2000 AAAP ANNUAL MEETING PROCEEDINGS 

Workshop I: Physician Health

Peter A. Mansky, MD, New York State Physician Health Program, Slinger-lands, NY; Penelope P. Ziegler, MD, The William J. Farley Center, Williamsburg, VA; Anne Linton, MD, Betty Ford Center, Rancho Mirage, CA

Dr. Mansky reviewed basic concepts of physician health and impairment, its incidence and presentation. For example, the Hughes1 study showed physicians use alcohol daily, 10.4%; 5 or more drinks per day at least 1 time in the past month, 9.3%; heavy drinking (5 or more drinks daily), .6%.; substance abuse or dependence among physicians some time in their life, 8%; in the past year, 2%.

Information was presented on various models of physician peer assistance programs and their interface with licensure boards, disciplinary systems and credentialing organizations. Efforts of the Physician Health Committee of AAAP and other physician health groups were described. These efforts protect confidentiality of medical records of doctors who are receiving treatment for substance use disorders and other psychiatric illnesses.

Dr. Ziegler described aspects of successful reentry and relapse prevention planning for physicians completing primary addiction treatment who are preparing to return to medical practice. Essential elements of continued treatment and monitoring include facilitated recovery group therapy, urine drug screens and an individualized relapse prevention plan geared to the individual physician's relapse risks and triggers. It is important to participate in Twelve Step programs and specialized mutual support meetings.

Dr. Linton presented an interesting and challenging case of a female physician with severe addictive disease, bipolar disorder and chronic pain. Workshop attendees participated in a discussion of this case and other issues raised during the workshop.

Several topics for future exploration include incidence and appropriate treatment approaches for comorbid psychiatric illnesses in addicted physicians, issue of discrimination against physicians in recovery from substance use disorders, sexual compulsivity and boundary violations among physicians, and self-medication of psychological and/or physical symptoms as a precursor to development of substance use disorders by physicians.

References

  1. Hughes PH, et al. JAMA. 1992;267:2333-2339.

 

Workshop II: Bioethics

William B. Lawson, MD, PhD, Howard University Hospital, Washington, DC

Recent addiction research has implicated the role of heredity in substance use disorders. Moreover the technology may soon be avail-able to determine the genetic basis of factors that may contribute to addictions. Concerns include 1) the problem of stigmatizing individuals with high-risk markers, 2) shifting of treatment resources to treatment of biological factors rather than psychosocial factors, 3) misinterpretation of this data, and 4) using such markers inappropriately to explain inter-ethnic variation.

Dr. Lawson discussed the stigmatizing of individuals through the historical misuse of psychiatric and behavioral genetics. He cited as examples, the Eugenics Movement, euthanasia in Hitler’s Germany and modern racist theories. He enumerated several aspects embodied in the Human Genome Project, which could result in abuse. These included the genetics of behavior, "genetics is destiny" and issues of genetics and environment.

African American involvement in negative medical research was presented, including Civil War medical experimentation and the Tuskegee Project. Barriers to African-American physician participation in research trials were enumerated. These included complex forms, provider compliance issues, researcher’s beliefs and biases, less time to spend with patients, lack of information about clinical re-search, and concern for loss of patients. Barriers to African-American patient participation were also presented. These included less access to healthcare, lack of physician recommendation, less participation of physicians in clinical research, distrust of medical research as well as patient compliance issues. Negative experiences with the health care system, level of education and literacy, transportation, inconvenience and overall racial discrimination are also barriers.

The issue of how psychiatric disorders can be so common and so genetic at the same time was discussed. "The Genetics of Common Disease" is a new emerging paradigm to ex-plain this. Other such common disorders with substantial genetic components include asthma, hypertension, diabetes, coronary artery disease, epilepsy and many types of cancer.

He explored regulatory issues in genetic testing. A genetic test is one which is per-formed on presymptomatic individuals to determine the presence of a particular heritable gene or DNA of established prognostic significance for purposes of genetic counseling or medical management, or prospectively on population samples for epidemiologic purposes.1 Regulatory issues in genetic testing included FDA regulations and usage of genetics tests for certain diseases and disorders. Several issues were presented for consideration. First, who owns genetic data? Is it the individual, the state, employers? Second, what is the proper use for genetic data? Is it for prevention of disease, research, reproductive decisions, individual counseling? The conclusions were that we need to be vigilant so that discoveries are properly used and that the humanitarian goal of maximizing individual freedom and potential is realized. The first requirement is accurate information about genetics and psychiatry followed by effective public education and finally organization of political strength.

