Educational Intervention for Polysubstance Abusing Pregnant Women

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Table of Contents

Introduction
Review of the Literature
Proposed Research
Evaluation
Conclusion
References

Introduction

Though the negative impact is considered common knowledge, substance and even polysubstance use rates in expecting women remain unacceptably high and further exacerbated by psychiatric comorbidities, environmental stressors, and limited support and welfare (Forray, 2016). In the United States, almost half (40%) of those with a lifetime drug use disorder and a quarter of those who have abused both alcohol and drugs within the last year are women. Moreover, it is the peak reproductive years (18-29) during which women are at the highest risk of developing substance use disorders (Forray, 2016). In the 2012 national survey, 6% of pregnant US women admitted to doing illicit drugs, while 8.5% drank alcohol and 15.9% smoked cigarettes (Forray, 2016). It was estimated that 380,000 infants were exposed to drugs, 500,000 – to alcohol, and over a million – to nicotine in utero. An important step toward the resolution of the issue is enabling a better understanding of the future impact of prenatal drug exposure. This paper reviews the state-of-art literature and proposes action research that identifies the developmental consequences of newborn drug addiction.

Review of the Literature

Existing research addresses the use of various substances, alone or in combination, in pregnant women and describes their detrimental effects. Tobacco is the most common substance used by pregnant women, with the use rates negatively correlated with the mother’s level of education, income, and access to social services. Stroud et al. (2018) report that in general populations, one in ten pregnant women smokes, while in the underprivileged communities, it is up to two per ten pregnant women. Maternal marijuana (MJ) use is another common form of drug use in pregnant women whose occurrence in the United States increased by 62% between 2002 and 2014 (Stroud et al., 2018). Stroud et al. (2018) explain the surge in the greater acceptance of MJ and the changing political landscape that has led to the legalization of the previously controlled drug in some states. Besides, the potency of tetrahydrocannabinol (THC), the main psychoactive ingredient in MJ, has increased threefold since 1995.

Stroud et al. (2018) argue that not enough attention is paid to polysubstance abuse as studies on pregnant women and the developmental consequences of prenatal drug exposure tend to focus on specific substance use disorders. However, it appears that individuals who use a particular type of substance are likely to be accepting of others as well. For instance, it has been established that twenty to thirty percent of pregnant women who smoke endorse MJ use. The opposite is also true: between 66% and 75% of expecting mothers using MJ are open to tobacco smoking. For this reason, Stroud et al. (2018) studied not just co-exposure but rather the synergetic impact of tobacco smoking and MJ use on the neurobehavioral patterns of an infant. The study’s findings demonstrated several negative consequences of tobacco and marijuana use and co-use. Exposed infants scored lower on self-regulation: they lacked a self-soothing capacity and could not compose themselves as well as non-exposed children in response to stimuli. Mothers’ use of tobacco and MJ resulted in children’s less adaptive autonomic and increased irritability.

Cocaine use became a major public health threat during the crack cocaine epidemic in the 1980s. Children born to cocaine-addicted mothers were labeled “crack babies” and predicted to suffer irreversible damage (McCarthy, Kabir, Bhide & Kosofsky, 2014). Today, cocaine is abused by 0.6-3% of pregnant women in developed countries (McCarthy et al., 2014). It is estimated that in the United States, almost seven million children have been exposed to this drug in utero (McCarthy et al., 2014). Buckingham-Howes, Berger, Scaletti, and Black (2013) report that children who suffered prenatal cocaine exposure (PCE) display poorer motor performance and reflexes at one month post-partum compared to non-exposed children. Later, PCE may be associated with delayed speech and language development as well as decreased attention and emotional expressivity (Buckingham-Howes et al., 2013). In adolescence, children of cocaine-addicted mothers may show worse scores on language and memory tasks.

Given the detrimental effects that taking drugs during pregnancy has on the mother’s and the child’s health, it is important to establish the determinants of this behavior. Reasons why women use illicit drugs while expecting a child were the focus of a study carried out by Mburu, Ayon, Mahinda, and Kaveh (2015), who had in-depth interviews and focus group discussions with 45 pregnant women. Eight-seven percent of women recruited for the research routinely used heroin, but only 27% of them restricted their substance use to this particular drug, which confirms how common polysubstance abuse is (Mburu et al., 2015). The majority of the combinations involved alcohol, cigarettes, cannabis, Rohypnol, solvents (glue), and cocaine.

The thematic analysis of the interview material allowed for identifying four running themes hinting at the reasons behind pregnant women’s drug use. Many respondents admitted that not only pregnancy was not a barrier to stopping drug use, but it served as a prompt to start or continue (Mburu et al., 2015). For many women, the pregnancy was unexpected and, hence, stressful. It is the hardship of carrying a child without any support that motivates them to use drugs. It became apparent that the intention to conceive moderated drug use: these women who planned their pregnancies reduced drug use. They explained that the desire to have a child motivated them to research information on the detrimental effects of illicit substances. However, complete cessation was uncommon because, while respondents’ motivation to do drugs was no longer the hypnotic or sedative effects, they had to fight withdrawal symptoms. The male partner had leverage in changing drug use patterns – for better or for worse. Supportive partners helped women to manage addiction, while those who used drugs themselves were enabling.

