SUBSTANCE ABUSE

Substance abuse is defined as the ability to meet major role obligations, an increase in
legal problems or risk-taking behavior, or exposure to hazardous situations because of an
addicting substance.

A person is substance dependent when he/she has withdrawal symptoms following

discontinuation of the substance, combined with abandonment of important activities, spending
increased time in activities related to the substance use, using substances for a long period of
time than planned, or continued use despite worsening problems because of the substance use.

Common Substances Abused During Pregnancy

Cocaine

It is derived from Erythroxylum coca, a plant grown almost exclusively in South

America. When sniffled into the nose or smoked in a pipe, cocaine is absorbed across the
mucous membranes and affects the central nervous system. As a result, vasoconstriction
occurs.

Alkaloidal cocaine concentrated mixture, produces an even more rapid and intense
high when inhaled dramatic, in fact, that immediate death may result to
cardiac failure.

Cocaine is exceptionally harmful during pregnancy because the extreme vasoconstriction

can severely compromise placental circulation leading to premature separation of
placenta which results to preterm labor and fetal death.
Infants born to cocaine-dependent women can suffer the immediate effects of intracranial
hemorrhage and an abstinence syndrome of tremulousness, irritability and muscle
rigidity.
Cocaine use can be detected by urinalysis because the metabolites of the cocaine can be
detected in uterine up to 1 week after use.

Amphetamines

Methamphetamine a nuerostimulant and neurotoxin that has pharmacologic effect

similar to cocaine, it is more commonly used in communities than cocaine because it is
easily and cheaply manufactured in home laboratories.
Ice, a rock type of methamphetamine that is smoked, can produce high concentrations of
the drug in maternal circulation.
Women develop blackened and infected teeth.
Newborns whose mothers used the drug show jitteriness and poor feeding at birth and
may be growth restricted.
Marijuana and Hashish

Both are obtained from the hemp plant, cannabis.

When smoked, they produce tachycardia and a sense of well-being.
Some women use marijuana to counteract nausea in early pregnancy.
Associated with loss of short-term memory and an increase incidence of respiratory
infection in adults.
Frequent user may be advised not to breastfeed because of reduced milk production and
the risk to the newborn from excretion of the drug in the breastmilk.

Phencyclidine

Developed in the 1950s as an IV anesthetic but it is no longer used that way because
although it creates a sense or euphoria, it also causes irritation and possibly long term
hallucinations and it is now seen most frequently as part of polydrug use by the rave
culture.
It may be particularly injurious to a fetus because the drug tends to leave the maternal
circulation and concentration in fetal cells.

Narcotic Agonists

It is used for relief of pain such as morphine, oxycodone, meperidine (Demerol), and
codeine, are widely abused drugs because the can be obtained by prescription and they
have a dramatic euphoric effect,
Heroine a raw illicit opiate that is also increasing in incidence in young adults.
- produces an immediate and short lived feeling of euphoria immediately
followed by sedation.
- Pregnancy complications related to its use include gestational hypertension
and because the drug is often injected with shared needles phlebitis, subacute
bacterial endocarditis and hepatitis B and HIV infection may occur.
- Abstinence symptoms
Nausea
Vomiting
Diarrhea
Abdominal pain
Shivering
Insomnia
Body aches
Muscle jerk
Heroine dependency in the pregnant woman is dangerous because it can result in fetal
opiate dependence and severe abstinence symptoms in the infant after birth.
Infants tend to be SGA and have an increased incidence of fetal distress and meconium
aspiration.
Inhalants

Inhalant abuse refers to the sniffing or huffing of aerosol drugs.

Frequently abused by adolescents, inhalants include model airplane glue, cooking sprays,
and computer keyboard cleaner. These substances contain Freon as a propellant which
can lead to severe respiratory and cardiac irregularities.
The respiratory depression they can cause could be enough to limit fetal oxygen supply to
a serious level.

