SECTION III

SUPERVISED CLINICAL EXPERIENCE

Estimated Time for Delivery: 750 hours

The field of substance abuse requires knowledge of pharmacology, psychiatry, general medicine, and psychology, as well as an understanding of the interaction of these disciplines. In order to insure that the trainee is well-versed in these areas, training programs must include both hands-on experience in clinical situations as well as classroom and seminar sessions. Areas of emphasis must be tailored to the practice requisite to the given specialty of the trainee, which will be different for psychiatry, internal medicine, family practice, etc. Opportunities to acquire skill in the following areas must, however, be included, and should be individualized relative to the medical specialty background of the trainee:

GOAL

Participants will be afforded practical application of their knowledge of pharmacology, psychiatry, general medicine, and psychology, as well as an understanding of the interaction of these disciplines.

OBJECTIVES

Upon completion of this section, participants will acquire individual skill in the following areas, relative to the medical specialty background of the trainee:

1. Develop knowledge and skills in the diagnosis and treatment of patients with substance abuse disorders and dual diagnoses in both inpatient and outpatient units.

2. Develop advanced knowledge and skills of drug action in the nervous system, drug treatment of specific disorders, ECT, and medication combined with psychotherapy.

3. Conduct of the psychotherapeutic techniques required for intervention and confrontation with the chronic drug abuser and dealing with the denial that causes the patient to resist entry into treatment.

4. Experience with collaborative therapy with other therapists who participate in the care of substance abuse patients, including nurses, social workers, psychologists, nurse practitioners, non-professional counselors, pharmacists and others.

5. Recognition and understanding of the special problems of the pregnant drug abuser and of the babies born to substance-abusing mothers.


Objective 1. Develop knowledge and skills in the diagnosis and treatment of patients with substance abuse disorders and dual diagnoses in the inpatient and outpatient units. Through lecture and clinical practice, trainees will:

    A. Recognize the signs and symptoms of the psychiatric disorders which often accompany the chronic use of each of the major categories of drugs.

    B. Develop basic knowledge inpatient/outpatient diagnostic evaluation and treatment planning -- during a half-day outpatient clinic during the first 6 months.

    C. Facilitate detoxification and rehabilitation among patients with dual psychiatric and addictive illness.


TRAINER NOTE

1. Allow 250 hours for this section.

2. Trainer will begin this section by reviewing the broad categories for substance abuse disorders:

      a. substance dependence
      b. substance abuse
      c. substance-induced disorders


CONTENT

A. Recognize the signs and symptoms of the psychiatric disorders which often accompany the chronic use of each of the major categories of drugs.

     Substance-related disorders go beyond substance dependence and abuse and closely related problems to include a wide variety of adverse reactions not only to drugs of abuse, but also to medications and toxins. The medications associated with substance-induced disorders range from anesthetics to over-the-counter medications and include such diverse drug categories as anticholinergics, antidepressives, anticonvulsants, antimicrobials, antihypertensives, corticosteroids, antiparkinsonian agents, chemotherapeutic agents, nonsteroidal anti-inflammatory agents, and disulfiram (antabuse). Several categories of substance-induced disorders can be induced by a wide range of nonmedicinal toxic materials such as heavy metals and industrial solvents, insecticides and household cleaning agents.

Substance Abuse Mental Disorders:

       a. Substance-induced delirium
       b. Substance-induced persisting dementia
       c. Substance-induced persisting amnestic disorder
       d. Substance-induced psychotic disorder
       e. Substance-induced mood disorder
       f. Substance-induced anxiety disorder
       g. Substance-induced sexual dysfunction
       h. Substance-induced sleep disorder
       i. Hallucinogen persisting perception disorder (flashbacks)


B. Inpatient/outpatient diagnostic evaluation and treatment planning

Diagnostic Criteria for Substance Dependence

A maladaptive pattern of substance use, leading to clinically significant impairment of distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

  • tolerance
  • withdrawal
  • substance taken over a longer period of time than intended
  • persistent desire or unsuccessful efforts to cut down or control substance use
  • great deal of time spent obtaining substance or recovering from its effects.
  • important social, occupational, or recreational activities are given up or reduced because of substance abuse.
  • substance use is continued despite knowledge of having a persistent or recurrent physical of psychological problem caused by or exacerbated by the substance use.

