drug use, over-the-counter and othernonprescription drug use, and alcohol use. ?? Prescribe according to a fixed schedule to minimize the reinforcement of symptoms, medication-seeking behavior, and illness behavior that occurs with “as needed” dosing. ?? Prescribe for short periods of time during treatment of acute syndromes. Avoid more than one refill and telephone refills. Reassess the patient at frequent intervals.
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?? Write prescription orders in such a way as to make them impossible to alter. As an example, write the prescription as “dispense 30 (thirty).” ?? Document prescription rationale, including the exact quantity prescribed. The clinician should remain alert for clues that a patient might be seeking psychoactive medication by exaggerating symptoms (8). These individuals may complain of losing prescriptions or medications and repeatedly report running out of medications before the time that would be expected if medications were taken as prescribed. They often seek narcotic or tranquilizer prescriptions from multiple physicians or claim that another doctor, who is now unavailable, prescribed a certain narcotic that now needs to be refilled. They may insist on a particular drug by brand name and claim that nothing else works or demand an immediate prescription of a strong narcotic for a chronic illness. Educating all patients about the effects of drugs is important. Activities to be avoided while taking the medication and potential interactions with other medications need to be understood. The clinician should describe the potential for a drug to produce dependence if directions are not followed and make clear the dosage and effect when mixed with other substances. The clinician should also warn about the dangers of misuse of a drug and assess the patient’s understanding.
HIStOry Directing questions in the history to levels of use of alcohol, tobacco, and other drugs helps to indicate when further investigation is needed. Patients tend to minimize substance abuse problems and often give inaccurate information regarding quantity consumed. Alcoholics may underreport the actual amount of alcohol consumed but may be more accurate regarding frequency of use. When asked questions regarding quantity and frequency of substance use, patients may feel threatened or defensive or may be concerned about confidentiality. Self-report of use is more accurate when patients are sober and less accurate when they are intoxicated. The best quantitative data are obtained when asking about the specific use on a specific memorable day (eg, “Tell me what you drank yesterday”).
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ACOG Technical Bulletin / Int. J.
Several instruments have been developed that can be very useful as brief screening tests in the office and can be integrated into a patient intake questionnaire. The most widely known of these is a four-question screening test known as the CAGE questionnaire (9). This questionnaire has a 91% sensitivity and 77% specificity for detecting problem drinking. One positive response indicates reason for concern; two positive responses indicate that a problem is likely. The CAGE questions are shown in the box. At the time of the comprehensive initial office visit or annual checkup, patients should be asked whether they consume alcohol. If the patient states that she does not drink, usually no further screening is necessary. Patients who respond that they do drink should be asked the CAGE questions to help ascertain the level of their alcohol consumption. By combining the CAGE with the broader, standard office interview questions, the primary care clinician has a reasonably effective means of detecting current or developing alcohol dependence. Patients who reply affirmatively to only one of the first three CAGE questions may respond to brief office intervention, often combined with more frequent follow-up visits. The need for an “‘eyeopener” is generally considered a more serious indication of alcohol dependence. Whether treatment consists of office interventions or referral depends upon the individual physician’s experience and judgment. Use of CAGE questions in patient interviews and brief office intervention techniques have been integrated into the curricula of many medical school and residency programs.
Gynecol.Obsret. 47 (1994) 65-72
Other questionnaires that may assist the clinician in discovering problem drinking include the T-ACE (lo), the MAST (Michigan Alcohol Screening Test) and Brief MAST (1 l), and a Trauma Scale (12).
Psychologic and Physical Findings There are a variety of common presenting complaints that are associated with substance use problems. Psychologic problems associated with substance abuse or
Signs and Symptomsof Substance Abuse Physical Findings Track marks and other evidence of intravenous drug use Alcohol on the breath Scars, injuries Hypertension Tachycardia or bradycardia Tremors Slurred speech Self-neglect or poor hygiene Liver or renal disease Runny nose Chronic cough Cheilosis Nervous mannerisms (eg, frequently licking lips, jitters, foot tapping) Pinpoint or dilated pupils Reproductive dysfunction (hypogonadism, irregular menses, miscarriage, infertility, fetal alcohol syndrome) Psychologic
CAGEQuestionnaire C = Have you ever felt you ought to I;ut down on your drinking? A = Have people Annoyed you by criticizing your drinking? G = Have you ever felt bad or Puilty about your drinking? E = Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye opener)? Ewing JA. Detectingalcoholism:the CAGE questionnaire. JAMA 1984;252:1907
Problems