Alcohol

Although alcohol can be legally purchased and is served at social functions, it is just as
detrimental to fetal growth as illicit drugs.
There is little documentation regarding how much alcohol must be ingested before fetal
alcohol spectrum disorder, a syndrome with recognizable facial feature, possible
cognitive challenges, and memory deficits, occurs; therefore, women are advised to drink
no alcohol during pregnancy.

Risk factors

There are many factors that can lead to pregnant women susceptibility to substance abuse which
includes:

Life stressors with poor coping skills.

Limited social support systems.
Easy access to alcohol and illicit substances.
Previous traumatic crises.
Those who have identity/self-esteem problems.
Individuals with mental health disorders.
Women with reproductive problems.
Eating disorders appear more likely to develop substance abuse problems
Earn below poverty level
Were exposed to violence as a child
Have a history of domestic abuse
Suffer depression or other mental health problems
Have less than a high school education
Are unmarried
Are unemployed
Are involved with the criminal justice system

Manifestations
Maternal drinking is related to fetal alcohol syndrome, which results in

facial abnormalities
short stature
mental retardation

Infants born to cocaine-dependent women can suffer the immediate effects of:

intracranial hemorrhage and an abstinence syndrome of tremulousness

irritability
muscle rigidity

Newborns whose mothers used amphetamines shows:

jitteriness
poor feeding at birth
may be growth restricted.

Inhalants

severe respiratory
cardiac irregularities.

Marijuana and Hashish

When smoked, they produce tachycardia and a sense of well-being. They are also
associated with loss of short-term memory and an increased incidence of respiratory
infection.

Phencyclidine

causes irritation and possibly long term hallucinations and it is now seen most frequently
as part of polydrug use by the rave culture.

More significant long-term developmental problems may be seen in babies who are born with
growth failure or various organ problems. Other drugs may cause malformations of the heart,
brain, bowel, or kidneys that can have significant impact on long-term development and
outcome. Babies who have been exposed to drugs, alcohol and/or cigarettes are at higher risk for
SIDS (sudden infant death syndrome)

Medical Management
Counselling
Motivational Interviewing
Motivate the patient to reduce/stop drinking and/or seek further treatment
Cognitive-Behavioral Treatment
Identify life stressors, high-risk situations for drinking, and coping skills deficits
Use modeling and rehearsal
Relapse Prevention
Identify triggers, practice avoiding, emphasize responsibility
Methadone
Methadone maintenance enables stabilization of the mothers drug use and
lifestyle, and can also facilitate access to comprehensive antenatal and postnatal
care.
The most common treatment for heroin abuse in pregnant women
Buprenorphine
Linked to better treatment adherence with fewer side effects and overdoses than
methadone

Diagnostic Procedures and Laboratory Examinations

Screening tools

4 Ps

Have you ever used drugs or alcohol during the Pregnancy?

Have you had a problem with drugs or alcohol in the Past?
Does your Partner have a problem with drugs or alcohol?
Do you consider one of your Parents to be an addict or alcoholic?
Any woman who answers yes to 1 or more questions should be referred for further
assessment
TACE
ToleranceHow many drinks does it take for you to feel high?
AnnoyedHave people annoyed you by criticizing your drinking?
Cut downHave you felt the need to cut down on your drinking?
Eye-openerDo you need to have an eye-opener to get started in the morning?

Maternal hair analysis good screening test for detecting maternal drug use during the previous

3 months with drug metabolites persisting for up to 3 months in the

infants hair after birth, is falsely positive in those women exposed

passively to second-hand smoke from crack cocaine and marijuana.

Meconium analysis gives a picture of the drug use pattern during the latter half of pregnancy

and may be the ideal screening test for maternal drug use. Because

meconium can be attained only at delivery, it is not useful for

antepartum screening.

Urine toxicology determines the presence or absence of a drug in a urine specimen. It may be

useful as a follow up to a positive interview screen.

Nursing Care Management

Closely monitor maternal and fetal well-being

Explain the benefits of abstinence of substance abuse during pregnancy
Discuss possible effects of drugs on the newborn.
Provide support to the client and family
Provide support for decision to stop substance use.
Provide education opportunity (pamphlets, consultation with appropriate persons)