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Drug Abu •• Information and Monitoring Project
DRUG ABUSE SERIES
California O.partment of Alcohol and Drug Programs
Chauncey L Veatch III, Director
COCAINE USE AND PREGNANCY
~ ':~~ .. -.' ; ,
; " , ..
Health and Welfare Agency Clifford L. Allenby, Secretary
lift ~5 1993
State of California George OeukmeJlan, Governor
If you have issues viewing or accessing this file contact us at NCJRS.gov.
The Monograph Serlel, Iisued by the Drug Abuse Information and Monitoring ProJect, Is preplred for and funded by the State of CalifornIa Department of Alcohol and Drug Program under contrlCt. 1# 0-0053-5 and 0-0001-7. The primary purpose of this .erles Is to provide Information to the drug abu.e treatment community and to the general public on the epidemiology and treatment of new and changing conditions In drug abuse.
• The material herein doe. not necessarily reflect the opinion., official policy, or position of the Department of Alcohol and Drug Program of the State of California. The view. of thl •• tudy are solely those of the authorl.
All material In thl. volume except quoted paUlge. from copyrighted lOurce. Is In the public domain and may be u.ed or reproduced without permlllion from OAIMP or ADP or the authors. Citation of the source Is appreciated.
141579
rtment of Justice ~~~io~:f~nstltute of Justice
as received from th,e been reproduced exactl~ 0 Inions stated In
This dOCU~~~~i~:~on originating It. poln~ d~ ~1~~~~e~sarllY r~present person oro t re those of the authors an, I Institute of Justice. thisdocumen a , 'es of the Natlona the official position or POIICI, I hted material has been
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and Drug Service (NCJRS). - , • I Justice Reference , to the National Cnmlna S s stem requires permission
Further reproduction outside of the NCJR y of the copyright owner,
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COCAINE USE AND PREGNANCY
By Elizabeth Piper Oe.chenea, Ph.D •
Drug Abuae Information and Monitoring Project
Neuropaychlatrlc Inatltute
Unlveralty of california, Loa Angelea
April 1988
The author would like to IICknowledge the aaalatance of KathlHn West.
Edited by Cindy Higliahl W.de •
PREFACE
In September 1988, the California Department of Alcohol and Drug Programs (ADP) formally sponsored the initiation of the Drug Abuse Information and Monitoring Project (DAIMP) at UCLA. One of the primary objectives of this project Is to conduct ethnographic and epidemiological research in order to provide information on new and changing conditions In drug abuse trends. A secondary objective of the project Is to provide an assessment of the extent of drug abuse to social policy makers for adequate planning and allocation of resources to deal with the prevention and treatment needl. As a third objective, DAIMP will produce a series of research monographs focusing on special drug abuse iSlues that are useful to California's drug program network.
The problem of drug abuse has been recently compounded by several developments. These developments Include the Increase In amounts of traditional drugs (e.g., heroin and cocaine) being Imported Into the United States by an Increasing number of rout .. , the appearance of new forms of cocaine (e.g., freebase and crack), and the Increa .. In frequency of cocaine use by pregnant women.
Clinicians and he.lth practitlonen In obitetrici and gynecology, pediatrics, and In drug treatment centers are facing an overload of patlentl. There are currently very few facilities within the state or county which speCialize in the problems of substanc&-abuslng pregnant women, the addicted mother and her baby. The limited facilltl .. which do exist do not always have the Immediate resources to meet the Increasing demand for services (see Lazarus and West, 1987). A recent nationwide campaign launched by the March of Dime. to Inform persons of the dangers of • drug use during pregnancy is a positive step in the right direction, but more efforts are needed specifically In the areas of education, prevention, and treatment.
As part of the DAIMP drug abuse serl.l, this monograph pr .. ent. general Information about cocaine and specific Information about cocaine abuse and its effect. on pregnancy. It Is Intended to educate treatment speCialists, drug educators, and physicians as well as the lay public about the problems associated with cocaine use during pregnancy. As part of the continuing research on drug 6buse, the current monograph represents an Important contribution to the understanding and treatment of a serious problem facing our SOCiety.
Chauncey L. Vutch III, Director California Department of Alcohol and Drug Programs
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Preface
Fact Sheet
TABLE OF CONTENTS
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• , ••••• 1
... ••••••••••••••••••••••••••••••••• "' •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• III
executive Summery •..•••••••••.•.•••••••••••••••••••••••••••••.•••••..•••.••••••••.•••••••••..•••.•.•••..•.•••.•••••••.••.• ~,~ .......•.....• v
I. Introduction ••••••••••••••••••••••••.••.••••••••••••.•••.•••••••••.••.•••••••• , ............................................... 1
II. Origins .•.•.•.••••••.•.•••••••..•.••••••••••••••••.•••.••••.•••.••••.•.••••••...••.••••••••••.•••••••••.•••••..•..••...•.......• 2
III. Statistics •••••• e ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 4
IV. Psychopharmacology ••••.•••••••••••••.••••..••••••.•••••••.•••••••.••••••.••••••••.•••••••••••..••••..••..•.•••..• 11
V. Effect. of Cocaine U •• During Pregn.ncy ................................................................ 18
VI. Treatment Implication •...•..•.................. 11 ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 24
VII. Prevention Ind Intervention StratagIH ....................•..........•.......•..•.•.•.•.•........... " ...... 25
VIII. Conclusion •••••.•••.••••.•••••.••••••••••••.••••••••• 0 •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 28
IX. R •• ourc ••.•••••••••••••••••••• 111 ............................................................................................ 28
X. Reference •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 110 ••••••••••••••••••••••••••••••••••••••••••••••••••• 33
Appendix A 40
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FACT SHEET
WHAT IS COCAINE AND WHAT ARE ITS DIFFERENT FORMS?
Cocaine, In Its various forms, Is a central nervous syltem (CNS) stimulant. Cocaine
hydrochloride Is a crystalline powder. Cocaine freebese and "crack" are more potent forms of
cocaine which have been extracted from cocaine hydrochloride.
HOW IS COCAINE MOST COMMONLY USED?
Cocaine hydrochloride Is most often Inhaled nasally, (e.g., sniffed or snorted through a straw
or from a spoon) but can allo be Injected. The "high" from a lingle hit ulually lastl about twenty
mlnut... Fraabale and crack are ulually Imoked In Wlter pipet and produce a more rapid, Intenle
and Ihort-lived euphorll. However, the feellngl of euphorll are ulually followed by feellngl of
Irritability and restl8lln811 and may contribute to adverta health consequencel.
WHO IS USING COCAINE?
The median age at onset for cocaine ulell during the young adult years (agel 18-25). The
highest prevalence of cocaine ule II allO amongst thll age group; the lecond highest prevalence
group II thole agel 28-34.
WHY ARE PEOPLE USING COCAINE?
Since the 19701 when It Wli believed to be a recreational drug wHh no dangerouilide
effectl, cocaine u .. reached epidemic proportlonl and contlnu .. to Increale. The Intenle euphoria
can Iud to paychologlcal addiction to cocaine, and recent studlel luggest there II phYllcal
addiction a~ well. A rise In cocaine overdolel and deathl are gradually ludlng to a greater
aWirenel1 of the dangers of cocaine.
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WHAT IS KNOWN ABOUT THE TERATOGENIC1 EFFECTS AND TOXICITY OF COCAINE USE
DURING PREGNANCY?
Stud I •• hav •• hown that maternal coca In. use may cause abruptio plac.nta. (I ••. ,
pr.matur ••• paratlon of the plac.nta from the uteru.) which can lead to spontan.ous abortion and
maternal h.morrhag.. Babl .. born to cocaln.u.lng wom.n oft.n undergo wlthdrawalsyndrom.,
.xhlbltlng .ymptom •• uch II Jlttarln ... , Irritability, and flst-.ucklng. Other stud I •• hav. shown an
Increa.ed risk of .udd.n Infant death syndrome (SIOS), prematurity and low birth w.lght. Animal
r .... rch sugg.sts the pre •• nc. of aya, brain, and bon. d.fects In Infant •• xpo.ed to cocaine In
ut.ro .
1 Teratog.n .. ls r.fers to the d.velopm.nt of physical d.fects In the .mbryo.
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EXECUTlVE SUMMARY
The 19808 wltnelled an epidemic increale In cocaine Ule, new methods of ingeltion and
new varletlel of cocaine. In particular, the Introduction of "cracf(l' and rock cocaine have led to
greater probleml.2 Whereal the use of cocaine In the 19601 and 19701 wal thought to be safe,
current relearch Indlcatel that cocaine 'I both phYllcally and plychologlcally addicting. Moreover,
the effectl of crack ule are more powerful than thOle of cocaine becaule it II Ingested quicker and
there II a more Intenle "cralh". The rapid and Intenle euphoria II followed by feellngl of
reltleunela and Irritability and a dealre to repeat the experience. An unfortunate r .. uit of the
Increale In cocaine ule among women II the dllcovery that lerioul h8lith consequencel can
occur with cocaine ule during pregnancy both to the women and their unborn children.
The Increaalng rat .. of cocaine ule by women are documented by leveral reportl, Including
the Drug Abule Warning Network (DAWN), the Natlonallnltitute on Drug Abuse Houlehold Survey,
and the CAL-DADS reportl which monitor admllllonl to drug treatment programl. There have
been Increal .. In emergency-room mentlona and drug-related deathl due to cocaine ule (NIDA,
1987) and In the percentage of women admitted to treatment programa. Moreover, the proportion of
pregnant women in treatment programa Increased dramatically, up 118% from 1984 to 1985 (CEWG,
1988).
Sniffing or Inortlng la reportedly the moat frequent method of cocaine use, but thla may
change aa the u .. of crack becom .. more wId .. pread. A alngle Inhalation or numeroua Inhalatlonl
may be taken. The Mhlgh" from. lingle line, or "hft'l, uau.lly ,.ata about twenty minutes. Freebale
.nd crack .... amoked In pipes or clgarettea mixed with tobacco or marijuana or In a waterplpe.
Smoking producea • more rapid .nd Intenle euphoria than Inlfflng. However, the Initial f .. llngl of
energy, power, and competence .re loon replaced with reltleunell, Irritabllity,.nd. dellre to
keep on freebaalng (Cohen, 1981). The effecta from IntravenoualnJectlon of cocaine vary .ccordlng
2 The reader la referred to D.n. Hunt', paper on crack In the DAIMP Drug Abuae Sert .. for further Inform.tlon.
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to the dosage level and the rate of administration. The high I. Immediate and typically 'asta 10-15
minutes. Again, the effects are similar to smoking in that users have a strong desire to repeat the
experience.
