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Mothers

Pregnancy can be a special time for a woman. There is no more important job than bringing a healthy life into this world. You may be frightened or feel alone if you are currently pregnant and using substances, but there is still time for you to make changes to help your baby. We know you want what is best for your baby and there is support available. If you are looking for help, call the Tennessee Redline at 1-800-889-9789.

The earlier a medical professional is involved in your pregnancy, the better off your baby will be. The severity and duration of drug withdrawal the baby experiences after birth can be significantly decreased. Prenatal care is very important. If you do not yet have a doctor, click here to see a list of obstetricians near you.

It is important to talk to a medical professional about all the medications you are taking, including prescription pain pills. Don’t be scared to talk to your doctor about medications or drugs you take while you are pregnant: they are there to help you, not punish you. By talking to a medical professional before your pregnancy, you can reduce the chances of your baby being born with Neonatal Abstinence Syndrome (NAS).

Sometimes, people can begin to rely on drugs or prescription pills to try to make them feel better if they are sad, depressed, lonely, or stressed out. If you are concerned about feeling this way, talk to your doctor or look at this self-assessment.

Babies born with NAS can suffer from withdrawal symptoms such as fever, seizures, blotchy skin, continuous crying, rapid breathing, respiratory problems, and extreme sensitivity to sounds and light. In many cases, doctors and nurses give these newborns methadone or, the same drug used to treat heroin addiction, or morphine to ease their constant pain.

If you follow this “Healthy Baby Checklist”, it can help you stay on track to keep you and your baby healthy.

mother

Strong Baby Knox

Improving the well-being of mothers, infants and children is an important community health goal for the Knox County Health Department. Their well-being determines the health of the next generation and can help predict future public health challenges for families, communities and the health care system. The Strong Baby project is an effort to promote healthier families and infants.

For more information on healthy pregnancy, please visit strongbabyknox.org.

Have a conversation with your healthcare practitioner

If you are prescribed or taking one or more of the following prescription pain medications, talk to your healthcare practitioner about treatment or other alternatives:

Opioid pain medications, central nervous system depressants, stimulants, anti-depressants, Neurontin (gabapentin), alcohol, street drugs such as heroin or meth, and non-prescription drugs.

If you are pregnant, or may become pregnant, your baby’s health is dependent on yours. When you use a drug, tobacco, caffeine, or drink alcohol, it significantly impacts how your baby develops in the womb. Tobacco and caffeine use can have a big effect on the health of your baby. Tobacco and caffeine can be even more dangerous to your baby when combined with other drugs.

It is not too late to seek help. Contact your medical practitioner or call the Tennessee Redline at 1-800-889-9789 in order to give your baby a healthy start.

Prescription Medications

There are a variety of reasons you may be taking prescription medications. However, these medications may have an impact on the development of your baby. Whether you take this medication with a prescription or for other reasons, it is important to be aware of the potential impact.

Preventing Pregnancy

The Health Department provides access to Voluntary Reversible Long-Acting Contraceptives for women. If you would like information on how to prevent pregnancy if you are using opioid drugs, find your nearest health department here.

Health Insurance

What do I do if I do not have health insurance?

Pregnant women with low income are eligible for TennCare based on the following scale:

 

 

How do I sign up for TennCare (health insurance) if I don’t have medical insurance?

To enroll in TennCare for medical insurance, call the Tennessee Health Connection at 1-855-259-0701 or click here.

How do I sign my baby up for health insurance?

Some birthing facilities can help you sign up your baby for TennCare or CoverKids. You may also visit the TennCare website or CoverKids website to sign up yourself here.

What do I do if I don’t have an obstetrician (pregnancy doctor)?

For a list of pregnancy centers or OBGYNS in Tennessee that provide free or low-cost services, click here. You may also call your local health department. Tennessee health departments may be found by clicking here.