Memory loss Depression Anxiety Panic Paranoia Unexplained mood swings Personality changes Intellectual changes Sexual promiscuity Dishonesty Unreliability Adapted from Cyr MG. Assessment and diagnosis. In: Dub6 CE, Goldstein MD, Lewis DC, Myers ER, Zwick WR, eds. Project ADEPT curriculum for primary care physician training. Vol 1. Providence, Rhode Island: Brown University, 1989
ACOG Technical Bulleiin /Int. J. Gynecol. Obstet. 47 (1994) 65-72
dependence frequently are brought to the attention of the clinician by a relative. Vague physical symptoms such as fatigue, insomnia, headaches, sexual problems, and loss of appetite should prompt early suspicion of substance use. Definitive psychologic and physical evidence of substance abuse usually does not become apparent until late in the disease process. Findings considered to be “red flags” for substance abuse are summarized in the box. laboratory
Tests
for Screening and Diagnosis
Blood Alcohol Level Screening for alcohol abuse by questionnaire has a higher probability of detecting problem alcohol use than laboratory tests. Tests are best used to aid the assessment of alcohol abuse. Determining the blood alcohol level has limited application since ethanol is eliminated relatively rapidly. It will not predict the patient’s overall drinking behaviors. Important indicators of tolerance to alcohol are blood alcohol levels of greater than: w 300 mg/dl at any time ??100 mg/dl during a routine physical examination ??150 mg/dl without evidence of gross neurologic impairment Liver Function Tests Liver fUnCtiOU tests are of some use in assessing the severity of alcohol consumption. An assessment of ‘yglutamyltransferase is the most sensitive liver function test for alcohol abuse but is only about 50% sensitive in detecting problem drinking. It is one of the best early indicators of alcoholism and is elevated in 75% of subjects who have been drinking for several weeks. After a patient stops drinking, several weeks must pass before this test returns to normal. Aspartate arninotransferase and alanine aminotransferase (formerly known as serum glutamic-oxaloacetic transaminase and serum glutamate pyruvate transaminase, respectively) have low sensitivity and specificity for alcohol consumption. Hematologic Tests An elevated mean corpuscular volume in the complete blood count may reflect the macrocytosis associated with chronic alcohol abuse. This may be due to direct
69
toxic effects of ethanol upon the developing erythroblasts in bone marrow, associated folate or vitamin B,, deficiency, or liver disease. Anemia may be due to folate deficiency, gastrointestinal bleeding, or suppression of bone marrow. Blood panels show some promise for identification of alcohol abuse but have not been particularly useful in clinical practice. Toxicology Urine toxicology screens are widely used to detect common drugs of abuse. Immunoassay procedures are the most sensitive of these techniques, but confirmatory testing with gas chromatography/mass spectrometry is used by many laboratories to reduce false-positives. Certain foods (eg, poppy seeds) and medications (eg, decongestants) produce false-positives. Urine drug screening is not foolproof, just as questionnaires will not always identify substance abuse problems because of patient denial. When used appropriately, a urine drug screen can identify a substance abuse problem when other detection methods have not. A total drug-screening program should consist of both questionnaires and drug testing. Most laboratories perform a standard “drug panel” aimed at the most commonly used illicit drugs (eg, marijuana, cocaine, amphetamines, barbiturates, opioids). Less commonly used illicit drugs (eg, LSD) may not be detected. Population and regional trends in illicit drug use are often known by local emergency medicine departments. These may serve as a source for more specific information about local trends in drug abuse and prompt more specific testing. When the physician suspects that drug use is associated with clinical behavior or outcome, directed questioning may be informative. Sometimes the patient may have consumed an adulterated substance or the phenomenon of denial may prohibit discovery of the substance in this way. In these circumstances, the physician must use any local knowledge of what drugs are “on the street” combined with information from emergency departments and, finally, observation of the patient’s behavioral status (eg, hallucinations, agitation, drowsiness) and examination (eg, alcoholic fetor, white powder in nares) to assist in drug testing. Individuals wishing to avoid detection of their substance use may attempt to adulterate the specimen or dilute or “washout” a substance by consuming large
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ACOG Technical Bulletin /Inr. J Gynecol. Obsret. 47 (1994) 65-72
quantities of water prior to testing. The increased sensitivity of modem drug tests usually results in detection despite these attempts. Screening with prior approval can be random and is useful in helping persons in denial who are resistant to therapy. Ethics of Drug Testing Since positive results have implications for patients that transcend their health, they should give informed consent prior to testing. When there is no suspicion of substance abuse, random checks of a patient’s urine for substances are unethical. A false-positive from such testing might have devastating consequences for the patient and clinician. The patient’s medical records are confidential, and protection of herrights is of the utmost importance. Medical circumstances occasionally arise in which this consent is considered unnecessary or unobtainable. Patients who are in a stupor, unconscious, or show obvious signs of intoxication need to be tested in order to direct further medical interventions.