Specify if this pattern exhibits with or without physiological dependence.

Course specifiers:

  • early full remission
  • early partial remission
  • sustained full remission
  • sustained partial remission
  • on agonist therapy
  • in a controlled environment

Diagnostic Criteria for Polysubstance Dependence

     1.Reserved for behavior during the same 12-month period when the person was repeatedly using at least three groups of substances, but no single substance predominated.

     2. During this same period, the dependence criteria were met for substances as a group but not for any specific substance.


Diagnostic Criteria for Other or Unknown Substance-Related Disorders

1. Used in classifying substance-related disorders associated with substances not listed above including:

  • anabolic steroids
  • nitrite inhalants
  • nitrous oxide
  • over-the-counter and prescription drugs

2. Substance Withdrawal

3. Substance Intoxication

4. Substance-Induced Disorders


Diagnostic Criteria for Course Specifiers for Substance Dependence

1. Early full remission
2. Early partial remission
3. Sustained full remission
4. Sustained partial remission
5. On agonist therapy (where applicable)
6. In a controlled environment (where applicable)


Diagnostic Criteria for Substance Abuse

1. Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one or more of the following, occurring within a 12-month period:

  • recurrent substance use resulting in failure to fulfill major role obligations at work, home, or school;
  • recurrent substance use in situations where it is physically hazardous (e.g., driving);
  • recurrent substance use related legal problems
  • continued substance use despite persistent social or interpersonal problems caused by effects of substance use.

2. Symptoms have never met the criteria for substance dependence for this class of substance.


Diagnostic Criteria for Substance Abuse Withdrawal

1. Development of substance-specific syndrome due to cessation of heavy. prolonged substance use.

2. Substance-specific syndrome causes clinically significant distress or impairment in important areas of functioning.

3. Symptoms are not due to general medical condition and are not better accounted for by another mental disorder.


Diagnostic Criteria for Substance Abuse Intoxication

1. Development of reversible substance-specific syndrome due to recent ingestion of or exposure to a substance.

2. Clinically significant maladaptive behavioral or psychological changes due to effect of substance on central nervous system and develop during or shortly after using substance.

3. Symptoms are not due to general medical condition and are not better accounted for by another mental disorder.


EXERCISE

As part of clinical rounds, the Trainees will evaluate patients presented to them and make assessment. Trainer will supervise this process.

Addiction and Coexisting Psychiatric Disorders

    Comorbidity (dual diagnosis) is the diagnosis of two or more psychiatric disorders in a single patient. Included in this classification are patients diagnosed with dual diagnosis or as mentally ill chemical abusers (MICA's). There is a high prevalence of additional psychiatric disorders among persons seeking treatment with alcohol, cocaine, or opioid dependence. In general, the probability of comorbidity is higher for those with a lifetime diagnosis of an opioid or cocaine disorder than those with cannabis use.

Historical Overview

1. Mental Illness
2. Stigma

Assessment

1. Mental Status Exam
2. Suicide Assessment

Overview of Psychiatric Disorders

1. Axis I
2. Axis II

Dual Diagnosis Issues

1. Differential Diagnosis
2. Medication

Addiction Treatment

1. Special problems of MICA population
2. Treatment Barriers
3. Networking Strategies


Requirements of differential diagnosis and treatment of MICA patients:

  • Initial examination must include complete psychiatric history, mental status examination, and developmental and family history.

  • Patient undergoes detoxification and is substance free before coexisting psychiatric disorders can be effectively diagnosed.

The high prevalence of combined addiction and general psychiatric disorders in psychiatric facilities raises questions about which modalities can best be applied to the treatment of this difficult clinical problem. This problem is all the more difficult to address because the impact of substance abuse on the course of major mental illness is not well known, and because it is not clear whether modalities generally used to treat the two types of pathology are compatible.


TRAINER NOTE

Trainer will discuss:

  • reports that the dually diagnosed fare less well in conventional care than do singly diagnosed patients, e.g, schizophrenics with additional substance abuse and alcoholics with major depression;

  • recent attempts to treat the dually diagnosed alone in supportive grouptherapy;

  • attempts at service integration.