Cocaine actl directly on the central nervoul system (CNS) producing effects similar to
those of other stlmul.nts .nd to some .nesthetlcs. Cocaine .It .... the metabolism of specific
neurotranlmitters (e.g., norepinephrine, dopamine, lerotonln, .nd .cetylchollne) In norm. I
Interneural communication (Jonel, 1984)3. this brain (eNS) stimulation causes an Increaae In
he.rt rate, accompanied by vasoconstriction, pupil dilation, a rise in blood sug.r, and a feeling ot
euphorl. (G.y, 1981). Cocaine .Iso decrease •• ppetlte, Increases restless nell, .nd Induces I.ck of
sleep. Hypertenllon .nd hypermetabolism m.y lead to conwilion .nd/or eNS hemorrh.ge (G.y,
1981).
Depal1dlng on the chronicity of usa .nd douge, .n .stonlshlngly '.rge .nd varied number
of .cute .nd chronic effect. of cocaine ule have baan reported. Thele Include phYIICII' compl.ints
(e.g., blurred vlllon, dlzzlnell, mUlcle pain, dyurthrla4, dry skin, cheat palnl, Insomnl., weight
10SI, and tremors), cardl.c .nd relplratory failure, .nd selzul'8l. Psychological system effectl
Include paranol., visual hallucln.tlonl, delullonl, cravlngl, antllOClIl beh.vlor, anxiety, lnitabillty,
leth.rgy, depresllon, tactile halluclnatlonl, .nd tremors.
Cocaine abule II more frequent among freebal. smokers and Intravenous (IV) users .s
there II. higher potential tor toxicity. Side effectl of crack uselnclud.'ncrealed aggreSSion,
deprelllon, hurt palpltatlonl, arrhythmiaS, and heart .ttack. Use of crack by pregnant women .nd
nursing moth .. may be .ssoclated wtth damage to the tatul al cOCillne paseel through the
3 R8Iearch studies h.ve shown that cOCillne blockl norepinephrine reuptake .t the synaptic Junction, leaving .n excels of catechol.mlne neurotransmitters.
4 Dyurthrla r.' .... to difficulty In lpeaklng or poorly articulated lpeech which .re ulually related to motor nerve d.m.g ••
5 Arrhythml. Is any chang. In the normal pattern of the heartbeat.
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placenta and/or breaat milk (Gold, 1987). Wlthdrawalayndromell characterized by depre .. lon,
!)oclal withdrawal, Irrltlblltty, craylngl, tremors, mUlcle peln, eating dlsturbanc8l,
electroencephalograph Ie (EEG) changel, decrealed energy, and exce .. lye.leeplng (Jone., 1984;
Gold, 1987).
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EFFECTS OF COCAINE USE DURING PRE('~NANCY
There ar. f.w at~dl'l of the .ff.ctl 01 cocaln. UI' during pregnancy and thol. that do exist
are oft.n methodologically flawed. Many ar. cal. studl'l by phYliclanl with no control group and
littl.lnformatlon regarding the patlent'l drug ule history. Neverthelell, studies which point out the
adv.rse Iide .fflctl of cocaine UI' during pregnancy do exist.
Many studies Indicate that mat.rnal cocaine ule during pregnancy can lead to abruptio
placenta.s and Ipontan.oul abortion of the fatUI. Studl.1 on pregnant ewel have led researchers
to b.lleve that cocaine Increa .. 1 mat.mal blood prellure and decrea .. 1 uterln. blood flow. On.
pOlilble conlequence of thll II fetal hypoxemia (lack of oxygen). Cocaine abule by pregnant
women il allO all~clated with prematurity, low birth weight, and Intrauterine growth retardation.
Cocaln.expoled Infants often dllplay the following withdrawal symptom.: tremulou.nell,
mUlcular rigidity, rapid breathing, lnitabillty, jitt8rlnell, vigoroul lucking, andl poor ltate control •
Ther. have b.en no studt" on the long-term effectl on the cocaln.expoled Infllnt.
The Incr .... In cocaine use by all women, particularly among tho.e whc) ar. of childbearing
ag. (18-40) or who ar.already pregnant, hal Important Impllcatlonl for the nl1edlcal profellion and
drug treatment programl. Health care providen mutt be able to identify pregnant drug ulera and,
knc1wlng the potential effects of the drug, be able to advi .. the patient accordingly. It I. ell.ntlal
that pregnant women be Informed of the poulble effectl of their drug u .. I.)n the fetul and the
n.waorn.
Prevention and Interv.ntlon strategies can help to reduce the del.lterloue effect. of drug us.
during pregnancy. Federal, ltate, and localagencl .. can provide the impetul to fund public
education. ~nrollment In pr.natal care and/or drug treatment program. can help inform women of
the dangers of cocaln. U18 during pregnancy. Therapeutic family day·-care c.ntera with program.
for drug-abu.lng wom.n and their children provide In Important environment for parent training •
8 AbruptiO placentae II the parting of the placenta from the uterul before birth.
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I. INTRODUCTION
The 19ao. have witnelled an epidemic increase In cocaine use, new methods of Ingestion
and new varieties of cocaine. Statistics from emergency room records, coroners' reports, and drug
treatment clinics Indicate an increase In cocaine ule among all socioeconomic levell, ethnic
groups, and both lexel. Cocaine il no longer perceived al the "safe", recreational drug of the
19701; It hal become known al a dangeroul lubstance with high potential for abuse and addiction.
Unfortunately, there il an extreme lack of public awarenell of the dang81'8 of cocaine use.
However, the media has 'iacilitated public education by dramatizing eventlsuch al lerloullnjurlel
to and deaths of movie stars, athletel, and other celebrltl... In addition, during the lall few years,
there hal been an Increale In televilion advertillmentl for drug abull treatment programl.
Recently, the March of Dlmel launched an advertiling campaign aimed at prevention of drug ule by
pregnant women.
Although the incrull In cocaine use and the high potential for drug addiction are by
themlelves problematic, of greater concern are thel8rfoul effects of cocaine use on society. The
economics of drug ule are a major problem. Compuilive us .... tend to spend a large portion of
their Income maintaining their habit, Thll can lead to unemployment, family instability and, often,
to criminal activity. Another problem 'I the decrease In productivity and efflc~ency in the workplace.
Cocaine use, in particular, hal been directly related to traffic and work place aCCidents, violent
crime and police corruption. FII1IIIIy, cocaine ule hal a major Impact on public health reaourcel
and cost.. Not only II there I burden on the health profe .. lon to provide care for thele Individuals,
but there 'I allO In IncreaM In health Inlurance premiums al a relult of the Ineresll In tiaalth
related problema and drug treatment admlilioni.
Although there 'e a paucity of literature on the problemlof cocaine UII during pregnlncy,
there II Increallng evidence of lerioul health conlequences of cocaine UII during pregnancy. For
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example, there may be maternal compllcatlonl during pregnancy luch al hypertenllon, selzur8l, •
relplratory arrest and cardiac failure (Ritchie and Greene, 1980). There Ilallo a greater Incidence
IIbby:\cocalne\cocalne.=:.doc==Ju::!.Iy::.27.:....:. '::1188:...;"=---___________________________ _
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of lpontan80ul lbortlon (Chalnoff, Burns, Schnoll, & Buml, 1985). Second, there may be
compllcatlonl during and after delivery. Statistic. Indicate that the number of admlllions to
neonatal Intensive care unltl due to cocaine expolure In utero hal risen Iharply In the past few
Y ..... •
II. ORIGINS OF COCAINE
There II both archaeological and anthropological evidence that coca leavlI were
extenllvely uled by the Indlanlln South America (Siegel, 1982). ay the mld-1800l, coca had
Ipread to Europ. wh.re It waf\ uled In variOUI medical and nonmedical pr'paratlonl luch as wines,
clgarett.l, and ch.wlng gum. After Iiolation of coca In. (an alkaloid) and early experlm.ntatlon
which revealed Its Itlmulant and local anelthetlc propertln, It Wli proclaimed a ''Wonder'' drug
(Sleg",1984). The u .. of cocaine wal curtailed by the 1914 HarrilOn Act which labeled It as a
narcotic. Thll act reltricted and controlled the m.nufacture, poII .. llon, IIle, .nd dlltrlbutlon of
cocaine. ThuI, an early epidemic ~f cocaine UII for recreation. I and medical purposel wal
effectively thwarted by the federal leg Illation.
Illicit UI. of cocaine re-emerged In the 1870 •. It hal been .uggelted that thll redllcovery
wallnevltable due to the drug's euphoric .nd Itlmulant propertlel (Gay and lnaba, 1978). However,
It II "10 probable tim coc.lne wa. only one of many drugl tim proliferated during the drug culture
In the United Statelln the 1 HOI and 701. In tim r-1od, coc.ln. u ... g.n .... ,1y believed cocaine
wa. IIf. to u .. al I recreational drug becau .. It wal not .ddlctlve. Some of the myth. about
coca In. which u.,.nded Itl u .. Include: It II In 'phrodillac, It Increa ... creative and phYllcal
performance, It .... ucea fatlgu. and .ppetlte, and It cau ... euphoria (Alhely, 1875; Gottll.b, 1878;
Pi1l1l1pI and .Wynn., 1980).
Between 1970.nd 1873 when cocaine UII dramatically Increaled, the patternl of ule
changed .nd the .dv ..... effectl of coca In. were ftrat noted. The onAt of Intravenoul UI' of
• cocaine and smoking freeball were alloclated with cocaln. abu .. Ind lIrIoul lid. eff.eta,
1Ibby.\cocaIne\cocalne.doc July 27, ,_,.
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Including overdose and death. The first medical admission to an emergency room for freebase
smoking occurred In 1974 at UCLA (Siegel, 1979). ,
In the 1980s, the epidemic of Ucrack" and rock cocaine use have brought even more
problems1. The effects of crack use are more powerful than those of cocaine because It Is Ingested
quicker and there i. a more Intensellcra.W'.
One response to the new epidemic ha. been to Increase the public's awareness of the
dangera of cocaine u.e. The Natlonallnatltute on Drug Abuse (NIDA) ha. launched a major media
and public education campaign aimed at the prevention of cocaine u .. (Prevention Networks, April
1988). A telephone hotllne for cocaine us .. wa. set up In May of 1983 by Wa.hton, Gold, and
Pottalh (1984). Over 70,000 call. were logged during the first three monthl of operation. Despite
the.e and many other effort., cocaine u.e ha.lncreased dramatically In the 1980s.
