223
SCIENTIFIC FOUNDATION OF CLINICAL PRACTICE: OPIATE USE IN PREGNANT WOMEN* LORETTA P. FINNEGAN, M.D. Director
TERESA HAGAN, M.S. W. Program Director
KAROL A. KALTENBACH, PH.D. Director of Research
Family Center Department of Pediatrics Thomas Jefferson University Hospital Philadelphia, Pennsylvania
D URING THE PAST DECADE the growing numbers of substance abusers have overwhelmed the treatment system. These numbers are reflected in the increased incidence of drug exposed infants in nurseries throughout the country. In New York City 50% of all child abuse and neglect cases involved drug abuse. If alcohol is included, the percentage increases to 64%. 1 During an eight-week period in 1989 the Philadelphia Perinatal Society and Philadelphia Department of Public Health screened eight city hospitals for the prevalence of cocaine associated births. Cocaine associated births totaled 16.3%, with a range of 6.4% to 24.3%.2 In response to this crisis, treatment programs find it necessary to modify traditional methods of treatment. This manuscript will discuss methods adopted by Family Center, a program for pregnant drug dependent women and their children at Thomas Jefferson University Hospital in Philadelphia. These recommendations are based on demonstration research accomplished at the Center under the auspices of grants from the National Institute on Drug Abuse from 1972 until the present. *Presented in a panel, Scientific Foundations of Clinical Practice, as part of a Symposium on Pregnancy and Drug Abuse: Perspectives and Directions held by the Committee on Public Health of the New York Academy of Medicine, the Medical and Health Research Association of New York City, Columbia University School of Public Health, the Maternal and Child Health Program of the New York County Medical Society, the Greater New York March of Dimes, and Agenda for Children Tomorrow March 22, 1990 at the New York Academy of Medicine.
Vol. 67, No. 3, May-June 1991
224
2
2
4
L
L.P. FINNEGAN AND,flOTHERS THAFR5,
P~~~~~~~~~~~~-
FINP1A
A
I
HISTORICAL OVERVIEW For many years researchers regarded substance abuse as a consequence of a defective addictive personality. They sought to discover the characteristics and the one variable that distinguished addict and nonaddict populations on a myriad of demographic and personality variables. "Instead of discovering just one reliable characteristic, they discovered at least 11, none of which accounts for the majority of variance between groups, but each of which increases the probability of drug use to a certain extent.' '3 Consequently, the quest for one variable was replaced by a search for the one combination of established variables that best explains substance abuse. Nearly every well-designed longitudinal study utilizing multivariate analysis produced a different set of explanatory variables, all related to substance abuse in a statistically significant manner. No one set, however, explains more than a moderate amount of variance.3 Bry et al.4 responded to these variations by using the multiple risk factors hypothesis. This is a notion that the findings are disparate because substance abuse is a function of the number of etiological factors instead of a particular set of them. "When this hypothesis was tested on a data set containing six of the eleven most commonly supported etiological characteristics, the results revealed a highly significant relationship between the number of these characteristics and the probability of current abuse. Subjects exhibiting none of the risk factors reported a lower percentage of substance abuse than the population at large, with the presence of each additional risk factor being associated with a four and one half times increase in magnitude of risk.' '3 For example, in a retrospective study Hagan5 compared a population of drug-addicted and nonaddicted women from similar socioeconomic backgrounds. The following variables were found significant: Chemical abuse within the family of origin: 83% of addicted women had chemical abuse in one or both parents; 75% of those parents were alcoholic. This is in contrast to 35% of nonaddicted women. It should be noted that more than half of the 35% had a drug or alcohol addicted sibling. Sexual assaults: 67% of addicted women had been sexually assaulted in comparison to 15% of nonaddicted. Of drug-addicted sexual assault victims, 75% were raped before the age of 16 years, and the youngest had been eight years of age. Physical assaults: 60% of addicted women had been physically assaulted in childhood, in contrast to 20% of nonaddicts. Using the Moos Family Environment Scale,6 families of addicted women were found to have had lower levels of cohesion (p =