C. Detoxification and rehabilitation among patients with dual psychiatric and addictive illness.

Psychodynamic Factors and Psychopathology

1. acute and chronic organic mental syndromes associated with alcoholism.
2. attention-deficit disorder, residual type.
3. schizophrenia
4. borderline syndrome
5. affective disorders
6. other personality and neurotic disorders, e.g. anxiety
7. alcohol or opioid withdrawal
8. dementia
9. cerebral atrophy
10. depression


EXERCISE

Unit Chiefs and instructors will conduct emergency psychiatry case conferences which will include discussion of patients who presented at the emergency room during the previous week. Trainees will act as discussants, and provide follow-up for patients admitted to the substance abuse treatment facilities.


Relapse Prevention

TRAINER NOTE

Using handouts/overheads, Trainer will provide a general overview of of the relapse prevention model of treatment for substance abusers.

CONTENT

Relapse Prevention as a cognitive-behavioral treatment combining behavioral skill-training procedures with cognitive intervention techniques to assist individuals in maintaining desired behavioral changes. It uses a psychoeducational self-management approach to substance abuse designed to teach patients new coping responses (e.g., alternatives to addictive behavior), to modify maladaptive beliefs and expectancies concerning substance abuse, and to change personal habits and life-styles.

Topic areas to be reviewed include:

  • Treatment Goals and Treatment Philosophy
  • Definition of Lapse and Relapse
  • Overview of High-Risk Situations for Relapse
  • Covert Antecedents of Relapse
  • Assessment and Specific Intervention Strategies
  • Global Life-Style Strategies
  • Social Support in Couples and Families


TRAINER NOTE

Using overhead/handouts, Trainer will provide an overview of the concept of rehabilitation for alcohol and other substance abuse and present some guidelines for the appropriate referral and treatment of patients.

CONTENT

It should be noted that the aim is to establish a rehabilitation program that will probably do the most good. Participants should bear in mind, that no adequately controlled investigations have been carried out to test the most basic assumptions in rehabilitation.

Three basic goals of a "general" substance abuse treatment program:

1. Maximize physical and mental health of the patient.

2. Enhance motivation for achieving abstinence through educating the patient and his family about the usual course of the disorder and using appropriate medications and behavior modification techniques.

3. Help the patient to rebuild a life without the substance through vocational and avocational counseling, family counseling, etc.


Recommendations for Establishing a Rehabilitation Program:

1. Whenever possible, use outpatient rehabilitation rather than inpatient.

2. If inpatient rehabilitation is used, keep it as short as possible.

3. Avoid using most medications in the treatment of substance abuse after withdrawal is completed.

4. Use group more than individual counseling.

5. Use self-help groups such as Alcoholics Anonymous, Narcotics Anonymous, and Cocaine Anonymous.

6. Recognize that there is no evidence that any one specialized and expensive form of psychotherapy is more effective.

7. Incorporate formal relapse prevention procedures into the treatment and aftercare phases of rehabilitation.

8. Reach out to family members and friends of substance-dependent individuals and educate them as to what can be expected about the treatment program.

9. Maintain continued contact with the patient for at least 6 - 12 months

10. For men and women with few social supports or with chaotic life situations, consider using a half-way house for 3 to 6 months while promoting aftercare and self-help group participation.


SELECTED READINGS

Kleber, HD. Opioids Detoxification in Textbk on SA Treatment, NY: AP Press, p.194, 1994.

McLellan AT, et al: The Addiction Severity Index. Health Services Research & Development Project 255. Veterans Administration, Washington, 1979.

McClellan AT, et al: An improved diagnostic evaluation instrument for substance abuse patients: The addiction severity index. J of Nerv and Mental Disease 168:26-33, 1980.


Objective 2. Promote understanding of advanced knowledge and skills of drug action in the nervous system, drug treatment of specific disorders, ECT, and medication combined with psychotherapy.

A. Recognize the signs and symptoms of the psychiatric disorders which often accompany the chronic use of the major category of drugs.

