Perinatal substance use: A prospective evaluation of abstinence and relapse
Introduction
Approximately 11% of reproductive age women use illicit substances, 25% use cigarettes, and 30% binge drink or use heavy amounts of alcohol (Substance Abuse and Mental Health Services Administration, 2013). Pregnancy interrupts the pattern of substance use in many women. Nearly 50% of pregnant women who smoke cigarettes (Tong et al., 2008) and 70–90% of women who use illicit substances (Ebrahim and Gfroerer, 2003, Massey et al., 2011) achieve abstinence in pregnancy. Similar abstinence rates are reported among pregnant women with heavy alcohol use (Massey et al., 2011, Substance Abuse and Mental Health Services Administration, 2013). Offsetting the pregnancy-related decrease in substance use is the precipitous increase that occurs during the 6 months to one year after delivery (Ebrahim and Gfroerer, 2003, Gilchrist et al., 1996, Howell et al., 1999). For example, close to half of women who attain abstinence to smoking in pregnancy relapse within two weeks of delivery (Colman and Joyce, 2003), and 80% relapse within six months (DiClemente et al., 2000).
While existing data consistently illustrate the moderating effect of pregnancy on the course of substance use, most information, with the exception of studies of smoking in pregnancy, is derived from cross-sectional surveys and retrospective reports. Methodologically, it is easiest to focus only on one substance, and thus few studies have compared abstinence across substances. However, it is possible that the addictive properties of various substances differ making it harder for pregnant women to cease the use of one substance compared to another. From a clinical perspective, it would be useful to determine whether the likelihood of abstinence in pregnancy from cigarettes, illicit substances or alcohol is uniformly similar because resources could be devoted to the substances that are more difficult to stop.
It is also unknown whether the risk of relapse after delivery is the same across substances. The majority of research has focused on smoking relapse postpartum (Colman and Joyce, 2003, Gyllstrom et al., 2012, Kaneko et al., 2008, Park et al., 2009, Ruger et al., 2008, Tong et al., 2008, Tran et al., 2013, Yasuda et al., 2013), with only a handful of studies looking at postpartum alcohol relapse (Ebrahim et al., 1998, Jagodzinski and Fleming, 2007a, Jagodzinski and Fleming, 2007b, Nayak and Kaskutas, 2004). One of these studies found that at 6–12 weeks postpartum 37.8% of women who were frequent drinkers before pregnancy reported postpartum risky drinking, with 18% reporting heavy episodic drinking, 5% frequent drinking only and 15% reporting both behaviors (Jagodzinski and Fleming, 2007a). Another study found that women who reported at risk drinking postpartum were almost six times more likely to have had at risk drinking prior to pregnancy (Jagodzinski and Fleming, 2007b). However, there are no studies that evaluated women's patterns for drinking from pregnancy through delivery and into the postpartum period. Very little is known about the relapse process for illicit substance use following pregnancy. The only information currently available on the relapse process postpartum was collected nearly 20 years ago from a cross-sectional national survey (Ebrahim and Gfroerer, 2003).
Prospectively collected data can explore complicating factors such as concurrent substance use, and present a detailed picture of the abstinence and relapse process in perinatal women. The goal of this report is to chart the prospective course of substance use in a cohort of perinatal women with a pre-pregnancy history of substance use, and to compare rates of abstinence and relapse to the various substances, during pregnancy and after delivery. Specifically, the course of cigarettes, alcohol, marijuana and cocaine use in pregnancy and after delivery was examined. Patterns of concurrent substance use during this period were also examined. Data from a psychotherapy treatment trial for pregnant substance using women that included two years of post-pregnancy follow-up were analyzed.
Section snippets
Participants
The analytic cohort was drawn from the Psychosocial Research to Improve Drug Treatment in Pregnancy trial, a comprehensive, multicenter, prospective study, which has been described elsewhere in detail (Yonkers et al., 2012). Briefly, data where gathered between 2006 and 2012 as part of a randomized controlled trial to compare drug treatment outcomes for nurse-delivered motivational enhancement therapy (MET) coupled with cognitive behavioral therapy (CBT) and brief advice from an obstetrical
Results
Fig. 1 shows the flow of participants from initial screening through the end of the follow-up period. A total of 152 women met baseline substance use criteria and were included in the analysis for abstinence (potential abstinence cohort), and 126 of the 152 women achieved abstinence prior to delivery and were included in the postpartum relapse analysis (potential relapse cohort). There were no significant differences in clinical characteristics between participants in the included in the
Discussion
This study examined the onset of abstinence from cigarettes, alcohol, marijuana and cocaine in pregnancy and the pattern of relapse to these substances following delivery. To the knowledge of the authors, this is the first study to prospectively examine pregnancy-related abstinence and postpartum relapse into substance use. This was explored in a carefully characterized cohort of women followed for two years after delivery. Pregnancy-related abstinence rates were high among participants who
Role of funding source
This study was supported by the National Institute on Drug Abuse grants R01 DA 019135 to Dr. Yonkers and R01 DA025555 to Dr. Ruger. Dr. Forray is supported by K12 DA000167. None of the funding sources had any role in study design; in the collection, analysis, or interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Contributors
Drs. Yonkers and Ruger were responsible for the conduct of the study. Drs. Forray, Yonkers, Lin and Mr. Merry were responsible for the statistical analyses and interpretation of the data. Dr. Forray was responsible for initial draft of the manuscript, with contributions from Dr. Yonkers and Mr. Merry. Drs. Forray, Yonkers, Ruger, Lin, and Mr. Merry were responsible for critical review and editing of the manuscript.
Conflict of interest
In the past year, Dr. Yonkers received royalties from Up To Date, the content of which has no relationship to this project. Drs. Forray, Ruger, Lin and Mr. Merry have nothing to disclose.
Acknowledgements
We thank Heather B. Howell, LCSW for her work in managing the clinical trial, Ruth M. Arnold, PhD and Christina M. Lazar, BA for their research assistance, and Daniel Cheong, MPH for assistance with data cleaning.
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