III. STATISTICS
A.lncldence/Prevalence
Statistic. from the National Survey on Drug Abuse2 from 1972 to 1982 (Abelson and Miller,
1985) show a slight Increase In prevalence of cocaine use among young adult. (ages 18-25) In
1972-1975, followed by a .harp Increa .. from 1978 to 1979, and a leveling off from 1979 to 1982
(from 9% In 1972 to 28% In 1985) (1M Figure 1). For youth and older adub, there hal been a
generallncrea .. in lifetime prevalence rat .. (from 1.5% to 8.5% and from 1.8% to 8.5%, ropectlvely,
from 1972 to 1982). For all age groupa, In 1982 the estimated prevalence of penon. ever trying
cocaine wa. 22 million (Abellon. Miller, 1885). In comParilOn, the ntlmllted number of frequent
u ... of cocaine (I.e., within the paat month) I. ov .. 4 million peraon ••
1 The reader I. referred to Dana Hunt'. paper on Crack In the DAIMP Drug Abu .. Serlo for further Information.
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5 The National Survey on Drug Abu .. I. a .erle. of nationwide studio that began In 1971 under • the sponsorahlp of the National Comml.slon on Marijuana and Drug Abu... Currently, It I. conducted Jointly by the Re.pon.e Analysis Corporation and George Wa.hlngton Unlveralty and Is sponsored by NIDA. The National Survey II a self-report interview with a nationwide household probability IImple.
libby;, cocaine' cocaJna.doc JUly 27, , _ II
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Ther.l. very Ilttl. r .... rch which provid.s statistics on coca In. us. during pregnancy. Yet
It Is possible to determine an estimate of the prevalence among women of childbearing age from the
National survey. Table 1 shoWl that the highest proportion of users among females is among those
of childbearing age (ag •• 18-34) •
IIbby.\cocaine\coc.J"..doc July 27, 18181a
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T
30
25
20
15
10'
5
0
27.5 '* 28. 3
/ 10"'"9." Adt4tta
19.11 12. 7 13;/
9./-Otd,,1' Adutt.
J 8.5 6.S
~ 11th
1.6
~ 2. 5 i I ,9 1.6
72 74 76 77 79 82 Year
FIGURE 1
Tr.nd. in tif.tim. pNt)at.nce of (Jooai.rwJ au. for thr.e age group. (l9?2-l982)
Source: Abelson & Miller, 1985, p. 40.
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Table 1
Cocaine Prevalence Rates Based on the 1982' National Survey on Drug Abuse3
Percent Who Used Cocaine
Past Past Ever Year 30 Days
Mal .. Youth, 12-17 years old 7 5 2 Young AduHI, 18-25 years old 35 25 9 Mld-AduHI, 28-34 years old 28 13 4 Older AduHI, 35 or older 7 3 1
Femalel Youth, 12-17 years old 8 3 2 Young AduHI, 18-25 years old 22 13 5 MId-AduHI, 28-34 years old 18 9 3 Older AduHI, 35 or older 2 1 0
In a survey of young aduHI in New York State, Kandel at al. (1985:92) reported that "women
who used cocaine exclusively are Ie .. likely to have had I child". However, their data show that
48% of women who ule cocaine along wHh other drugl have had a chUd, al had 48% of tholl who
uled only marlJuanl. In comparilOn, 72% of non-drug-ullng femal .. were parenti.
The Increallng rat .. of cocaine u .. by women In the palt few years are documented In
IIveral report.. In thl IUrvey of ~II .... In the Nlw York trl-ltitl a .... to the Cocaine Hotline, Gold at
al. (1985) found a largl IncreaH In the proportion of female u ..... from 1183 to 1884 (24% to 42%).
Flgurel from thl Drug Abu .. Wlrnlng Network (DAWN) 1110 Indicate an Increa .. In Emergency
Room mentlonl and drug-related death. due to cocaine u .. (NIDA, 1987). According to ltatlltlca
pr ... nted It the CommunHy Epidemiology Work Group (CEWG) Meetlngl (1888), thl perclntage of
women Idmltted in 1985 to treatment programlin Los Angele. for cocaine u .. ro .. from 31% In
3 From: R. Cllyton, 1985, p. 11.
IIbby:\cocaIne\cocaIne,doc July 27, ,1lI81a
6
1983 to 38% (Huuon & Strantz). Moreover, the proportion of pregn.nt wom.n In treatm.nt
program. Increa.ed dram.tlcally, up 118% from 1984 to 1985. Th. Incr ..... mong pregn.nt ,
f.m.I ••• eeklng treatm.nt for coca In •• urpa •• ed the Incr .... In pregnant women seeking
treatment for any oth.r drug4. Thl. situation I. particularly probl.matlc becau.e many programs
are ort.nted toward. tr .. tm.nt for heroin addict ••
Statistic. obtained from the C.llfornla D.partment of Alcohol and Drug Program. (ADP) (see
Tabl •• 2-4) prellnt .pldemlologlcallndlcatora of the ext.nt of cocaln. u •• by fem.les In C.llfornla.
Tabl. 2, which was conltrUcted from CAL-DADS d.ta, pre •• nt. the number and perc.nt of f.males
.dmltted to drug treatment program. by age group category. Over 8&% of the wom.n admitted to
drug treatm.nt program. In California were between the .g .. of 21 .nd 30. Th. hlgh.st percentage
of cocaln. u ...... re thoe. between the .g .. of 18.nd 35. StatlstlCl for Lo. Ang.I •• , San Diego
and San Franclaco from the DAWN .yst.m (aee Table 3) Indlcat. that the number of Emergency
Room death. attrlbutabl. to cocaln.lncreaaed st .. dlly from 1981 to 1984 whll. the ratio of males to
f.m.I •• r.malned falrty conatant. Other d.ta on cocaln ..... l.ted death. ( ... T.bl. 4) Indicate a
genera! Incr .... ln the number of death. from 1880 to 1985. Although a high proportion of d .. ths
among female. occurred among tho .. ag .. 21-35, the percentag .. vary In each ag. category from
year to year. In .ummary, the .vallabl. statistic. Indicate that cocaln. u.e ha. Increaaed .mong
women, e.pecl.lly tho •• of chlldbeartng ag ••
8 Se. Jun. 1988 CEWG proceeding.
lib.. ; coc.Ine COCAJne,cSoc Ju, 27, llJ111lt
7
•
•
8 • TABLE 2
CAL-DADS
Admissions for Cocaine to Drug Treatment Programs
Female. Only 1982-1988
1982-1983 1983-1984 1984-1985 1985-1988
Age N % N % N % N %
0-15 15 1.2 14 1.0 19 0.7 35 1.1 1~20 189 15.8 185 13.5 335 13.0 400 12.4 21-25 441 38.5 553 40.3 932 38.2 1148 35.8 2~30 318 28.2 388 28.8 788 30.5 971 30.2 31-35 182 13.4 189 12.3 328 12.7 449 14.0 38-40 eo 5.0 58 4.3 121 4.7 153 4.8 41 + 25 2.1 25 1.8 55 2.1 83 2.0
• TOTAL 1208 100.0 1373 100.0 2574 100.0 3217 100.0
Source: Callfornll! State Department of Alcohol and Drug Program.
TABLE 3
DAWN Drug Mention Death. for Cocaine *
Lo.Anael .. San DINO San Francisco
Num_of %of Number of %of Number of %of Fernal .. Total Female. Total Femal .. ---I2tal
1982 97 38.8 42 43.8 55 33.1
1983 138 35.2 40 40.0 82 38.0
1984 418 40.3 88 50.0 150 31.7
• Source: California State Department of Alcohol and Drug Programs
* Includes drug-related and drug-Induced deaths.
9
.' TABLE 4
Cocaine Deaths *
Females by Age Group
1980 1981 1982 1983 1984 1985
N % N % N % N % N % N %
State
0-15 1 10.0 0 0.0 0 0.0 1 3.3 1 2.9 1 3.2
16-20 1 10.0 2 18.7 2 10.0 3 10.0 2 5.7 2 8.5
21-25 5 50.0 1 8.3 5 25.0 12 40.0 10 28.8 5 18.1
26-30 2 20.0 3 25.0 7 35.0 5 18.7 11 31.4 10 32.2
31-35 1 10.0 4 33.3 3 15.0 8 20.0 7 20.0 8 19.4
38-40 0 0.0 1 8.3 2 10.0 0 0.0 2 5.7 1 3.2
41 + 0 0.0 1 8.3 1 5.0 3 10.0 2 5.7 8 19.4 • TOTAL 10 10 20 30 35 31
Los Angeles
0-15 1 25.0 0 0.0 0 0.0 0 0.0 0 0.0 1 7.1
18-20 0 0.0 2 33.3 1 9.1 2 11.8 0 0.0 0 0.0
21-25 0 0.0 1 8.3 3 27.3 8 35.3 3 17.8 2 14.3
26-30 2 50.0 0 0.0 2 18.2 3 17.8 8 47.1 4 28.8
31-35 1 25.0 3 33.3 3 27.3 5 29.4 5 29.4 4 28.8
36-40 0 0.0 1 8.3 2 18.2 0 0.0 1 5.8 0 0.0
41 + .0 0.0 0 0.0 0 0.0 1 5.9 0 0.0 3 21.4
TOTAL 4 8 11 17 17 14
Source: California Department of Alcohol and Drug Programs, from Vital Statlstlca
* Includes only drug-Induced deaths • IIbb .\cocaJne\cocaJn •. doc July 27, laee It
•
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B. Demographic.
The demographic ch.racteristlc. of cocaine u.ers h.ve not ch.nged 'ignlflcantly for .everal
years. o.t. from the 1982 N.tlon.1 Survey show th.t there Is. correl.tlon between education,
Income, occupatlon.1 prestige .nd cocaine use. ThOle groupl with the I.rgest percent.ge of users
tend to be college-educated (or higher), employed In • m.n.gerl.1 profel.lon, .nd earning over
$50,000. year. Other stud Ie. h.ve .hown th.t the greatest proportion of Ulers .re white male.
(Gold, W.shton, .nd D.ckls, 1985; Schnoll, Karrfg.n, Kitchen, D.ghestanl & H.nsen, 1985;
Schuster and Fischman, 1985).
The recent "crack" epidemic has resulted In a .lIght change In demographics. Inform.tlon
from neonatal Icreen. In Lo. Angeles Indicates that cocaine I. the mOlt widely used drug among
low Income Blackl.nd HI.panlc women (West, 1887)5. Thl. new pattern I. probably rel.ted to the
Incre.sed .vall.bllity .nd lower cost of rock cocaine (crack) In .peclflc .r ....