Role of the Obstetrician-Gynecologist in Diagnosis and Treatment Obstetrician-gynecologists generally are unaware of options and community resources available for substance abuse intervention and treatment. Hospital social workers are among the best resources for this information. There are several important roles the primary care provider fills in the diagnosis and treatment of substance abuse that benefit these patients. Often, encouragement and support provided by the physician may lead the patient to reduce or eliminate substance use. This aids in preventing medical and psychosocial complications of substance use. Patient education and early diagnosis and referral for treatment are key parts of this total patient care. As the most significant health care practitioner for many women, the obstetrician-gynecologist may be influential in a patient’s decision to accept treatment or referral. The obstetrician-gynecologist may wish to offer or participate in treatment for low-level substance abuse. This may consist of follow-up office visits to monitor substance use, substance abuse, or treatment compliance. Providing additional information through direct-
ed readings and educational materials about substance abuse is beneficial. Self-help and other treatment programs like Narcotics Anonymous, Alcoholics Anonymous, and Al Anon are important resources. Family members may be involved to help address different aspects of the substance abuse problem. Finally, the obstetrician-gynecologist should be willing to encourage the patient’s participation in her treatment plan. Prescription of potentially addictive medications should be avoided. Treatment or referral for medical or psychiatric complications and comorbidities should be managed in accordance with the physician’s expertise in this field and the patient’s wishes. Barriers to Diagnosis and Treatment Not all patients will readily acknowledge a substance abuse problem and cooperate with a treatment plan. It is helpful, therefore, for the clinician to be aware of certain common impediments to diagnosis and treatment. Denial is a psychologic defense against acknowledging the personal pain caused by a substance abuse problem. This contributes to underreporting of consumption and resistance to treatment. The denial may be subconscious, thus keeping patients from getting relevant information and treatment. If tolerance to a substance develops, it may contribute to denial. With continued use of an addicting drug, the patient experiences fewer and fewer effects of the drug over time. Higher doses are required to achieve the desired effect. Patients often do not feel or appear intoxicated, even after recent drug use. Attempts by others to “help” the substance abuser by smoothing over problems which result from substance abuse are known as “enabling.“This may consist of covering at work or school, hiding the substance use problem from superiors, supplying alcohol or drugs to avoid confrontation or other unpleasant effects, and minimizing or ignoring the substance abuse problem. The physician may actually be an enabler through the provision of inappropriate prescription drugs, providing doctor’s notes for work missed because of substance abuse, or by giving tacit approval for substance abuse by not addressing the problem. Physicians may have their own uncertainty about the appropriateness of personal substance use habits. They often misunderstand the chronic, relapsing nature of alcohol or psychoactive substance abuse and dependence. They may not
A COG Technical Bulletin / Int. J. Gynecol. Obstet. 47 (1994) 65-72
appreciate the intensity of the urge to use and the preoccupation with the substance the patient experiences. Physicians should avoid contributing to addiction by prescribing nonaddictive medications whenever they are available. If the patient has a significant other who has adapted to the substance use problem in order to maintain equilibrium in their relationship, this codependency is particularly important to consider when the patient is resistant to referral or seeking help. Treatment or counseling aimed at the issues of codependency is often required. Pharmacologic Agents Used in Treatment While clinicians already play a prominent role in promoting smoking cessation programs, it is anticipated that the introduction of new oral and transdermal nicotine substitutes will bring increasing numbers of patients for therapy. A recent review of these systems suggests that physician support and education must be used in conjunction with any prescription for these therapies (13). Introduction of nicotine gum was the first attempt to provide a substitute for cigarettes. Early popularity of this approach has been dampened by recognition that cigarette craving is not reduced since peak and trough swings occur with gum consumption. The recently approved transdermal systems may overcome this limitation by achieving sustained trough levels over long periods of time. Short-term results suggest that the number of active nicotine patch users who quit smoking is about twice that of placebo patch users. There is little evidence to suggest that the patch should be used longer than 6-8 weeks. Relapse prevention is just as important with cigarettes as with other substances, and long-term behavior modification and reinforcement are extremely important. Data on the use of nicotine gum and patches in special populations (eg, those with coronary artery disease, pregnant women) are limited. Patients in treatment programs for other drugs may be taking supplemental pharmacologic agents. The three most commonly used agents are disulfiram (Antabuse), methadone, and naltrexone (Trexan). Disulfiram is used to ensure abstinence from alcohol in conjunction with supportive therapy. Ingestion of alcohol while taking this medication results in nausea and vomiting. Liver
71
functions should be monitored regularly in these patients. Methadone is used to treat narcotic withdrawal. This long-acting narcotic is used in maintenance treatment of narcotic addiction. Naltrexone is used to block the “high” associated with opioid drug use. It is used in detoxified, formerly opioid-dependent patients to help prevent relapse. Patients with intact families and jobs benefit most from this treatment.
Summary Obstetrician-gynecologists have a clear role in substance abuse prevention and treatment. Knowledge of key risk factors, familiarity with substance abuse screening techniques, and identification of the symptoms and signs of abuse are all components in this process.
REFERENCES 1.
National Institute on Drug Abuse. National Household Survey on Drug Abuse: highlights, 1988. Rockville, Maryland: U.S. Department of Health and Human Services, 1990; DHHS publication no. (ADM)90- 168 1
2.