Reference

  1. American Association of Medical Colleges, 2000

 

Workshop III: Building a Research Career

Roger D. Weiss, MD, McLean Hospital, Belmont, MA; Frances R. Levin, MD, Columbia University, New York State Psychiatric Institute, New York, NY; Kathleen T. Brady, MD, Medical University of South Carolina, Charleston, SC; Edward V. Nunes, MD, New York State Psychiatric Institute, New York, NY

The purpose of this workshop was to help addiction psychiatrists with the development of their research careers. Dr. Weiss presented an overview of key review criteria for National Institute on Drug Abuse (NIDA) grants. These included: 1) Significance (Is the study important? How will scientific knowledge be advanced?); 2) Approach (Is the conceptual framework adequately developed and appropriate to the aims? Does the applicant acknowledge potential problems and consider alternatives?); 3) Innovation (Are there novel concepts? Are the aims original and innovative? Does the project challenge existing paradigms or develop new methodologies/technologies?); 4) Investigator (Is there appropriate training and experience to do this work?); 5) Environment (Do senior researchers contribute to probability of success? Is there collaboration? Does the institution support, e.g., provide a statistician?)

Overview of common flaws includes: the research question is too broad or ambitious; feasibility isn’t well established, e.g., no pilot data; there is insufficient attention paid to un-controlled or confounding variables. Other ad-vice included involving a senior mentor and giving them pieces to read along the way; writing a federal grant is an ordeal and applicants probably won’t be successful the first time (the average is 2.3 times to rewrite and resubmit grants); allow enough time. The research environment and support is critical; can interests be turned into a classical research question? In the scientific method comparisons must be made between one thing and another, contrasting condition, i.e., those who become abstinent with those who don’t. Careful chart reviews can be published in The American Journal on Addictions.

Many people need to examine whether they will do research simultaneously with a clinical career, or get a research fellowship and stop clinical work for a while. As a clinician, "access to the clinical populations" is an asset and maybe a research psychologist can be identified to collaborate with. This allows time to become more expert in research and in writing papers, thus enriching a career. Pro-gram announcements show what NIDA is interested in and Requests for Applications (RFAs) have money attached. Both are on their website, www.nida.nih.gov.

Pharmaceutical industry grants have pros and cons. They provide money, access to populations, research learning opportunities, multi-site trials and access to other investigative teams. Sometimes a researcher can add-on studies and get papers published. However these rigorously prescribed grants are not very creative. Sometimes drug companies fund small pilot studies to see if there is a promising idea. It is the marketing division that often funds investigator-initiated studies. Make certain that negative results can be published.

After the presentation, the workshop participants asked questions about research and sought advice from the panel.

 

Workshop IV: Immunotherapy of Drug Addiction

Donald R. Wesson, MD, Drug Abuse Sciences, Inc., Los Altos, CA; Karen Miotto, MD, Medical Director, Los Angeles Ambulatory Care Clinic

Immunotherapies are in various stages of development for treatment of nicotine, cocaine, PCP and methamphetamine. The underlying principle of immunotherapy in treatment of drug abuse or drug toxicity is binding of a drug to specific anti-drug antibodies and sequestering it in the vascular compartment where it is unavailable to the brain, heart or other organs.

Passive immunization involves infusion of preformed monoclonal or polyclonal anti-drug antibodies. Passive immunotherapy is used now for emergency treatment of drug toxicity (e.g., DigibindTM for treatment of digitalis toxicity) or to neutralize snake venom. In a research context, passive immunization is used to demonstrate the behavioral effects of anti-drug antibody binding.

Active immunization involves administration of a vaccine that induces patients to produce their own antibodies. This may be of clinical utility in preventing development of drug abuse, in relapse prevention following treatment, or both. The biology of immunotherapy of drugs of abuse is complex and in a nascent stage of development.

Dr. Wesson explained that passive immunization can potentially be used to treat drug overdoses by removing a drug from the brain or other key organs. Anti-drug antibodies trap drug molecules when they diffuse into the bloodstream so they are no longer available to return to the tissues. A potential clinical use of this is the treatment of cocaine overdose.

In active immunization the body makes its own antibodies to cocaine. There is a delay (days to weeks) before antibodies are developed. Since cocaine itself doesn’t produce an immune response, it must be attached to a protein carrier to make it immunogenic. Even combined with a protein carrier, cocaine itself turns out not to be the most efficient substance to evoke an anti-cocaine antibody response. The generic term for a compound used to evoke a specific immune response is called a "hapten" In vaccines, usually an adjuvant is also added to enhance the immune response. The following diagram shows the elements of a vaccine.

