Healthy People 2020: Illicit Drug Use in Pregnancy
The Office of Disease Prevention and Health Promotion carries on a tradition every decade to produce a new agenda filled with grand, but realistic goals to aid United States citizens in leading longer, healthier lives. Healthy People 2020 aims to: 1) Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; 2) Achieve health equity, eliminate disparities, and improve the health of all groups; 3) Create social and physical environments that promote good health for all; and 4) Promote quality life, healthy development, and health behaviors across all life stages.” It plans to do this by utilizing evidence-based knowledge, identifying priorities, increasing public awareness and understanding, and engaging multiple sectors’ participation. This work includes more than 1,200 objectives accompanied by baselines, data, and targets to accomplish by 2020. It is crucial for every citizen, clinic, and hospital to be working together to meet these goals (Healthy People 2020, 2016a).
Healthy People 2020: MICH-11.4:
One of the 1,200 objectives under the umbrella of maternal, infant, and child health (MICH-11) stands to “increase abstinence from alcohol, cigarettes, and illicit drugs during pregnancy.” A further sub-category, MICH-11.4, deals with illicit drug abstinence in pregnancy with females from 15-44 years of age. MICH-11.4 has a baseline set at 94.8% from 2007-2008 with a target of 100%. This leaves a goal of a 5.2% increase in illicit drug abstinence. Data obtained from the 2007-08 National Survey on Drug Use and Health proposed the following questions: “How long has it been since you last used [marijuana or hashish, cocaine, "crack," heroin, hallucinogens, inhalants]? How long has it been since you last used (a pain killer, tranquilizers, stimulants, sedatives) that was not prescribed for you, or that you took only for the experience or feeling it caused? Are you currently pregnant? If yes, how many months pregnant are you?” To clarify, illicit drugs are defined as marijuana or hashish, cocaine (including crack), inhalants, hallucinogens (including PCP and LSD), heroin, and nonmedical use of psychotherapeutics (Healthy People 2020, 2016b).
Population at Risk:
Illicit drug use during pregnancy is common — probably even more common than anyone would think. It is difficult to gain accurate illicit drug use data because few individuals are willing to release the information. Women have faced rejection and stigmatization from not only their social circles, but also healthcare services. While accurate national estimates for pregnant drug users may be absent, studies report that approximately a third of drug users undergoing treatment are female and over 90% of these women are of childbearing age (15–44 years of age) (Madgula, Groshkova, & Mayet, 2011). As of 2013, populations with the highest rates of illicit drug use include African American women, women ages 15-24, metropolitan women, and women living in poverty (Healthy People 2020, 2016b).
Marijuana is the most often used illicit drug, followed closely by cocaine. Studies have shown women have higher tendencies to abuse illicit drugs than men (Wong, Ordean, Kahan, 2011). Substance abuse is often not identified prior to conception and most of these pregnancies are unplanned (Madgula, Groshkova, & Mayet, 2011). Unfortunately, the illicit drug abuse by pregnant women has high rates of maternal, fetal, and neonatal morbidity. Of particular significance, overdosing with injected drugs poses a risk for death, especially for individuals who inject alone. They often are in situations where peers are not trained in overdose resuscitation or are reluctant to call for help because they have fear of legal consequences, or they are where medical help is not available or accessible in a timely manner (CDC, 2012). These women are less likely to seek prenatal care and are at a higher risk of having HIV, hepatitis, and other sexually transmitted infections (STIs) (Wong, Ordean, Kahan, 2011). Early detection can facilitate early and beneficial intervention, including treatment of maternal and neonatal withdrawal and counseling and referral for long-term treatment (Wong, Ordean, Kahan, 2011).
It would be beneficial to screen every woman regardless of socioeconomic status, race, age, or other demographics for substance abuse, but it remains a highly controversial topic. While verbal assessments are the most common method of assessment, urine or saliva drug screens, which are more accurate tests, are not as easily attainable for this reason. Meconium testing is another method of assessing for prenatal drug use, but at that point, it is too late in the pregnancy to prevent neonatal complications (Madgula, Groshkova, & Mayet, 2011). Women are placed in an exceedingly vulnerable position when asked to go through drug testing and expose psychosocial histories. If a woman is concerned about providing a sample or is reluctant to do so, healthcare providers should focus on developing a trusting relationship before suggesting toxicology testing (Wong, Ordean, Kahan, 2011).