American College of Obstetricians and Gynecologists. Substance abuse in pregnancy. ACOG Technical Bulletin 195. Washington, DC: ACOG, 1994
3. American College of Obstetricians and Gynecologists. Smoking and reproductive health. ACOG Technical Bulletin 180. Washington, DC: ACOG, 1993
4. Blume SB. Women and alcohol: a review. JAMA 1986; 256: 1467-1469
5. U.S. Department of Health and Human Services. Prevention 89/90: federal programs and progress. Washington, DC: U.S. Government Printing Office, 1990
6. Ritchie JM, Greene NM. Local anesthetics. In: Gilman AG, Goodman LS, Rall TW, Murad F, eds. The pharmacological basis of therapeutics. 7th ed. New York: Macmillan, 1985:302-321 Schuckit MA, ed. Drug and alcohol abuse: a clinical guide to diagnosis and treatment. 3rd ed. New York: Plenum Medical Book Co, 1989:45-95 Dubovsky SL, Weissberg MP. Use of addictive drugs. In: Clinical psychiatry in primary care. 2nd ed. Baltimore, Maryland: Williams & Wilkins, 1982: 130-133 Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA 1984;252:1905-1907
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10. Sokol RJ, Martier SS, Ager JW. The T-ACE questions: practical prenatal detection of risk-drinking. Am J Obstet Gynecol 1989;160:863-870
12. Skinner HA, Holt S, Schuller R, Roy J, Israel Y. Identification of alcohol abuse using laboratory tests and a history of trauma. Ann Intern Med 1984;101:847-851
11. Pokomy AD, Miller BA, Kaplan HB. The brief MAST: a shortened version of the Michigan Alcoholism Screening Test. Am J Psychiatry 1972;129:342-345
13. Fiore MC, Jorenby DE, Baker TB, Kenford SL. Tobacco dependence and the nicotine patch: clinical guidelines for effective use. JAMA 1992;268:2687-2694
This Technical Bulletin was developed under the direction of the Committee on Technical Bulletins of the American College of Obstetricians and Gynecologists as an educational aid to obstetricians and gynecologists. The committee wishes to thank James T. Christmas, MD, for his assistance in the development of this bulletin and Robert A. Welch, MD, and Robert J. Sokol, MD, for their contributions to this bulletin. This Technical Bulletin does not define a standard of care, nor is it intended to dictate an exclusive course of management. It presents recognized methods and techniques of clinical practice for consideration by obstetrician-gynecologists for incorporation into their practices. Variations of practice taking into account the needs of the individual patient, resources, and limitations unique to the institution or type of practice may be appropriate. Requests for photocopies should be directed to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923. Copyright 0 July 1994 ISSN 1074-8628 THE AMEGICAN COUEGE OF OGSTETRICIANS AND 6YNECOWGISTS 409 12th Street, SW Washington, DC 20024.2l88
Journal of Gynecology
& Obstetrics 47 (1994) 65-72
ACOG technical bulletin
Substance abuse Number 194 The obstetrician-gynecologist can play a role in substance abuse prevention and treatment. This role may include screening patients by use of questionnaires; providing education, treatment, and referral; guiding and referring high-risk patients; advising patients of social and support groups; practicing safe prescription writing; and addressing the needs of adolescents. Misuse of illegal and controlled drugs, alcohol, and tobacco constitutes a significant national health problem. Data from the most recent National Household Survey on Drug Abuse (1) indicate that 29% of Americans smoke cigarettes, up to 6.7% abuse beverage alcohol, 2% use psychotherapeutic drugs (eg. sedatives, tranquilizers, stimulants, and analgesics), and 7% use illicit drugs (eg, marijuana, cocaine, opioids). Of the nearly 60 million women of childbearing age (15-44 years), over 5 million (9%) have used marijuana or cocaine in the past month. Substance abuse is typified by a wide variety of use patterns, chronic relapsing patterns of dependence, and variation in individual responses and prognosis. Many of those who abuse substances use more than one substance-either an illicit substance or alcohol or tobacco. Typically with alcohol, a woman begins drinking in her teens with problem drinking beginning after 25 years of age. She is often introduced to alcohol or other drug abuse by a codependent male partner.
Subsbum
of Mum and Their Side Effects
Substance abuse can have serious implications for the health of women. Among them are adverse effects on reproductive function and pregnancy (2).
July 1994 In addition to the substance-specific effects described in this bulletin, there are also more generic risks of substance abuse. Abuse of substances is associated with unhealthy life styles. For example, the abuser may trade sex for drugs, exposing her to sexually transmitted diseases. Substance abusers are also at risk for malnutrition. Drug users who share needles are at risk of contracting blood-borne infections such as infection with human immunodeficiency virus or hepatitis B virus. Tobacco
Chronic cigarette smoking has been well documented to have a major adverse impact on women’s health (3). Nicotine is the most studied and most pharmacologically active substance found in cigarette smoke. It is readily inhaled into the lungs as particulate matter in smoke, and blood levels vary depending on the inhalation habits of the smoker, nicotine content of tobacco smoked, and presence or absence of filters. This waterand lipid-soluble substance is metabolized by the liver, kidneys, and lungs, with most eliminated from the body through urinary excretion within 2 hours of cigarette smoking. Coronary artery and peripheral vascular disease, respiratory illness (chronic obstructive lung disease), peptic ulcer disease, esophageal reflux, and cancer (lung, oropharynx, larynx, esophagus, bladder) are morbidities associated with chronic tobacco smoking. Marijuana
Marijuana is derived from the plant Cannabis sarivu. Its principal psychoactive ingredient is 1,Ptetrahydrocan-
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ACOG Technical Bulletin /Int. J. Gynecol. Obstet. 47 (1994) 65-72
