I SUBSTANCE USE AND ABUSE ^297 ^325 ^385 ^448

The use of tobacco, alcohol, and illegal drugs constitutes a substantial national health problem. In the United States, an estimated 21% of all women use tobacco products, 15.8% of women aged 12 years and older are binge drinkers, and 10.8% of nonpregnant women aged 15-44 years reported illicit drug use in the past month.

Evaluation of a patient for tobacco, alcohol, or other substance abuse requires appreciation of the high prevalence and wide distribution among the population of such behavior, along with the ability to take a thorough history. Traditionally, physicians have had low rates of detection and refer­rals in nonpregnant women. Obstetrician-gynecologists have an ethical obligation to learn and use a protocol for universal screening by question­ing for illicit drug and at-risk drinking on all patients. Universal screening is the key: screening only patients who may be perceived to be at risk leads to the low rates of detection. Direct questioning of patients about their use of tobacco, alcohol, and other drugs is preferable to vague inquiry. When there is evidence of substance abuse, obstetrician-gynecologists should be able to perform a brief intervention and refer patients to appropriate treatment.

Addiction is a chronic, relapsing behavioral disorder that affects the functioning of the brain and other major organs. It is not a moral problem, an indication of bad character, a sign of weakness, or a failure of the will. Because substance abuse and dependence are medical conditions, health care providers have a key role to play in their prevention and treatment.

Smoking

Cigarette smoking is the largest preventable cause of premature death and avoidable illness among women in the United States. Physicians and office staff can encourage smoking cessation by ensuring that all smok­ers are identified, monitored, and counseled appropriately at every office visit.

Screening and Assessment

The Agency for Healthcare Research and Quality recommends a brief smok­ing cessation intervention known as the “5 A’s” for screening and treating tobacco dependence (see Box 3-13). The 5 A’s are applicable to outpatient office visits. Meta-analysis has shown that this intervention is not only clin­ically effective but also extremely cost-effective relative to other commonly used disease prevention interventions and medical treatments. Smoking

Box 3-13. The Five A’s Brief Smoking Cessation Intervention

Ask about tobacco use. Identify and document tobacco use status for every patient at every visit.

Advise to quit. In a clear, strong, and personalized manner, urge every tobacco user to quit.

Assess willingness to make a quit attempt. Is the tobacco user willing to make a quit attempt at this time?

Assist in quit attempt. For patients unwilling to make a quit attempt at the time, address tobacco dependence and willingness to quit at next clinic visit.

Arrange follow-up. Schedule follow-up contact, preferably within the first week after the quit date.

Data from Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: U.S. Preventive Services Task Force reaffirma­tion recommendation statement. U.S. Preventive Services Task Force.

cessation interventions delivered by health and social care providers (eg, physicians, dentists, nurses, psychologists, and social workers) markedly increase cessation rates compared with interventions with no health care provider involvement (eg, self-administered interventions).

Clinicians can enhance the motivation of individuals to quit by reviewing the many health risks associated with smoking and the numerous benefits of living smoke free. Smoking contributes to deaths from cancer, cardio­vascular disease, and respiratory diseases. Women who smoke increase their risk of osteoporosis, secondary amenorrhea, and menstrual irregular­ity. Women often do not appreciate that smoking also is associated with early menopause and infertility. Counseling of adolescents should focus on associations that are important to them, such as body image issues. For example, in the “Advise” portion of the 5 A’s approach for adolescents, personalize the message to include the fact that smoking may be associated with bad breath, clothing odors, skin changes, and limp, dull hair.

Utilizing motivational interviewing, which is discussed in more detail in the “Well-Woman Annual Health Assessment” section earlier in Part 3, has been shown to be effective in eliciting behavior change. Follow-up that reinforces the health risks of smoking and provides appropriate referrals for additional cessation counseling and medical therapy is an important component of smoking cessation intervention.

For the patient willing to make a quit attempt, use counseling and pharmacotherapy (unless contraindicated) to help her quit. Adolescents, smokeless tobacco users, and light smokers should not routinely use phar­macotherapy. For patients unwilling to make a quit attempt at first, address tobacco dependence and willingness to quit at the next clinic visit. The fol­lowing systematic approach to patients is helpful:

1. Suggest and encourage the use of problem-solving methods and skills for smoking cessation (eg, identify “trigger” situations).

2. Provide social support as part of the treatment (eg, “We can help you quit”).

3. Arrange social support in the smoker’s environment (eg, identify a “quit buddy” and smoke-free space).

4. Provide self-help smoking cessation materials.

Every state offers free smoking cessation telephone counseling that smokers can access through a toll-free number, 800-QUΓT-NOW. Quit lines offer counseling and information on local resources, and they have been proved to increase smoking cessation rates and decrease relapse. This multifaceted counseling approach has been found in meta-analysis studies to be extremely helpful in helping patients to quit. New Current Procedural Terminology codes have been developed for patient counseling.