The study by Mburu et al. (2015) has two important implications that should be considered when designing an intervention for drug-using mothers-to-be. Firstly, the supportiveness of the environment was found to be a significant determinant of the intensity of use. Secondly, knowledge about the effects of drug use, though moderated by pregnancy intention, prompted women to reduce the number of drugs they were taking. Therefore, an effective intervention should combine both elements – education and psychological support. Terplan, Ramanadhan, Locke, Longinaker, and Lui (2015) tested a purely psychological intervention that employed contingency management (positive and negative reinforcement) and motivational interviewing-based (MIB) techniques. The latter helped women resolve inner conflicts and ambiguities regarding their substance use. The participants were given comprehensive feedback and were consulted regarding the advantages and disadvantages of their behavior (Terplan et al., 2015). Terplan et al. (2015) report shorter stay at the hospital after delivery as a result of the Intervention. Yet, lower maternal toxicity and postnatal retention were not achieved, which compels one to investigate whether an educational intervention would prove more effective.

Proposed Research

Statement of the Problem

Substance and polysubstance use in pregnant women lead to a multitude of deleterious consequences for the children starting at birth and persisting into adolescence. In the United States, every sixth pregnant woman admits to smoking tobacco and almost every tenth – to drinking alcohol. Though some drugs decline in prevalence, such as cocaine, whose use peaked in the 1980s, substances like marijuana have become more normalized and even legalized in some states. Each of the substances is a danger to a child’s health on its own, and when combined, the effects are exacerbated. What is concerning is that pregnancy does not stop women from abusing drugs, and for some, it event serves as a trigger to initiate use as a means of stress management or bonding with a partner. It has been established that the supportiveness of the environment and the awareness of drug use effects on the child’s health may serve as protective factors against continued drug use. However, purely psychological interventions do not always yield desired results, which is why it is timely and important to test the effectiveness of educational interventions.

Research Questions

The research question and the hypotheses can be formulated as follows:

RQ: Can a brief intervention (BI) result in positive spontaneous or after-intervention changes in the pattern use of psychoactive substances in pregnant women?
- A brief intervention will not result in positive spontaneous or after-intervention changes in the pattern use of psychoactive substances in pregnant women as compared to their pattern use before the Intervention.
- A brief intervention will result in positive spontaneous or after-intervention changes in the pattern use of psychoactive substances in pregnant women as compared to their pattern use before the Intervention.

Definition of Variables

The proposed research investigates the relationship between two variables – one independent (IV) and one dependent (DV). Since the goal of the study is to confirm the possibility and measure the effects of BI (Brief Intervention) administered to consenting pregnant women, BI is the independent variable. In turn, the dependent variable is the use of psychoactive substances (tobacco, alcohol, marijuana, cocaine) operationalized as categorical. The researchers are to log whether the women in the study succeeded in complete cessation or not. At that, frequency of use, intentions, cravings, and other measures and dimensions are not heeded.

Description of the Setting and the Intervention with Goals

Brief Intervention is a standardized tool used in primary care that seeks to identify current or potential substance use problems and encourage those at risk to make positive changes to their use patterns (Tamashiro, Milanez & Azevedo, 2020). The tool was not designed to treat dependency, nor is it appropriate for working with patients suffering from severe addiction. The rationale lies in taking hold of a problem at an early stage and influencing the patient, which is often possible due to the continuous nature of therapeutic relationships.

The proposed criteria for inclusion are age (≥18), confirmed use after filling the questionnaire, willingness to participate in the research, and explicit consent confirmed in an Informed Consent Form. While all expecting mothers who are concerned about their substance use are welcome to join, a special focus will be on women who use various substances. The Intervention is to be administered in person at the same prenatal outpatient clinic where participants will be recruited. The first BI is to take place right after filling out the questionnaire. It takes approximately thirty minutes and aims to identify individual consumption-inducing factors and educate participants on their potential consequences. After the initial Intervention, women are to go through shorter sessions (five-ten minutes) at each obstetric consultation.

Increased attention will be paid to patients’ own reflections regarding their addiction so that they do not feel lectured but rather engaged in the process of managing substance use throughout pregnancy. Another focal point of the Intervention is the discussion of cessation/ decrease strategies with women and tailoring them to each individual case. During BIs, care providers are to avoid labels like “alcoholic” or “drug addict”; confrontation, blaming, and criticism are also strongly discouraged.