nabinol, which is present in large quantities in each marijuana cigarette. This lipophilic substance accumulates in fatty tissues for days before being metabolized by the liver and eliminated in the feces. Marijuana smoking has been associated with tachycardia, exercise intolerance, bronchitis, sinusitis, andpharyngitis. Chronic consumption leads to anovulation and decreased sperm count and motility. Alcohol Beverage alcohol is a water-soluble compound that is readily distilled from a variety of plants. It undergoes first-order metabolism in the liver, and metabolic products are excreted by the kidneys. In 1984, alcohol abuse or dependence was the fourth most frequent psychiatric diagnosis in 18-24-year-old women (4). Approximately 100,000 deaths per year can be attributed to the misuse of alcohol (5). Alcohol use is associated with 50% of fatal automobile accidents, 68% of drownings, 54% of fires, and 48% of serious falls. Chronic alcohol consumption has multiple adverse health effects and is associated with a number of cancers. It is also linked to malnutrition, including deficiencies in thiamine, riboflavin, pyridoxine, niacin, and vitamin C. Cocaine Cocaine is a lipophilic alkaloid extracted from the leaves of Erythroxylon coca. It is generally consumed by snorting, “free-basing” (inhaling cocaine vapors combined with an organic solvent), or smoking the alkaloid itself as “crack.“Cocaine’s major site of action is at the nerve terminal, where it inhibits dopamine, norepinephrine, and serotonin uptake. This results in intense vasoconstriction, arrhythmia, and a concomitant rise in blood pressure (6). Other adverse consequences are seizures, cerebrovascular accidents, psychosis, nasal septal perforation, malnutrition, and hyperthermia. Some cocaine users may trade sex for drugs, resulting in a higher incidence of infectious disease complications, including but not limited to syphilis, hepatitis, and acquired immunodeficiency syndrome (AIDS). Opioids Opioids are a class of drugs derived from opium and synthetic compounds with similar actions. The proto-
typical opioid is morphine. Heroin (diacetylmorphine) is more potent on a gram-for-gram basis but is believed to exert its effects chiefly by being metabolized to morphine. Codeine is methylated morphine and is also metabolized to the parent compound. Other opioids, such as meperidine (Demerol), methadone (Dolophine), and oxycodone (Percodan), are structurally dissimilar to morphine but share its pharmacologic properties, probably by stimulating the same receptors. These agents produce euphoria, somnolence, and decreased sensitivity to pain. Adverse effects of opioid use include constipation, nephrotic syndrome, and overdose. Inhalants Use of inhalants (“glue sniffing,” solvent abuse) tends to be limited to adolescents. These substances are lipophilic and readily pass through the respiratory tract. Their use may be accompanied by arrhythmias leading to sudden death. They may also cause bone marrow toxicity, liver damage, renal failure, peripheral neuropathy, atrophy, parethesias, cerebellar signs, and organic brain syndrome. Hallucinogens Phencyclidine (PCP, “angel dust”) is an amphetaminelikecompound. Lysergic aciddiethylamide (LSD) shares many similar properties. Both of these agents are thought to aggravate latent schizophrenia. Their use may lead to chronic psychosis, flashbacks, and violent behavior. Amphetamines and Barbiturates Abuse of medications may occur alone or in combination with other substances to reduce the uncomfortable side effects of polydmg abuse. Use of amphetamines (“uppers”) may be accompanied or followed by use of barbiturates (“downers”); benzodiazepines may be taken with cocaine (“moon-walking”). Repeated ingestion of these central nervous system stimulants and depressants may lead to cognitive impairment and psychologic depression.
Prevention Obstetrician-gynecologists have important opportunities for prevention of substance abuse. Three of the key areas in which they can make an impact are prescribing
ACOG Technical Bulletin /Int. J. Gynecol. Obstet. 47 (1994) 65-72
appropriately, encouraging healthy behaviors through providing appropriate information and education, and identifying and referring patients already abusing drugs. Several occasions for substance abuse screening and prevention exist in daily practice. Pregnancy and visits for medical problems which may be exacerbated by substance abuse are two examples. Awareness of populations that may be at higher risk for substance abuse can aid clinicians in their prevention efforts: ??Biological daughter of alcoholic or drug-abusing parent(s) ??Spouse of an alcoholic or drug abuser ?? Women who have recently experienced a traumatic life event -Divorce or separation -Death of spouse or significant other -Job loss -Retirement -Rape or sexual abuse -Witness to a traumatic event ?? Women with a physical handicap or disability ?? Health care professionals ?? Women who have a psychiatric disorder (eg, depression, psychosis, anxiety, hyperactivity) When prescribing potentially addictive substances, the clinician should carefully assess the risks of drug treatment and should consider nonpharmacologic treatments or nonaddicting medications whenever possible (7). Potentially addictive drugs should be initially prescribed at a dose adequate to relieve symptoms and then be reduced gradually to the smallest effective dose. Use of the following guidelines may be helpful: ?? Take a thorough history of current and past prescription drug use, over-the-counter and othernonprescription drug use, and alcohol use. ?? Prescribe according to a fixed schedule to minimize the reinforcement of symptoms, medication-seeking behavior, and illness behavior that occurs with “as needed” dosing. ?? Prescribe for short periods of time during treatment of acute syndromes. Avoid more than one refill and telephone refills. Reassess the patient at frequent intervals.
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?? Write prescription orders in such a way as to make them impossible to alter. As an example, write the prescription as “dispense 30 (thirty).” ?? Document prescription rationale, including the exact quantity prescribed. The clinician should remain alert for clues that a patient might be seeking psychoactive medication by exaggerating symptoms (8). These individuals may complain of losing prescriptions or medications and repeatedly report running out of medications before the time that would be expected if medications were taken as prescribed. They often seek narcotic or tranquilizer prescriptions from multiple physicians or claim that another doctor, who is now unavailable, prescribed a certain narcotic that now needs to be refilled. They may insist on a particular drug by brand name and claim that nothing else works or demand an immediate prescription of a strong narcotic for a chronic illness. Educating all patients about the effects of drugs is important. Activities to be avoided while taking the medication and potential interactions with other medications need to be understood. The clinician should describe the potential for a drug to produce dependence if directions are not followed and make clear the dosage and effect when mixed with other substances. The clinician should also warn about the dangers of misuse of a drug and assess the patient’s understanding.
