International Rural Health & Rural Nursing Research Conference

International Rural Health & Rural Nursing Research Conference

International Rural Health & Rural Nursing Research Conference Rapid City, SD July 20, 2016 integrity | caring | altruism | social justice | maximizing human potential WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING R i s k s t o R u r a l H e a l t h : To b a c c o a n d O t h e r S u b s t a n c e Use and Impacts on the Health of Maternal Child Populations Jo Ann Walsh Dotson PhD RN Assistant Professor of Nursing Washington State University College of Nursing Spokane, WA Objectives Decide, once and for all, what is and is not rural (just

kidding). Review characteristics of womens health and care in rural areas. Examine the prevalence and impact of substance use by pregnant and parenting families. Review policy and practice implications regarding substance use by MCH populations in rural settings. Consider responsibility of nurses and other health professionals in rural settings. integrity | caring | altruism | social justice | maximizing human potential WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING The well-being of mothers, infants, and children determines the health of the next generation and can help predict future public health challenges for families, communities, and the medical care system. HP 2020 integrity | caring | altruism | social justice | maximizing human potential WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING Worldwide Infant Mortality Rates (IMR) - often used as an indicator of the level of health in a country

World Rank 1 50 95 108 121 122 167 179 187 188 220 222 224 Country AFGHANISTAN INDIA BRAZIL SAUDI ARABIA CHINA MEXICO UNITED STATES CANADA UNITED KINGDOM AUSTRALIA NORWAY

JAPAN MONACO IMR 115.08 (worst) 41.81 18.6 14.09 12.44 12.23 5.87 4.65 4.38 4.37 2.48 2.08 1.82 (best) IMR = deaths of children under one year of age per 1,000 live births. Source: The World Fact Book CIA 2015 Estimates integrity | caring | altruism | social justice | maximizing human potential WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING WHO Womens Health Fact Sheet 2013 Adolescent girls are increasingly using tobacco and alcohol, which risks compromising their health,

particularly in later life. In some places girls are using tobacco and alcohol nearly as much as boys. For example, in the WHO Region of the Americas (including North and South America), 23% of boys and 21% of girls aged 13-15 reported that they used tobacco in the previous month. integrity | caring | altruism | social justice | maximizing human potential WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING Rural Womens Health National Rural Health Association 2013 Maternal, infant, and child health rank as a top ten concern by rural health experts. Pregnancies to women in rural areas are more likely to be unplanned, and the women more likely to be younger, less educated and unmarried women and to be unplanned. Rural women are particularly susceptible to poor prenatal care due to fewer resources available to them. Obstetrics providers, in particular, are in short supply in rural areas; urban counties average nearly 35 obstetricians per 1,000 residents, while rural counties average less than 2 per 1,000 residents. Women in rural areas are less likely to have adequate transportation, complicating the fact that many rural hospitals do not offer obstetric services, and those that do have shortages of providers and trained staff. Lack of access to care has been linked with poorer outcomes among women.

integrity | caring | altruism | social justice | maximizing human potential WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING Health Disparities in Rural Women ACOG 2014 Significant health disparities exist between rural and urban women. 22.8% of U.S. women aged 18 years and older live in rural settings. About 20% of births in US occur in rural areas. U.S. rural women are more than likely to smoke cigarettes, and in some regions of the country, have higher rates of heavy alcohol consumption. Rural women aged 1864 years reported the highest rates of delayed care or no medical care due to cost (18.6%) and no health insurance coverage Obstetric and Reproductive Health Outcomes - some studies document rural women have Higher rates of hospitalizations with complications during pregnancy Higher rates of low birth weight (LBW) and preterm birth More reliance on female sterilization (35%) than women living in large metropolitan (24%) or fringe metropolitan (25%) areas Poorer access to contraception and more unintended pregnancies than women in more urban areas. Poorer access to specialty care (OB, perinatologists and neonatologists) integrity | caring | altruism | social justice | maximizing human potential

WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING Substance Use in Pregnancy Substance use in pregnancy typically includes the use of tobacco, alcohol, marijuana, and illicit drugs. WHO defines illicit drugs as those used for non-medical use that are prohibited by international law. These drugs include: amphetamine- type stimulants, cannabis, cocaine, heroin and other opioids, and MDMA (ecstasy). Substance dependence includes tolerance, withdrawal, taking a drug in larger amounts over longer periods than originally intended, the desire or ineffective attempts to reduce or cease drug use, extensive amounts of time involved with substance use, and persistent use despite problems attributed to the substance. Substance abuse is a maladaptive pattern of use that results in clinically significant functional impairment, characterized by one or more of the following: failure to fulfill reasonable obligations drug use in dangerous situations continued use despite recurrent legal, social, and psychological problems associated with the substance. WHO, 2006

integrity | caring | altruism | social justice | maximizing human potential WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING Substance Use by Pregnant Women Worldwide % US % 3.9 7 Tobacco 7 16 Alcohol - 8.5 0.5