C. Socl.1 .nd P.ychologlcal Ch.racterlltlca of Ulerl
According to the NIDA N.tlon.1 Household Survey d.ta, the medl.n .ge .t onset of cocaine
ule Is during the young .dult period (.gel 18-25). Molt of tho .. reporting cocaine use In 1982 h.d
begun uling cocaine two to three y .. rs prior to the lurvey. However, cocaine Ulers m.y .'so be
polydrug u ..... who started uling other drug. at .. rller .g... For example, O'M.lley, Johnlton .nd
B.chman (1985) point out .Imllarltln between nIIlriJuan. Ulerl.nd cocaine u .... Kandel at .1.
(1985) h.ve luggeated that marijuana UN In adolftlCence predlctll.ter cocaine ule. F.ther'1
educatlon.llevet we •• 110 • 'Ignlflcant predictor Ilmong women; other predlctOl'l were .dolescent
ule of cigarattn and alcohol. In addition, p..,..rellated .. ctore Including degree of peer activity and
peer orientation wwe found related to cocaine ule. Molt relpondenta have reported they u.ed
cocaine for the following I'8lllOn.: (1) to experiment, (2) to get hlgh,.nd (3) to have a good time
with friend. (O'M.lley, JohrG\'\l.t)n, and Bachman, 1885). The picture of the cocaine u .... , then, II th.t
• Sin the 1988-7 program reporting forms of the Child Abuse Prevention OffIce for LOl Angeles County which il .pproximately 8% BI.ck and 35% Hllpanlc, there were 70% Blackl, 18% Hllpanlc, and 14% White women who h.d u.ed cocaine .ccordlngto neon.talecreens.
IIbby:\cocAine\cocAin •. doc July 27, 111111111
10
of a polydrug UHf who started ullng cocaine after Initial marijuana ule and whole first experience
with cocaine wal within hll/her peer group.
IV. PSYCHOPHARMACOLOGY
A. Methodl of Ule
In the United Statel, there are three primary methodl of ule: Inlfflng (Inortlng), Imoklng,
and Intravenoul Injection.
Sniffing or Inortlng II reportedly the molt frlquent method but thll may change al the use
of rock cOClllne becomel more wId .. p .... d. The cocaine hydrochloride II chopped Into powder on
a surface (ulually glall) and formed Into a "lIn8". The line II Inhaled through a straw or similar
device. A single Inhalation or nLimerOUI Inhalatlonl may be taken. The "high" from a lingle line, or
"hit", ulually lastl about twenty mlnut ...
Coca paste Imoklng wal first reported In San FrancllCO and Loa Angel .. In the 19701
(Cohen,1981). Cocaine bale (freebase) smoking hal become Increallngly popular. Kltl are sold
with which to convert cocaine hydrochloride Into freeba... First, the cocaine hydrochloride II
diliolved In a mixture of wat ... and baking loda. Then the freeba .. II extracted by adding a solvent
which ''freel'' the cocaine from the wat.... When the IOlvent II heated to a very high temperature It
evaporat8l, 184IIvlng behind a solid reeldue of freeba .. cOClllne. Thll extraction procell for freebase
can be dangeroul becau .. the organiC IOlventl Involved are highly volatile. On the oth ... hand,
"crack", which II allO a form of freeba .. , II extracted by combining cocaine hydrochloride with a
solution of ammonia or baking loda and wat.. When heated or agitated, the purified cocaine forms
an 011 which lepam81 from the wat... The remaining cocaine 1011d1fl .. Into chunkl or rockl.
Freebase and crack are Imoked In waterplpet or clgaratt .. mixed with tobacco or mariJuana.
Smoking producel a more rapid and Inten .. euphoria than Inlfflng.
11
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•
The effectl from Intravenoul Injection of cocaine vary according to the dOllge level and the •
rate of administration. The high II immediate and typically lastl 1()'15 mlnutea.
lib" ; c:oc:aine\c:oc:aine.doc Ju, 27. 1_111
• B. Effect. of Cocaine U.e
Cocaine act. directly on the central nervous system (CNS) producing effects similar to
thole of other stlmulantl and to lome anestheticl. Cocaine alters the metabolilm of specific
neurotranlmltters (e.g., norepinephrine, dopamine, serotonin, and acetylcholine) In normal
Interneural communication (Jones, 1984)8. Thl. brain (CNS) stimulation caulel an increase in
heart rate, accompanied by va.oconstrlctlon, pupil dilation, a rile In blood lugar level., and a
feeling of euphoria (Gay, 1981). Cocaine al.o decrease. appetite, Increa ... restles.nesl, and
Induces a reduced need for .Ieep. Hypertension and hypermetabolism may lead to conwlsion
Ind/or CNS hemorrhags (Gay, 1981).
Cocaine u ..... appear to progrell through four stag .. of Intoxication: ,uphorla, dYlphorla,
paranoia and p.ycholl. (hallucination. Ind delu.lonl). Some Indlvlduall experience these stagel
In a lingle epl.ode, oth .... may expertence them with chroniC low dosage patternl of use.
• Depending on the chronicity of un Ind dOllge, an astonl.hlngly large and varied number of acute
•
and chronic effectl of cecalne Ute have been reported. Th8l81nclude phy.lcal complalntl (e.g.,
blurred vllion, dlzztn"l, mu.cle pain, dYlirthrla7, dry Ikln, chest palnl, Insomnia, weight lOIS, and
tremors), cardiac and respiratory failure, Ind seizures. Psychological system effect. Include
paranOia, vilual hallucination., d.lu.lonl, cravlngl, antlloclll behavior, anxiety, Irritability, lethargy,
depre •• lon, tactile hallucination., and tremon.
In I survey of call .... to the 800-hotllne, Gold found the follOwing .ymptoml .peciflc to the
varlou. method. of administration (1878:774):
(1) Intrlnau' u ... Mllcally exhibit nalll.OI'8I or bleeding, .Inu. congestion and headaches, chronic 1'hlnHI.,8 and '.nlftlng.'
8 Research stud Ie. have .hown that cocaine block. norepinephrine reuptake at the synaptic junction, leaving an exce .. of catecholamine n.urotran.mltt .....
7 DYllrthria ref .... to difficulty In lpeaklng or poorly artlcullted speech which are ulually related to motor nerve damage.
e Rhlnltll II the Inflammation of nalll mucous membranes and nail I dllcharge,
12
- -------------- ---- - -------------------- -.
(2) Freebl ... exhibit chronic cough, lore throat, and chest congestion that may be al80ciated with longer term lung damage and pulmonary dysfunction.
(3) Intravenoul u ..... often luffr from ab.ces ... at Injection eltesand serlou. Infections such a. hepatltll or endocardltll. .
Irrespective of the route of administration, cocaine can trigger an acute toxic reaction, which may be characterized by dlzzlnesl, blurred vI.lon, confUlia", paranOia, and tremulousne .. that sometimes lead. to conwilionl, cardiac arrhythmla1 ,and respiratory or cardiac failure requiring Immediate medlcallnterv.ntlon. Relatively recent reports of death from Intranasal cocaine have shown that toxic blood levels of the drug can In fact be achieved by this route of admlniltJ'ltlon (1984:n4).
C. Abu .. and Addiction
Cocaine abu18 II more frequent among freeblse smokers and IV users as there Is a higher
potential for toxicity. Both the rapid absorption and route of administration vary the toxicity (Jon .. ,
1984). Symptoml of toxicity Include preconwilive movementl, followed by conwl.'on. and
cardlovalCular arid respiratory failure.
There are Hveral phyalcaland Plychologlcallymptoms of cocaine abuse, many of them
13
•
Identlflabl.. For exampl., th .. II a patt." of pathological U18 ( •• g., Inability to reduce or stop use; •
Intoxication throughout the day; epiSodes of cocaln. overdos.; Sleg.', 1982). There may also be
Impairment In social or occupational functioning ( •• g., 10 .. of job, legal difficulties, economic
hardlhlp, and lou of frlendl).
According to the Am.-lcan Plychlatrlc Auoclatlon's (1980) Diagnostic and Statistical
Manual of Mental DI.ord .... (DSM.III), third Edition there are three categorlel of cocaine abuH
clasllfled al a m.ntal disorder: cOCl~n. Intoxication, coca;n. Imoklng dlaorder, and cocaine-
Induced PlychOiIL
Although many peopl. believe cocaln. II not addicting, th .... II Iufflcl.nt evfd.nce to
support the exllt.nee of both phYllcal and plychologlcal addiction to cOCIln.. Cravlngl 'ead to
compuilive and repeated UH, deaplt. adverae effect.. Wlthdl'lwal Iyndrome II characterized by
deprelllon, social withdrawal, In'ftabillty, Cl'lvlngl, tr.mors, mUlCt. pain, eating dllturbancea,
9 Endocarditis I. a defect In which the lining of the heart and heart vaivea become Inflamed.
10 See footnote 4.
1Ibby:\eoc.Jne\eoc.Jne.doc July 27, ,_11
•
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electroencephllographlc (EEG) changll, decreased energy, and exces.'ve sleeping (Gold, 1987;
Jones, 1984). Psychological dependence on cocaine has also been documented (Gold, 1987).
Some of the symptoms of potential addiction to be noted are: attempted suicides, headaches,
seizures, panic attacks, wide mood swings, IIxuallmpotence, major personality changes, unusual
job problems, marital stress, and unexplained financial problems (Gold, 1987). Tolerance of
cocaine produces depreSSion, lethargy, cognitive Impairment, social withdrawal and lack of sexual
desire (Gold, 1984).
V. EFFECTS OF COCAINE USE DURING PREGNANCY
There II a paucity of publilhed rel .. rch on the .ffectl of cocaine u .. during pregnancy.
Most of this r .... rch Is conducted by physicians who r.port th.'r finding_ In cas. studies. Usually
there II no control group and very little information regarding the patient'S drug ule history.
However, there II Iufflclent .vldence of the .ffectl of cocaine on the mother and her fetus •
Coca in. actl peripherally to Inhibit narv. conduction and prevent norepinephrine reuptake at the nerve terminall, producing increaled norepinephrine levels with sublequent valoconatrlction, tachycardia and a concomitant acute rill In blood pressure (Ritchie and Greene, 1980). Placental YalOCo(1Wictlon allo occurs (Sherman and Gautierl, 1972), decreallng blood flow to the fetus. An Increased frequency of uterine contractlonlln humanl hal been reported (Weiner, 1980).
Furthermore, cocaine expotUr8 In utero Ilgnlftcantly Intart ... with an Infant'l ability to maintain adequate stat. control In the neonatal period, a factor which placel cocalna-expoHd infantl In a category of high rilk Ilmilar to infanta expoHd to narcotici In utaro (p. 339). Chllnoff at al. (19881).
