Community Approaches to Prevention and Early Intervention

Community Community Approaches to Approaches to

Prevention and Early Prevention and Early InterventionIntervention

Jan Campbell, R.N., B.S.N.Sue Spooner, R.N., C.P.N.P.

January 2007

The tiny hand of 21-week-old fetus Samuel Alexander Armas emerges from the mother’s uterus to grasp the finger of Dr. Joseph Bruner.

“Hand of Hope”

The ProblemThe Problem

Perinatal Substance AbusePerinatal Substance Abuse

National Pregnancy and National Pregnancy and Health SurveyHealth Survey

Illicit drugsIllicit drugs 5.5%5.5% CocaineCocaine 1.9%1.9% MarijuanaMarijuana

2.9%2.9% AlcoholAlcohol 18.8%18.8% TobaccoTobacco 20.4%20.4%

CRT vs. SAMHSA Data:CRT vs. SAMHSA Data:Substance Use in Substance Use in

PregnancyPregnancy

0%

5%

10%

15%

20%

25%

Alcohol Tobacco IllicitDrugs

CRT/4P'sPlusSAMHSA

Riverside CountyRiverside CountySubstance-Exposed Substance-Exposed

BabiesBabies Preliminary data indicate 13% of Preliminary data indicate 13% of

women screen positive for substance women screen positive for substance useuse

In 2004, there were 29,545 birthsIn 2004, there were 29,545 births

Applying 13%, which is considered a Applying 13%, which is considered a low estimate, 3,841 babies were born low estimate, 3,841 babies were born exposed to drugs and/or alcoholexposed to drugs and/or alcohol

San Luis Obispo CountySan Luis Obispo CountySubstance-Exposed Substance-Exposed

BabiesBabies• Preliminary data indicate 38.5% of Preliminary data indicate 38.5% of

women screen positive for substance women screen positive for substance useuse

• In 2005, there were 2,640 birthsIn 2005, there were 2,640 births

• Applying 38.5% which is considered a Applying 38.5% which is considered a low estimate, 1,016 babies were born low estimate, 1,016 babies were born exposed to drugs and/or alcoholexposed to drugs and/or alcohol

Substance Use Rates Substance Use Rates Across California Across California

CountiesCounties

0%5%

10%15%20%25%30%35%40%45%50%

M B SL SB V H A F R

Alcohol Use Patterns Alcohol Use Patterns After Knowledge of After Knowledge of

Pregnancy:Pregnancy:San Luis Obispo, Riverside San Luis Obispo, Riverside

vs. CAvs. CA

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

Daily 3-6d/ wk 1-2d/ wk <1d/ wk

SLORiversideCA

Predictors of Low Birth Predictors of Low Birth WeightWeight

Tobacco has a 3x greater Tobacco has a 3x greater impact than cocaine on impact than cocaine on

predicting low birth predicting low birth weightweight

TobaccoTobacco Decreases oxygen to fetusDecreases oxygen to fetus Baby is born too early Baby is born too early Small babies (low birth Small babies (low birth weight) weight) Nicotine withdrawalNicotine withdrawal More likely to die from More likely to die from SIDSSIDS Learning and behavioral Learning and behavioral problems problems

MarijuanaMarijuana Right after birthRight after birth

Hard time respondingHard time responding ShakesShakes Hard time comfortingHard time comforting

Long-term affectsLong-term affects Trouble paying attentionTrouble paying attention Aggressive behaviorsAggressive behaviors

Baby Exposed to Baby Exposed to CocaineCocaine

Cocaine, Cocaine, Methamphetamines, Methamphetamines,

HeroinHeroin Drugs can starve parts of the baby’s Drugs can starve parts of the baby’s body and body and prevent it from growingprevent it from growing

Can cause stroke or heart attack in Can cause stroke or heart attack in the wombthe womb

Can cause miscarriage, early birth Can cause miscarriage, early birth and nervous and nervous system problemssystem problems

SIDSSIDS

Learning and behavioral problemsLearning and behavioral problems

AlcoholAlcohol

Low birth weightLow birth weight Small brain with brain Small brain with brain

damagedamage Heart problemsHeart problems Kidney problemsKidney problems MalformationsMalformations Facial dysmorphologyFacial dysmorphology

Newborn baby boy with pronounced features of FAS and severe heart disease.  Birth weight and length less than 5th percentile for gestational age.

Prenatal alcohol Prenatal alcohol exposure is the leading exposure is the leading

preventable cause of preventable cause of birth defects, birth defects, developmental developmental

disorders, and mental disorders, and mental retardation in children retardation in children

Journal of the National Association of Journal of the National Association of Neonatal Nurses 2005Neonatal Nurses 2005

Cause of Cause of FAS/FASDFAS/FASD

The sole cause of FAS/FASD The sole cause of FAS/FASD is women is women drinking alcoholic beverages drinking alcoholic beverages during during pregnancy.pregnancy.