5.4 Marijuana Illicit Difficult to obtain accurate data due to: Underreporting of substances which are or have been illegal. Risk of legal sanctions by pregnant women who do report Definition of use is variably defined, including use in last year, trimester, month, amount. Multi-drug use is common, making recall difficult. integrity | caring | altruism | social justice | maximizing human potential WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING Trends in substance

use by pregnant women in the US Cigarette use is decreasing, but this may be offset by ecigarette or vaping and chew. Marijuana is the most commonly used recreation drug used during pregnancy Pregnant users perceive marijuana as low risk and safe, due in part due to historical use to treat nausea, Prevalence of marijuana use is expected to increase in the US, especially in those states where recreational use is legalized (Colorado, Washington, Alaska and Oregon) or anticipated to pass legislation soon (Massachusetts, California, Missouri, Hawaii, Maine, Nevada and Ohio) Heroin use has increased slightly over the last decade, but non-medical use of opioids has increased by over 30% in the last few years. Alcohol use continues, especially in conjunction with other substances. integrity | caring | altruism | social justice | maximizing human potential WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING

Use of alcohol, illicit drugs and other psychoactive substances during pregnancy can lead to multiple health and social problems for both mother and child, including miscarriage, stillbirth, low birthweight, prematurity, physical malformations and neurological damage. Dependence on alcohol and other drugs can also severely impair an individuals functioning as a parent. integrity | caring | altruism | social justice | maximizing human potential WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING WHO recommendations identification and management of substance use and substance use disorders in pregnancy Governing principles I. Prioritizing prevention. II. Ensuring access to

prevention and treatment services III. Respecting patient autonomy IV. Providing comprehensive care. V. Safeguarding against discrimination and stigmatization. Recommendation to assure Screening and interventions for hazardous substance use Psychosocial interventions for substance use disorders Detoxification or quitting programs for substance dependence Pharmacological treatment Support of breastfeeding with monitoring Management of infants exposed to alcohol and other psychoactive substances integrity | caring | altruism | social justice | maximizing human potential WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING

Long Term Short Term Effect of prenatal drug exposure * Effects Nicotin e Alcohol Marijuana Opiates Fetal Growth Effect Strong effect No Effect

Effect Anomalies ? Strong effect No Effect No Effect Withdrawal No Effect No effect No Effect Strong Effect Neurobehavi or

Effect Effect Effect Effect Growth ? Strong Effect No Effect No Effect Behavior Effect Strong Effect Effect Effect

Cognition Effect Strong Effect Effect ? Language Effect Effect No Effect * Achievement Effect Strong Effect

Effect * No data Source: Behnke & Smith (2013) integrity | caring | altruism | social justice | maximizing human potential WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING Prevention Program Logic Model Risk Factor Substance Risk Target Outcomes Marijuana Infant complications including prematurity, tremors and exaggerated startle (Moro reflex), poor suck Improved infant status and feeding

Tobacco Low birth weight, prematurity Decreased maternal use, improved birth outcomes, decreased environmental smoke Alcohol Poor birth outcomes, cooccurrence, Fetal Alcohol Spectrum Disorder (FASD) Decreased alcohol intake, decreased incidence of FASD Opioids neural tube defects, congenital heart and other Neonatal abstinence syndrome (NAS)

Opioid management, decreased incidence of defects and NAS Sources: Dotson, Henderson and McGraw, 2003 integrity | caring | altruism | social justice | maximizing human potential WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING Why do women want to quit using substances? 1.Pregnancy (65.8%) 2.Needing help (23.7%) 3.Family (18.4%) 4.Tired of the lifestyle (16.7%). Individuals residing in rural areas have unique beliefs, social ties, attitudes, and financial hardships. Research about the role of these factors in treatment access and motivation could be used to minimize treatment barriers. Jackson and Shannon, 2012 integrity | caring | altruism | social justice | maximizing human potential WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING Practice Implications Health Care Providers

In the absence of research, and because of concerns regarding impaired neurodevelopment, ACOG recommends that women who are pregnant or contemplating pregnancy should be encouraged to discontinue all substances. Seek education and resources about detection, notably the Prenatal Risk Overview, which has been integrated into many EHRs. Improve your own skills training DOES improve your skills. RX for Change Public Health Efforts to address marijuana use should be coordinated with tobacco and alcohol prevention. State and federal surveys must be changed to separate marijuana from illicit drug lists in order to increase accuracy of reporting. State birth certificates should be changed to add marijuana use to reporting alongside alcohol and tobacco use