In 1978, the ponlbliity of .. vere wlthdraWlI Iyndrome among neonat .. who .. mothers
uled cocaine Wli fIrIt reported by Bllnlck at al. (1978). Lat_stuc:lI .. have Ihown conflicting
flndlngl. For example, In a Itudy of eight Infantl born to moth ... with a hlltory of cocaine abulI,
Madden at al. (1988) reported no evidence of Iymptomatology or lignl of taratogenlclty,11 even .
though the urine toxicology screens were all pOlltlve. Only on. of the .Ight Infantl manlt.lted
11 Teratogenicity Is the development of physical defectl In the embryo.
1Ibby:\c:oc:aIna\c:oc:aIna.doc July:n, 111."
14
symptoms of neonatal drug wtthdrawal which Included mild Jltterlness and tachypnea.12 It II
generally believed that Madden et al. Ignored lome of the other symptoms which luggest the
Infants were affected by maternal cecaine ule. Madden et al. did not flnd "life threatening"
symptoms, but the babies did exhibit mild symptomatology. Some of the babies were Initially
catatonic 13 and had poor state control.14
Other fetal effects of maternal cocaine UN reported from da .. collected by Bean In 1988
from Martin Luther King Hospital In LOI Angeles (Mondanaro forthcoming, NIOA) Include:
prematurfty, neonatal Intoxication and wtthdrawal, cerebra-vascular aCCidents, necrotizing
enterocolltls,15 decreased alertne •• and SIOS. Cocalne-expo.ed newborns exhibited symptoml of
Jltterln .. s, hypertonicity (Increased tone), exce .. lve crying, Increased appetite, extreme Irritability,
and/or decreaHd conK'lIblllty, alternating periods of lethargy and reduced response to stimulation.
Chasnoff at al. reported an Increased risk of S~den Infent Death Syndrome (SIOS) (1988b) and
perinatal cerebrallnferctlon 18 (1988c).
In studying the teratogenicity of cocalne!n humans, Blngol at al. (1987) compared 50
abusers (Group 1), 110 polydrug abusers (Group 2) and 340 non-substance users (Group 3) among
women from two inner-city hospitals In New York City. They found flve of the Infantlln Group 1 had
major congenital malformations, as did some of the Infentl In the other groups, but cardiac and
skull defects were present only In Group 1lnfentl. Withdrawal symptoms (e.g., Irritability, crying,
vigoroulsucklng) were also found In 10% of the babies whose mothers had used cocaine only,
12 rachypn. fa an abnormally rapid rate of b .... thlng.
13 A person Is catatonic when he/she can not move due to tigld mUICI ...
14 Poor state control refers to the preHnce of Inappropriate behavior for a situation. For example, a person goes to lleep when tickled.
15 NecrotIzing enterocolltll II a ludden Inflammatory bowel disord.... Symptoml Include destruction of the stomach and Intestinal lining and pol,onlng of the Intestinal area.
18 Perinatal cerebral infarction refers to a localized area of decay In the brain, occurring during a period from 28 weeki of pregnancy to 28 daYI after birth.
15
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•
• Ther. Ir. 1110 prellmlnlry finding. from two other stud I •• which .ugg.st thlt Intraut.rine
expo.ure to cOCiln. Iffectl the ophthllmlc Iystem. Chlngel in the eye'l blood tillueland ,
abnorma' smallnell In one eye of an Inllnt whOIl mother regularly used cOCilne were reported by
Te.k.lnd Tres. (1987). I •• nberg, Spl.r.r, andlnk.lI. (1987) eXimined 13 cOClln.lntoxlClted
neonate. and found abnormalities In the Iri. v .... ,. (e.g., vasodllatlon17 and tortuou.1ty18). The
authors .uggest that the presence of abnormally-dllated or tortuous Iris vel.ell In a neonate should
alert the phy.lclan to the pos.lbility of coca In. Intoxication and the n.ed to obtain a urine test.
Confirmation of the dllgno.l. of cOCIln. Intoxication will help to en.ur. evaluation of the neonat.'s
envlronm.nt.
In a matched IImpl. study comparing 70 wom.n who r.ported u.lng coCiln. during
pregnancy with 70 wom.n from the gen8l'l1 obstetric population at Northwestern Memorial Ho.pltal,
Mac'Gregor «al. (1987) found that u .. of cocaine wa.allOclated with lower birth weight and lower
• geltltlonalage at delivery, an Incr .... In pm,"" labor and delivery, and delivery of small for
gestatlonalag' Infant.. Although the authon recognlz. the limitation. of th.lr .mlll study, they
•
emphl.lz. the IlgnlflClnc. of adverse .ffect. of cOCIlne ule during pregnlncy.
In a study of 53 women (23 on cocaine, or cOClln.and herOin, 15 oplate-ebu.lng women,
and 15 non-Iubstancelbullng wom.n), Chilinoff at al. (18M, 198811) found a higher rat. of
spontaneoul abortlonl Imong tho .. ullng cOCIlne. During the third trimester, lome of the women
expert.nced abruptiO placentae ImmlCliat.1y following a IIH-lnJectlon of cocaln.. This IIf.
threatening compllcatfon pro .. bly results from the cOCIlne-lnduced hyperten.lon and
valoconstrtctlon. Ackw at I'. (1883) I'SO reported two calli where abrupt'o placentae Wli
as.oclated with cocaine u.e.
Abruptio pllc.nta. and premature delivery were found among cocalne-addlcted wom.n In
the study of 237 pregnant women by Finnegan (1987). The cocalne-addlcted women were twice al
17 Va.odllatlon II a wid.nlng of blood v .... I ••
18 Tortuou.1ty mean. twisted or winding.
libby: \ cocaIn.' cocaIne,doc July 27, 1II1II18
16
likely to luffer Ibruptlo pllcentle thin other drug-dependent women Ind four tlmel more likely
than drug-free women. Premature delivery occurred In 21% of the cocaln .. ddlcted women in
comPllrl.on to 11 % of the women taking other drug. and 4% of the drug-fr .. women.
Fifty polydrug UI .. (cocaine and methadone), 50 methadone patient., and 50 drug-free
moth .. were compared In a study by Ryan, Ehrlich and Finnegan (1987). A higher rate of
Ipontaneoul abortion and fetal death. were found In the cocaine group. In addition, there ware
Ilgnlflcant dlfferencH between the cocaine Ind drug-fr .. groupi In Infant birth weight, length, head
circumference Ind Apgar ICores, the cocaine group being lower for each. Among realonl for these
dlfferenc .. may be the general IHe style of the drug dependent mother, Including poor nutrition and
hyperactivity. Moreover, there Wli I greater Incidence of deathl from SIOS fn the cocaine group.
In a more comprehenllve study, InkelH It II. reviewed the medical recordl of an pregnant
women and neonat .. IUlpected of having been exposed to Illicit drugl from January 1, 1983 to
Decema 31, 1885 In Los Angele •• Out of 17,751 denverl .. , 108 neonat .. (0.1%) had a po.ltlve
toxicology screen for cocaine (40%), PCP (21%), oplltel (3%), amphetamln .. ("%), or I
combination of other drug. (8%). More Importantly, Inkell. It al. (p. 3) reported that "from 1983 to
1885 the known Incidence of mothers/newborn. exPOled to cocaine Increaad from 0.8 to 4.0 per
1,000 dellverle." (I .. Figure 2). The most recent statistics from Hlrbor/UCLA Medical HOlp1ta1
show even larger IncreaHlln the Incidence of po.ltlve toxicology ICI'Hns for cocaine. In 1983
there were 0.85 pOlltlve toxicology screenl for cocaine per 1,000 live blrthl, al compared to 5.08 In
1985, 9.33 In 1_ Ind 23.10 In 1"7 (yonekura, 1818). The conclullon by Inkenl It II. belt
summlrlzel the flndlngl to date on the effectl of cocaine u .. during pregnancy (1987:2141):
ThIM data suggnt that cocaine exposure during pregnancy II anocllted with Increaled Incidence of previoul abortion I, lack of prenatal care, Increaled presence of meconlum,18 prematurity, Intrauterine growth retardation (IUGR), IncreeHCIlevel
17
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•
•
•
of neonatal carl, prolonged neonatal hOlplta1 stay, frequent foster care mothe,.. AddltloNlIIy, molt neonatel expoled have .igniflcant Iymptomatology (lee Figure 3).
The symptomatology In Infantl 'expOled to cocaine Intrauterlnely II reportedly caused by the
sympathomimetic20 action of cocaine (Inkelel et al., forthcoming). Thul, the oblerved symptoms
are similar to those of narcotic withdrawal, but lei. pronounced. It Is hypotheSized that Infants
experience "residua" cocaine intoxication rather than cocaine withdrawal.
The relult. of one study of the effect. of Intrauterine expOlure to crack, e.g., alkaloidal
cocaine, (LeBlanc, Parekh, Nalo, & Gla .. , 1987) are Ilmilar to thOle of earlier research which did
not lpeclfy the type of cocaine uled. Reporting on a clinical study of 38 intantl, LeBlanc et al.
(1987) stIIte that none of the Intant •• howed evidence of congenital malformation. Nonethelell,
neurologic and behavioral abnormalltle. (e.g., tremulouln ... , ln1tablllty, and mu.cular rigidity)
were obterYed In I ... than half of the Intant. and were of short duration. LeBlanc et al. do caution,
however, that the pO.llblllty exist. of long-term adverse effectl •
20 A drug which II Iympathomimetlc caUsel effects that look like those cauled by the sympathetic nervouisystem.
1Ibby:\cocaIne\cocaIne.doc July 27, Ieee.
18
19
• Figure 2. Neonatal Drug Expolure (1983-1985)
(/)
lJ..J t- O Poly ~ Other <t 2: 35 0 Opiates 0 lJ..J [3 PCP 2:
.. 30
a • Cocaine lJ..J (/) 25 0 a.. x 20 • lJ..J
I
c..? :::> 1 5 a:: a LL.. 10 0
a:: 5 lJ..J CD ~
0 :::> 2: 1983 1984 1985
YEAR
Source: Inkeles et al., unpublished paper
• 1Ibby:\~"'\eocaIne.cIac July 27, ,eee '-
-----~~~----~--- -
"
20
• Figure 3. Symptoml of N.-onatal Coca In. Expolur.
100 eNS GI Respiratory
~-------~----------
CI'l I.;.J
75 ~ q: z 0 I.;.J
Z
Q I.;.J CI'l 0
50 a.. • x I.;.J
1 I.;.J
Z 14
~ .' u . ~ 0 .,. u
25~ ~ ~, Q ,;
Source: Inkeles et al., unpublished paper
•
Some of the other major problems of cocalne-expo.ed neonate., Including low birth weight
and prematurity, can be partially explained by the lack of prenatal care and maternal malnutrition.
