International Journal of Technology Assessment in Health Care, 8:Suppl. 1 (1992), 101-105. Copyright © 1992 Cambridge University Press. Printed in the U.S.A.
Alcohol and Narcotics Epidemiology and Pregnancy Risks Ragnar Olegard Moelndal Hospital, Sweden
Abstract Among alcohol and narcotics, alcohol is most comprehensively documented as a teratogen. However, for all other narcotics, data are continuously accumulating, convincingly displaying the teratogenic effects. The proportions between "somatic" teratogenicity and "behavioral" teratogenicity vary between the different agents. Preventive work in prenatal clinics and among social workers, as well as objective mass media attention to the problem, seems to have lowered the incidence of severe fetal alcohol syndrome where the above-mentioned activities have been practiced. The female alcohol consumption in Sweden decreased from 1976 to 1985; thereafter, a slow continuous increase is underway again, in Sweden the number of recruits to narcotic abuse peaked in the 1970s and early 1980s. Thereafter, the number of recruits among females decreased, but abuse has continued among the members of the older age groups.
ALCOHOL
One consequence of female heavy drinking is a fetal alcohol syndrome (FAS) in the offspring (25;26;28). An infant or child with a complete FAS is affected in three categories: growth retardation, which is prenatal and typically without postnatal catchup; typical facial dysmorphism with microcephaly, short palpebral fissures with flat maxillary area, and nasal bridge with thelecanthus and poorly developed filtrum and thin elongated upper lip; early central nervous system dysfunction includes different degrees of mental retardation, mostly of mild degree, and neurological and neuropsychological symptoms. The latter category includes hyperactivity, distractibility, impulsiveness, perceptive disorders, coordination difficulties, ataxia, and di- and hemiplegias (4;18). In the neonatal period, visual- and somatosensoric-evoked response resembles that seen after severe asphyxias (25). Hypoplasia of the optic nerve produce severe visual handicap in at least 20% of complete FAS, only 20% having a normal vision (30). Persons with complete FAS have a stable clinical and mental picture into adulthood (29). The risk of complete FAS is 20-40% if alcohol abuse continues through pregnancy. Most infants and children escaping a complete FAS after gestational alcohol abuse acquire fetal alcohol effects (FAE), which indicates that one or two of the three main categories of symptoms is not represented. Alcohol abuse increases the risk of spontaneous abortions, and of preterm labor and smallness for date to about 20%. Perinatal mortality is increased about 10 times. FAS is seen with certainty only after heavy drinking, probably correlating to daily intakes exceeding 30 cl of strong spirit for a substantial period throughout pregnancy. Between 9 cl and 30 cl of strong spirit daily, group differences have been found in development and neurobehavior per101
Olegard
formance compared to populations with a consumption below 9 cl or total sobriety (22). The incidence of complete FAS was estimated by us in Gothenburg in 1976 to be 1 in 600 liveborn infants (25). In an inquiry we made in 1983 on behalf of a governmental selected committee, the incidence in Gothenburg and also in Sweden overall had decreased to 1 in 2,400 liveborn infants (27). At least three investigations have shown that intervention early in pregnancy and cessation of alcohol consumption before the tenth week of gestation has a very favorable effect on outcome, although it does not completely abolish the risk for malformations or slighter neuropsychological problems (3;26). The present incidence is not known. AMPHETAMINE
In contrast to alcohol, amphetamine abuse during pregnancy does not produce a distinct embryofetopathy with dysmorphism (21). The prospective investigations performed show significant reduction in intrauterine growth including an increased risk of microcephaly at birth. The only proper prospective study with long-term follow-up is from Larsson (22) in Stockholm and shows somatic catch-up growth postnatally but remaining neuropsychiatric problems at 7 years of age related to amphetamine abuse throughout pregnancy, but not to postnatal and environmental factors (21). There is a very slight absolute increase of organ malformations in most materials, although the statistical power of the investigations have not been able to show significance (21;24). If there is a slight increase for malformations, it is at least very slight and very much less than the probably 10-20% risk with alcohol abuse. HEROIN-MORPHINE
As with amphetamine, there is no dysmorphic or embryofetopathic picture described after heroin abuse (9;23). Available materials show an increased rate of preterm deliveries (about 30%), lightness for gestational age (30%), and neonatal microcephaly (
Alcohol and Narcotics Epidemiology and Pregnancy Risks Ragnar Olegard Moelndal Hospital, Sweden
Abstract Among alcohol and narcotics, alcohol is most comprehensively documented as a teratogen. However, for all other narcotics, data are continuously accumulating, convincingly displaying the teratogenic effects. The proportions between "somatic" teratogenicity and "behavioral" teratogenicity vary between the different agents. Preventive work in prenatal clinics and among social workers, as well as objective mass media attention to the problem, seems to have lowered the incidence of severe fetal alcohol syndrome where the above-mentioned activities have been practiced. The female alcohol consumption in Sweden decreased from 1976 to 1985; thereafter, a slow continuous increase is underway again, in Sweden the number of recruits to narcotic abuse peaked in the 1970s and early 1980s. Thereafter, the number of recruits among females decreased, but abuse has continued among the members of the older age groups.