B. Use of psychoactive medications in the treatment of psychiatric disorders often accompanying the use of the major categories of drugs.

C. For internists and family practitioners, in particular, diagnosis and management of the medical sequelae of addiction, including hepatic, central nervous system, infectious, and HIV illness.


TRAINER NOTE

Allow 200 hours for delivery of this section.


CONTENT

A. Signs and symptoms of psychiatric disorders accompanying chronic use of the major categories of drugs

     All drugs of abuse cause intoxication, all induce psychological dependence, and all are self-administered by an individual to change his or her level of consciousness or increase his psychological comfort. For each of the drug classes the Trainer will do the following

  • discuss the most usual history
  • note the usual physical signs and symptoms 
  • note the most prominent psychological difficulties
  • present an overview of relevant laboratory tests.


Guidelines for addressing the most clinically significant problem first:

1. Any patient who has taken enough of a drug to seriously compromise his or her vital signs is regarded as having an overdose or a toxic reaction.

2. Patients who demonstrate a drug-related clinical syndrome with relatively stable vital signs but show strong evidence of drug withdrawal (even with confusion or psychotic symptoms) are labeled withdrawal cases.

3. Patients with stable vital signs and no signs of withdrawal, but with levels of drug-induced confusion, are regarded as having an organic brain syndrome (OBS), even if the hallucinations or delusions are part of the clinical picture.

4. Patients with vital signs, no evidence of clinically significant confusion, and no signs of withdrawal, but who show hallucinations and/or delusions without insight, are regarded as having a psychosis.

5. Most remaining patients are expected to be demonstrating a flashback or a drug-induced depression or anxiety state.


TRAINER NOTE

Trainer will present an overview of the general signs and symptoms of drug problems while indicating the basic differences and problems encountered with each class of drugs.

1. Toxic Reaction

     a. overdose that occurs when an individual has taken so much of the drug that the body support system no longer works.
    b. this diagnosis takes precedence even if signs of confusion or psychosis are present.

2. Withdrawal or Abstinence Syndrome

     a. symptoms usually opposite of the acute effects of that same drug.
     b. length of withdrawal syndrome varies directly with the half-life and the intensity increases with the usual dose taken and the length of time over which it is taken.

3. Organic Brain Syndrome (OBS)

Marked by confusion, disorientation, and decreased intellectual functioning along with stable vital signs in the absence of signs of withdrawal.

A. Typical History
     a. drugs that produce confusion at relatively low doses
     b. factors that predispose a person to confusion: e.g. physical debilitation, advanced age, prior head trauma, long history of drug or alcohol abuse.

B. Physical Signs and Symptoms

C. Psychological State

D. Relevant Laboratory Tests
     a. blood or urine toxicological screens
     b. neurological examination
     c. blood tests
     d. skull x-rays
     e. spinal tap
     f. EEG

4. Psychosis

Drug-induced psychosis occurs when an awake, alert, and well-oriented individual with stable vital signs and no evidence of withdrawal, experiences hallucinations and delusions without insight.

A. Typical History
     a. usually seen in individuals who have repeatedly consumed CNS depressants or stimulants.
     b. abrupt onset -- within hours or days
     c. dramatic disturbance
     d. may result in patient being brought to emergency room by police

B. Physical Symptoms

C. Psychological State

D. Relevant Laboratory Tests
     a. none specifically for diagnosis of psychosis
     b. urine or blood screens might show presence of drugs.

5. Flashbacks

Most often seen with the cannabinols and the hallucinogens, a flashback is the unwanted recurrence of drug effects.

A. Typical History
     a. most frequently seen in individuals who have repeatedly used marijuana or hallucinogens.
     b. history of past drug use with no recent intake to explain episode of feeling high.

B. Physical Symptoms

C. Psychological State

D. Relevant Laboratory Tests
     a. none specifically for diagnosis of flashback
     b. rare cases might require neurological examination to rule out brain damage

6. Anxiety and Depression

Not only can symptoms of sadness and nervousness temporarily develop in the context of substance use, but even severe depressive episodes and symptoms resembling major anxiety syndromes can occur with heavy and repeated intake of substances.

