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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

~ ':~~ .. -.' ; ,

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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

Permission to reproduce thiS copyr g 1

gran~~¥ifornia Dept. of A1coho = -- Programs

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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25

20

15

10'

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27.5 '* 28. 3

/ 10"'"9." Adt4tta

19.11 12. 7 13;/

9./-Otd,,1' Adutt.

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~ 11th

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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

•

•

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

•

•

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

•

•

•

" ••

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

•

•

•

• 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. "

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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.

Gold, M. S., Washton, A. M., & Dackls, C. A. (1985). Cocaine abuse: Neurochemistry, ph.nomenology, and treatm.nt. In N. J. Kozel, & E. H. Adam. (Eds.), Cocaln. UM In America: Epidemiologic and clinical perspectives (National Institute on Drug Abuse R .... rch Monograph 61, Pp. 130-150, DHHS Publication No. (ADM)85-1414). Wa.hlngton, DC: U.S. Government Printing OffIce.

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Lazarul, W. " W.It, K. (1987). Back to Ballcl: Improvlna the Health of cailfornla'i N.xt G.neratlon. A Report of the Children'. R .... rch Inltltute of California and the Southern California Child Health Network. Santa Monica, CA: Southern California Child Health Network.

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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 ••

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38

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