Potential clinical uses of cocaine vaccine include: 1) relapse prevention after treatment and 2) prevention of cocaine abuse among high-risk individuals.

To be clinically useful, a cocaine vaccine would need to produce sustained blood levels of cocaine antibodies. At this time, the technical feasibility of producing sustained anti-drug antibody levels has not been demonstrated. Additionally, once a person has been vaccinated, it is possible that biochemical markers of the vaccine would be detectable for many years. If the vaccine were used to prevent cocaine abuse, the person may carry a biological marker of the vaccination that could be used against them by insurance carriers or others. This is an issue that has been raised largely by academics, however parents should be given a chance to express their opinions.

Dr Miotto explained that a review of various classes of vaccinations included the killed/inactivated (such as typhoid or salk polio), acellular (those which contain an antigenic component that primes the immune system, i.e., haemophilus influenzae B - HIB), attenuated live organisms (such as measles, mumps or rubella), toxoid (a type of treated toxin such as diphtheria and tetanus combined) and conjugated vaccines (i.e. diphtheria and tetanus combined with pertussis, which acts as an "adjuvant" to increase immune response). The development of these traditional immunotherapies included concerns for the nature of the pathology, the entry or spread, illness production, and type of immune response produced. In contrast to these concerns associated with infectious disease, there are other issues that must be addressed to provide protection against a chronically administered drug. These issues include the rapidity of drug use, blockage overcome by high doses of drugs, and the possibility that repeated doses of antibodies will be needed to neutralize the drug of abuse.

One of the first major advances in the area of immunotherapy designed for drug abuse was achieved by Schuster’s group, which pioneered the development of an immunization against heroin in a primate model. Cur-rent work has built on the achievement of these previous studies to focus on the use of antibodies for stimulant drugs in animals and humans. Multiple immuno-stimulant studies for the development of immunotherapy were reviewed with particular attention to the analysis of outcome. Key outcome aspects included rapid clearance of the antibody after drug use, measures of drug seeking behavior after antibody treatment, and renal elimination of the antibody drug of abuse complex. In the specific case of cocaine, one obstacle to overcome has been the lack of immune response produced by cocaine. Compared to other antigens, cocaine is small in size and only exists in the bloodstream for a short time before hydrolysis occurs. Attempts to increase the immunity of cocaine include the use of a protein carrier or "adjuvant". Advances in chemistry in the area of catalytic antibodies were developed by Shultz and Learner, and this led to the development of catalytic anti-bodies for cocaine. These antibodies exhibit enzymatic-like properties and have been shown to accelerate the rate of hydrolysis for cocaine in order to prevent cocaine from entering the central nervous system.

Other encouraging developments for the use of immunotherapy for drug addiction include the creation of antiidiotypes, which do not require exposure to the pathogen and take advantage of the antibody’s capacity to assume various molecular shapes and confirmations. Schabacker has performed such studies where antiidiotypes have been used in mice to mimic the configuration of the cocaine molecule in order to create anti-cocaine anti-bodies. This along with other bio-molecular advances in the area of monoclonal antibodies have allowed researchers to overcome obstacles of recognition and incompatibility which suggest great promise for the future.

Workshop V: Pathological Gambling

Marc N. Potenza, MD, PhD, Yale University, New Haven, CT; Nancy M. Petry, PhD, University of Connecticut Health Center, Farmington, CT; James R. Westphal, MD, Louisiana State University, Shreveport, LA; Kathleen T. Brady, MD, PhD, Medical University of South Carolina, Charleston, SC

Pathological gambling (PG) represents a public health concern of increasing magnitude. Despite significant morbidity and mortality associated with excessive patterns of gambling, disordered gambling behaviors frequently go unnoticed for significant periods of time prior to clinical intervention. With the prevalence rates of PG rising in the setting of increased access to legalized gambling, there exists a growing need for early identification and treatment.