A. Typical History
     a. repeated intoxication with depressant drugs precipitate depressive symptoms
     b. withdrawal from depressants associated with temporary anxiety disorders
     c. intoxication with stimulants precipitates major anxiety syndromes
     d. withdrawal from stimulants resembles depression.

B. Physical Symptoms

C. Psychological State

D. Relevant Laboratory Tests
     a. steps must be taken to rule out obvious physical pathology: EEG,WBC,CPK


EXERCISE

A series of clinical case studies of patients exhibiting various drug toxicity and withdrawal states will be presented by the Trainer. Trainees will identify the drug of abuse and make recommendations concerning treatment strategies.


SELECTED READINGS

Kolata G: New drug counters alcohol intoxication. Science 234:1198-1199, 1986.

Kosten TR et al: Bromocriptine treatment of cocaine abuse inpatient maintained on methadone. Am J Psychiatry 145-381-382, 1988.

Mello N & Mendelson J: Buprenorphine suppresses heroin use by heroin addicts. Science 207:657-659, 1980.


Objective 3. Promote understanding and mastery of the psychotherapeutic techniques required for intervention and confrontation with the chronic drug abuser and dealing with the denial that causes the patient to resist entry into treatment.


    A. Provide hands-on experience with the psychotherapeutic techniques involved in the management of the chronic drug abusing patient, including individual psychotherapy, marital therapy, family therapy, behavioral therapy and group therapy.

    B. For psychiatrists, in particular, hands-on experience with the psychotherapeutic techniques involved in the management of the chronic drug abusing patient, including individual psychotherapy, marital therapy, family therapy, behavior therapy and group therapy is important.

TRAINER NOTE

1. Trainer will present material using overheads and handouts.
2. Provide participants with opportunity to practice skills using role-play.
3. Allow 200 hours for delivery of this section.


CONTENT

Present an overview of psychotherapy as it relates to addiction treatment, a rationale for its use here, and general factors in addiction treatment focussing on the following points:

1. The therapist must devote much time and energy to introduce the patients to treatment and to engage them in it.

2. The treatment goal must be formulated early and kept in sight.

3. The therapist must give much attention to developing a positive relationship and supporting the patient.

4. The therapist must keep abreast of the patient's compliance with the overall drug treatment program through patient's self-report, urinalysis, and information from treatment staff and family.

5. If the patient receives methadone, attention should be given as to when the patient feels therapy is best, before or after the daily dose.


Psychotherapeutic techniques adapted for substance abuse treatment:

1. psychodynamic approaches
2. supportive-expressive psychotherapy
3. interpersonal psychotherapy
4. cognitive therapy

Present an overview of family treatment techniques and their application to substance abusing individuals:

1. Structural-strategic therapy: Structural and strategic types of therapy are combined because they were developed by many of the same practitioners, and shifts between the two theoretical models are frequently made by these therapists, depending on family needs. Trust of structural family therapy is to restructure the system by creating interactional change within the session. The therapist actively becomes a part of the family, yet retains sufficient autonomy to restructure the family.

Symptoms are seen here as maladaptive attempts to deal with difficulties that develop a homeostatic life of their own and continue to regulate family transactions. The therapist here seeks to substitute new behavior patterns for the destructive repetitive cycles.

This therapy was used by Stanton & Todd (1982) successfully with heroin-addicted patients who were on methadone maintenance.

2. Psychodynamic Therapy: Though rarely used with substance abuse patients, it has some limited use. Symptoms here are seen in context of his or her own historical past as well as that of every family member. This as well as the primary goal: achieving second-order change-- change the entire family system so the dysfunction does not occur in other family members once the symptoms of the Index Patient (IP) have been alleviated. Cornerstones for implementation of this approach: therapist's self-knowledge and detailed family history. Therapist must thoroughly understand his or her own emotional reaction as well as those of the family.

A specific technique helpful for substance abuse is the "family of origin technique" developed by Framo 1981.

3. Bowen's Systems Theory: Cognitive factors are emphasized and affect is minimized. Systems theory focuses on triangulation, which implies that wherever there is emotional distance or conflict between two individuals, tensions will be displaced onto a third party, issue, or substance.

