Evidence-based management of substance misuse in pregnancy

Working with pregnant women with problematic substance useMany women who use substances problematically are reluctant to contact health services or seek support during their pregnancy (Macrory, 1998).

“All the time we have to confirm in our surroundings that we are capable of taking care of our children” (EMCDDA, 2009)

“No one, not even social services did not have a clue about me taking drugs. That was pact between me and my partner – we must not tell anyone about our drug use if we want to keep this baby” (EMCDDA, 2009)

Maintaining engagement

• Women who misuse alcohol or drugs may be wary of contact with health and social care services.

• They can feel inadequate as mothers and fear they will be criticised.

• They may also fear that the baby will be taken away from them by children’s social care.

Barriers to engagement

Evidence suggests the following barriers to engagement with antenatal services (RCOG/RCM, 2010) :

• Feeling awkward or ill at ease.

• Fearing being judged.

• Staff being judgemental or having a poor attitude.

• Staff lack of knowledge of support or services available.

• Lack of understanding by staff of issues faced by the woman.

Partnership working

• To overcome these barriers, partnership working is vital.

• To engage and maintain a woman in support the practitioner must work in a non-judgemental, person centred way.

• The longer term harms from disengagement need to be considered rather than short term potential risk.

• A pragmatic approach with individualised care may be more appropriate than expecting abstinence and compliance.

(Goodman, 2009)

Catalyst for change (DoH, 2007: Macrory, 1998)

• Pregnancy or wanting a baby can be a catalyst for change.

• It presents an opportunity to work closely with the woman to reduce her use and engage her in treatment.

• Pregnancy represents a change of life – a new opportunity.

Women’s voices (EMCDDA, 2009)

“At the time that drug addicted women get to know that they are pregnant the self-motivation to interrupt the drug use is the strongest of all.”

(Social Worker)

“After the birth I took things seriously. Slowly I reduced drug use. If [I’d known] before that the baby [would] change my life... I would get pregnant even earlier.”

(Drug-using mother)

Management of the antenatal mother (DoH, 2007)

The objectives of management are to achieve medical, social and psychological stability by:

• Engagement for close monitoring of antenatal care and substance treatment.

• Co-ordination of services – care should be multidisciplinary.

• Risks and needs should be assessed early.

• Agencies should consider convening case conferences around unborn children if there appears to be a significant risk of harm when they are born.

Management of the withdrawing baby

• This is a specialist area of care, but the basic principles are outlined here.

• Some babies may suffer neonatal abstinence syndrome when they are born - essentially the baby is suffering withdrawal symptoms from the maternal drug use.

• It is important that frontline practitioners are able to recognise symptoms of withdrawal in the baby and access multidisciplinary support for both mother and baby.

Identifying neonatal abstinence syndrome

• A new-born baby who has been exposed to opiates or methadone in the womb needs to be identified quickly.

• Symptoms are:

– High pitched crying and fast breathing.– Fever, sneezing, trembling, irritability.– Diarrhoea and vomiting.– Excessive sucking and difficulty in comforting.– Muscle spasms and occasionally seizures.

Management of the withdrawing baby and its mother

• An irritable and distressed baby can present difficulties in bonding for the mother.

• Both mother and baby require specialist support to manage baby’s withdrawal from opiates and support mother and baby bonding.

• Breastfeeding should be encouraged, even if the mother continues to use drugs, except where she uses cocaine or crack cocaine, or a very high dose of benzodiazepines (DoH, 2007).

Management of the withdrawing baby: continuing problems (Rassool, 2001)

Effects of other drugs may present after a few days/weeks and need specialist assessment. These may be:

• Feeding difficulties • Sleeplessness • Excessive crying• Muscle spasms and tremors• Startle response• Developmental delay – i.e. visual acuity

Women who use alcohol in pregnancy (BMA, 2007, DoH, 2007)

Women who drink alcohol in pregnancy increase the risk of developmental and birth disorders in the baby. The range of problems are referred to as foetal alcohol spectrum disorder (FASD).

Key points about FASD

• Early pregnancy is the most crucial timeto avoid alcohol – the first 3 months.

• Ideally, women should abstain from alcohol throughout the pregnancy and while trying for a baby.

• Prevention of FASD requires an multi-disciplinary team approach involving antenatal, social services and substance misuse practitioners.

Main signs and symptoms of FASD

• Cranial and facial distortion.

• Learning disability.

• Hyperactivity.

• Impaired emotional, social and

cognitive development.

• Attention deficits.

Alcohol and pregnancyNICE guidelines: ANTENATAL CARE (2008)

• Pregnant women and women planning a pregnancy should be advised to avoid drinking alcohol in the first 3 months of pregnancy if possible because it may be associated with an increased risk of miscarriage.

• If women choose to drink alcohol during pregnancy they should be advised to drink no more than 1 to 2 UK units once or twice a week (1 unit equals half a pint of low strength lager or beer, or one shot [25 ml] of spirits. One small [125 ml] glass of wine is equal to 1.5 UK units).

• Women should be informed that getting drunk or binge drinking during pregnancy (defined as more than 5 standard drinks or 7.5 UK units on a single occasion) may be harmful to the unborn baby.

Health promotion: The role of practitioners (BMA 2007)

• Practitioners should give ongoing advice on FASD and offer support at all stages of pregnancy as part of routine support.

• Health advice should be supplemented with ‘take home’ printed information on the risks of consuming alcohol during pregnancy.

• Include health promotion initiatives include targeting women at risk including those in ‘difficult to reach’ groups.

Monitoring: The role of practitioners (BMA 2007)

• Verbal drug and alcohol screening should be performed during routine antenatal support and care (see the resource on Basic assessment).

• Antenatal care should include alcohol monitoring.

• All antenatal practitioners should be trained and able to deliver brief intervention counselling or refer on to specialist services.

References• BMA (2007) Fetal Alcohol Spectrum Disorders. London, British Medical Association. • Department of Health (England) and the devolved administrations (2007). Drug

Misuse and Dependence: UK Guidelines on Clinical Management. London: Department of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive.

• EMCDDA (2009) Women’s voices: experiences and perceptions of women who face drug-related problems in Europe. Luxembourg, European Monitoring Centre for Drugs and Drug Addiction.

• Goodman A (2009) Social Work with Drug and Substance Misusers, 2nd ed. Exeter, Learning Matters.

• Macrory F (1998). Drug use, pregnancy and care of the new-born. In: Rassool, Substance Use and Misuse. Oxford, Blackwell.

• NICE (2008) Ante Natal Care. Clinical Guideline 62. available at: http://www.nice.org.uk/guidance/cg62/chapter/1-recommendations#lifestyle-considerations

• Rassool G H (1998) Substance Use and Misuse. Oxford, Blackwell. • RCOG/RCM (2010) Pregnancy and complex social factors: A model for service

provision. Royal College of Gynecologists/Royal College of Midwives. NICE.