Women experience more difficulty with smoking cessation than do men, especially in the initial cessation period, and women are more prone to relapse. Clinicians can provide brief, effective relapse prevention treat­ment by reinforcing the patient’s decision to quit, reviewing the benefits of quitting, and assisting the patient in resolving any residual problems encountered from quitting.

Many women are deterred from quitting smoking because of the fear of weight gain. Approximately one half of those who stop smoking gain weight and most will gain fewer than 10 lb. Weight gain is not caused by a change in chronic resting metabolic rates after smoking cessation; tobacco smoke is not an anorectic or a thermogenic agent. Weight gain with smoking cessation seems to be caused by a transient increase in oral intake without any change in physical activity. Following a nutritious diet of low-caloric foods, drinking large amounts of noncaloric or low-caloric liquids, and engaging in regular exercise can help smokers cope with withdrawal symptoms and minimize weight gain. Several medications prescribed for smoking cessation (particularly nicotine replacement) may help delay weight gain; however, once the medications are discontinued, most women experience weight gain.

Pharmacotherapy and Other Evidence-Based Smoking Cessation Aids

Pharmacologic treatment for smoking cessation (including nicotine replace­ment therapy and sustained-release bupropion and varenicline) should be offered to all women attempting smoking cessation unless it is contra­indicated (see Table 3-7). These products may be used in combination for patients who are experiencing difficulty quitting. The clinician needs to be aware of the black box label warning on bupropion (which also is used to treat depression) and varenicline in regard to suicide ideation.

Table 3-7. Smoking Cessation Aids

*Cost of a course of treatment.

Data from Fiore MC, Jaen CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and dependence: 2008 update. Clinical Practice Guideline. Rockville (MD): Department of Health and Human Services; 2008.

Patients should be counseled and monitored for abrupt mood changes. The U.S. Food and Drug Administration has issued a warning concerning an increase in cardiovascular events for those individuals with cardiovas­cular disease who use varenicline. A downloadable, comprehensive, and patient-centered chart of evidence-based smoking cessation interventions with effectiveness ratings can be found at www.whatworkstoquit.tobacco- cessation.org/NTCCguide.pdf. Hypnotherapy and the use of herbal rem­edies have not proved to be effective for achieving smoking cessation.

Alcohol and Other Drug Use and Abuse

Excessive alcohol consumption contributes to more than 100,000 deaths in the United States each year. In addition to motor vehicle accidents, suicide, and homicide, heavy drinking contributes to deaths from heart disease, cancer, and stroke. Half of all cirrhosis deaths are linked with alco­hol. Menstrual disorders, early menopause, and osteoporosis are among the gynecologic consequences of alcohol abuse. Condom use is inversely correlated with alcohol use.

Substance use, abuse, and dependence can have serious implications for women’s health. Among these implications are adverse effects on reproductive function and pregnancy. Liver disease, stroke and other cere­brovascular diseases, an increase in certain malignancies, and behavior that results in malnutrition or the acquisition of serious infections, such as human immunodeficiency virus (HIV) and hepatitis, are some of the consequences noted in women who abuse alcohol or other substances.

Deaths from prescription painkiller overdoses increased more than 400% between 1999 and 2010, with nearly 48,000 women dying of pre­scription painkiller overdoses during that period. The nonmedical use of prescription drugs, particularly opioids, sedatives, and stimulants, has been cited as an epidemic in the United States, accounting for increasing numbers of emergency department visits and deaths from reactions and overdoses. Those who abuse prescription drugs most often obtain them from friends and family, either through sharing or theft.

The role of the obstetrician-gynecologist or primary health care provider includes appropriate prescribing, universal screening by questionnaire, brief intervention, and referral. Prompt intervention that goes beyond screening may help the patient come to terms with her substance abuse problem. The obstetrician-gynecologist also can be effective in encourag­ing a patient’s participation in the engagement and maintenance of her treatment and in planning for relapse prevention. Potentially addictive medications should be prescribed with caution in patients with a substance abuse history (see also “Preventing Prescription Drug Abuse” later in this section).

Screening and Assessment

All women should be screened annually for alcohol and substance abuse, including prescription drug abuse, using a validated questionnaire. Box 3-14 includes examples of validated alcohol screening questionnaires. The “Drug Use Screening Tool” created by the National Institute on Drug Abuse is a brief web-based interactive assessment that guides clinicians through a series of questions to identify risky substance use in adult patients. The accompanying resources assist clinicians in providing patient feedback and arranging for specialty care, where necessary, using the 5 A’s of intervention (see www.drugabuse.gov/nmassist/).

Women may not disclose tobacco, alcohol, or other substance use for a variety of reasons. Fears regarding disclosure can include the fear of inter­vention by government agencies, when reporting can result in punishment, incarceration, or loss of child custody. Clinicians should be aware of the variety of adverse effects and examination findings related to substances that are commonly abused and follow up on these findings as appropriate.

