Alcohol Abuse during Pregnancy

QUICK LESSON ABOUT Alcohol Abuse during Pregnancy Description/Etiology No level of alcohol is known to be safe during pregnancy and drinking is not recommended. Many women do drink during pregnancy; sometimes this is because they are unaware they are pregnant. Many healthcare professionals believe that screening all pregnant clients for alcohol use and advising them of the dangers of drinking during pregnancy is critical. A clinical diagnosis of alcohol use disorder (AUD) using the criteria in theDiagnostic and Statistical Manual of Mental Disorders, 5th edition(DSM-5), requires exhibition of a recurrent pattern of use within a 12-month period that adversely affects personal functioning. A severity specifier (i.e., mild, moderate, severe) is then assigned based on the number of symptoms. Criteria for AUD include the manifestation of at least two of the following: consumption of alcohol in larger amounts over a longer period than was intended; a desire or unsuccessful attempts to cut down or controlalcohol use; spending large amounts of time on activities related to the obtaining of, use of, and recovery from alcohol; cravings; being unable to meet obligations at home, work, or school due to alcohol; continued use despite social or interpersonal problems caused by use; giving up social, recreational, or occupational activities; continued use even with physical or psychological problems; tolerance; and withdrawal. DSM-5 was published in 2013, replacing the DSM-IV. The DSM-IV chapter on “Substance-Related Disorders” included substance dependence, substance abuse, substance intoxication, and substance withdrawal, and then discussed specific substances (e.g., alcohol, amphetamines). The DSM-5 divides these disorders into two categories: substance use disorders (SUD) and substance-induced disorders (intoxication, withdrawal, and other substance/medication-induced mental disorders). Thus it removes the distinction between abuse and dependence and instead divides each disorder into mild, moderate, and severe subtypes. Drug craving has been added as a criterion for substance use disorder, whereas “recurrent legal problems” has been removed. In the DSM-5, substance abuse is referred to as substance use disorder whereas in the research literature and treatment field the terms substance abuse and substance dependence continue to be commonly used. Authors Jan Wagstaff, MA, MSW Cinahl Information Systems, Glendale, CA Jessica Therivel, LMSW-IPR Cinahl Information Systems, Glendale, CA Reviewers Lynn B. Cooper, D. Criminology Chris Bates, MA, MSW Cinahl Information Systems, Glendale, CA July 31, 2015 Alcohol consumption may disrupt a woman’s menstrual cycle and increase her risk of infertility, miscarriage, stillbirth, and premature delivery. Biophysical effects of alcohol during pregnancy include nutritional deficiencies, pancreatitis, alcoholic ketoacidosis, alcoholic hepatitis, and cirrhosis. Fetal alcohol spectrum disorder (FASD) covers a range of effects of maternal alcohol consumption upon the fetus: it is a leading cause of birth defects, developmental disabilities, and mental retardation in children. In the United States, an estimated 50,000 children are born each year with fetal alcohol effects. Many of these children will be of low birth weight and approximately 5,000 will have fetal alcohol syndrome (FAS), a more severe pattern of problems caused by maternal alcohol consumption. Research also links sudden infant death (SID) with fetal exposure to alcohol. Newborns of women who binge drank (defined as the consumption of 4 or more drinks over the course of 2 hours or less) during their first trimester are at a substantially increased risk of SID. Alcohol misuse additionally has been shown to disrupt maternal bonding and attachment after birth. Victimization by sexual assault is more common among women who drink, especially younger women. The disinhibition that results from alcohol consumption may lead to Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2015, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206 risk-taking behavior, which can result in unplanned and/or unwanted pregnancy. Women with AUD are more likely to have personal trauma histories that predate their disorder than women without AUD, including being victims of physical and sexual assault and intimate partner violence (IPV). They also have a higher prevalence of eating disorders and addictions to prescription pain and sedative medications. If her AUD is not treated, a woman’s entire social support system and social network can break down. A common barrier to treatment is denial; many women with alcohol problems seek help only when their condition becomes chronic or they experience a traumatic event directly related to alcohol use. Society often judges women with alcohol disorders more harshly than men. Because of this many women will prioritize health- and family-related problems to avoid addressing any problematic alcohol use when seeing healthcare and social service professionals. Pregnant women can easily be screened as part of their routine treatment; the earlier this is completed, the better. In the United