Friends & Family

A pregnancy can be an exciting and scary time for the woman and her family. All involved want what’s best for the mother–to-be and the baby. Most women stop using prescription pain medications, illegal drugs and alcohol during pregnancy. However, some may not know how dangerous continuing these drugs can be for their unborn baby.

People use substances for a variety of reasons. In the case of prescription drugs, this may be under the supervision of a physician. Other women may be using substances to help them cope with the everyday stressors in her life.

In some situations, women may deny use of these substances, but there are warning signs friends and family members can look for.

Warning Signs of Drug Use

The use and abuse of drugs are serious issues that should not be ignored or minimized and we should not sit back and hope they just go away.  If left untreated, use and abuse can develop into drug dependence.  As a result, it is important to recognize the signs and symptoms of drug abuse early.  If you’re worried that a friend or family member might be abusing drugs, here are some of the warning signs to look for:

Physical and health warning signs of drug abuse:
  • Eyes that are bloodshot or pupils that are smaller or larger than normal.
  • Frequent nosebleeds–could be related to snorted drugs (meth or cocaine).
  • Changes in appetite or sleep patterns.
  • Sudden weight loss or weight gain.
  • Seizures without a history of epilepsy.
  • Deterioration in personal grooming or physical appearance.
  • Injuries/accidents and person won’t or can’t tell you how they got hurt.
  • Unusual smells on breath, body, or clothing.
  • Shakes, tremors, incoherent or slurred speech, impaired or unstable coordination.
Behavioral signs of drug abuse
  • Drop in attendance and performance at work or school; loss of interest in extracurricular activities, hobbies, sports or exercise; decreased motivation.
  • Complaints from co-workers, supervisors, teachers or classmates.
  • Unusual or unexplained need for money or financial problems; borrowing or stealing; missing money or valuables.
  • Silent, withdrawn, engaging in secretive or suspicious behaviors.
  • Sudden change in relationships, friends, favorite hangouts, and hobbies.
  • Frequently getting into trouble (arguments, fights, accidents, illegal activities).
Psychological warning signs of drug abuse
  • Unexplained change in personality or attitude.
  • Sudden mood changes, irritability, angry outbursts or laughing at nothing.
  • Periods of unusual hyperactivity or agitation.
  • Lack of motivation; inability to focus, appearing lethargic or “spaced out.”
  •  Appearing fearful, withdrawn, anxious, or paranoid, with no apparent reason.

Helpful Hints for Friends and Family

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If you believe your loved on is struggling with an alcohol or drug problem, you have probably heard the following excuses. Here are some helpful hints to help you communicate with your loved one and get them the help they need.

Additional Tips

When your loved one is ready for a change, acknowledge her strengths, anticipate problems and pitfalls to changing, and assist the woman in generating her own plan for obtaining a drug-free lifestyle. Problem solve with her things that might get in the way of her success and how she can overcome those barriers. Work on plans for referral to treatment (i.e., help her make an appointment and offer to drive her there).

Once your loved one has quit using drugs or alcohol, acknowledge her success and how she is helping her infant and herself; have her share how she has succeeded and how she is coping with the challenges of not using. Offer to be available for assistance if she feels that she wants to use drugs/alcohol again. Provide assistance with treatment referrals and support in continuing that treatment: Discuss triggers and social pressures that may lead to relapse, and help the woman plan for them. Understand during this time that your support and that of others around her are essential to her remaining sober. Also remember that you cannot do it all and professionals are there to help.

Often, people who have reached a point of recovery from their drug use relapse or get high again. Please remember that addiction is a chronic relapsing disease. If this happens, remain supportive and guide the woman toward identifying what steps she used to quit before. Offer hope and encouragement, allow the woman to explore the negative side of quitting and what she can do to deal with those issues. (How did she deal with those issues in the past? Explore what worked and what didn’t work for her.) Offer to provide assistance in finding resources to help her return to abstinence. If relapse occurs, call the Tennessee REDLINE at 1-800-889-9789.

