Presentation on theme: "Dr Mary Rowlands Consultant Psychiatrist in Substance Misuse, ENDAS"— Presentation transcript:
1Dr Mary Rowlands Consultant Psychiatrist in Substance Misuse, ENDAS SOLOMON’S JUDGEMENT Alcohol/Illicit drug use, misuse and dependent use Pharmacological interventions in pregnant substance misusersDr Mary RowlandsConsultant Psychiatrist in Substance Misuse, ENDAS
2LECTURE OVERVIEW Introduction –evidence limitations Classification of misuse & dependenceGender & stigmatisationEffects of selectively clinically important drugsEvidence base of prescribing in pregnancyInteractive learning-Clinical multiagency practice & care pathways
3Evidence-based practice is mostly extrapolated from non-pregnant studies Evidence base for effects of illicit drugs on pregnancy (database search Medline, PsychLit)Evidence base for pharmacology interventions in pregnancy now established (BAP 2004)Pharmacological studies: Secretion of non-prescribed/prescribed drugs in breast milkClinician weighs these limitations, social care needs and complex clinical presentation of pregnant drug misuser in the assessment of risk to foetus to guide multi-agency managementSolomon had no evidence but used “clinical”judgement and chose the real motheras the woman whon acted in the best interest of her child
4Differences between ICD-10 & DSM-4 ICD-10 classification of Harmful use (physical, psychological harms causing damage to health)Nature of harm identifiable and specified criticism is it is limited to healthContinuous use for >1 monthTime similar to DSM-4 in intermittent use of >12 monthsDSM(IV) abuse emphasises social complications including impairment of adult functional roles, recurring in physically hazardous situations , legal, interpersonal; never met criteria for dependence
5Dependence definitions are more specific and similar Control loss (compulsion), tolerance, withdrawal, (neuroadaptation) secondary symptoms of salience & persistenceICD-10 difference-reinstatement after abstinenceDSM-4 difference is social,occupational, or recreational activities given up or reducedDSM5(2010) will emphasise that difference between abuse and dependence is the addicted state i.e. it is a behavioural difference in terms of pathological “disease” definition
6Legality, availability & potency of abused substances changed in 20th Century Cultural assimilationof “alien drugs “ is poorLegal until 1920Contrasts with lifting of wartime alcohol restrictions
7Unchanging social disapproval of female substance misuse denigrates womenModern social pressures are hypocriticalexpecting women to match men in amounts abused e.g. binge pattern
8Greater stigmatisation and adverse childcare outcomes compared to male drug misusers Greater physical complications from substance misuse compared with males for same quantity of substance becausethere are gender differences in body mass,and fat to water distribution for water soluble drugs e.g.alcoholMore common for substance dependent women to be in physically and emotionally abusive relationships
9Mary Hepburn: Empowering women to make informed reproductive health choices Prevalence of drug misuse has increased in both genders 2:1in terms of recent drug related deaths butM:F drug specialist service users is 3:1improved was 4:1
10Common themes in pregnant drug misusers Ambivalence-fear of maternal roleVersus motivation to change++Low self esteem, extreme guiltAssociated deprivation,domestic violenceReduced fertility but not infertile
11Common themes in pregnant drug misusers Irregular / absent periodsNo contraceptionUnplanned pregnancy common, further turmoilRisky chaotic lifestyle,Salience of drug seekingPoor multiagency attendance, avoids Social Service and antenatal
12Alcohol-our favourite drug Use <1 to 1 alcohol unit daily in pregnant (RCOG)Non-pregnantHazardous use:>2-5 units daily (RCPsych)Harmful use: >5 units dailylikely physical damage, especially bingesFoetal alcohol syndromeMay have modified syndromeDose related effect includingrepeated binges & individual susceptibility
13Foetal Alcohol Syndrome Underweight,small in body length at birthpoor growth and developmentfailure to thriveIrritable or fractitious, tremulous,Poor sucking responseHeart defects- about 30%Kidney problems-structural physiologicalHyperactivityDelayed development-psychomotor & language
16Stimulants- Physical signs of intoxication TachycardiaHypertensionSweatingPyrexiaDilated pupilsBut not always because:Chronic users develop tolerance
17Stimulant Withdrawal “Crash”- depression, lethargy, hunger Later- Craving, anxiety, irritability, depression, suicidal ideationExtinction- Specific cue related cravings
18Amphetamine effect on foetus Low dose no evidence. Harmful use:Higher dose, increased frequencyDecreased head circumferenceLength and birth weightGrowth restrictionIncreased rates of abruptionSevere (Dependence):intracranial lesions- cystshaemorrhage, infarction
19Cocaine most severe stimulant effects Meta-analysis of studies showed similar effects to polydrug misuse whether or not they misused cocaine.Polydrug misuse was the norm in one Australian study.