HIStOry Directing questions in the history to levels of use of alcohol, tobacco, and other drugs helps to indicate when further investigation is needed. Patients tend to minimize substance abuse problems and often give inaccurate information regarding quantity consumed. Alcoholics may underreport the actual amount of alcohol consumed but may be more accurate regarding frequency of use. When asked questions regarding quantity and frequency of substance use, patients may feel threatened or defensive or may be concerned about confidentiality. Self-report of use is more accurate when patients are sober and less accurate when they are intoxicated. The best quantitative data are obtained when asking about the specific use on a specific memorable day (eg, “Tell me what you drank yesterday”).
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Several instruments have been developed that can be very useful as brief screening tests in the office and can be integrated into a patient intake questionnaire. The most widely known of these is a four-question screening test known as the CAGE questionnaire (9). This questionnaire has a 91% sensitivity and 77% specificity for detecting problem drinking. One positive response indicates reason for concern; two positive responses indicate that a problem is likely. The CAGE questions are shown in the box. At the time of the comprehensive initial office visit or annual checkup, patients should be asked whether they consume alcohol. If the patient states that she does not drink, usually no further screening is necessary. Patients who respond that they do drink should be asked the CAGE questions to help ascertain the level of their alcohol consumption. By combining the CAGE with the broader, standard office interview questions, the primary care clinician has a reasonably effective means of detecting current or developing alcohol dependence. Patients who reply affirmatively to only one of the first three CAGE questions may respond to brief office intervention, often combined with more frequent follow-up visits. The need for an “‘eyeopener” is generally considered a more serious indication of alcohol dependence. Whether treatment consists of office interventions or referral depends upon the individual physician’s experience and judgment. Use of CAGE questions in patient interviews and brief office intervention techniques have been integrated into the curricula of many medical school and residency programs.
Gynecol.Obsret. 47 (1994) 65-72
Other questionnaires that may assist the clinician in discovering problem drinking include the T-ACE (lo), the MAST (Michigan Alcohol Screening Test) and Brief MAST (1 l), and a Trauma Scale (12).
Psychologic and Physical Findings There are a variety of common presenting complaints that are associated with substance use problems. Psychologic problems associated with substance abuse or
Signs and Symptomsof Substance Abuse Physical Findings Track marks and other evidence of intravenous drug use Alcohol on the breath Scars, injuries Hypertension Tachycardia or bradycardia Tremors Slurred speech Self-neglect or poor hygiene Liver or renal disease Runny nose Chronic cough Cheilosis Nervous mannerisms (eg, frequently licking lips, jitters, foot tapping) Pinpoint or dilated pupils Reproductive dysfunction (hypogonadism, irregular menses, miscarriage, infertility, fetal alcohol syndrome) Psychologic
CAGEQuestionnaire C = Have you ever felt you ought to I;ut down on your drinking? A = Have people Annoyed you by criticizing your drinking? G = Have you ever felt bad or Puilty about your drinking? E = Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye opener)? Ewing JA. Detectingalcoholism:the CAGE questionnaire. JAMA 1984;252:1907
Problems
Memory loss Depression Anxiety Panic Paranoia Unexplained mood swings Personality changes Intellectual changes Sexual promiscuity Dishonesty Unreliability Adapted from Cyr MG. Assessment and diagnosis. In: Dub6 CE, Goldstein MD, Lewis DC, Myers ER, Zwick WR, eds. Project ADEPT curriculum for primary care physician training. Vol 1. Providence, Rhode Island: Brown University, 1989
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dependence frequently are brought to the attention of the clinician by a relative. Vague physical symptoms such as fatigue, insomnia, headaches, sexual problems, and loss of appetite should prompt early suspicion of substance use. Definitive psychologic and physical evidence of substance abuse usually does not become apparent until late in the disease process. Findings considered to be “red flags” for substance abuse are summarized in the box. laboratory
Tests
for Screening and Diagnosis
Blood Alcohol Level Screening for alcohol abuse by questionnaire has a higher probability of detecting problem alcohol use than laboratory tests. Tests are best used to aid the assessment of alcohol abuse. Determining the blood alcohol level has limited application since ethanol is eliminated relatively rapidly. It will not predict the patient’s overall drinking behaviors. Important indicators of tolerance to alcohol are blood alcohol levels of greater than: w 300 mg/dl at any time ??100 mg/dl during a routine physical examination ??150 mg/dl without evidence of gross neurologic impairment Liver Function Tests Liver fUnCtiOU tests are of some use in assessing the severity of alcohol consumption. An assessment of ‘yglutamyltransferase is the most sensitive liver function test for alcohol abuse but is only about 50% sensitive in detecting problem drinking. It is one of the best early indicators of alcoholism and is elevated in 75% of subjects who have been drinking for several weeks. After a patient stops drinking, several weeks must pass before this test returns to normal. Aspartate arninotransferase and alanine aminotransferase (formerly known as serum glutamic-oxaloacetic transaminase and serum glutamate pyruvate transaminase, respectively) have low sensitivity and specificity for alcohol consumption. Hematologic Tests An elevated mean corpuscular volume in the complete blood count may reflect the macrocytosis associated with chronic alcohol abuse. This may be due to direct