NANDA Diagnoses:
Pertinent nursing NANDA diagnoses for these patients include: 1) Imbalanced nutrition: less than body requirements related to economic reasons; 2) Denial related to vulnerability, fear, or inadequate support systems; 3) Powerlessness related to failed attempts at recovery; and 4) Knowledge deficit related to lack of information about adverse effects of illicit drug use in pregnancy.
1) Imbalanced nutrition: less than body requirements related to economic reasons can play into various scenarios. Many substance abusive mothers are uninsured, low-income women. While they can place priority on attaining illicit drugs, proper prenatal care can be costly too. Many drug abusers have insufficient dentition that can affect the mother’s nutritional status. A woman’s dietary quality, particularly in the first trimester of pregnancy, has a profound influence on the pregnancy result. With this population at risk, there is a high likelihood the woman will not even be aware of the pregnancy at that point. Babies can be born at a low birth weight and develop obesity and cardiovascular disease regardless of nutrition in the second and third trimesters. Insufficient nutrition also predisposes mothers to pre-eclampsia (Fowles et al., 2011).
2) Denial related to vulnerability, fear, or inadequate support systems can stem from a lack of education, emotion, or negative stigma associated with illicit drug abuse by itself, let alone during pregnancy. Most women are not willing to disclose information about their drug habits and tend to withdraw in anger as a defense ploy. Conversely, if trust with the health care provider is established, many may be delighted to openly discuss their drug habits and seek help (Madgula, Groshkova, & Mayet, 2011). Stigma research has consistently demonstrated that healthcare professionals have a perceived controllability over drug abuse. This causes intolerant attitudes and presumptuous judgments towards these drug abusers that can potentially affect the care the patient receives (Van Boekel, Brouwers, Van Weeghel, & Garretsen, 2013).
3) Powerlessness related to failed attempts at recovery can create difficult psychological barriers to overcome. Dependence occurs when the following criteria are met: more frequent use than intended, inability to reduce use, amount of time seeking the substance, physical effects of use and withdrawal symptoms, use replacing other activities, continued use despite problems, tolerance, and use to avoid withdrawal symptoms (CDC, 2012). The individual’s attitude to the substance misuse and changes in motivation in relation to being pregnant must be sensitively explored. Pregnancy cause reduction of substance use but there is a high risk of relapse in the postpartum period (Madgula, Groshkova, & Mayet, 2011). While increasing motivation to change is a key treatment goal, long term recovery from substance abuse depends on transforming motivation from the extrinsic sources such as family, friends, support groups, healthcare workers, etc. This often initiates personal help seeking and changes the intrinsic values of the patient (Breda & Heflinger, 2011).
4) Knowledge deficit related to lack of information about adverse effects of illicit drug use in pregnancy occurs mainly from unplanned pregnancies and insufficient education. Women participating in illicit substance abuse are at a higher probability to be engaging in illicit, unprotected sex. These kinds of pregnancies were unexpected and drug use has teratogenic effects on the fetus from the moment of conception. Although the placenta protects the fetus from a lot of harmful substances, illicit drug use can trigger several adverse effects. To name a few: it can impair oxygenation, alter neurotransmitters, decrease brain growth, shorten attention span/memory, and cause intrauterine growth restriction and a low birth weight for the future baby (Behnke & Smith, 2013). If polydrug use is present, it is important to determine whether they are at a recreational level of use or if they have already reached a level of dependence (Madgula, Groshkova, & Mayet, 2011).
Prevention:
To expedite the goals of Healthy People 2020 Objective MICH-11.4, priority should be placed on the national strategy to reduce drug demand. It is important to prevent, reduce, and treat substance abuse along with the behavioral, social, environmental, and structural factors that contribute to illicit use of drugs. It is suggested that delivery of the public health strategies and review of recent programmatic efforts will integrate prevention services for persons who use drugs illicitly. Unfortunately, many women are commonly lost in the follow-up process after treatment or diagnosis without coordination of care. These services provide multiple prevention services at a single location, coordinate referrals, and provide linkage to services delivered at multiple venues. This creates seamless access to the help and education these patients need. Such collaboration and coordination are needed to ensure that provided services meet the needs of persons who use drugs illicitly and that the methods of service delivery are acceptable both to providers and to clients. Health-care providers should be confident to screen and provide information or counseling to their patients who abuse illicit drugs. Without this direct access, women are less likely to pursue healthcare and will not be exposed to educational materials concerning care or prevention. Community-based outreach and peer educators have established trust and rapport with people who use drugs illicitly and are in a position to guide these individuals to reduce risky behaviors. Outreach is particularly useful in reaching these women who are not ready to enter substance abuse treatment or to be involved in other interventions for risk reduction (CDC, 2012).
