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...on Women

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Fall 2008

Treating pregnant women dependent on opioids is not the same as treating pregnancy and opioid dependence: A knowledge synthesis for better treatment for women and neonates. (review).

Winklbaur B; Kopf N; Ebner N; Jung E; Thau K; Fischer G. Addiction 103(9): 1429-1440, 2008. (134 refs.)
Aims: Through a novel synthesis of the literature and our own clinical experience, we have derived a set of evidence-based recommendations for consideration as guidance in the management of opioid-dependent pregnant women and infants. Methods PubMed literature searches were carried out to identify recent key publications in the areas of pregnancy and opioid dependence, neonatal abstinence syndrome (NAS) prevention and treatment, multiple substance abuse and psychiatric comorbidity. Results Pregnant women dependent on opioids require careful treatment to minimize harm to the fetus and neonate and improve maternal health. Applying multi-disciplinary treatment as early as possible, allowing medication maintenance and regular monitoring, benefits mother and child both in the short and the long term. However, there is a need for randomized clinical trials with sufficient sample sizes. Recommendations: Opioid maintenance therapy is the recommended treatment approach during pregnancy. Treatment decisions must encompass the full clinical picture, with respect to frequent complications arising from psychiatric comorbidities and the concomitant consumption of other drugs. In addition to standardized approaches to pregnancy, equivalent attention must be given to the treatment of NAS, which occurs frequently after opioid medication. Conclusion: Methodological flaws and inconsistencies confound interpretation of today's literature. Based on this synthesis of available evidence and our clinical experience, we propose recommendations for further discussion.

Assessment reactivity to follow-up in a study of women's treatment for alcohol dependence.

Worden BL; McCrady BS; Epstein EE. Addictive Behaviors 33(6): 831-835, 2008. (7 refs.)
Little research has been conducted on symptom reductions in response to assessments in clinical trials, despite the impact such reactivity may have on interpretation of outcomes. Reactivity to data collection procedures during post-treatment follow-up may obscure treatment effects. The current study examined whether female participants (n = 102) in a trial of cognitive-behavioral treatment for alcohol dependence had lower drinking quantity and frequency immediately after participating in follow-up assessments. Repeated measures ANOVAs were used to compare each participant's drinking among two-week time periods immediately before the follow-up, directly after the follow-up, and between follow-ups. No assessment reactivity was found for 9 or 15 month follow-up interviews, but was suggested at a 12 month in-person interview.

Buprenorphine and methadone treatment of opiate dependence during pregnancy: Comparison of fetal growth and neonatal outcomes in two consecutive case series.

Kakko J; Heilig M; Sarman I. Drug and Alcohol Dependence 96(1-2): 69-78, 2008. (31 refs.)
Aim: To compare the effects of fetal buprenorphine and methadone exposure during maintenance treatment of pregnant heroin dependent subjects. Design and setting: A population based comparison of consecutive, prospectively followed buprenorphine-exposed pregnancies in Stockholm County, Sweden, to retrospectively analyzed consecutive methadone-exposed pregnancies. Participants: All 47 pregnancies in 39 women with opiate dependence and buprenorphine maintenance treatment 2001-2006, and all 35 methadone-exposed pregnancies (26 women) 1982-2006 in Stockholm County. Measurements: Intrauterine growth, birth outcome, malformations, neonatal adaptation, withdrawal syndrome and infant mortality. Findings: Buprenorphine-exposed pregnancies resulted in 47 uneventful live births (2 twin pairs), 1 stillbirth (for which no explanation was found) and 1 miscarriage. The birth weight of the infants was normal. Neonatal abstinence syndrome (NAS) occurred in 19 cases (40.4%), the majority mild in nature and only 7 (14.9%) needing withdrawal treatment. Compared to 35 infants born after intrauterine methadone exposure at the same hospital since 1982 (77.8% of them exhibiting NAS and 52.8% needing withdrawal treatment), there were significant advantages with buprenorphine treatment: birth weight was higher, due to longer gestation. Incidence of NAS of any intensity, as well as incidence of NAS that required pharmacological treatment was lower, while length of hospital stay was shorter. When buprenorphine treatment started pre-conception, NAS at any level was significantly less frequent than in subjects with post-conception initiated treatment (7/27, 26%; 12/20, 60%, respectively). Conclusions: Data from this non-randomized comparison suggest that buprenorphine may offer advantages for treatment of opiate dependence during pregnancy.

Comparison of characteristics of opioid-using pregnant women in rural and urban settings.