This approach is commonly used with substance abusing adolescents and can be applied in clear, easy steps. It can also be used for married drug abusing adults and their families.

4. Behavioral Family Therapy: Commonly used with substance-abusing adolescents and can be elaborated in clear, easily learned steps.


Present an overview of behavioral therapy.

A variety of cognitive-behavioral treatment approaches based on social learning theory has emerged in the past two decades. Broad spectrum approaches incorporate social learning and behavioral principles, such as self-monitoring, functional analysis, social skills training, problem solving, and relaxation training. Strong support exists for some elements of these treatments, including social skills training, cognitive therapy and relapse prevention treatment.

The followin will be presented in detail:

a. Skill-building techniques (e.g. relaxation, exercises, assertiveness training)
b. Positive reinforcement for the attainment and maintenance of sobriety or other approved behaviors.
c. Contingency contracting with individuals who abuse variety of substances.


Present an overview of Group Therapy

Elements of Group Therapy for Addiction

     1. Pregroup Preparation with outreach and preparation to increase motivation, reduce premature dropouts, ease fears and resistance to group modality, and increase self-awareness.

     2. Structure established through group contract, shared norms, abstinence, commitment to talk about feelings.

     3. Safety on the physical, therapeutic, and psychological levels.

     4. Confrontation vs. Support: relating to patients in an empathic, supportive, understanding manner. How group leader handles the central task of managing the anxiety that the group process, particularly confrontation, inevitably stimulates in the group members and manages to keep it at a tolerable level.

     5. Cohesion and the "Addict Identification" is associated with tenure in the group.


TRAINER NOTE

Trainer should emphasize the active role of leadership demanded by the Group Therapist in managing the safety and structure of the group to modulate anxiety, address acting-out behavior, and to intervene if necessary by setting limits and upholding the group contract. Point out how the therapist may become the focus of anger, dependency, and countertransference feelings and the mediator of struggles.

EXERCISE

Using case studies, participants will practice techniques of the group therapist through roleplay. Case studies will be provided by each Trainer based on client data as provided within individual institutions where training is conducted.


SELECTED READINGS

Annis HM: A relapse prevention model for treatment of alcoholics. In Miller WE, Heather (Eds). Treating Addictive Behaviors, NY: Plenum, 1986.

DeLeon G: Therapeutic community research: Overview and implications. Chptr 7 in DeLeon, G & Ziegenfuss Jr. JT (Eds). Therapeutic Communities for Addictions: Readings in Theory, Research and Practice. Springfield, IL: Charles C. Thomas, 1986.

Galanter M, et al: Combined Alcoholics Anonymous and professional care for addicted physicians, Am J Psychiatry, in press.

Steinglass P: The sobriety-intoxication cycle: Family problem-solving and alcoholic behavior. Chapter 6 in The Alcoholic Family. NY: Basic Books,1988.

Woody GE, et al: Psychotherapy for opiate addicts: Does it help? Arch Gen Psychiatry 40:639, 1983.

Wurmser L: Mr. Peckinsniff's horse? (Psychodynamics in compulsive drug use). Chapter 4 in Blaine JD, Julius DA (Eds). Psychodynamics of Drug Dependence. NIDA Research Monograph. US Gov't Printing Office 1977, 36-72.


Objective 4. Experience with collaborative therapy with other therapists who participate in the care of substance abuse patients, including nurses, social workers, psychologists, nurse practitioners, non-professional counselors, pharmacists and others.


TRAINER NOTE

Allow 50 hours for delivery of this section.

CONTENT

Physicians should be able to consult with, and refer patients to addiction specialists, alcohol and drug treatment programs, and mutual self-help groups. This section will provide an overview of theoretical & practical aspects of consultation/liaison psychiatry, including models of care, and psychopathology in the substance abuse treatment setting.

EXERCISE

1. Using case studies, trainer will describe the various clinical situations in which a physician may want to consult an addiction specialist or refer a patient to an addiction treatment program.