Alcohol is a teratogen.Alcohol is a teratogen. “ Of all the substances of abuse (including cocaine, heroin, and marijuana), alcohol produces by far the most

serious neurobehavioral effect in the fetus”

IOM report to Congress 1996

FASD FactsFASD Facts 100 percent 100 percent

preventablepreventable Leading cause of Leading cause of

preventable mental preventable mental retardationretardation

Not caused on purposeNot caused on purpose Can occur anywhere Can occur anywhere

and anytime pregnant and anytime pregnant women drinkwomen drink

Not caused by biologic Not caused by biologic father’s alcohol usefather’s alcohol use

Not a new disorderNot a new disorder

FASD and the BrainFASD and the Brain Prenatal alcohol exposure Prenatal alcohol exposure

causes brain damage.causes brain damage.

Effects of FASD last a Effects of FASD last a lifetime.lifetime.

People with an FASD can People with an FASD can grow, improve, and function grow, improve, and function well in life with proper well in life with proper support.support.

FAS and the BrainFAS and the Brain

Effects of Alcohol on Effects of Alcohol on the Brainthe Brain

FAS: CNS EffectsFAS: CNS Effects

Mental retardationMental retardation Developmental delaysDevelopmental delays HyperactivityHyperactivity Behavior problemsBehavior problems Speech/language dysfunctionSpeech/language dysfunction

People with FASD have People with FASD have difficulty:difficulty:

Following instructions Following instructions Discerning the difference between truth Discerning the difference between truth

and fictionand fiction Thinking about abstract conceptsThinking about abstract concepts Organizing Organizing Storing and retrieving informationStoring and retrieving information Understanding social expectationsUnderstanding social expectations Comprehending and responding to other Comprehending and responding to other

people’s feelingspeople’s feelings Bonding or building personal attachment Bonding or building personal attachment

and trustand trust

Alcohol DoseAlcohol Dose 1 drink/week1 drink/week

Hyperactive and aggressive behaviorsHyperactive and aggressive behaviors

Moderate to heavy useModerate to heavy use Delinquent behavior and overall Delinquent behavior and overall

problem behaviorproblem behavior

Any alcohol use pregnancyAny alcohol use pregnancy 3.2 x risk for delinquent behavior3.2 x risk for delinquent behavior

Comparing FASD to OtherComparing FASD to OtherBirth DefectsBirth Defects

0

5000

10000

15000

20000

25000

30000

35000

40000

HIV MD Spina DS FAS FASD

Estimated Number of Estimated Number of FASFAS

Fetal Alcohol Syndrome (FAS)Fetal Alcohol Syndrome (FAS)1 in 500 births1 in 500 births

Combined estimated number of Combined estimated number of FASDFASD

5 in 500 births5 in 500 births

Journal of the National Association of Neonatal Nurses 2005Journal of the National Association of Neonatal Nurses 2005

Economic Cost of FASEconomic Cost of FAS

Cost the nation Cost the nation $5,400,000,000 in 2003.$5,400,000,000 in 2003.

Each individual with FAS will Each individual with FAS will cost US $1,500,000 to cost US $1,500,000 to $3,000,000 in his or her $3,000,000 in his or her lifetime.lifetime.

If you are pregnant If you are pregnant or think you could be or think you could be

pregnantpregnantDO NOT USE ANY:DO NOT USE ANY:

Alcohol (beer, wine, liquor)Alcohol (beer, wine, liquor) Tobacco/MarijuanaTobacco/Marijuana Illicit drugs Illicit drugs

(methamphetemines, heroine, (methamphetemines, heroine, cocaine)cocaine)

Message

What Now?What Now?

Community Community CollaborationCollaboration

Development of a Development of a Community TeamCommunity Team

Who Should be on a Who Should be on a Community Team?Community Team?

People with passionPeople with passion Respected leaders in the Respected leaders in the

communitycommunity People with passionPeople with passion People with the authority to People with the authority to

commit resources and make commit resources and make decisionsdecisions

People with passionPeople with passion

Community Team Community Team ConsiderationsConsiderations

KnowledgeKnowledge1.1. ObstetricsObstetrics2.2. Public Health NursingPublic Health Nursing3.3. Child Protective ServicesChild Protective Services4.4. Mental HealthMental Health5.5. Substance Abuse TreatmentSubstance Abuse Treatment6.6. Healthy Start ( if it exists in the Healthy Start ( if it exists in the

community)community) Community orientationCommunity orientation Authority and influenceAuthority and influence SizeSize CompatibilityCompatibility Consumer representationConsumer representation