Heil SH; Sigmon SC; Jones HE; Wagner M. American Journal of Drug and Alcohol Abuse 34(4): 463-471, 2008. (25 refs.)
Historically, research on opioid use during pregnancy has occurred in urban settings and it is unclear how urban and rural populations compare. We examined sociodemographic and other variables in opioid-using pregnant women seeking treatment and screened for participation in a multi-site randomized controlled trial. Women screened in rural Burlington, Vermont (n = 54), were compared to those screened in urban Baltimore, Maryland (n = 305). Rural opioid-using pregnant women appear to have some characteristics associated with better treatment outcomes (e. g., less severe drug use, greater employment). However, they may face additional barriers in accessing treatment (e. g., greater distance from treatment clinic).

Correlates of prenatal alcohol use.

Meschke LL; Hellerstedt W; Holl JA; Messelt S. Maternal and Child Health Journal 12(4): 442-451, 2008. (30 refs.)
Objectives: To identify correlates of prenatal alcohol use in a statewide population-based sample. Methods: A self-reported survey was conducted in 67 prenatal clinics in Minnesota with 4,272 women at their first prenatal visit. Chi-squared and multivariate logistic regression analyses were conducted to identify risk markers associated with any prenatal alcohol use. Results: Nearly 27% of the respondents were calculated as having used alcohol during pregnancy. In multivariable analyses, the following were risk markers for prenatal alcohol use: older age, being unmarried, lower gravidity, greater depressed mood, currently smoking, exposure to intrapersonal violence, a history of not remembering things because of alcohol use, and feelings that the respondent should reduce her drinking. Subsequent analyses revealed that the association of intrapersonal violence with prenatal drinking was mediated by whether the woman reported that she did not remember things while drinking or that the woman felt she should reduce her drinking. Conclusions: The demographic and behavioral correlates reported here are consistent with previous research. The significance of two alcohol behavioral factors (i.e., not remembering things and feeling that she should reduce her drinking) suggest that the women who drank during pregnancy would likely have substance abuse issues.

Ethical issues in practice with older women who misuse substances.

Koenig TL; Crisp C. Substance Use & Misuse 43(8/9): 1045-1061, 2008. (73 refs.)
Older women who misuse substances represent a growing population within the United States. Yet, helping professionals lack guidance in addressing ethical issues that arise in working with these older women. The purpose of this article is to (a) examine what we know about older women who misuse substances, (b) address professional ethical dilemmas and other ethical issues that emerge in treating and delivering services to older women, (c) identify barriers for treatment, and (d) propose practice recommendations. Specifically, the authors examine the overarching professional ethical dilemma or tension between client autonomy and professional beneficence that emerges in treating and delivering services to older women. Implications are delineated for professional education, gender-and age-sensitive substance misuse services, and research and policy efforts.

Gender differences in response to emotional stress: An assessment across subjective, behavioral, and physiological domains and relations to alcohol craving.

Chaplin TM; Hong K; Bergquist K; Sinha R. Alcoholism: Clinical and Experimental Research 32(7): 1242-1250, 2008. (59 refs.)
Background: Women and men are at risk for different types of stress-related disorders, with women at greater risk for depression and anxiety and men at greater risk for alcohol-use disorders. The present study examines gender differences in emotional and alcohol craving responses to stress that may relate to this gender divergence in disorders. Methods: Healthy adult social drinkers (27 men, 27 women) were exposed to individually developed and calibrated stressful, alcohol-related, and neutral-relaxing imagery, 1 imagery per session, on separate days and in random order. Subjective emotions, behavioral/bodily responses, cardiovascular arousal [heart rate (HR), blood pressure (BP)], and self-reported alcohol craving were assessed. Results: Women reported and displayed greater sadness and anxiety following stress than men and men had greater diastolic BP response than women. No gender differences in alcohol craving, systolic BP or HR were observed. Subjective, behavioral, and cardiovascular measures were correlated in both genders. However, for men, but not women, alcohol craving was associated with greater subjective emotion and behavioral arousal following stress and alcohol cues. Conclusions: These data suggest that men and women respond to stress differently, with women experiencing greater sadness and anxiety, while men show a greater integration of reward motivation (craving) and emotional stress systems. These findings have implications for the gender-related divergence in vulnerability for stress-related disorders, with women at greater risk for anxiety and depression than men, and men at greater risk for alcohol-use disorders than women.

Management of chemical dependence in pregnancy.

Christensen C. Clinical Obstetrics and Gynecology 51(2): 445-455, 2008. (41 refs.)
Although the percentage of pregnant patients who use illicit drugs is relatively low, the effects can be devastating on both mother and fetus-loss of custody, growth restriction, placental abruption, and death. The practicing obstetrician may be unfamiliar with the various presentations of chemical dependency in pregnancy, including intoxication and withdrawal, and difficulty in making the diagnosis. The obstetrician is in the unique situation of being responsible for the safety of both mother and fetus, which may involve engaging the unwilling patient in treatment.