2. Trainees will participate in the Consultation/Liaison Seminar and Case Conference.

3. Trainer will provide handouts on referral options, strategies, and potential local resources.


Clinical situations in which a physician may want to consult with addiction specialists or make referrals:

1. Persons who present evidence of physical dependence on drugs often require detoxification and specialized treatment.

2. Persons who have evidence of alcohol-related health problems such as hepatitis, pancreatitis, or depression, who need to become abstinent should be referred to a specialized program.

3. Persons who have been unable to overcome their substance abuse behavior, following an office-based intervention.


Methods to Increase Patient Follow-Through on Substance Abuse Referral:

1. Physician advises the patient that he would like a second opinion from a specialist, emphasizing the medical aspect of the referral.

2. Physician should help the patient set up the appointment by making the phone call while the patient is in the examination room.

3. A referral letter summarizing the patient's medical problems and the reason for the referral should be sent prior to the patient's appointment with the specialist.

4. The physician would inform the consultant that s/he would like feedback on the case, even if patient failed to appear.


Objective 5. Recognition and understanding of the special problems of the pregnant drug abuser and of the babies born to substance-abusing mothers.


CONTENT

A multifaceted, efficient treatment approach for substance abusing perinatal women is necessary. The United States Department of Health and Human Services estimates that more than 100,00 cocaine-exposed babies are born each year. According to a study conducted by the National Association for Perinatal Addiction Research , at least 11% of pregnant women nationwide use illegal drugs during pregnancy.

TRAINER NOTE

Allow 50 hours for delivery of this section.

Problems accompanying abuse of opiates by pregnant women:

     1. Opiate Withdrawal in the Neonate
     2. Elevated rates of intrauterine death
     3. Low-birth-weight infants
     4. Premature delivery
     5. 2-5% risk for neonatal mortality


TRAINER NOTE

Trainer will emphasize the importance of prevention as a first step in treatment of this syndrome and recommend that pregnant addicts on methadone maintenance should reduce dosage to 20 mg daily or less during the last 6 weeks of pregnancy.


Treatment of Opiate Withdrawal Syndrome

1. General support and observation: keeping the child warm, quiet environment and observing electrolytes, glucose, and other physiological parameters.

2. With moderate to severe symptoms, child can be treated with paregoric.

3. Treatment with methadone, or phenobarbital, or diazepam with dosages.(163D&AA)

4. Controlling symptoms with clonidine.

5. It is possible to treat addicted infants of mothers on methadone maintenance by having them breast feed while they continue to take their methadone with additional drugs administered to the child as needed.


Fetal Alcohol Syndrome

Symptoms include: multiple spontaneous abortions, baby with low birth rate for gestational stage, malformations in facial structure, ventricular septal defects of the heart; malformations of the hands and feet, levels of mental retardation, later behavioral or learning problems.

Some factors contributing to the syndrome: amount of ethanol involved, the timing of the drinking, the possible role of associated nutritional deficiencies.


Treatment of Fetal Alcohol Syndrome:

1. Prevention is the only treatment.

2. Advise women not to drink at all during pregnancy, or if they must drink, to keep their alcohol intake as low as possible.


SELECTED READINGS

Bell P, Evans J: Counseling the Black Client. Hazelden Foundation, Center City, MN, 1981. Cultural Competence for Evaluators: A guide for alcohol and other drug abuse prevention practitioners working with ethnic/racial communities. Office for Substance Abuse Prevention, 1992.

Egelko S, Galanter M, et al: Treatment of perinatal cocaine addiction: Use of the modified therapeutic community. Am J of Drug and Alcohol Abuse, 22(2), 185-202, 1996.

Egelko S, Galanter M, et al: Evaluation of a multi-systems model for treating perinatal cocaine addiction. In press, J of Substance Abuse Treatment.

Galanter M, et al: A general hospital day program combining peer-led and professional treatment of cocaine abusers. Hospital and Community Psychiatry, 44, 644-649, 1993.

Matera C, Warren W, Moomjy M, Fink D, Fox H. Prevalence of us of cocaine and other substances in an obstetric population: Results of an anonymous cross-section study. American Journal of Obstetrics and Gynecology 1991; 164:625.

Raskin V. Psychiatric aspects of substance abuse disorders in childbearing populations.


   

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