Fifty-six percent of the women In the study by Inkells at al. did not receive postnatal medical care.
Many substanc .... buslng women are afraid becau.e Identified drug-abusers are routinely reported
to Child Protective Servlc .. and this would r .. ult In losl of custody of their Infants after delivery.
Finnegan (1988) expr .. ses concern about the ability of moth.,. addicted to crack to care for their
children. Besld .. medical, psychological and aoclologlcal problems, Cflck-addlcted women have
little time or ability to provide for their children and are unlikely to I .. k prenatal andlor postnatal
care. There II also a fifteen to twenty fold Incr .... In the probability that the Infant will have SIDS.
This danger should be pointed out to women using cocaine.
The InCl .... In the number of cocalne-addlcted pregnant women admitted to prenatal and
neonatal programl throughout the state has led to more medical r .... rch. Unfortunately, there Is a
lack of sociological and soclal-psychologlcal res .. rch In this area. Although some res .. rch Is
ongoing, there neods to be a gr .. ter effort to conduct aclentlftc stud I .. with control groups.
Moreover, there II a great need for r .. ults of such r .... rch to r .. ch the publiC, particularly women
of childbearing age.
The problems of cocaine Ibuse during pregnancy, Itl effect on neonat .. , and the need for
further aclentlftc study 'I weiliummarlzed by Inkelll et II. (forthcoming, p. 21):
By 1985 cocaine had become the mOlt common illicit drug to which neonates delivered at Harbor-UCLA Medical C.nt ..... expoled. Cocaln •• bUM by pregnant women II alaoclated with d.lltwloul effectl on pregnancy and the neonate Including Ibruptlo place ... , prematurity,.nd low birth weight. All Infanta who wwe cocalne-expoHd were symptomatic. Conaequently, neonatel with the pwlnatalllgni and Iymptom. d.lCribed should. be acreened for expoaure to cocaine. Th ... Infantl ulually require a higher level of care and .... more likely to be found In Intermedlate.nd Intenllve care nura"el. e.rly Identlftcatlon of cocalne-abullng pregnant women and appropriate medical and plychologlcallnterventlon, Including good prenatal care Ind I decrea .. or elimination of cocaine UH, mlY Improve the outcome of their pregnancies. Further prolp8Ctlve studies, including tho.e examining the effeetlven"l of maternal detoxification .re nec .... ry to confirm this hypothesll. Moreover, the long term conaequenc81 of Intrautertne cocaine
21
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exposure remlln to be determined. •
________ Ubby:\cocaIne\cocaIne.doc July 7:7, 1818 Ie _____ _
• VI. TREATMENT IMPUCATIONS
There are at l8Ist two Important needs for treatment of cocaine use In pregnancy:
(1) counselors In drug treatment programs must be able to recognize the risks of cocaine use during pregnancy; and
(2) obstetricians or other h8llth care providers who treat pregnant women, must
(a) 181m how to Identify pregnant drug users, (b) know the potential effects of the drug(s) on the course of pregnancy and the fetus, and (c) be able to ad vii' the patient accordingly.
Additional considerations involve appropriate pedlatrtc follow-up care for the cocaine-exposed newborn and appropriate social support for the ongoing caregiver of these high-risk infants and children.
The drug treatment program counselora need to be given Information on the risks of
cocaine ule durtng pregnancy. Specifically, they must wam the client of the Increaled pOlllbll1ty of
abruptio placentae with attendant rlskl of death for both the woman and fetul. They Ihould also
• Inform the pregnant mother of the pOlllbl. effect I on the newborn baby (e.g., severe withdrawal
syndrome, low birth weight, poor IIIte control, congenital malformatlonl and ongoing CNS
damage) and on the young child (e.g., developmental retardation).
•
The American Council on Drug Education has provided a pamphlet for phYllclans to Inform
them about pregnancy and drug use and to provide some guidance on how to counsel their
patlentl. They suggalt that physlclanl take a routine drug history of all pregnant women. In
addition, a drug ICrHn can be added to the routine urine test and uHd al a diagnostic when the
doctor II IUlplcloul of drug abu... After counllllng, phYllclanl and their iliff Ihould continue to
playa key role In coordinating the neeenary special aarvIcea for the patient and her Infant.
VII. PREVENTION AND INTERVENTION STRATEGIES
One method of preventing drug ule during pregnancy Is to educate the public. Rnponslble
federal, ltate, and local agenclel can provide Impetul for public education by Informing all of the
drug treatment centara within their constituency" If proper and adequate Information II given to
IIbby:\COQJ".\COQJ"..doc July 27, ,_18
22
counselors at drug treatment centers, they will be able to advise women of childbearing age about
the dangers of drug use during pregnancy.
Prevention programl can also be Initiated within the school system. With the high rates of
teenage pregnancy, it would be advisable to include the Issue of drug abuse during pregnancy In
junior high and high school heaith education programs.
Legal Interventions or prevention strategies Include: (1) Involuntary commitment of pregnant
women, (2) court-orders to force maternallurgery for the sake of fetaIIH.savlng, (3) state litigation
regarding pregnant women's choice of locatlonl for her delivery, (4) waivers of certain maternal
rights, and (5) criminal or civil prosecution of pregnant women whose behavior may be perceived al
"child endangerment."
Incentive programs to aid In the Identification of subltance-abullng pregnant women may
increase the polllbility of enrollment In prenatal care and/or drug treatment programs. Therapeutic
family day-care centera which offer programs tor subltanc .. buslng women and their newborns
offer a good environment for parent training which p'rovldes secondary prevention and Intervention
with hlgh-rllk mothers.
Examplel of current Intervention programl with cocaln .. bullng mothers are the Family
Center at Thomas Jefferson University Hospital In Philadelphia, Pa. and the SAM (Substance
Abusing Mothers) Clinic It the Hlrbor/UCLA MedlCiI Center In Lo. Angeles, Ca. Both of these
programl provide prenatal, perinatal, and postnatal Iervlc .. Including obstetrical, medical,
plychOIOCIaI, Ind Iddlctlon-related service.. The muitldlaclpltnary team It the SAM Clinic consists
of a perlnatologl8t, OB-GYN houHltaff, certified nurse midwives, family practice resident., a
plychlatry resident, IOCIaI work_, nutritionist, Ind nu .... educator. Patients Ire given Indlvldull
counlelling In addition to the group clinic. Inpatient detoxification II lvallable for selected cocaine
and opiate addicts. A preliminary evaluation of the SAM cliniC, comparing "clinic" and control
groupi Indlcatel that the clinic provided comprehensive care which resulted In positive
conlequences, Including fewer pretenn dellveriel, fewer drug-Intoxicated and/or low blrthwelght
IIbby.\cocaIne\cocalne.doc July 27.11118"
23
•
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bablll, and fewer Infantl needing neonatallntenllve care (yonekura, 1988). Programlsuch al this
are crucial given the Increallng number of lubstance abusing mothers using cocaine •
IIbby:\cocaIne\cocaIne.doc July 27, 1_18
24
VIII. CONCLUSION
The current epidemic of cocaine use among young adults (ages 18-34) is especially
significant becau •• of the Increasing ~umber of pregnant women and women of childbearing age
using cocaine. Although there has been limited research on the effects of cocaine use during
pregnancy, It Is now known that there can be severe consequences. Studies have shown that
cocaine use can lead to spontaneous abortions of the fetus, premature births, neonatal
cerebrovascular problem., neonatal wtthdl'lwal syndrome, and sudden infant death syndrome
(SIDS). Unfortunately, too little is known amongst the general public about the dange,. of cocaine
use during pregnancy, despite campaigns by organizations such .s the March of Dime.. The lack
of drug treatment facllltl •• Ind the Inadequacy of ho.pltal re.ource. to adequltely deal with the
riling number of women who ule coca Ina during pregnlncy Ire foremost concerns.
1Ibby:\~ne\~ne.doe July 27, 11118 II
25
•
•
•
• SERVICES
Cocaine Hotline
Los Angeles Drug Abuse Hotline
Cocaine Anonymous Hotline
L.A. County
SELF HELP GROUPS
Los Angeles County
Orange County
San Fernando Valley
BOOKS
IX. RESOURCES
(800) 282-2463 (COCAINE)
(213) 839-1141
(213) 859-2208
(714) 820-4324
(818) 447-2887
(714) 850-1011
(818) 988-1777
• Cohen, Sidney, Cocaine: The Bottom Line. The American Council for Drug Education, 1985.
•
Cohen, Sidney, Cocaine Today. American Council on Marijuana and Other Psychoactive Drugs, 1981.
DuPont, Robert L Getting Tough on Gateway Drugs: A Guide tor the Family. AmGrican Psychiatric Press, 1984.
Fromme, Marlene et al. Cocaine: A Seduction and Solution. Crown Publishers, 1984.
Gold, Mark S. aOo-Cocalne. Bantam Books, 1984.
Hafen, Brent & Franiden, Kathryn J. Cocaine. Hazelden Publishers, 1982.
Peteraen, Roe.i C. at II. Cocaine: A Second Look. Smith, David E. Dogoloff, Lee, Eds. American Council on Drug Education, 1983.
Stone, Nanette. Cocaine. C.N. Potter, 1984.
Stone, Nanette. COCIln~ PharmacolOGY. Effect!Rand Treatment of Drug Abuse. National Institute on Drug Abuse, eHarch Monograph S .. 50, 1984.
Stone, Nanette. Learn About Cocaine. Haalden Publishers, 1983.
IIbby:\coc:alne\coc:alne.doc July 27, lMIe
26
JOURNAL ARTICLES
Egan, Donald J. " R~blnlon, David O. "Cocaine, Magical Drug or Menace?" International Journal of the Addlctionl, 14(2), 1979.
Mittleman, Hollace S., Mittleman, Roger E. & Eller, Bernard. "Cocaine." American Journal of Nursing, September 1984.
Mittleman, Roger E. & Wetll, Charlel V. "Death Cauled by Recreational Cocaine Ule: An Update." Journal of the Amerl1:8n Medical Alloclatlon. October. 12, 1984.
MAGAZINE ARTICLES
Anderson, Kurt. "Cralhlng on Cocaln •• " Tim., April 11, 1983.
Demarest, Michael. "Cocaine: Middie-Cla .. High." Time, July 8, 1981.
Van Dyk., Craig & Byck, Robert. "Coca In •• '' Scl.ntlflc American, March 1982.
Van Dyke, Craig" Byck, Robert. "Kldl and Cocaine." Newsweek, Mar. 17, 1988.
Van Dyk., Craig & Byck, Robert. "Cocaln.: Th. Evil Empire." N.wsweek, F.b. 25, 1985.