Maternal risk factors for fetal alcohol syndrome and partial fetal alcohol syndrome in South Africa: A third study. (review).

May PA; Gossage JP; Marais AS; Hendricks LS; Snell CL; Tabachnick BG et al. Alcoholism: Clinical and Experimental Research 32(5): 738-753, 2008. (104 refs.)
Objectives: This is a third exploration of risk factors for the two most severe forms of fetal alcohol spectrum disorders (FASD), fetal alcohol syndrome (FAS) and Partial FAS (PFAS), in a South African community with the highest reported prevalence of FAS in the world. Methods: In a case control design, interview and collateral data concerning mothers of 72 first grade children with FAS or PFAS are compared with 134 randomly selected maternal controls of children from the same schools. Results: Significant differences were found between the mothers of FASD children and controls in socio-economic status, educational attainment, and a higher prevalence of FASD among rural residents. The birth order of the index children, gravidity, and still birth were significantly higher among mothers of FASD children. Mothers of children with a FASD are less likely to be married and more likely to have a male partner who drank during the index pregnancy. Current and gestational alcohol use by mothers of FASD children is bingeing on weekends, with no reduction in drinking reported in any trimester in 75 to 90% of the pregnancies that resulted in an FAS child or during 50 to 87% of PFAS-producing pregnancies. There was significantly less drinking among the controls in the second and third trimesters (11 to 14%). Estimated peak blood alcohol concentrations (BAC)s of the mothers of PFAS children range from 0.155 in the first trimester to 0.102 in the third, and for mothers of FAS children the range is from 0.197 to 0.200 to 0.191 in the first, second, and third. Smoking percentage during pregnancy was significantly higher for mothers of FASD children (82 to 84%) than controls (35%); but average quantity smoked is low in the 3 groups at 30 to 41 cigarettes per week. A relatively young average age of the mother at the time of FAS and PFAS births (28.8 and 24.8 years respectively) is not explained by early onset of regular drinking (mean = 20.3 to 20.5 years of age). But the mean years of alcohol consumption is different between groups, 16.3, 10.7, and 12.1 years respectively for mothers of FAS, FASD, and drinking controls. Mothers of FAS and PFAS children were significantly smaller in height and weight than controls at time of interview. The child's total dysmorphology score correlates significantly with mother's weight (-0.46) and BMI (-0.39). Bivariate correlations are significant between the child's dysmorphology and known independent demographic and behavioral maternal risk factors for FASD: higher gravidity and parity; lower education and income; rural residence; drinks consumed daily, weekly, and bingeing during pregnancy; drinking in all trimesters; partner's alcohol consumption during pregnancy; and use of tobacco during pregnancy. Similar significant correlations were also found for most of the above independent maternal risk variables and the child's verbal IQ, non-verbal IQ and behavioral problems. Conclusions: Maternal data in this population are generally consistent with a spectrum of effects exhibited in the children. Variation within the spectrum links greater alcohol doses with a greater severity of effects among children of older and smaller mothers of lower socio-economic status in their later pregnancies. Prevention is needed to address known maternal risk factors for FASD in this population.

Patterns of alcohol (especially wine) consumption and breast cancer risk: A case-control study among a population in Southern France.

Bessaoud F; Daures JP. Annals of Epidemiology 18(6): 467-475, 2008. (42 refs.)
PURPOSE: The association between alcohol consumption and breast cancer has been largely investigated, but few studies have investigated the effects of average intake when the pattern of drinking is taken into account. We sought to examine the association between drinking pattern of alcoholic beverages, particularly wine, and breast cancer using different statistical approaches. METHODS: Our study included 437 cases of breast cancer, newly diagnosed in the period 2002-2004, and 922 residence- and age-matched controls. RESULTS: Women who had an average consumption of less than 1.5 drinks per day had a lower risk (odds ratio [OR] = 0.58, 95% confidence interval [CI] = 0.34-0.97) when compared with nondrinkers. This protective effect was due substantially to wine consumption since the proportion of regular wine drinkers is predominant in our study population. Furthermore, women who consumed between 10 and 12 g/d of wine had a lower risk (OR = 0.5 1; 95% CI = 0.30-0.9 1) when compared with non-wine drinkers. Above 12 g per day of wine consumption, the risk of breast cancer increased, but the association was nonsignificant. CONCLUSIONS: Although no association between the pattern of total alcohol consumption and breast cancer was found, the type of alcoholic beverage seemed to play an important role in this association. Our results support the hypothesis that there is a threshold effect that risk decreased or was not modified for consumption under a certain threshold. Above that threshold, risk increased, however. The drinking pattern of each type of specific beverage, especially wine, seems important in terms of alcohol-breast cancer association. Low and regular wine consumption does not increase breast cancer risk.