Practitioners

Opioid Abuse in Pregnancy: Guidelines for Health Care Practitioners

Effects on Pregnancy and the Child

  • Chronic heroin abuse is associated with an increased risk of fetal growth restriction, abruption placentae, fetal death, preterm labor, and intrauterine passage of meconuim. These effects may be related to the repeated exposure of the fetus to opioid withdrawal and the effects of withdrawal on placental function and may also occur in other types of opioid abuse.
  • First-trimester use of codeine has been associated with congenital heart defects in three of four case-control studies. No association has been described between the use of other opioids during pregnancy and an increased rate of birth defects.
  • The lifestyle issues associated with illicit drug use put a pregnant woman at risk of engaging in activities such as prostitution, theft, or violence, to support herself and her addiction. The consequences of these activities pose a host of risks to the fetus.
  • Neonatal abstinence syndrome (NAS):
    • Occurs when newborns of opioid-abusing mothers are withdrawn from narcotic exposure. NAS usually manifests within hours to weeks of birth, when the child is separated from opioids in the mother’s body.
    • Symptoms of NAS include hyperactivity of the central and autonomic nervous systems, uncoordinated sucking reflexes leading to poor feeding, increased irritability, and high-pitched crying.
  • Long-term data for children with in-utero narcotic exposure is limited, but studies have not found significant decreases in cognitive development with maternal opioid abuse.

Utilize the Controlled Substance Monitoring Database

For healthcare providers seeking to query a patient’s prescription history, registering to become a user on the CSMD website may be accomplished by navigating to www.TNCSMD.com and click on “Register” and provide all required information. The email address provided should be personal and confidential. Once approved, the new user will receive an email with their login credentials for the database.

Do not use naloxone to diagnose opioid dependence in pregnant women as opioid withdrawal may precipitate preterm labor or fetal distress.

Pseudoaddiction is a situation in which a patient’s legitimate chronic pain is undertreated with pain medication, leading the patient to act in a way that resembles addictive behavior. This condition usually arises when a clinician is reluctant to prescribe enough of a controlled drug to provide adequate symptom relief. It is important to carefully distinguish pseudoaddiction from true substance abuse.

Treatment

Comprehensive prenatal care and monitoring, chemical dependency counseling, and other psychosocial services for women with opioid dependence should be a part of any treatment plan. It is important to give a woman all of her treatment options so she can make an educated and informed decision.

Methadone
  • The rationale for opioid-assisted therapy during pregnancy is to prevent complications of illicit opioid use and opioid withdrawal, encourage prenatal care and drug treatment, reduce criminal activity, and avoid risks to the patient of associating with a drug culture. Comprehensive opioid-assisted therapy that includes prenatal care has been shown to reduce the risk of obstetric complications.
  • Perinatal methadone dosages are managed by addiction treatment specialists within registered methadone treatment programs. A list of local treatment programs can be found at the federal Substance Abuse and Mental Health Services Administration.
  • The severity of NAS does not appear to differ based on the maternal dosage of methadone treatment.
Buprenorphine
  • Buprenorphine is the only opioid which may be legally prescribed for the treatment of opioid dependence in an office-based setting. Physicians wishing to prescribe this medication must undergo specific credentialing.
  • Advantages over methadone include a lower risk of overdose, fewer drug interactions, the ability to be treated on an outpatient basis without the need for daily visits to a methadone clinic, and evidence of less severe NAS.
  • Disadvantages to buprenorphine include reports of hepatic dysfunction, lack of long-term data on infant and child effects, a clinically important patient dropout rate due to dissatisfaction with the drug, a more difficult induction with the potential risk of precipitated withdrawal, and an increased risk of diversion.
  • The drug is available as a single agent or combined with naloxone, but the single agent is recommended during pregnancy. Although the single agent has a higher risk of abuse, it also has a reduced risk of exposing the fetus to naloxone which could lead to dangerous withdrawal symptoms.
Medically-supervised withdrawal
  • Not recommended because of its association with high relapse rates.
  • If this is to be undertaken, however, supervised withdrawal should ideally occur during the second trimester and with the aid of a perinatal addiction specialist. If the only alternative to medically-supervised withdrawal is continued illicit drug use, the withdrawal should take place as soon as possible no matter the trimester.