PG, the most extreme form of disordered gambling, has been included in the Diagnostic and Statistical Manual of Mental Disorders since the third edition in 1980.1 It is included in the category of Impulse Control Disorders Not Elsewhere Classified, a heterogeneous grouping of disorders also including kleptomania, intermittent explosive disorder, pyromania, trichotillomania, and impulse control disorder not otherwise specified. There has been considerable discussion as to the relationship of PG to obsessive-compulsive, drug use and other impulse control disorders, and clarifying these relationships is an area of current investigation.2

The current diagnostic criteria for PG share many features with drug use disorders. For example, specific inclusionary criteria exist for tolerance ("needs to gamble with increasing a-mount of money in order to achieve the de-sired excitement"), withdrawal ("is restless or irritable when attempting to cut down or stop gambling"), diminished control ("has repeated unsuccessful efforts to control, cut back or stop gambling"), and interference in major aspects of life ("has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling").1 In addition to phenomenological similarities, e-merging data suggest some shared biological mechanisms for PG and substance use disorders, findings which have implications for the testing of treatment strategies for individuals with PG.

PG is thought to affect approximately 1% of the general adult population.3-5 Level 2 gambling, or problem gambling exclusive of PG, appears to be more widespread than PG. Moreover, rates among adolescents have consistently been found to be two- to four-fold higher than in adults.5 Taken together, the findings suggest that problem and pathological gambling are more prevalent than several major "common" psychiatric disorders, including schizophrenia and bipolar disorder.

Significant adverse events are associated with PG. It is estimated that 17%-24% of individuals with PG attempt suicide at some point in their lives.6 A National Gambling Impact Study Commission (NGISC) was recently organized to investigate the effects of gambling on the inhabitants of the United States.7 The Gambling Impact and Behavior Study (GIBS) performed for the NGISC report concluded that individuals with problem and PG had higher rates of: 1) recent job loss and receipt of unemployment and/or welfare benefits; 2) bankruptcy filing; 3) arrest; 4) incarceration; 5) divorce; and, 6) poor mental health.3 Additionally, those with PG were found to report being in worse physical health than individuals with less severe gambling behaviors.3 The GIBS estimated an overall cost to society of 5 billion annually in the United States due to problem and PG.3 Together, the data indicate that problem and PG are associated with significant morbidity and mortality.

Comorbid psychiatric illness, particularly substance use disorders, is common in individuals with pathological gambling.8 For example, rates of comorbid nicotine dependence have been reported in the range of 60%-85%,4,8 alcohol abuse or dependence from 45%-55%,9,10 and illicit drug use disorders up to 40%.4,8 Conversely, individuals with substance use disorders have higher than expected rates of PG. For ex-ample, 15% of individuals in outpatient treatment for cocaine dependence were found to have PG.11 Moreover, individuals with co-morbid PG and a substance use disorder were found to have higher rates of psychiatric admissions and suicidal thoughts and actions than those with either disorder alone.

For many years, Gamblers Anonymous (GA) has been the mainstay of treatment, although there exist data suggesting that greater than 90% of those entering GA drop out of treatment by one year, with the majority leaving after one or two meetings.12 Fortunately, recent studies are suggesting that behavioral and pharmacological treatments appear effective, at least in the short-term treatment of individuals with PG. For example, structured cognitive behavioral therapies are emerging as an effective strategy for targeting symptoms of PG.13-15 Independent studies of selective serotonin reuptake inhibitors and the muopioid antagonist naltrexone have been demonstrated in double-blind, placebo-controlled trials to be efficacious and generally well-tolerated in the short-term treatment of individuals with PG.16,17 Larger trials with extended periods of follow-up are required to assess more fully the long-term benefits of these and other specific treatments.

It has been suggested that research in the area of PG is at a stage comparable to where substance abuse research was several decades ago. Indeed, additional research is warranted into the classification, etiology, and treatment of PG. Of at least equal importance is the general need for increased education and targeted prevention efforts directed at engaging individuals into treatment.

References

16. Hollander E, DeCaria CM, Finkell JN, Begaz T, Wong CM, Cartwright C. A randomized double-blind fluvoxamine/placebo crossover trial in patho-logical gambling. Biol Psychiatry. 2000;47:813-817.

17. Kim SW, Grant J. The psychopharmacology of pathological gambling. Sem Clin Neuropsychiatry. in press.

 

Workshop VI: Adolescents and Substance Abuse: Assessment and Treatment Considerations

Robert P. Milin, MD, University of Ottawa Faculty of Medicine, Royal Ottawa Hospital, Ottawa, Ontario; Deborah Deas, MD, Medical University of South Carolina, Charleston, SC

Adolescence is a period of major risk for the onset of substance abuse. The development of substance abuse in adolescence is seen through a series of stages (legal to illegal and softer to harder drugs) with each prior sub-stance use stage acting as a "potential gate-way" to the next stage. Adolescent substance use lends itself well to a bio-psycho-social model. The disruption of developmental tasks, education, employment and family role responsibilities are well-established negative consequences of adolescent substance abuse.