Community Team Community Team ExampleExample

Director Maternal and Child HealthDirector Maternal and Child Health Director Mental HealthDirector Mental Health Director Substance Abuse TreatmentDirector Substance Abuse Treatment Director Child Protective ServicesDirector Child Protective Services Director Healthy StartDirector Healthy Start Public Health NursingPublic Health Nursing ObstetricianObstetrician PediatricianPediatrician County Board of SupervisorsCounty Board of Supervisors Presiding Judge, Drug Dependency Presiding Judge, Drug Dependency

CourtCourt

The Community Team The Community Team ConsiderationsConsiderations

Make sure there is representation from “the Make sure there is representation from “the basic six”basic six”

Recruit people with a community Recruit people with a community orientationorientation

Seek people who are respected in the Seek people who are respected in the communitycommunity

Invite those with authority of influenceInvite those with authority of influence Keep the group a manageable size: 8-12Keep the group a manageable size: 8-12 Make sure team members are compatibleMake sure team members are compatible Involve consumers in a useful and Involve consumers in a useful and

respectful wayrespectful way

The Leadership InstituteThe Leadership Institute

A 3½ day learning and planning A 3½ day learning and planning experienceexperience

Intended to give the team a shared Intended to give the team a shared understanding of the key issues in understanding of the key issues in substance use among pregnant and substance use among pregnant and parenting womenparenting women

Designed to produce an initial plan for Designed to produce an initial plan for the team to use as the members return the team to use as the members return to their communityto their community

The Core The Core InterventionIntervention

SScreecreenn

Screen all pregnant women for substance use. Screen all pregnant women for substance use. Largely this is accomplished by making Largely this is accomplished by making screening a fixed part of primary prenatal care.screening a fixed part of primary prenatal care.

AAssesssesss

Those women who screen positive are given a Those women who screen positive are given a field assessment to determine if they are in fact field assessment to determine if they are in fact using drugs. using drugs.

RRefereferThose women who are found to be using drugs Those women who are found to be using drugs are referred to an appropriate type of drug are referred to an appropriate type of drug treatment.treatment.

TTreatreatThose women who are referred to drug Those women who are referred to drug treatment receive quality, gender-specific drug treatment receive quality, gender-specific drug treatment that is appropriate for their treatment that is appropriate for their circumstances.circumstances.

Where Where DoDo We Start? We Start?

Successful Successful ImplementationImplementation

of a Perinatal Screening, of a Perinatal Screening, Assessment, Referral Assessment, Referral

and Treatment Programand Treatment Program

How Do We Begin?How Do We Begin?

Build your support servicesBuild your support services Referral and treatmentReferral and treatment

Mental HealthMental Health Drug and AlcoholDrug and Alcohol Private psychologist and Private psychologist and

therapisttherapist

TrainingTraining It is important to train your It is important to train your

provider prior to implementation provider prior to implementation of the SART Programof the SART Program

Dinner with providers and Dinner with providers and wives/husbandswives/husbands

Key note speaker - a physician Key note speaker - a physician knowledgeable and respected in the knowledgeable and respected in the area of perinatal substance usearea of perinatal substance use

Establish a Good Establish a Good Support SystemSupport System

Needs to be integrated as a routine part of Needs to be integrated as a routine part of prenatal care (not a psychosocial issue but prenatal care (not a psychosocial issue but a health issue)a health issue) This is a health issue for all pregnant womenThis is a health issue for all pregnant women

Present the program as a complete packagePresent the program as a complete package Provide assessment formsProvide assessment forms Instructions/staff training (ongoing basis)Instructions/staff training (ongoing basis) Collection of DataCollection of Data Educational MaterialsEducational Materials

““I am concerned” brief interventionI am concerned” brief intervention PamphletsPamphlets

Referral ProcessReferral Process Easy to useEasy to use

Clear easy to use formsClear easy to use forms Minimal information to fill outMinimal information to fill out Contact numbers answered by a personContact numbers answered by a person

Followed up in a timely mannerFollowed up in a timely manner Contact clients within 2 to 3 days Contact clients within 2 to 3 days

Feedback to the physicianFeedback to the physician Respond back to referring physician Respond back to referring physician

regarding outcome of referralregarding outcome of referral

Share DataShare Data Give feedback on screening data Give feedback on screening data

to physician on a regular basisto physician on a regular basis

Physician’s practice compared to Physician’s practice compared to overall overall

county resultscounty results

Value of RespectValue of Respect Respect professionalism of OB Respect professionalism of OB

providers byproviders by Providing scientific proofProviding scientific proof Best PracticesBest Practices

Respect provider’s time by Respect provider’s time by Bringing all necessary materials Bringing all necessary materials Providing training and ongoing supportProviding training and ongoing support

Respect provider as a partner byRespect provider as a partner by Visiting as often as necessaryVisiting as often as necessary What can we do for youWhat can we do for you

Respect provider’s commitment Respect provider’s commitment to SART byto SART by

Acknowledging their contributionAcknowledging their contribution

Respect provider’s commitment Respect provider’s commitment to their to their patients’ meanspatients’ means

Providing accurate and timely Providing accurate and timely feedback feedback

Respect provider’s interest in Respect provider’s interest in real results real results meansmeans

Working with other agencies to Working with other agencies to make sure make sure referrals are acted uponreferrals are acted upon

What does a What does a screening screening

program look program look like?like?