SCIENTIFIC FOUNDATION OF CLINICAL PRACTICE: OPIATE USE IN PREGNANT WOMEN* LORETTA P. FINNEGAN, M.D. Director
TERESA HAGAN, M.S. W. Program Director
KAROL A. KALTENBACH, PH.D. Director of Research
Family Center Department of Pediatrics Thomas Jefferson University Hospital Philadelphia, Pennsylvania
D URING THE PAST DECADE the growing numbers of substance abusers have overwhelmed the treatment system. These numbers are reflected in the increased incidence of drug exposed infants in nurseries throughout the country. In New York City 50% of all child abuse and neglect cases involved drug abuse. If alcohol is included, the percentage increases to 64%. 1 During an eight-week period in 1989 the Philadelphia Perinatal Society and Philadelphia Department of Public Health screened eight city hospitals for the prevalence of cocaine associated births. Cocaine associated births totaled 16.3%, with a range of 6.4% to 24.3%.2 In response to this crisis, treatment programs find it necessary to modify traditional methods of treatment. This manuscript will discuss methods adopted by Family Center, a program for pregnant drug dependent women and their children at Thomas Jefferson University Hospital in Philadelphia. These recommendations are based on demonstration research accomplished at the Center under the auspices of grants from the National Institute on Drug Abuse from 1972 until the present. *Presented in a panel, Scientific Foundations of Clinical Practice, as part of a Symposium on Pregnancy and Drug Abuse: Perspectives and Directions held by the Committee on Public Health of the New York Academy of Medicine, the Medical and Health Research Association of New York City, Columbia University School of Public Health, the Maternal and Child Health Program of the New York County Medical Society, the Greater New York March of Dimes, and Agenda for Children Tomorrow March 22, 1990 at the New York Academy of Medicine.
Vol. 67, No. 3, May-June 1991
224
2
2
4
L
L.P. FINNEGAN AND,flOTHERS THAFR5,
P~~~~~~~~~~~~-
FINP1A
A
I
HISTORICAL OVERVIEW For many years researchers regarded substance abuse as a consequence of a defective addictive personality. They sought to discover the characteristics and the one variable that distinguished addict and nonaddict populations on a myriad of demographic and personality variables. "Instead of discovering just one reliable characteristic, they discovered at least 11, none of which accounts for the majority of variance between groups, but each of which increases the probability of drug use to a certain extent.' '3 Consequently, the quest for one variable was replaced by a search for the one combination of established variables that best explains substance abuse. Nearly every well-designed longitudinal study utilizing multivariate analysis produced a different set of explanatory variables, all related to substance abuse in a statistically significant manner. No one set, however, explains more than a moderate amount of variance.3 Bry et al.4 responded to these variations by using the multiple risk factors hypothesis. This is a notion that the findings are disparate because substance abuse is a function of the number of etiological factors instead of a particular set of them. "When this hypothesis was tested on a data set containing six of the eleven most commonly supported etiological characteristics, the results revealed a highly significant relationship between the number of these characteristics and the probability of current abuse. Subjects exhibiting none of the risk factors reported a lower percentage of substance abuse than the population at large, with the presence of each additional risk factor being associated with a four and one half times increase in magnitude of risk.' '3 For example, in a retrospective study Hagan5 compared a population of drug-addicted and nonaddicted women from similar socioeconomic backgrounds. The following variables were found significant: Chemical abuse within the family of origin: 83% of addicted women had chemical abuse in one or both parents; 75% of those parents were alcoholic. This is in contrast to 35% of nonaddicted women. It should be noted that more than half of the 35% had a drug or alcohol addicted sibling. Sexual assaults: 67% of addicted women had been sexually assaulted in comparison to 15% of nonaddicted. Of drug-addicted sexual assault victims, 75% were raped before the age of 16 years, and the youngest had been eight years of age. Physical assaults: 60% of addicted women had been physically assaulted in childhood, in contrast to 20% of nonaddicts. Using the Moos Family Environment Scale,6 families of addicted women were found to have had lower levels of cohesion (p =