27
•
Van Dyk., Craig" Byck, Robert. "Colombian Connection: How a Billion-Dollar Network Smugglea • Pot and Coke In the U.S." Time, Jan. 29, 1878.
Van Dyk., Craig" Byck, Robert. "Getting Straight." Newsweek, June 4,1984.
PAMPHLETS
Hafen, Brent Q. & Franlden, Kathryn J. "COCIIlne." Hazelden Education Service., 1881.
Hafen, Brent Q. " Franlden, Kathryn J. "Cocaine." Phoenix Hou ...
GOVERNMENT PUBUCATIONS • NATIONAL INSTITUTE ON DRUG ABUSE
AdamI, Edgar H. " Durell, Jack. "Cocaine: A Growing PubliC H .. lth Problem." Coca In.: Phal'l11llcot~ Effectalaand Treatm.nt of Abu... R .... rch Monograph Sertea 50, 1984. EdRor: Jo n rabOws •
Kozel, Nicholl. J. " Adam., Edgar H. Cocaine U .. in Am .... ca: Epld.mlologlc and Clinical Parspectlv ... R .... rch Monograph Sert •• 81, 1885.
Fllchman, Marian W. The Behavlonl Pharmacology of Cocaine In Human •• Re ... rch Monograph Series 50, 1984.
Phllllpl, Joel L A Cocaine Bibliography, (nonannotated). Natlonallnatltute on Drug Abuse Relearch Monograph 8,1874.
Reed, Beth G, Belchner, Georg. M., " Mondanaro, JOlett.. Treatment Servlc .. for Drug Dependent Women, Vol. II. Treatment R .... rch Monograph Sarle., 1882 •
. 1 •
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GOVERNMENTPUBUCATIONS-OTHER
Peterson, Robert C. "Stillman, Richard D., Eds. Cocaine: 1977. U.S. Alcohol, Drug Abuse, and Mental Health Administration, 1.977.
FILMS
Cocaine Abuse: End of the Line Audience: High School and Adult
,
Richard Dreyfu .. narrate. thl. film about flve people of different age. and walk. of life who become hooked on cocaine. Dramatization. by .ub,ect. them.elve. trace the evolution of their addiction. 27 min. Produced and distributed by Aim. Media, 8901 Woodley Ave., Van Nuy., CA 91405-4878. (818) 785-4111.
Cocaine Blue. Audience: High School and Adult
Thl. award-winning fllm examln .. cocaine's hlltory, effect., and cultural Impact. Narrated by Hoyt Axton, It Include. Interviews with UI8I'I, narcotic. offlc .... , and leading medical expert., plu •• urveillance footage of a cocaine tran .. ctlon, and a shootout In lin actual cocaine "bust." 30 min. Produced by Barbour Langley" Alloclate.. DIstributed by Pyramid Film., Box 1048, Santa Monica, CA 90408. (213) 828-7577.
Cocaine: Beyond the Looking Gla .. Audience: High School and Recovered U .....
Four former cocaine abusers effoctlvely tell their storl .. , from dependency to recovery. 30 min. Produced by Dick Young for Haalden Education Material.. Distributed by Hazelden Education Material., Film Department, 15425 PI .... nt Valley Rd., Center City, MN 55012. (800) 328-0500 (out.lde Mlnne.ota) or (812) 257-4010 (In Mlnne.ota).
Cocaine Pain Audience: High School and Adult
Five people dllCu •• their atruggle to "klct' cocaine in footage taken at group therapy ses.lon.,ed by Dr. Richard MIII_, founder and director of Cokendera. 32 min. Produced by the Jay Gary Mitchell Film Co. DIstributed by Simon" Schulter, 108 Wilmont Rd., Deel1leld, IL 80015. (800)821-7870.
Cocaine-The High. and Lon Audience: Adult
A form. COCIlne addict trac .. the Itep. that led to h_ addiction and dl.cu .... her treatment and recovery In a panel formlt documentary 'eaturlng Drs. Mark Gold (of 8GO-COCAINE) and Conwey Hunt •• 28 min. Produced by Touchstone Communication As.oclat... DIstributed by FMS Production., 1777 N. Vine St., Lo. Angel .. , CA 90028. (800) 421-4809.
Hooked on a Line Audience: High School and Adult
Thl. two-part film look. at the medical .ymptom. and problem. of u ..... , and the effect. of use on their live •• Part 11. "The 01 ..... ," Part 21. "Getting W.II.u 54 min. Produced and dlltrlbutad by Palm Beach Institute Foundation, 1014 N. Olive Ave., West Palm Beach, FL 33401. (305) 833-7553.
IlbOy:\cocaJn4l\cocaJrie.doc July 27, 1. "
28
SnoWitorm In the Jungle Audience: High School and Adult
Jacques Coust .. u and hllson Jean Michel captured this dramatic footage while on an 18-month expedition In the Amazon jungle. It depicts the ritual use of coca by Indians, the cultivation of the plant by p .... nt farmel'l, and th, manufacture of cocaine by trafflckel'l. 47 min. Produced by the Cou8teau Society and Turner Broadcasting. Distributed by Turner Broadcasting, 1050 Techwood Drive NW, Atlanta, GA 30318. (404) 827-2200.
The Cocaine Trail Audience: High School and Adult
This film follows the cocaine trail from cultivation to Importation Into the United Stat... Federal, state, and local officials dlacun strategies for controlling the cocaine trade. 25 min. Produced by NBC News. DIstributed by Simon Ie Schuster, 108 Wilmont Rd., Deerfield, IL 60015. (800)621-7870.
The Physiological Effects of Cocaine Audience: Profe .. lonals
Pharmacological and chemical dependency counllior Randy Cox d~crtbel the physical properties of cocaine, Its effects on bodily syltems, and common methods of neet use. An excellent teaching tool for professionals. 20 min •. Produced and distributed by Hazelde" Education Materials Department, 15425 PI .... nt Valley Rd., Center City, MN 55012. (800) 328-0500 (outside Minnesota) or (812) 257-4010 (In Mlnn .. ota).
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RESOURCE PERSONS
Council on Perinatal Subatance Abule of LOl Angelel County, Inc. 313 North Figueroa Street, MZ-1 ' LOI Angeles, CA 90012 (213) 974-9683
Kathleen Welt Dr. Judy Howard UCLA Project Pride Rehabilitation Center Department of Pediatrics 1000 Vet .... n Avenue LOl Angelel, CA 90024 (213) 825-4821
Project Support Martin Luther King General HOlp1ta1 Dr. Milton Lee Dr. Xylina Sean Alsoclate Director Neonatology 12021 Wilmington Avenue LOl Angel.l, CA 90058 (213) 803-4850, 4857
Eden Center (daycare program) Martin Luther King General HOlp1ta1 12021 Wilmington Avenue LOI Angelel, CA 90058 (213) 803-4857
Infantl and Subatance Abullng Mothera Obltetrfcal Servlc. Dr. M. Lynn Yonekura Chief, Dlvllion of Obltetrfca Harbor-UCLA Medical HOlp1ta1 (213) 533-3585
Harbor-UCLA Medical Hospital 1000 W. CarlOn StrMt Torranc. CA 8OIOt Dr. Stan Inkell. (213) 533-3501
1Ibby.\cocaIne\cocaIne.doc July 27, 1818.
30
X.REFERENCES
Abelson, H. I., & Miller, J. D. (1985). A decade of trends In cocaine use In the household population. In N. J. Kozel, & E. H. Adams, (Eds.), Cocaine use in America: Epidemiologic and clinical perspectives (National Institute on Drug Abuse Research Monograph 81, Pp. 35-49, DHHS Publication No. (ADM)85-1414). Washington, DC: U.S. Government Printing Office.
Acker, D., Sachs, B. P., Tracey, J. J., & Wise, W. E. (1983). Abruptio placentae associated with cocaine use. American Journal of ObstetriCS and Gyn.cology, 146: 220-221.
Adams, E. H., & Durell, J. (1984). Cocaine: A growing public health problem. In J. Grabowski (Ed.), Coca In.: Pharmacology •• ff.cts. and treatm.nt of abull (National Instltut. on Drug Abus. Reaearch Monograph 50, Pp. 9-14, DHHS Publication No. (ADM)84-1328). Washington, DC: U.S. Governm.nt Printing OffIc ••
Adams, E. H., & Kozel, N. J. (1885). Cocaine use In Am .... ca: Introduction and overview. In N. J. Kozel, & E. H. Adams, (Eds.), Cocaine un In America: Epidemiologic and clinical p.rspectlves (Natlonallnstltut. on Drug Abus. Reaearch Monograph 81, Pp. 1-7, DHHS Publication No. (ADM)85-1414). Washington, DC: U.S. Governm.nt Printing OffIce.
American Council for Drug Education. (1988). Druas and pregnancy: It's not worth the risk. Rockvlll., MD.: The American Council for Drug Education.
A.sh.,y, R. (1975). Cocaln •• Its history. UIIS and .ffects. N.w York: St. Martin's Pr ....
Blngol, N., Fuchs, M., Dlaz, Y., Ston., R. K., & Gromlsch, D. S. (1987). T.ratogenlclty of cocaine In humans. Th. Journal of Pediatrics, 110 (1): 93-98.
Bllnlck, G., Wallach, R., Jerez, E., & Ackerman, B. (1978). Drug addiction In pregnancy and the neonate. American Journal of Obstetrics and Gynecoloay, 125 (2): 135-142.
Chasnoff, I. J. (1985). Eff.cts of maternal narcotic VI. nonnarcotic addiction on neonatal n.urob.havlor and Infant d.v.'opm.nt. In T. M. Plnkert (Ed.), Curr.nt research on the consequencea of maternal drug abuH (National Institute on Drug Abuse Research Monograph 59, Pp. 84-93, DHHS Publication No. (ADM)85-1400). Washington, DC: U.S. Government Printing Office.
Chasnoff, I. J., Bums, W. J., & Schnoll, S. H. (1884). Perinatal addiction: The effects of maternal narcotic and nonnarcotic subltance abuse on the fetus and neonate. In L S. Harris (Ed.), probl.ms of drug dependence. 1983. Proceedings of the 45th Annual Scientific Meetings. The Commltt .. on Probl.ms of Drua Dependenc •• Inc. (National Institute on Drug Abu .. Reaearch Mo~~raph 48, Pp. ~221, DHHS Publication No. (ADM) 84-1318). Washington, DC: U. S. Government Printing OffIce.
Chasnoff, I. J., Bums, W. J., Schnoll, S. H., & Bums, K. A. (1886). Cocaine uHln pregnancy. The N.w England Journal of Medlcln., 313: eee-ee9.