The The SARTSART System System

SScreeningcreening

AAssessmentssessment

RReferraleferral

TTreatmentreatment

ScreeningScreening PParentsarents Did either of your parents ever have aDid either of your parents ever have a

problem with alcohol or drugs?problem with alcohol or drugs? PPartnerartner Does your partner have a problem withDoes your partner have a problem with

alcohol or drugs?alcohol or drugs? PPastast Have you ever drunk alcohol?Have you ever drunk alcohol?

PPregnancyregnancy In the month before you knew you were pregnant, In the month before you knew you were pregnant,

how many how many cigarettescigarettes did you smoke? did you smoke? In the month before you knew you were pregnant, In the month before you knew you were pregnant,

how many how many beers beers did you drink?did you drink? In the month before you knew you were pregnant, In the month before you knew you were pregnant,

how much how much marijuanamarijuana did you smoke? did you smoke?

AssessmentAssessment

What?What? When?When? How How

much?much?

Referral: A Brief Referral: A Brief InterventionIntervention

““I am concerned….”I am concerned….” Abstain from drugs or Abstain from drugs or

alcoholalcohol ““I see you are upset….”I see you are upset….” Come to consensusCome to consensus Refer: a “warm handoff”Refer: a “warm handoff”

Treatment: Level of Treatment: Level of CareCare

negneg “handshakehandshake”

pospos FA - FA - brochurebrochure

4P’s+4P’s+ FA+FA+ pretreatmentpretreatment

groupgroup

outpatientoutpatient

residentialresidential

I

II

IIIa

IIIb

IVaIVb

The Perinatal Substance Abuse The Perinatal Substance Abuse

4P’s Plus4P’s PlusAssessment ProgramAssessment Program

Seeks to address the impact of alcohol, tobacco Seeks to address the impact of alcohol, tobacco and illicit drug use during pregnancy and the and illicit drug use during pregnancy and the benefits of early interventionbenefits of early intervention

Works with prenatal providers on integrating Works with prenatal providers on integrating substance abuse screening, assessment and substance abuse screening, assessment and referral as a routine part of prenatal carereferral as a routine part of prenatal care

Focuses on the education of the professional Focuses on the education of the professional community and the community at large regarding community and the community at large regarding the impact of alcohol, tobacco and illicit drugs the impact of alcohol, tobacco and illicit drugs during pregnancy and the benefits of early during pregnancy and the benefits of early interventionintervention

FundingFunding

Helped fund Leadership TeamHelped fund Leadership Team

Funded 2 years of training and Funded 2 years of training and consultation with consultation with

National Training Institute (Dr. Ira National Training Institute (Dr. Ira Chasnoff)Chasnoff)

Provided funding for infrastructure for Provided funding for infrastructure for BeginningsBeginnings

March of DimesMarch of Dimes

Funded Funded Printing of brochures, Printing of brochures,

postersposters Trainings Trainings Media campaignsMedia campaigns

Maternal Child and Adolescent Maternal Child and Adolescent HeathHeath

Title V FundsTitle V Funds

Licensure of 4P’s Plus assessment Licensure of 4P’s Plus assessment tooltool

Purchase of “I am concerned” brief Purchase of “I am concerned” brief intervention booksintervention books

Printing of 4P’s Plus assessment Printing of 4P’s Plus assessment tooltool

Staff two positions for perinatal Staff two positions for perinatal substance abuse programsubstance abuse program

Educational materialsEducational materials

The California The California EndowmentEndowment PamphletsPamphlets WebsiteWebsite PostersPosters

Federal GrantsFederal Grants

Healthy Healthy StartStart

Local ResourcesLocal Resources Universities Universities

Cal Poly San Luis ObispoCal Poly San Luis Obispo Graphic arts and photography for posterGraphic arts and photography for poster Web designWeb design

Community FoundationsCommunity Foundations Preventive Health GrantsPreventive Health Grants

HospitalsHospitals

We Can Make A Difference

For more information…For more information…Please call for Please call for

questions or additional questions or additional information:information:

Jan Campbell, MCAH Director, San Jan Campbell, MCAH Director, San Luis ObispoLuis Obispo

(805) 781-5592(805) 781-5592

Sue Spooner, MCAH Director, Sue Spooner, MCAH Director, RiversideRiverside

(951) 358-5192(951) 358-5192

Thank youThank you