Dr. Deas explained that an adequate assessment across multiple domains should provide an overview of the adolescent and allow for the formulation of individualized alcohol/ drugs, education status, family functioning, peer relationships, legal status, psychiatric disorders/distress and use of free time. The use of reliable and valid assessment instruments will provide comparisons to a normative sample, assist in measuring change in a patient over time and set the stage for research studies. There are assessment instruments on the NIDA website, www.nida.nih.gov. Treatment should: 1) be intensive and of sufficient duration to change attitudes and behaviors; 2) be sensitive to cultural and socioeconomic realities; 3) include family involvement; 4) include self-help and support; 5) include pro-social recreational activities.

Dr. Milin explained that the marked prevalence and significance of comorbid psychopathology demonstrated by adolescent substance abusers make it imperative that adequate evaluation of other psychiatric disorders occur in adolescent substance abusers to assist with more specific and comprehensive treatment. In a community sample of adolescents, those with alcohol use disorders (AUD) showed 80% comorbidity with other psychiatric disorders; including SUD, as alcohol use level increased there was an associated increase in lifetime occurrence of depressive, disruptive behavior and drug use disorders. In general, AUD followed the onset of other psychiatric disorders. Comorbidity was associated with an earlier age of onset of AUD and mental health treatment. Rates of lifetime mood and disruptive behavior disorders are generally higher among adolescents with current SUD than among adolescents without SUD. Substance Abuse (SA) has been identified as a clinically significant problem in adolescents hospitalized with a primary psychiatric disorder. Comorbid adolescent SUD may negatively impact the course of another psychiatric disorder such as depression and schizophrenia.

Treatment considerations include: 1) use a multidimensional systematic assessment including assessment of withdrawal syndrome; 2) provide an integrated multidisciplinary or interdisciplinary treatment using a wide range of treatment modalities and social support especially for adolescents with comorbidity; 3) consider habilitation vs. rehabilitation; 4) flexibility is a key factor taking into consideration motivation/readiness to change; 5) treatment approaches include 12-step, psychosocial and cognitive behavioral models in residential, in-patient, day and outpatient programs.

Overall, adolescent SA treatment reduces substance use. Studies of pretreatment factors predictive of outcome have for the most part demonstrated inconsistent findings. However, delinquency and conduct disorder have been consistently associated with poorer treatment outcome. Treatment completion, parental involvement and attendance at after-care sup-port have been associated with better outcome. Abstinence has been associated with improved behavior. Post-treatment factors such as high quality and satisfaction of social sup-ports, greater self-esteem and coping skills have been found to be associated with abstinence. Re-lapse rates tend to be greater in adolescent substance abusers (> 60%) than in adults, and most often associated with post-treatment social/peer influence. Other post-treatment factors predictive of relapse include drug craving and less involvement in productive and recreational activities. Many issues remain unresolved in assessing treatment outcome. Extensive clinical research is required to further understand and develop reliable and valid treatment programs for adolescents with SUDs.

 

Workshop VII: How to Give a Lecture

Marianne T. Guschwan, MD, New York University, New York, NY; Susan Tapert, PhD, University of California, San Diego, CA

Dr. Guschwan discussed the preparation and delivery of a lecture. The focus then shifted to how to answer questions asked in a lecture, and finally how to handle emergencies that might arise. The elements of giving a lecture that were identified included: 1) preparation covering such items as knowing the audience, knowing the material, having lecture goals, developing an outline, using visuals and practicing; 2) delivery including activities such as arriving early, distributing an outline, standing and actually delivering, beginning with and repeating major points, maintaining eye contact, using one’s personality to engage, watching the clock and closing; 3) handling questions incorporating strategies such as restating the question and addressing hostile and rambling questions; and 4) emergencies, including unavailability of slides.

Dr. Tapert presented the latter half of the workshop and gave an interactive demonstration on how to prepare effective slides on PowerPoint software. A live demonstration of how to animate a slide was given. She began with an overview of necessary hardware and software and followed it with a discussion of the pros and cons of this medium. PowerPoint was then discussed including using templates, slide layouts, text (including examples of colors and fonts), views, footers, graphics and animation. The projection equipment and presentation process was discussed including brightness of the room, resolution and visual acuity, portability, changing slides and set up.

Finally, the presenters demonstrated the use of web sites to prepare a lecture or lecture series and provided resources for outlines, slides and other information. Also, resources on the web were recommended including the Alcohol Medical Scholars Program as a good place to begin for substance use disorders lectures - demonstrated on a live Internet connection. The final 30 minutes of the workshop was an interactive experience with the audience asking questions about both lecturing and preparing slides.