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Ch.snoff, I. J., Bums, W. J., Schnoll, S. H., & Bums, K. A. (19888). Effects of cocaine on pregnancy outcome. In L S. Harris (Ed.), Problems of drug dependenc •• 1985. Proc.edlngs of • the 47th Annual Scientific Meetings. The Committee on Problems of Drua Dependence. Inc. (Natlonallnstitut. on Drug Abuse Research Monograph 87, Pp. 335-341. DHHS Publication No. (ADM) 8&-1448). Washington, DC: U. S. Gov.rnment Printing OffIc ••
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Cha.noff, I. J., Hunt C., Klettar, R. at al. (1988b). Increased risk of SIDS and respiratory pattern abnorma'"' .. In cocalnHxpo.ed Infant •• Pediatric Re.earch, 20: 425.
Cha.noff, I. J., Bu ... y, M. E., Savich, R., I. Stack, C. M. (1988C). Perinatal cerebral Infarction and maternal cocaine use. Journal of Pediatric., 108: 458.
Cha.noff, I. J., Schnoll, S. H., Bum., W. H., I. Burn., K. Maternal nonnarcotic substance abuse during pregnancy: Effect. on Infant development. Neurobehavloral Toxicology and Teratology, In prell.
Children of Addict. and Nonaddlct., Service. Re.earch Report, NIDA, 1988.
Chitwood, D. D. (1985). Pattern. and conslquencea of cocaine ulI.ln N. J. Kozel, I. E. H, Adams (Ed •• ), Cocaine u .. In America: Epidemiologic and clinical penpectlve. (National Institute on Drug Abu .. Re8earch Monograph 81, Pp. 111-129, DHHS Publication No. (ADM)85-1414). Wa8hlngton, DC: U.S. Government Printing OffIce.
Clayton, R. R. (1985). Cocaine use In the United Statea: In a blizzard or just being Inowed? In N. J. Kozel, I. E. H. Adami (Ed •• ), Cocaine u .. In America: Epidemiologic and clinical perspectives (National Institute on Drug Abull Reaearch Monograph 81, Pp. 8-34, DHHS Publication No. (ADM) 85-1414). Washington, DC: U.S. Government Printing OffIce.
Cocaine and Pregnancy, NIDA Notes No.3, August 1988.
Cocaine U.eln America, Prevention, Networkl, NIDA, Aprt11188.
Cohen, S. (1981). Cocaine Today. Rockville, MD: The Amwican Council for Drug Education.
Cohen, S. (1985). Reinforcement and rapid delivery system8: Understanding advene conaequenc .. of cOCillne. In N. J. Kozel, I. E. H. Adam. (Ed •• ), COCillne u.e In America: EpidemiolOGic and cllnlCIII p!l!pectivlH (National Institute on Drug Abu.e Relearch Monograph 81, Pp. 151-157, DHHS PubllClitlon No. (ADM)85-1414). Wa.hlngton, DC: U.S. Government Printing OffIce.
Drug Dependence In Pregnancy. (1988). Service. Reaearch Monograph Serfea, National Institute on Drug Abu... Wa8hlngton, DC: U.S. Government Printing OffIce.
American P.ychlatrlc AllOClatlon. (1980). Diagnostic and Statistical Manual of Mental Disorders, third Edition.
Egan, D. J.I. RoblnlOn, D. O. (1171). Cocaine: Magical drug or menace? international Journal of the AddlctloM 14(2):231-241.
Evans, M. A.I. H.rbllOn, R. D. (1977). Cocaine, me"!u'-J~., LSD: Pharmacologic effect I In the fetul and newborn. In J. L Rementarta (ed.) Drug Abu •• In Pregnancy and Neonatal Effect •• p.195. St. Loul.: C.V. Mo.by Co.
Flnneg.n, LP. (1988). Cited In Alcohol, Drua Abu ... and Mental Health Newa, 14(3):4. Wa.hlngton, D.C.: U.S. D.partment of Health and Human Service ••
Flnneg.n, LP. (1188). Neonatal Abstln.nce Syndrom.: A ..... m.nt and Ph.rmacoth .... py.ln Rubaltelll, F.F. I. Granatl, B. (Ed •• ) Neonatal Therapy: An updat •• Excerpta MedICII: New York, pp. 122-148.
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Flnnegln, LP., Emlch, J.P., Connaughton, J.F. & Wieland, W. (1972) Comprehensive care of the pregnant addict and Its effect on maternal and Infant outcome. Proceedings of the 34th Annual Scl.ntlflc Meeting of the Committee on the Probl.ms of Drug Dependence of the National R.search Council. National Institute on Drug Abuse Research Monograph. Washington, D.C.: U.S. Government Printing Office, pp" 372-390.
Fischman, M.W. (1984). The behavioral pharmacology of cocaine In humans. In J. Grabowski (Ed.), Cocaln.: PharmacolOGY, .ffect., and treatment of abu.e (Natlonallnltltut. on Drug Abus. Res .. rch Monograph 50, Pp. 72-81, DHHS Publication No. (ADM)84-1326). Washington, DC: U.S. Government Printing OffIce.
Gawln, F.H., & Kleber, H.D. (1885). Cocaine u .. ln a treatm.nt population: Patterns and diagnostic distinction •• In N. J. Kozel, & E. H. Adam. (Ed •• ), Cocaln. use In America: Epld~mlologlc and Clinical penpectlv •• (Natlonallnatltut. on Drug Abus. Re.earch Monograph 61, Pp. 182-192, DHHS Publication No. (ADM)85-1414). Washington, DC: U.S. Government Printing Offlc ••
Gay, G.R. (1981). YQu've come a long way, babyl Coke time for the American lady of the elghtl.s. Journal of PsYchoactlv. Druas, 13 (4): 287-318.
Gay, G.R., & Inaba, D.S. (1978). Acute and chronic toxicology of cocaln. abu.e: Current sociology, tr .. tment and. rehabilitation. In Mule, S.J. (Ed.), Cocaine: Chemical, biological, clinical, social and treatment aspects, pp. 245-252. Cleveland: CRC Pre ...
Glanzer, W. D., And.-.on, K. N., & Anderson, L E. (1985). The Mo.by Medical Encyclopedia •. N.Y.: New American Ubrary.
Glass, L & EVln., H. E. (1978). Perinatal drug abuM. Pediatric Annals, 8 (2): 41-59.
Gold, M. S. (1984). 800-cocalne. Toronto: Bantam Book ••
Gold, M. S. (1987). Crack Abu .. : It.lmpllcatlonl and Outcom ••• R •• ldent and Staff PhYllclan, July: 45-53.
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Mlttl.man, R. W. It Watll, C. V. (1984). Death caUlact by recreational cocaln. U ... Journal of the Am.rlcan Medical Alloclatlon 252 (14): 1881-1893.
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lIbtly:lcocaIne cocaIne.doc Ju. 27, 1l1li818
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APPENDIX A
OVERVIEW OF DRUG USE AND PREGNANCY
According to the literature on tlie problem of drug abuse and pregnancy, some of the
general factora of major concern are (Wager and Keith, 1985):
(1) Inadequate or no prenatal care for pregnant drug users;
(2) multiple drug (polydrug) u .. and the effect of successive and simultaneous use;
(3) variability In patterns and amounts of drug use;
(4) adulterant. In street drugl; and
(5) lack of InfOl'l'Mtlon on drug .ffecta among both patl.nt. and health car. providers.
Among the mora common medl~1 compll~lonl reported In pregnant women addicted to narcotlca sr.: an.mla, vaglnltll, hepatltll, and poIlt.ve ... ology for AIDS. Th. obltetrlc complication. for . narcotlce addlctl Include: Intrauterln. growth retardation (IUGR), .pontaneoul abortion, premature rupture of membrln .. , preclpitoul dillvery, tox.mla, and abruptio placental. The neonatal complications includ.: low birth w.ight, chromOiomal and n.uromotor abnormalltl .. , deprelled Apgar .corel21 at birth, and drug wlthdrawal22•
Ther. II very Ilttl ....... rch on the eoclologlcaland/or plychologlcalalpectl of drug abule
by pregnant women. Drug addiction during pregnancy I. currently con.ldered to be a crlm.
(Ro18nbaum, 1979). ConHquently, thl pregnant .ddlct may encounter .oclalltlgma and be
treated with disdain by phYilclanl and hOlpltalltaff. Noneth.,eu, there may b. lome 'ympathetlc
phYllclan. or staff who will recognize thl dang .. to the fatUI If thl woman attemptl to withdraw
from drugl without adequatl medical lupervilion .nd eoclal IUPport. Aft .. birth there are other
compllcatlonl, Including removal of the baby from the moth .... care. Thll destroYI an Important
proce .. known al Infant-moth .. bonding. Moth .... who kHP th.lr blbl .. flnd It difficult to maintain
21 An Apgar ICor. ~Ia teet to determln. a nlwborn babY'1 health between 1 and 5 mlnut.lafter birth, which II .cored on 5 fectora, Including heart rat., breathing, mUICle ton., reflex .. , and color. A scor. from 0 to 3 Indlcat .... v •• dl ...... , from 4-7 moderatl, and from 7 to 10 normal.
22 Flnneg.n ha. dev.loped a neonatal ...... m.nt acall which II ulld to mea lure slgnl .nd symptoml of withdrawal. Although originally ulld only for withdrawal Iymptoml from herOin, it hal allo been applied to coca In ••
1Ibby:\cocaIne\cocaIne.doc July V. ,_ Ie
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their drug ullng habltl and to continue mothering. All too often the children are neglected. The
mother will f .. 1 guilty over the neglect or 1081 of her child.
The few long term studies of children exposed to drugs in utero have shown that by age 4 or
5 many children are developmentally delayed. Environmental deprivation, early separation, and
multiple foster care placements are factore which affect socia' and psychological development
(Weln.eln and West, 1988).
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~-, . .., ... ;:.: .... ~~" ..
• Oaily Record of Neonatal Withdrawal
SI;ns and Symptoms
Record presence (+) or absence (-) of symptoms. on each shift:
Irritability·
Tremulousness·
Hyperactive moro reflex·
Sneezing or yawning··
Increased sucking reflex··
High pitch~d cry·· Poor feeding··
Fever··
Finnegan (1986)
, 2 3 4
• Ol.ntle.··· ,
•
Spitting up, vomiting···
Respiratory distress···
Seizures···
Record VS from day shift:
Temperatur\,
Pulse
Reepiratlona
Weight
Medications:
Drug
Oose
Frequency
Urine Toxicolog'/ Screen (first 24 hrs,)
-mild witt'ldrlwll
I
·-additiona' symgtoms indicating mOd.rate withdrawal Me- ........
0,
M
5 6 7
,
I
I I