Evaluation

Data Collection and Instruments/ Measures

Data on substance use are collected at two points during the research. First, when participants take the ASSIST questionnaire (Alcohol, Smoking, and Substance Involvement Screening Test). The ASSIST screening tool was developed for the World Health Organization (WHO) by a group of researchers from all over the world. Its primary objective is to assist with the early identification of substance use risks and disorders in primary healthcare and general medical healthcare settings. The instrument covers a wide range of psychoactive substances: tobacco products, alcoholic beverages, cocaine, cannabis, amphetamine-type stimulants, inhalants, sedatives, hallucinogens, and opioids.

It may be that not all substances will be identified as currently in use by the prospective study’s participants, who will moderate the number of measures. The ASSIST screening tool mainly measures the fact and the frequency of use. These data are to help identify users and categorize them respectively (alcohol, marijuana, and other psychoactive substances). The second data collection is to take place after all the planned BIs are administered; it is to establish whether participants succeeded in complete cessation or continued their use.

Methods

The proposed study is to employ a quantitative longitudinal design. Quantitative research design deals with objective, numerical data and uses statistical, mathematical, and computational methods. When done right, this type of research is able to provide reliable results that are devoid of unnecessary subjectivity. Besides, quantitative research is apt for approaching complex problems as it helps to confine the scope to a limited number of variables. Moreover, a longitudinal quantitative design is an excellent choice for an intervention study that seeks to measure the effect size over an extended time period.

Ethical Considerations

Human subject research requires an ethical approach, especially when it comes to such sensitive topics as substance use during pregnancy, which may render participants especially vulnerable. To mitigate ethical risks, the prospective study will start with an accurate consent procedure during which women will be explained what the study entails. The process will include more than merely handing the participants a form to sign. It is crucial that participants make an informed decision, which is why they will learn the study’s duration, objectives, the nature of the Intervention, and the frequency of BI sessions. Furthermore, ethical data collection methods will be used: for instance, collecting unnecessary information that may be used for the identification of subjects will be avoided at all costs. Questions about data storage, access, use, and transmission are not discouraged and will be answered in an accurate manner. While it is best for the study’s validity to encourage participants to continue until the last follow-up, they are free to cancel anytime they want.

Data Analysis

Quantitative research design deals with objective, numerical data and uses statistical, mathematical, and computational methods. Firstly, descriptive statistics (mean, median, standard deviation, percentage) can provide an insight into the demographic characteristics of the sample as well as identify the prevailing psychoactive substance. Because the study compares the use patterns in the same sample before and after the Intervention, there needs to be found a statistical test that works for paired data. Because the dependent variable is categorical, Student’s t-test cannot be used. An appropriate choice is McNemar’s statistical test that uses 2X2 contingency tables with a dichotomous trait. Graph 1 demonstrates a sample output that can be used to illustrate the study’s findings.

Graph 1. The number of patients who continued and ceased using substances

Conclusion

Substance use in pregnant women continues to be a major public health concern in the United States. Prenatal drug consumption has deleterious consequences for both the mother and the infant. The proposed study takes into account that both the supportiveness of the environment and comprehensive information about the effects of drug use can motivate mothers-to-be to reduce or stop substance use. A Brief Intervention will be administered to consenting pregnant women over 18 years old at the early stages of pregnancy and repeated continuously during the next few months. It is expected that the intervention will lead to complete cessation of substance use for at least some types of psychoactive substances.

References

Buckingham-Howes, S., Berger, S. S., Scaletti, L. A., & Black, M. M. (2013). Systematic review of prenatal cocaine exposure and adolescent development.Pediatrics, 131(6), e1917–e1936.

Forray, A. (2016). Substance use during pregnancy.F1000Research, 5, F1000 Faculty Rev-887.

Mburu, G., Ayon, S., Mahinda, S., & Kaveh, K. (2020). Determinants of women’s drug use during pregnancy: Perspectives from a qualitative study.Maternal and Child Health Journal, 24(9), 1170-1178.

McCarthy, D. M., Kabir, Z. D., Bhide, P. G., & Kosofsky, B. E. (2014). Effects of prenatal exposure to cocaine on brain structure and function. Progress in Brain Research, 211, 277-289. doi:10.1016/B978-0-444-63425-2.00012-X

Stroud, L. R., Papandonatos, G. D., McCallum, M., Kehoe, T., Salisbury, A. L., & Huestis, M. A. (2018). Prenatal tobacco and marijuana co-use: Impact on newborn neurobehavior. Neurotoxicology and Teratology, 70, 28–39.

Tamashiro, E. M., Milanez, H. M., & Azevedo, R. C. S. D. (2020). ” Because of the baby”: Reduction on drug use during pregnancy.Revista Brasileira de Saúde Materno Infantil, 20(1), 313-317.

Terplan, M., Ramanadhan, S., Locke, A., Longinaker, N., & Lui, S. (2015). Psychosocial interventions for pregnant women in outpatient illicit drug treatment programs compared to other interventions. Cochrane Database of Systematic Reviews, (4), 1-53. doi: 10.1002/14651858.CD006037.pub3.

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