Web resources:

  1. www.aaap.org
  2. www.alcoholmedicalscholars.org
  3. www.nida.nih.gov
  4. www.microsoft.com/education/tutorial/classroom/ppt97/

 

Workshop VIII: Reducing Harm in Pregnant and Breast-Feeding Substance Users: A Woman-Centered Approach

Peter Selby, MD, University of Toronto Centre for Addiction and Mental Health, Toronto, Ontario

The film clip "Losing Isiah." was shown. An addicted mother hid her infant in the trash thinking she’d come right back after getting crack cocaine. Instead, she wakes up much later and realizes she doesn’t have her baby. Meanwhile, the trash men find the baby and take him to the hospital. A social worker gets involved. The audience was asked how they felt about the clip and why.

Pregnant drug users face several barriers accessing addiction, mental health and medical services. These include prejudice against substance using pregnant women, exclusion from addiction treatment programs, lack of child-care services and fear of child protection agencies. Traditional models of provider-centered and feto-centric care have led to further victimization and poor attendance at treatment centers or hospitals with greater likelihood of child apprehension. However, treatment can be provided in a destigmatized fashion while delivering a comprehensive range of medical, psychological, obstetric, neonatal, psychosocial, postpartum, addiction and follow-up care to pregnant substance users. Several issues need to be addressed, including psychiatric comorbidity, past sexual trauma, current domestic violence, child protection and housing. Addiction psychiatrists treating such women need to be aware of the risks and benefits of psychoactive medication especially methadone, buprenorphine and nicotine replacement to pregnant and lactating women. A woman-focused intervention in pregnancy can be effective to en-sure a safe outcome for both mother and child.

A non-judgmental environment (main-stream) facilitates treatment. An example is a facility with no outside identifiers that some-one is an addict. There would be a variety of people in the waiting room where no one knows who is an addict and who isn’t. This is mindfulness of respect. Patients also need to accept urine toxicology—ask them, "How will it help you?"—this normalizes the process.

Absolute honesty helps patients’ trust level. Ontario doesn’t have to report to child protective services (CPS) until the baby is born. If it is reported proactively, CPS may take the child immediately. The system in Toronto works because it is frontline and is a community action plan. It is important to de-brief cases as this work is very difficult on staff emotionally.

Most drugs are not tested in pregnant women. There are only 30 proven teratogens and women need to be counseled regarding risks. Women tend to overestimate the risk of mal-formation. Drugs safe in pregnancy may not be safe in breastfeeding. Drugs to avoid include carbamazepine, lithium, phenytoin.

Principles of prescribing drugs include: 1) choose older drugs and use the minimum effective dose, but note that the dose may need to be increased in the 3rd trimester; 2) avoid over-the-counter NSAIDS (non-steroidal anti-inflammatory drugs); 3) there is unknown risk with herbal remedies; 4) if deciding to stop, consider tapering slowly; 5) drugs that are safe for babies are safe for pregnant women.

Drugs of choice include: 1) depression – tricyclic antidepressants (TCAs) such as fluoxetine, paxil, sertraline; 2) migraine – acetaminophen, codeine, dimenhydrinate, TCAs, beta-blockers; 3) mania - lithium, haldol and carbamazepine.

The rationale for using methadone in pregnancy includes: 1) the overall benefits far out-weigh the risks (better nutrition, prenatal care); 2) there is a decrease in complications due to withdrawal; 3) it does eliminate opioid use; 4) tapering is not recommended due to relapse and withdrawal in the fetus; 5) neonatal withdrawal is about 30-60%. The advantages of buprenorphine are that it is a partial antagonist, has high affinity, and less neonatal withdrawal. The disadvantages are the difficult induction and ceiling effect.

Information about other drug use includes the following points: the teratogenic potential of cocaine is controversial; there are some reports of cleft palate with benzodiazepines; smoking leads to low birth weight; nicotine crosses the placenta and leads to increased blood pressure, increased fetal heart rate, and decreased fetal breathing movements; with alcohol the safe drinking limit is unknown and it is a proven teratogen; and antidepressants are safe.

Studies report that the natural history of drug use in pregnancy is that 20-40% of pregnant women quit, 50% reduce use, and 65-80% relapse 3 months postpartum.

 

2000 Proceedings

2000 AAAP Annual Meeting Proceedings Copyright 2001 AAAP