Pregnancy and race/ethnicity as predictors of motivation for drug treatment.

Mitchell MM; Severtson SG; Latimer WW. American Journal of Drug and Alcohol Abuse 34(4): 397-404, 2008. (27 refs.)
While drug use during pregnancy represents substantial obstetrical risks to mother and baby, little research has examined motivation for drug treatment among pregnant women. We analyzed data collected between 2000 and 2007 from 149 drug-using women located in Baltimore, Maryland. We hypothesized that pregnant drug-using women would be more likely than non-pregnant drug-using women to express greater motivation for treatment. Also, we explored race/ethnicity differences in motivation for treatment. Propensity score analysis was used to match a sample of 49 pregnant drug-using women with 100 non-pregnant drug-using women. The first logistic regression model indicated that pregnant women were more than four times as likely as non-pregnant women to express greater motivation for treatment. The second logistic regression analysis indicated a significant interaction between pregnancy status and race/ethnicity, such that white pregnant women were nearly eight times as likely as African-American pregnant women to score higher on the motivation for treatment measure. These results suggest that African-American pregnant drug-using women should be targeted for interventions that increase their motivation for treatment.

Screening pregnant young adults for alcohol and drug use: A pilot study.

Braaten K; Briegleb C; Hauke S; Niamkey N; Chang G. Journal of Addiction Medicine 2(2): 74-78, 2008. (45 refs.)
This study. ascertained the feasibility of offering a self-report alcohol and drug screen embedded in a general health habits survey to patients attending the Young Adult Reproductive Medicine Clinic and compared those who screened positive for a substance use problem with those who did not. An anonymous convenience sample of 100 young adults completed the Health Habits Survey, which included the CRAFFT screening test, designed specifically to identify substance-related problems in adolescent populations and recently recommended as a potential tool to reduce adverse outcomes from prenatal alcohol exposure. Eighty of the 100 respondents were pregnant and younger than aged 25 years, and they are the focus of the study. With a mean age of 18.2 years and 23.5 weeks gestation, most were single (75%) and had a high school education or less (75%). The majority (81%) was CRAFFT screen negative, but 15 answered yes to at least 1 CRAFFT question. There were no systematic differences between those with positive or negative CRAFFT screens. The CRAFFT, when embedded in a general health habits survey, seems to be a feasible option for pregnant young adults, but further studies to assess reliability, sensitivity, and specificity are recommended.

Substance abuse issues among women in domestic violence programs - Findings from North Carolina.

Martin SL; Moracco KE; Chang JC; Council CL; Dulli LS. Violence Against Women 14(9): 985-997, 2008. (15 refs.)
This article discusses the results of a survey of North Carolina domestic violence programs that found that substance abuse problems are common among program clients, yet only half of the programs had policies concerning substance-abusing clients, and one fourth had memoranda of agreement with substance abuse treatment providers. Most programs with shelters asked clients about substance use; however, one third of the shelters would not admit women if they were noticeably under the influence of substances while seeking shelter residence, instead referring them to substance abuse programs. Approximately one tenth of the domestic violence programs did not have any staff or volunteers with training in substance abuse issues. Implications are discussed.

Unintended pregnancy and prenatal behaviors among urban, black women in Baltimore, Maryland: the Baltimore Preterm Birth Study.

Orr ST; James SA; Reiter JP. Annals of Epidemiology 18(7): 545-551, 2008. (32 refs.)
PURPOSE: We explored associations between intendedness of pregnancy with maternal prenatal behaviors, including smoking, use of alcohol, use of illicit drugs, and late initiation of prenatal care. METHODS: Pregnant black women ages 18 years or older (N = 913) were enrolled in the study at their first visit to prenatal clinics in Baltimore, Maryland, at which time data were obtained from the women about intendedness of pregnancy. Data on behavioral risks were abstracted from clinical records, Logistic regression was used to adjust analyses for maternal demographic characteristics. RESULTS: Women with unwanted pregnancies were significantly more likely than women with wanted or mistimed pregnancies, or who were unsure about intendedness, to smoke (odds ratio [OR], 2.0; 95% CI, 1.2-3.3), use alcohol (OR, 2.1; 95% CI, 1.1-3.9), and use illicit drugs (OR, 1.8; 95% CI, 1.0-2.9) during pregnancy, and to initiate prenatal care in the third trimester (OR, 5.7; 95% CI, 3.5-9.4). CONCLUSIONS: Unwanted pregnancy is associated with prenatal behaviors that increase the risk of poor pregnancy outcomes. The facilitation of wanted pregnancies and reduction of harmful maternal behaviors may result in improved pregnancy outcomes in the United States.