States, estimates are that between 5% and 30% of women are screened during pregnancy for alcohol use. The postpartum period, therefore, may represent a unique intervention opportunity for women with AUD. Facts and Figures Treatment admission data indicate that approximately 20% of pregnant women entering treatment for substance use disorders were being treated for alcohol use disorder (McCabe & Arndt, 2012). Using 11 years of treatment admission data, researchers found that the rate of referrals from primary care went down in the period of years studied whereas referrals from the criminal justice system increased (McCabe & Arndt, 2012).One in 30 U.S. women is estimated to drink during pregnancy at high enough levels to cause FASD (National Center on Birth Defects and Developmental Disabilities, 2004). The Behavioral Risk Factor Surveillance System survey found that between 2006 and 2010, 7.6% of pregnant women in the United States used alcohol and 1.4% engaged in binge drinking (CDC Morbidity and Mortality Report, 2012). Risk Factors Pregnant girls ages 15-17 years have an increased risk of developing AUD and thus are especially in need of prevention services. Among women who are pregnant, those ages 35 to 44, White,and have a college education or are employed are the most likely to use at least some alcohol. Women with the greatest risk of having a baby with FASD are those who are under 30, living in poverty, have mental health issues, and have a history of substance dependency and/or incarceration. Women with little or no social supportcan be at higher risk. Women living in environments in which alcohol use is common and accepted may also be vulnerable. Women with parents with AUD are at greater risk for developing AUD. Women with mental health issues, especially depression, and those with high levels of stress brought on by life stressors (e.g., unemployment, being the victim of IPV or sexual assault) can also be at increased risk. Signs and Symptoms/Clinical Presentation Smelling of alcohol; having glazed or bloodshot eyes; changes in mood; drowsiness; sleep problems; blackouts; and unusual passivity or argumentativeness can be symptoms of AUD. Deterioration in appearance or hygiene may be a sign. An intoxicated person may have flushed skin, a decreased ability to pay attention, and/or forgetfulness. Social Work Assessment 1.Client History • Conduct a biopsychosocialspiritual assessment with the client, covering her developmental, emotional, psychological, and medical history and that of her family. Women with severe alcohol abuse are more likely to deny alcohol use than women who consume moderate amounts of alcohol. It is important to note that when designing interventions for women whose histories include depression and post-traumatic stress disorder (PTSD) related to physical or sexual assault or abuse, the confrontational approach traditionally used to deal with denial in addiction is unlikely to work 2.Relevant Diagnostic Assessments and Screening Tools • The Alcohol Use Disorders Identification Test (AUDIT) has 10 questions; research has shown it to be especially useful for screening women and persons who are non-White • The CAGE questionnaire is a commonly used screening tool for AUD because it has 4 questions that are simple and thus easy to remember • The TWEAK survey detects harmful drinking during pregnancy; it has 5 questions and can be administered in less than 2 minutes • The Prenatal Risk Overview (PRO) is a 10- to 15-minute structured interview that screens pregnant women for psychosocial risk factors that can affect pregnancy. Ithas been shown to have high specificity (i.e., identifying who is not at risk)and sensitivity in detecting AUD in pregnant women 3.Laboratory Tests of Interest to the Social Worker • Dependent on setting, it may be appropriate to have blood alcohol or breathalyzertesting completed • Fetal monitoring and/or ultrasounds may be indicated Social Work Treatment Summary Any reduction in drinking during pregnancy is considered beneficial (Armstrong et al., 2009). Screening all pregnant women is recommended; this can be combined with motivational interviewing techniques to educate women about the dangers of drinking during pregnancy and to reinforce abstinence (Kotrla & Martin, 2009; Armstrong et al., 2009). Motivational interviewing (MI) creates a positive, empathic relationship between the client and social worker that avoids argumentation, facilitates mutual trust, and encourages self-efficacy as the client engages in risk-benefit analysis (Hepworth et al., 2010). Women-only support or therapy groups and meetings may be beneficial since researchers have found that women with a history of trauma have more difficulty trusting male staff (Carlson, 2006). Cognitive behavioral therapy (CBT) addresses skills deficits and assists in the development and rehearsal of new skills, which can help women manage stress (Sampl & Kadden, 2001; Carlson, 2006; González-Prendes, 2008). Spirituality or religiosity can play a role in recovery; Alcoholics Anonymous (AA) is a 12-stepprogram that incorporates spirituality for anyone with a past or present AUD. However, AA may not work for everyone, and