Breastfeeding should be encouraged in both methadone and buprenorphine patients as minimal levels of these drugs are found in breast milk.

Screening Tools for Substance Use

If you think your loved one has a problem, ask them to answer the following questions. This screening tool is called the “CAGE Model” and can often lead to an individual understanding they have a problem with drugs or alcohol. If they answer yes to two or more questions, consultation with a medical professional is necessary.

CAGE

C   Have you ever felt you ought to cut down on your drinking or drug use?
A   Have people annoyed you by criticizing your drinking or drug use?
G   Have you ever felt bad or guilty about your drinking or drug use?
E   Eye-opener: Have you ever had a drink or drug first thing in the morning to steady your nerves or get rid of a hangover?

 

The CAGE can identify alcohol problems over the lifetime. Two positive responses are considered a positive test and indicate further assessment is warranted. If you answered yes to two questions or more, call the Tennessee Redline at 1-800-889-9789.

National Institute on Alcohol Abuse and Alcoholism

Screening for Abuse

  • A urine drug screen is the single most useful test to determine if someone is abusing controlled substances.
  • Before pregnancy and in early pregnancy, all women should be routinely asked about their use of alcohol and drugs, including prescription drugs. The patient should be informed that such questions are asked of all pregnant women to ensure they receive appropriate care and that all information will be kept confidential. Maintaining a caring and nonjudgmental approach will yield the most inclusive disclosure.

Signs and symptoms suggestive of a substance abuse disorder:

  • Seeking initial prenatal care late in pregnancy
  • Poor adherence to appointments
  • Poor weight gain
  • Sedation, intoxication, or withdrawal symptoms
  • Erratic behavior
  • Multiple requests for early refills of a prescribed controlled substance
  • Pressuring behaviors in the office, such as pleading for another prescription, excessively complimenting the prescribing practitioner, or threatening harm to self or others.

The “5P’s” is a validated screening tool for identifying prenatal substance abuse:

The 5Ps was adapted by the Massachusetts Institute for Health and Recovery in 1999 from Dr. Hope Ewing’s 4Ps (1990). The 5Ps is an effective tool of engagement for use with pregnant women who may use alcohol or drugs. The screening tool poses questions related to substance use by women’s parents, her peers, her partner, during her pregnancy and in her past. The non-confrontational questions elicit genuine responses that can be useful in evaluating the need for a more complete assessment and possible treatment for substance abuse. It is important to advise your patient that the responses she provides are confidential. A single “YES” to any of these questions suggests further assessment.

5P’s

  • Parents: Did any of your parents have a problem with alcohol or drug use?
  • Peers: Do any of your friends have a problem with alcohol or other drug use?
  • Partner: Does your partner have a problem with alcohol or drug use?
  • Past: In the past, have you had difficulties in your life because of alcohol or other drugs, including prescription medications?
  • Present: In the past month, have you drunk any alcohol or used other drugs?

ACEs

The CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study is one of the largest investigations of childhood abuse and neglect and later-life health and well-being.

The original ACEs Study was conducted at Kaiser Permanente from 1995 to 1997 with two waves of data collection. Over 17,000 Health Maintenance Organization members from Southern California receiving physical exams completed confidential surveys regarding their childhood experiences and current health status and behaviors.

The CDC continues ongoing surveillance of ACEs by assessing the medical status of the study participants via periodic updates of morbidity and mortality data.

To learn more about ACES study and to obtain the questionnaires for your practice, please visit CDC's website here.

 

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