Nursing Interventions:
Nursing interventions should be directed at educating about prevention, identifying help available, promoting physiological stability and well-being of the mom and baby, supporting client’s acceptance of reality of situation, and facilitating learning of new ways to reduce anxiety. They can also be focused on strengthening individual coping skills; incorporating client into supportive community environment; promoting family involvement in treatment process; and providing information about condition, prognosis, and treatment needs. Goals for these women include: engagement in treatment modalities by identifying and using support systems; assuming responsibility for own life and behavior; abstaining from drug(s) maintained on a day-to-day basis; verbalization of dependence condition and its impact on pregnancy, prognosis, and therapeutic regimen; and participation in follow-up care by making and keeping all appointments while managing therapeutic regimen.
Barriers:
Research suggests that women who use drugs during pregnancy face the following barriers to prenatal care: transportation, health insurance, “drug lifestyle”, and fear of having drug use identified and legal repercussions such as Child Protective Services (CPS) reports. Reasons for the lack of prenatal care in these women unconnected to drug use include similar barriers, such as: transportation, health insurance, scheduling appointments, and feeling that providers do not listen, take concerns seriously, or spend enough time with them. Perhaps the leading barrier is drug abuse itself. It’s been reported that some prioritize opportunities to use drugs over prenatal care (Roberts & Pies, 2011). Having health insurance, understanding the benefits of prenatal care, and a support system increase prenatal care. This is far more intensive than just telling women to discontinue their drug use habits. It requires acknowledging the complexity of the decision making process about prenatal care, the diversity among these women, and a focus on education and not solely on getting women to stop. Some interventions that may increase prenatal care utilization are: new messages about the effects of drug use during pregnancy, identification of steps that pregnant women who have already used drugs can take to increase chances of having healthy babies, clarification of CPS reporting policies, streamlined insurance applications, and easier access to providers who accept pregnancies with drug abuse histories (Roberts & Pies, 2011).
Locally, the Canandaigua Medical group supports Healthy People 2020 through their mission “to provide quality medical care to all age groups within our local communities.” They stand to enrich quality of life from birth until death and function under a philosophy of “Professionalism With Compassion.” It is a private practice owned by physicians (Canandaigua Medical Group, 2016a). Patients pay out-of pocket for services provided and may be reimbursed through insurances such as Blue Choice Option, Medicaid, or Blue Cross. In particular, the Canandaigua Medical group supports MICH-11.4 by employing Certified Nurse-Midwives (CNM). A CNM is an Advanced Practice Nurse with a specialty in both Nursing and Midwifery. They are required to hold an active Registered Nurse license and complete a Master of Science in Nursing. CNM’s provide healthcare for women with generally healthy, low-risk pregnancies. Certified Nurse Midwives are not limited to hospitals to practice. They commonly work in medical clinics, birthing centers, and even deliver at patients’ homes. Although it varies state to state, their scope of practice includes the ability to prescribe medications, devices, therapeutic services, and diagnostic procedures for all women of childbearing years (Canandaigua Medical Group, 2016b). It is common for Certified Nurse Midwives to work in collaboration with an Obstetrician & Gynecologist. These medical professionals provide consultation and assistance to patients who have high-risk pregnancies, develop complications, or have complex comorbidities. These women can benefit from a Certified Nurse Midwife in collaboration with a physician or an addictions nurse (Canandaigua Medical Group). Because CNM’s work with women before, during, and after their pregnancies, they are in an opportune position for patient screening and education. CNM’s have an opportunity to make an immense impact on Healthy People 2020’s Objective of increasing abstinence from illicit drugs.
Healthy People 2020 is here to improve quality and quantity of life. This ongoing process will not prosper without goals and objectives that can be realistically attained. Objective MICH-11.4 to increase abstinence from illicit drug use during pregnancy has been set as a target and many individuals must participate in reaching this goal. MICH-11.4 had set its baseline at 94.8% in 2007-2008. As of 2012-2013, MICH-11.4 has decreased to 94.6% (Healthy People 2020, 2016b). This is unacceptable when there are plenty of opportunities to reach, educate, screen, and treat these women. All medical professionals and even regular United States citizens need to be having these conversations and connecting these women to the help they need. The information and support is available, but the delivery and accessibility process contains gaps which need to be mended.