Cocaine in the cradle: a hidden epidemic

Infants of Mothers with Cocaine Use: Review of Clinical and Medico-Legal Aspects

Illicit drug use is a global problem that also affects pregnant women. Substance use and alcohol abuse during pregnancy may have various harmful consequences for both mothers and foetuses. Intrauterine exposure to illicit substances can be investigated through maternal reports and toxicological tests on mothers’ and/or newborns’ samples. While the negative effects of alcohol and opioid use on pregnancy, the foetus, and/or newborn are well established, the effects of cocaine use remain controversial. We performed a review of the literature to evaluate the current state of knowledge of the effects of intrauterine cocaine exposure on newborns’ and children’s long-term development and to highlight possible implications for health professionals dealing with women who use cocaine during pregnancy. Although intrauterine cocaine exposure has been associated with reduced infant measurements, no specific amount of cocaine use exerting such effects has been determined, and no long-term effects have been confirmed. The evidence of cocaine use during pregnancy justifies a clinical and social takeover of the mother and newborn without assuming that there will certainly be long-term damage related to intrauterine cocaine exposure, but also considering other possible associated factors.

GREATER RIGHT FRONTAL EEG ASYMMETRY AND NONEMPHATHIC BEHAVIOR ARE OBSERVED IN CHILDREN PRENATALLY EXPOSED TO COCAINE

Responses to emotion-inducing stimuli were examined in 27, 3- to 6-year-old children, who were prenatally exposed to cocaine, and 27 unexposed controls. Children were monitored for EEG activity and their affect during an infant crying, simulated maternal distress, and a mildly frustrating task. Multivariate analyses indicated that the cocaine-exposed children had greater right frontal EEG asymmetry, showed fewer empathic reactions to a crying infant as well as to their own mothers, and they were less proficient in completing a cooperative task. These findings highlight the need for continued longitudinal research on the effects of early drug exposure for later socioemotional development.

Infusing neuroscience into the study and prevention of drug misuse and co-occurring aggressive behavior

The etiology of behavioral precursors to substance misuse and aggression is viewed from the perspective of a developmental, multifactorial model of complex disorders. Beginning at conception, genetic and environmental interactions have potential to produce a sequence of behavioral phenotypes during development that bias the trajectory toward high-risk outcomes. One pathway is theorized to emanate from a deviation in neurological development that predisposes children to affective and cognitive delays or impairments that, in turn, generate dysregulatory behaviors. The plasticity of these neurobiological systems is highly relevant to the prevention sciences; their functions are reliant upon environmental inputs and can be altered, for better or for worse, contingent upon the nature of the inputs. Thus, social contextual factors confer significant influence on the development of this neural network and behavioral outcomes by increasing risk for, or protecting (1) against, dysregulatory outcomes. A well-designed intervention can exploit the brain's plasticity by targeting biological and social factors at sensitive time points to positively influence emergent neurobiological functions and related behaviors. Accordingly, prevention research is beginning to focus on perturbations in developmental neural plasticity during childhood that increase the likelihood of risky behaviors and may also moderate intervention effects on behavior. Given that the more complex features of neurobiological functions underlying drug misuse and aggression (e.g., executive cognitive function, coping skills, affect regulation) do not coalesce until early adulthood when prefrontal-limbic brain networks consolidate, it is critical that mechanisms underlying developmental risk factors are identified. An empirically driven prevention approach, thus, may benefit from consideration of (i) the type, effect, and developmental timing of the environmental impact on the brain, and (ii) the type and effect on brain function, and developmental timing of the intervention. This translational approach promises to eventually offer some direction for the design of effective interventions to prevent drug misuse and concomitant aggression.

The importance of neurobiological research to the prevention of psychopathology

There is both a biological and environmental component to the neural substrates for various forms of psychopathology. Brain dysfunction itself not only constitutes a formidable liability to psychopathology, but also has an impact on environmental and social responses to the individual, compounding the risk for an adverse outcome. Environmental conditions, such as social and physical stimulus deprivation, poverty, traumatic stress, and prenatal drug exposure, can further compromise brain function in the context of existing liabilities. The relationship between genetic and environmental processes is interactive, fluid, and cumulative in their ability to influence an individual's developmental trajectory and alter subsequent behavioral outcomes. Given the codependent relationship between these processes, brain function is now believed to be malleable via manipulations of the environment in ways that may decrease liability for psychopathology. Research that explores these relationships and ways in which interventions can redirect this developmental track may substantially advance both the science and practice of prevention. Studies attempting to isolate the neurobiological effects of socioenvironmental factors are reviewed, implications for intervention strategies are discussed, and a future research agenda is proposed to provide greater insight into specific brain-environment relationships. Armed with this knowledge, prevention scientists may eventually design programs that directly target these effects to reverse or attenuate negative outcomes.