Careful monitoring of THC levels in marijuana production settings Increase efforts to develop a clear message regarding marijuana use Being alert to efforts to recruit female smokers and respond accordingly integrity | caring | altruism | social justice | maximizing human potential WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING Nicotine addiction and treatment is important! Tobacco use has been causally linked to diminished birth weight again and again (and again) Pregnant women receive mixed messages about tobacco use its important you dont drink, or use other substances, but its OK to smoke if you must Tobacco use is often used in association with other substances Nicotine is a serious addiction Dont confuse the clients! integrity | caring | altruism | social justice | maximizing human potential WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING P O L I CY M A K E R I M P L I C AT I O N S Examine the cost of inaction Listen to communities regarding their needs and challenges

Support research on the topic of addictions and treatment Support innovation Allocate EQUITABLY AC A D E M I C / R E S E A RC H I M P L I C AT I O N S Translational research sustainable programs Interprofessional educational efforts on substance abuse and tobacco cessation counseling Partner with private and public providers to evaluate effectiveness of programming to create responsive and innovative programs for communities integrity | caring | altruism | social justice | maximizing human potential WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING References

Alharbi, F.F. and N. el-Guebaly. (2014). Exploring the Management of Cannabis Use Among Women and During Pregnancy. Addictive Disorders & Their Treatment. 13(2): p. 93-100. Baewert A, Jagsch R, Metz V, et al. (2012) Influence of site differences between urban and rural American and Central European opioiddependent pregnant women and neonatal outcome characteristics. European Addiction. 18(3):130-139 Bailey B, McCook J, Hodge A, McGrady L. (2012). Infant birth outcomes among substance using women: why quitting smoking during pregnancy is just as important as quitting illicit drug use. Maternal And Child Health Journal. 16(2):414-422. Day, N.L., L. Goldschmidt, and C.A. Thomas. (2006) Prenatal marijuana exposure contributes to the prediction of marijuana use at age 14. Addiction. 101(9): p. 1313-1322. Dotson, J. A., Henderson, D., & Magraw, M. (2003). A public health program for preventing fetal alcohol syndrome among women at risk in Montana. Neurotoxicology & Teratology, 25(6), 757. Garry, A., Rigourd, V., Amirouche, A., Fauroux, V., Aubry, S., and Serreau, R. (2009). Cannabis and Breastfeeding. Journal of Toxicology. Article ID 598149, 5 pages, DOI 10.11552009596149.. Harrison, P.A., A. Godecker, and A. Sidebottom. (2012). Validity of the Prenatal Risk Overview for Detecting Drug Use Disorders in

Pregnancy. Public Health Nursing. 29(6): p. 563-573. Heil S, Sigmon S, Jones H, Wagner M. (2008). Comparison of Characteristics of Opioid-Using Pregnant Women in Rural and Urban Settings. American Journal Of Drug & Alcohol Abuse. 34(4):463-471. Jackson A, Shannon L. (2012). Examining Barriers to and Motivations for Substance Abuse Treatment Among Pregnant Women: Does Urban-Rural Residence Matter?. Women & Health. 52(6):570-586. Jumah N, Graves L, Kahan M. (2015). The management of opioid dependence during pregnancy in rural and remote settings. CMAJ: Canadian Medical Association Journal. January 6;187(1):E41-E46. Ko, J., Farr, S., Tong, V., Creanga, A., and Callaghan, W. (2015). Prevalence and patterns of marijuana use among pregnant and nonpregnant women of reproductive age. American Journal of Obstetrics & Gynecology. 213(2): p. 201.e1-201.e10. SAMHSA, National Survey on Drug Use and Health: Model-Based Prevalence Estimates (50 States and the District of Columbia), Substance Abuse and Mental Health Services Administration, Editor. 2012-2013. Shishani, K., Stevens, K., Dotson, J., & Riebe, C. (2013). Improving nursing students' knowledge using online education and simulation to help smokers quit. Nurse Education Today, 33(3), 210-213. Shannon L, Havens J, Hays L. (2010). Examining Differences in Substance Use among Rural and Urban Pregnant Women. American Journal On Addictions. 19(6):467-473. Shaw M, Grant T, Barbosa-Leiker C, Fleming S, Henley S, Graham J. (2010). Intervention with substance-abusing mothers: Are there rural-urban differences?. American Journal On Addiction. 24(2):144-152. Tzilos, G., Hess, L., Chien-Wen Kao, J., and Zlotnick, C. Tzilos, G. (2013). Characteristics of perinatal women seeking treatment for marijuana abuse in a community-based clinic. Archives of Women's Mental Health. 16(4): p. 333-337. Wong S, Ordean A, Kahan M. (2011). SOGC clinical practice guidelines: Substance use in pregnancy: no. 256, April 2011. International Journal Of Gynaecology And Obstetrics. 114(2):190-202. World Drug Report United Nations Office on Drugs and Crime, Editor. 2015, United Nations: Vienna, Austria. integrity | caring | altruism | social justice | maximizing human potential WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING Thank you from Washington State

University College of Nursing! Questions/Comments Jo Ann Dotson at [email protected] integrity | caring | altruism | social justice | maximizing human potential WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING

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