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toxic effects of ethanol upon the developing erythroblasts in bone marrow, associated folate or vitamin B,, deficiency, or liver disease. Anemia may be due to folate deficiency, gastrointestinal bleeding, or suppression of bone marrow. Blood panels show some promise for identification of alcohol abuse but have not been particularly useful in clinical practice. Toxicology Urine toxicology screens are widely used to detect common drugs of abuse. Immunoassay procedures are the most sensitive of these techniques, but confirmatory testing with gas chromatography/mass spectrometry is used by many laboratories to reduce false-positives. Certain foods (eg, poppy seeds) and medications (eg, decongestants) produce false-positives. Urine drug screening is not foolproof, just as questionnaires will not always identify substance abuse problems because of patient denial. When used appropriately, a urine drug screen can identify a substance abuse problem when other detection methods have not. A total drug-screening program should consist of both questionnaires and drug testing. Most laboratories perform a standard “drug panel” aimed at the most commonly used illicit drugs (eg, marijuana, cocaine, amphetamines, barbiturates, opioids). Less commonly used illicit drugs (eg, LSD) may not be detected. Population and regional trends in illicit drug use are often known by local emergency medicine departments. These may serve as a source for more specific information about local trends in drug abuse and prompt more specific testing. When the physician suspects that drug use is associated with clinical behavior or outcome, directed questioning may be informative. Sometimes the patient may have consumed an adulterated substance or the phenomenon of denial may prohibit discovery of the substance in this way. In these circumstances, the physician must use any local knowledge of what drugs are “on the street” combined with information from emergency departments and, finally, observation of the patient’s behavioral status (eg, hallucinations, agitation, drowsiness) and examination (eg, alcoholic fetor, white powder in nares) to assist in drug testing. Individuals wishing to avoid detection of their substance use may attempt to adulterate the specimen or dilute or “washout” a substance by consuming large
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quantities of water prior to testing. The increased sensitivity of modem drug tests usually results in detection despite these attempts. Screening with prior approval can be random and is useful in helping persons in denial who are resistant to therapy. Ethics of Drug Testing Since positive results have implications for patients that transcend their health, they should give informed consent prior to testing. When there is no suspicion of substance abuse, random checks of a patient’s urine for substances are unethical. A false-positive from such testing might have devastating consequences for the patient and clinician. The patient’s medical records are confidential, and protection of herrights is of the utmost importance. Medical circumstances occasionally arise in which this consent is considered unnecessary or unobtainable. Patients who are in a stupor, unconscious, or show obvious signs of intoxication need to be tested in order to direct further medical interventions.
Role of the Obstetrician-Gynecologist in Diagnosis and Treatment Obstetrician-gynecologists generally are unaware of options and community resources available for substance abuse intervention and treatment. Hospital social workers are among the best resources for this information. There are several important roles the primary care provider fills in the diagnosis and treatment of substance abuse that benefit these patients. Often, encouragement and support provided by the physician may lead the patient to reduce or eliminate substance use. This aids in preventing medical and psychosocial complications of substance use. Patient education and early diagnosis and referral for treatment are key parts of this total patient care. As the most significant health care practitioner for many women, the obstetrician-gynecologist may be influential in a patient’s decision to accept treatment or referral. The obstetrician-gynecologist may wish to offer or participate in treatment for low-level substance abuse. This may consist of follow-up office visits to monitor substance use, substance abuse, or treatment compliance. Providing additional information through direct-
ed readings and educational materials about substance abuse is beneficial. Self-help and other treatment programs like Narcotics Anonymous, Alcoholics Anonymous, and Al Anon are important resources. Family members may be involved to help address different aspects of the substance abuse problem. Finally, the obstetrician-gynecologist should be willing to encourage the patient’s participation in her treatment plan. Prescription of potentially addictive medications should be avoided. Treatment or referral for medical or psychiatric complications and comorbidities should be managed in accordance with the physician’s expertise in this field and the patient’s wishes. Barriers to Diagnosis and Treatment Not all patients will readily acknowledge a substance abuse problem and cooperate with a treatment plan. It is helpful, therefore, for the clinician to be aware of certain common impediments to diagnosis and treatment. Denial is a psychologic defense against acknowledging the personal pain caused by a substance abuse problem. This contributes to underreporting of consumption and resistance to treatment. The denial may be subconscious, thus keeping patients from getting relevant information and treatment. If tolerance to a substance develops, it may contribute to denial. With continued use of an addicting drug, the patient experiences fewer and fewer effects of the drug over time. Higher doses are required to achieve the desired effect. Patients often do not feel or appear intoxicated, even after recent drug use. Attempts by others to “help” the substance abuser by smoothing over problems which result from substance abuse are known as “enabling.“This may consist of covering at work or school, hiding the substance use problem from superiors, supplying alcohol or drugs to avoid confrontation or other unpleasant effects, and minimizing or ignoring the substance abuse problem. The physician may actually be an enabler through the provision of inappropriate prescription drugs, providing doctor’s notes for work missed because of substance abuse, or by giving tacit approval for substance abuse by not addressing the problem. Physicians may have their own uncertainty about the appropriateness of personal substance use habits. They often misunderstand the chronic, relapsing nature of alcohol or psychoactive substance abuse and dependence. They may not