Estimating the dollar value of health outcomes from drug-abuse interventions

OBJECTIVES

People who abuse drugs suffer from a host of medical problems that impose costs on both the abusers and society as a whole. Drug-abuse treatment and other interventions can help alleviate these medical problems, leading to health status improvements for chronic drug users and reduced social costs. The authors' dual purpose here is to (1) propose a theoretically rigorous yet easy-to-apply methodology for estimating the health-related costs of drug abuse and (2) demonstrate the methodology by estimating the potential dollar value of avoiding adverse health consequences as a result of successful drug-abuse interventions.

METHODS

The authors' proposed multiattribute quality-adjusted life year methodology for estimating the value of avoiding morbidity and mortality involves eight steps to be followed sequentially. The framework is based on developing a common unit of well-being (i.e., quality-adjusted life year) that can be applied to all types of health conditions. If all health states can be denominated in this common unit, then the process of valuation is straightforward and consistent across all types of illnesses and diseases. The methodology is relatively inexpensive to execute because the estimation procedures are not complicated technically and the data demands are modest. Also, this approach incorporates elements from several disciplines, including psychology, epidemiology, medicine, and economics. Finally, the proposed methodology is flexible enough to cover a wide range of illnesses and diseases so that consistent and comparable estimates can be generated.

RESULTS

The authors estimate the dollar value of avoiding acute hepatitis B, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), hypertension, bacterial pneumonia, sexually transmitted diseases, and tuberculosis for a white male aged 32 years. The authors' results illustrate that estimated avoided morbidity values can vary significantly across the range of health consequences associated with drug abuse. At the upper end of the range, the value of avoiding only the morbidity associated with a single case of HIV/AIDS is approximately $157,811 for the period beginning with transmission of HIV, through late-stage HIV and AIDS, and ending just before death.

CONCLUSIONS

People who abuse drugs suffer from many medical problems in addition to their addiction. The proposed approach for estimating the dollar value of avoiding adverse health consequences provides policy analysts, evaluators, and researchers a method to calculate theoretically based benefit estimates for use in a benefit-cost analysis of drug-abuse interventions.

Neurosonographic imaging of small-for-gestational-age neonates exposed and not exposed to cocaine and cytomegalovirus

We sought to prospectively identify the role of neurosonography in the evaluation of a consecutive group of small-for-gestational-age (SGA) neonates, and also to identify the association of neurosonographic findings with cocaine exposure and cytomegalovirus (CMV) infection. Neurosonographic imaging was performed in 180 SGA neonates within 72 hours of birth. Urine samples were screened for CMV and cocaine metabolites (CM) in all cases. Sixty-five neonates (37.5%) had an abnormal neurosonographic appearance. Nine neonates were positive for CMV and 31 neonates were positive for CM. Focal echolucencies (27), ventricular dilation (27), and subependymal hemorrhages (12) were the most common neurosonographic abnormalities. The first two were more common with CM (p < .05). An abnormal neurosonographic pattern was seen more often in SGA neonates with CM (54.8%, 17 of 31; p < .05) and CMV (67%, 6 of 9; p < .01) as compared with the rest (32.6%, 44 of 135; p < .01). Among those without CM or CMV, prematurity was associated with an increased risk for abnormality (p < .001 between groups), specifically subependymal hemorrhage, ventricular dilation, and porencephalic cysts. Five CMV-positive neonates showed periventricular, echogenic foci mainly in the area of the frontal horn. Two new findings with SGA were caudate nucleus echogenicity and a "moth-eaten" appearance of the thalamus, each found in three infants. Neurosonographic imaging is useful in the evaluation of SGA neonates. Focal echolucencies and caudate echogenicity suggest maternal cocaine use, and periventricular echogenic foci strongly suggest fetal CMV infection.

Effect of prenatal cocaine on the acquisition of cocaine-induced taste aversions

Pregnant Long-Evans rats were injected SC twice daily with 20 mg/kg cocaine from gestational days (GD) 7-19. Vehicle controls were administered distilled water on these days. Pair-fed controls were similarly treated but allowed the same amount of food as consumed by the cocaine-exposed mothers. On postnatal day 1 (PND 1), pups of the mothers exposed to cocaine were surrogate-fostered. On PND 41, all subjects were grouped according to their history (cocaine, vehicle, and pair-fed) and were tested for their behavioral sensitivity to the aversive effects of cocaine by assessing their ability to acquire a cocaine-induced taste aversion. Rats from all three conditions were given saccharin to drink and then injected SC with either 0, 18, 32, or 50 mg/kg cocaine. Prenatal exposure to cocaine had no effect on the acquisition of aversions. Specifically, the prenatally exposed animals acquired the taste aversion in a dose-dependent manner similar to that of the controls. These data indicate that changes in sensitivity to cocaine are not necessary consequences of prenatal cocaine exposure.