Drug Testing

If drug testing is performed, it is incumbent on the medical practitioner, as part of the procedure in obtaining consent for testing, to provide informa­tion about the nature and purpose of the test to the patient and how the results will guide management. Clinicians should be familiar with state statutes that require illicit drug use reporting. Where there are laws that require disclosure, patients should be informed in advance about specific items for which disclosure is mandated.

When indicated, and when used appropriately and with informed con­sent, laboratory drug tests can help identify or confirm a substance abuse

problem overlooked by other detection methods. Although drug testing can be done on blood, hair, sweat, saliva, and nails, urine testing generally is the most practical option for the clinician’s office. Urine testing is easy

Box 3-14. Alcohol Use Screening Tools

T-ACE

• T—Tolerance

How many drinks does it take to make you feel high?

(More than two drinks = 2 points)

• A—Annoyed

Have people annoyed you by criticizing your drinking?

(Yes = 1 point)

• C—Cut down

Have you ever felt you ought to cut down on your drinking?

(Yes = 1 point)

• E—Eye-opener

Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

(Yes = 1 point)

A total score of 2 points or more indicates a positive screening for at-risk drinking

Alcohol Quantity and Drinking Frequency Questions

• In a typical week, how many drinks do you have that contain alcohol? (Positive for at-risk drinking if more than seven drinks)

• In the past 90 days, how many times have you had more than three drinks on any one occasion? ( Positive for at-risk drinking if more than one time)

Data from Sokol RJ, Martier SS, Ager JW. The T-ACE questions: practical prena­tal detection of risk-drinking. Am J Obstet Gynecol 1989;160:863-8, discussion 868-70 and National Institute on Alcohol Abuse and Alcoholism. Helping patients who drink too much: a clinician’s guide. Bethesda (MD): NIAAA; 2005. Available at: http://pubs.niaaa.nih.gov/publications/practitioner/CliniciansGuide2005/ Guide_Slideshow.htm. Retrieved July 26, 2013. and inexpensive, and it provides a reasonable testing window for com­monly used drugs (a few days in most cases). Mass-produced kits generate immediate results that can be discussed with the patient. A standard urine testing panel does not detect synthetic opioids and does not detect some stimulants and benzodiazepines, and testing alone cannot confirm intoxi­cation, abuse, or dependence. However, when combined with a thorough medical history, physical examination, and screening questionnaire, bio­physical drug testing can help the clinician provide appropriate interven­tions to the patient.

Intervention

If alcohol, illicit drug, or prescription drug abuse is identified, the health care provider should perform a brief motivational intervention as described in the American College of Obstetricians and Gynecologists’ Committee Opinion Number 423, Motivational Interviewing: A Tool for Behavior Change (see Bibliography). Given the potential consequences of alcohol abuse, illicit drug use, and prescription drug misuse during preg­nancy, counseling on the use of effective contraception methods should be included in the intervention (see also the “Family Planning” section later in Part 3).

Referral for Treatment

If alcohol or drug dependence is revealed, the patient should be referred to a substance abuse treatment specialist. No single treatment is appro­priate for all individuals with substance abuse problems. Recovery from substance abuse is a long-term process. Better outcome is seen in individu­alized programs that provide a greater range, frequency, and intensity of services. Treatment programs for women should look beyond simple absti­nence from further substance use and take into account the total health of the individual. Support services (eg, transportation and child-care services) can affect the success of substance abuse treatment. Social service depart­ments in many hospitals are an invaluable source of assistance and referral of patients with substance abuse problems. Many additional community and clinical resources are available (see Resources).

Preventing Prescription Drug Abuse ^335

Patient education is central in preventing intentional and unintentional drug diversion. When prescribing medications that may be misused, physi­cians should educate their patients on proper use, storage, and disposal of medications.

Patients who are prescribed opioid medications for legitimate pain con­trol are unlikely to abuse them. However, physicians should be aware of patients who try to exploit practitioner sensitivity to patient pain. Use of patient pain contracts and drug testing may help to reduce this exploita­tion. The U.S. Food and Drug Administration now requires manufacturers of extended-release or long-acting opioid analgesics to offer continuing education on safe prescribing of these drugs, and these programs will be helpful resources to physicians and other prescribers. Prescribers should also be aware of state laws that address the prescribing of opioids and other potential drugs of addiction (see also the “Acute and Chronic Pain Management” section in Part 4).

Patients should be instructed to take the medication only as it is pre­scribed to them. They should be cautioned to not share the medication with anyone else, including friends and relatives who may feel that taking the patient’s medication may help them. Medication that may be abused should be stored in secure places to prevent misuse by others, particularly youth who may obtain them without anyone knowing. Unused medica­tions should be taken to a pharmacy for proper disposal or thrown away mixed in coffee grounds or cat litter to discourage recovery of the medica­tions by someone intending to misuse the drug. In addition, women’s health care providers should consider referral to a pain management spe­cialist for women with chronic pain.

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