ALCOHOL
One consequence of female heavy drinking is a fetal alcohol syndrome (FAS) in the offspring (25;26;28). An infant or child with a complete FAS is affected in three categories: growth retardation, which is prenatal and typically without postnatal catchup; typical facial dysmorphism with microcephaly, short palpebral fissures with flat maxillary area, and nasal bridge with thelecanthus and poorly developed filtrum and thin elongated upper lip; early central nervous system dysfunction includes different degrees of mental retardation, mostly of mild degree, and neurological and neuropsychological symptoms. The latter category includes hyperactivity, distractibility, impulsiveness, perceptive disorders, coordination difficulties, ataxia, and di- and hemiplegias (4;18). In the neonatal period, visual- and somatosensoric-evoked response resembles that seen after severe asphyxias (25). Hypoplasia of the optic nerve produce severe visual handicap in at least 20% of complete FAS, only 20% having a normal vision (30). Persons with complete FAS have a stable clinical and mental picture into adulthood (29). The risk of complete FAS is 20-40% if alcohol abuse continues through pregnancy. Most infants and children escaping a complete FAS after gestational alcohol abuse acquire fetal alcohol effects (FAE), which indicates that one or two of the three main categories of symptoms is not represented. Alcohol abuse increases the risk of spontaneous abortions, and of preterm labor and smallness for date to about 20%. Perinatal mortality is increased about 10 times. FAS is seen with certainty only after heavy drinking, probably correlating to daily intakes exceeding 30 cl of strong spirit for a substantial period throughout pregnancy. Between 9 cl and 30 cl of strong spirit daily, group differences have been found in development and neurobehavior per101
Olegard
formance compared to populations with a consumption below 9 cl or total sobriety (22). The incidence of complete FAS was estimated by us in Gothenburg in 1976 to be 1 in 600 liveborn infants (25). In an inquiry we made in 1983 on behalf of a governmental selected committee, the incidence in Gothenburg and also in Sweden overall had decreased to 1 in 2,400 liveborn infants (27). At least three investigations have shown that intervention early in pregnancy and cessation of alcohol consumption before the tenth week of gestation has a very favorable effect on outcome, although it does not completely abolish the risk for malformations or slighter neuropsychological problems (3;26). The present incidence is not known. AMPHETAMINE
In contrast to alcohol, amphetamine abuse during pregnancy does not produce a distinct embryofetopathy with dysmorphism (21). The prospective investigations performed show significant reduction in intrauterine growth including an increased risk of microcephaly at birth. The only proper prospective study with long-term follow-up is from Larsson (22) in Stockholm and shows somatic catch-up growth postnatally but remaining neuropsychiatric problems at 7 years of age related to amphetamine abuse throughout pregnancy, but not to postnatal and environmental factors (21). There is a very slight absolute increase of organ malformations in most materials, although the statistical power of the investigations have not been able to show significance (21;24). If there is a slight increase for malformations, it is at least very slight and very much less than the probably 10-20% risk with alcohol abuse. HEROIN-MORPHINE
As with amphetamine, there is no dysmorphic or embryofetopathic picture described after heroin abuse (9;23). Available materials show an increased rate of preterm deliveries (about 30%), lightness for gestational age (30%), and neonatal microcephaly (