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appreciate the intensity of the urge to use and the preoccupation with the substance the patient experiences. Physicians should avoid contributing to addiction by prescribing nonaddictive medications whenever they are available. If the patient has a significant other who has adapted to the substance use problem in order to maintain equilibrium in their relationship, this codependency is particularly important to consider when the patient is resistant to referral or seeking help. Treatment or counseling aimed at the issues of codependency is often required. Pharmacologic Agents Used in Treatment While clinicians already play a prominent role in promoting smoking cessation programs, it is anticipated that the introduction of new oral and transdermal nicotine substitutes will bring increasing numbers of patients for therapy. A recent review of these systems suggests that physician support and education must be used in conjunction with any prescription for these therapies (13). Introduction of nicotine gum was the first attempt to provide a substitute for cigarettes. Early popularity of this approach has been dampened by recognition that cigarette craving is not reduced since peak and trough swings occur with gum consumption. The recently approved transdermal systems may overcome this limitation by achieving sustained trough levels over long periods of time. Short-term results suggest that the number of active nicotine patch users who quit smoking is about twice that of placebo patch users. There is little evidence to suggest that the patch should be used longer than 6-8 weeks. Relapse prevention is just as important with cigarettes as with other substances, and long-term behavior modification and reinforcement are extremely important. Data on the use of nicotine gum and patches in special populations (eg, those with coronary artery disease, pregnant women) are limited. Patients in treatment programs for other drugs may be taking supplemental pharmacologic agents. The three most commonly used agents are disulfiram (Antabuse), methadone, and naltrexone (Trexan). Disulfiram is used to ensure abstinence from alcohol in conjunction with supportive therapy. Ingestion of alcohol while taking this medication results in nausea and vomiting. Liver
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functions should be monitored regularly in these patients. Methadone is used to treat narcotic withdrawal. This long-acting narcotic is used in maintenance treatment of narcotic addiction. Naltrexone is used to block the “high” associated with opioid drug use. It is used in detoxified, formerly opioid-dependent patients to help prevent relapse. Patients with intact families and jobs benefit most from this treatment.
Summary Obstetrician-gynecologists have a clear role in substance abuse prevention and treatment. Knowledge of key risk factors, familiarity with substance abuse screening techniques, and identification of the symptoms and signs of abuse are all components in this process.
REFERENCES 1.
National Institute on Drug Abuse. National Household Survey on Drug Abuse: highlights, 1988. Rockville, Maryland: U.S. Department of Health and Human Services, 1990; DHHS publication no. (ADM)90- 168 1
2.
American College of Obstetricians and Gynecologists. Substance abuse in pregnancy. ACOG Technical Bulletin 195. Washington, DC: ACOG, 1994
3. American College of Obstetricians and Gynecologists. Smoking and reproductive health. ACOG Technical Bulletin 180. Washington, DC: ACOG, 1993
4. Blume SB. Women and alcohol: a review. JAMA 1986; 256: 1467-1469
5. U.S. Department of Health and Human Services. Prevention 89/90: federal programs and progress. Washington, DC: U.S. Government Printing Office, 1990
6. Ritchie JM, Greene NM. Local anesthetics. In: Gilman AG, Goodman LS, Rall TW, Murad F, eds. The pharmacological basis of therapeutics. 7th ed. New York: Macmillan, 1985:302-321 Schuckit MA, ed. Drug and alcohol abuse: a clinical guide to diagnosis and treatment. 3rd ed. New York: Plenum Medical Book Co, 1989:45-95 Dubovsky SL, Weissberg MP. Use of addictive drugs. In: Clinical psychiatry in primary care. 2nd ed. Baltimore, Maryland: Williams & Wilkins, 1982: 130-133 Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA 1984;252:1905-1907
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10. Sokol RJ, Martier SS, Ager JW. The T-ACE questions: practical prenatal detection of risk-drinking. Am J Obstet Gynecol 1989;160:863-870
12. Skinner HA, Holt S, Schuller R, Roy J, Israel Y. Identification of alcohol abuse using laboratory tests and a history of trauma. Ann Intern Med 1984;101:847-851
11. Pokomy AD, Miller BA, Kaplan HB. The brief MAST: a shortened version of the Michigan Alcoholism Screening Test. Am J Psychiatry 1972;129:342-345
13. Fiore MC, Jorenby DE, Baker TB, Kenford SL. Tobacco dependence and the nicotine patch: clinical guidelines for effective use. JAMA 1992;268:2687-2694
This Technical Bulletin was developed under the direction of the Committee on Technical Bulletins of the American College of Obstetricians and Gynecologists as an educational aid to obstetricians and gynecologists. The committee wishes to thank James T. Christmas, MD, for his assistance in the development of this bulletin and Robert A. Welch, MD, and Robert J. Sokol, MD, for their contributions to this bulletin. This Technical Bulletin does not define a standard of care, nor is it intended to dictate an exclusive course of management. It presents recognized methods and techniques of clinical practice for consideration by obstetrician-gynecologists for incorporation into their practices. Variations of practice taking into account the needs of the individual patient, resources, and limitations unique to the institution or type of practice may be appropriate. Requests for photocopies should be directed to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923. Copyright 0 July 1994 ISSN 1074-8628 THE AMEGICAN COUEGE OF OGSTETRICIANS AND 6YNECOWGISTS 409 12th Street, SW Washington, DC 20024.2l88