Secular Organizations for Sobriety (SOS) is an alternative (Bliss, 2007; Kaskutas, 2009). In one study,Native Americans had better outcomes when they were matched with motivational enhancement therapy (a derivative of MI) than with the AA model (Miller et al., 2007). Interventions that offer childcare help women attend programs (Welsh et al., 2008). Social workers should be aware of their own cultural values, beliefs, and biases and develop specialized knowledge about the histories, traditions, and values of their clients. Social workers should adopt treatment methodologies that reflect their knowledge of the cultural diversity of the communities in which they practice. . Problem During screening, pregnant client discloses alcohol use Goal Intervention Client will be counseled on Advise client about the risks alcohol use during pregnancy involved in drinking during pregnancy. If the client meets criteria for an AUD, conduct a biopsychosocialspiritual assessment and work together on devising an appropriate intervention. If client meets criteria for inpatient treatment for AUD, assist in referral to appropriate program . Applicable Laws and Regulations › The vast majority of countries set a legal age at which individuals can buy and consume alcohol. The most common is age 18 years, in a few countries it is age 16, and in a small number, including the United States, it is age 21. In a small number of countries drinking is forbidden, and about a dozen countries have no laws limiting alcohol consumption or purchase by age › Each country has its own standards for cultural competency and diversity in social work practice. Social workers must be aware of the standards of practice set forth by their governing body (e.g., National Association of Social Workers in the United States, British Association of Social Workers in England) and practice accordingly Available Services and Resources › World Health Organization (WHO), http://www.who.int/substance_abuse/en/ › National Institute on Alcohol Abuse and Alcoholism (NIAAA), http://www.niaaa.nih.gov › U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), http://www.samhsa.gov › U.S. Centers for Disease Control and Prevention, http://www.cdc.gov › Alcoholics Anonymous, http://www.aa.org › Harm Reduction Coalition, http://harmreduction.org/ › Secular Organizations for Sobriety (SOS), http://www.cfiwest.org/sos/index.htm Food for Thought › AUD in women is less likely to be identified by social workers than AUD in men › Although social networks generally are considered a protective factor against AUD, in some cases they can be detrimental by encouraging excessive alcohol use › Removal of a child who had been exposed to alcohol or drugs during pregnancy from the custody of the mother was found to increase the likelihood of a subsequent birth by two-fold, and to increase the likelihood of the mother’s consumption of alcohol or drugs during that pregnancy by three-fold(Grant et al., 2014) › In one survey 2.6% of women who had abortions stated that alcohol use was the reason for termination. 84% of these women reported heavy binge drinking or having experienced blackouts (Roberts et al., 2012) › Older pregnant women (i.e., age 35 and over) are more likely to drink than younger pregnant women. This may be a result of an increase in both physical and psychological stress felt by older pregnant women, although other risk factors for alcohol use disorder are likely to decrease with age (Meschke& Messelt, 2013) Red Flags › No level of alcohol consumption is known to be safe during pregnancy › Symptoms of alcohol intoxication and withdrawal can mimic those of many major psychiatric disorders; therefore, accurate screening and assessment are critical › Research suggests that consuming alcohol while pregnant increases the risk of SID › Cigarette smoking has been identified as a significant predictor of alcohol use during pregnancy across ethnicities › Alcohol use during mid-pregnancy can increase the risk that the mother will be non-responsive to the infant in the 12 months after birth (Pearson et al., 2012) › Heavy maternal alcohol consumption has been found to negatively affect fetal brain function. Evidence of diminished information processing may indicate the presence of structural damage to the brain (Hepper et al., 2012) Discharge Planning Whenever possible, follow up with the client and continue with support. Case management is recommended by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) for reaching the optimal level of care for substance-abusingpregnant women. Refer client to community-based peer support group (e.g., AA or appropriate 12-step program) References 1. American Psychiatric Association. (2013). Substance-related and addictive disorders. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Arlington, VA: American Psychiatric Association. 2. Armstrong, M. A., Kaskutas, L. A., Witbrodt, J., Taillac, C. J., Hung, Y. Y., Osejo, V. M., & Escobar, G. J. (2009). Using drink size to talk about drinking during pregnancy: A randomized clinical trial of Early Start Plus. Social Work in Health Care, 48(1), 90-103. 3. Austin, E. 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