20Cocaine in USA pregnant, dependent users research associated with severe socio-economic deprivation Confounding variable because infant mortality rates in these areas approached third world statisticsIncreased risk ofabnormal pregnancyoutcomes including increased rate of SIDSCocaine vasoconstrictionIncreased abruption
21Benzodiazepine effects on foetus Diazepam-No proven association:head & digit abnormalitiesisolated reports contaminated by polydrug & alcohol misuseChlordiazepoxide-non reproducible study showed increased teratogenicity in 0-42 days old foetusIn high doses,?empirical definition>60mg/day/>3/12Flat, flaccid baby at delivery after recent useLate pregnancy- increased neonatal hypothermia, hypotonia, respiratory depressionNeonatal withdrawal symptoms:-poor feeding in full term, lower APGAR scores-respiratory depression in premature babies
22Hallucinogenic drug effects on foetus Plastic effects, unpredictable bad trips so less reinforcing and addict has more controlMaternal health education that although unimportant clinically in adult, too little is known of the effect on the foetusEcstacy also has stimulant effects (MDMA-methylene,dioxy, methamphetamine)Isolated reports of neurotoxic effects in adults related to frequent use commonly used in moderate dosesNo research on effect on foetus, mothers may seek health education on effect in the first trimester
23Cannabis effects on foetus -most commonly used illicit drug No consistent morphological abnormalitiesSome loose association with reduced birth weight & height.Subtle neurobehavioural abnormalities with heavy drug use described but not evidenced
24Heroin dependence effects on foetus No increased morphological abnormalitiesReduced birth weight & height.Premature birthsIncreased(2.5 x general population)peri-natal death ratesIncreased maternal death rates
25Management of SU problems Assess in therapeutic relationshipHistory, MSE, physical, urines, bloodsOther investigations as indicatedPsycho-social investigationsPPS formulation of problemsDetermine prioritiesHarm reduction
28Clinical Management is still pragmatic !!! Methadone Reduction in the middle trimester not a graded evidence base but expert consensusHigh rate of miscarriage in this group but rate 1 in 5 for all pregnancies so informed consent to start methadone in first trimesterDrug misusers less often reach full term, but it may be more related to state of nutrition/placental functionIncreased blood volume in third trimester may require an increase in Methadone so all methadone reductions should stop theoretically at weeks if client informed maybe later
29Methadone in pregnancy Higher dose titration –Higher birth weights,Achieves more antenatal careHigher NASI-P titration 10 to 20 mls, 4 hourly using modified Maudsley guidelines and opiate withdrawal scalesHeroin withdrawal begins at 24 hrs+ for neonateMethadone withdrawal begins at 2-7 daysSub-acute withdrawal may persist for 4-6 months since slower metabolism in neonates (Bell GL)Acute withdrawal monitoring in first monthincreased risk of SIDS, failure to thrive,fits,infection
30Methadone Assess/Treatment Quantity, frequency and route of use duration of opiate (heroin or methadone) useStage of pregnancyPast AND CURRENT treatment responseMMT Plus Comprehensive multi-agency antenatal careContingency planning for lapses in a chronic relapsing condition, even if a trial of abstinence in highly motivatedRegular core group reviewsEssential contingency plans
31Methadone in pregnancy increases duration, reduces complications & improves birth weight Reduces illicit drugsReduces blood borne virusrisk to mother and babyIncreases antenatalengagementReduces foetal distress by?steady blood opiate levels<20ml reduces NAS butdoes not reduce illicitdrug use, or infant death rate
32Buprenorphine [Subutex] in pregnancy Same rationale as MethadoneCompetative agonistAgonist-Antagonist-less intense opiate side-effectsBlocks opiate based pain relief in labourNAS less severe but less established evidenceContinue with pre-pregnant stabilised patient with informed consent but initiation complicated by need for early withdrawalPrevious Buprenorphine stabilization needs to be considered
33Opiates-Postpartum Neonatal Withdrawal Syndrome (NAS) Narcan should not be given,Increases rate of perinatal mortality by precipitating severe withdrawalJittery babies, poor feedingHigh pitched cry,vulnerable to fits.Rx Neonatal Paediatrician,Obstetrician,or SCBUMay need oromorph
34Opiates- Postpartum follow-up Methadone exposed foetus showed no difference in developmental progress compared with socially matched peers, in S London(Burns 1996)
35Opiates-Postpartum follow-up The health and development of a group of children aged 3-7 years born to and reared by mothers who abused opiates when pregnant and who remained on methadone maintenance was compared to a group of age and socially matched control children.There was no difference between the two groups in terms of health and development although smaller head circumference measurements than the controls.
36Opiates-Postpartum follow-up More than half of the index children had been on the child protection register during infancy; all but one were off the register at the time of the studyResults suggest that drug-abusing women who are on methadone maintenance and attending a drug dependency unit may rear and care for their children as well as parents from a similar social background who are not drug abusers.
37Breast feeding Low breast milk drug level (DOH) All mothers encouraged 3% of maternal plasma level in one studyBut 1-2 hours after any opiate medication advisedBaby immunity improvedWeaning off gradually helps manage but insufficient milk drug level to avoid NASExceptRisk of vertical transmission HIVAlso in Hepatitis B / C
38Breast feeding contraindication if Pregnant drug misuser is chaotic, or inconsistent useNot engaged or stabilised on methadoneHigh dose Methadone >80mlsstabilised does not excludeCocaine (also passes intobreast milk)Heavy amphetamine useincreases neonatejitters, irritabilityBenzodiazepines sedate
39Ia: Evidence from meta-analysis of randomized controlled trials BAP Recommendations Categories of evidence for causal relationships and treatmentIa: Evidence from meta-analysis of randomized controlled trialsIb: Evidence from at least one randomized controlled trialIIa: Evidence from at least one controlled study without randomizationIIb:Evidence from at least one other type of quasi-experimental study
40BAP RecommendationsIII: Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studiesIV: Evidence from expert committee reports or opinions and/or clinical experience of respected authorities
41BAP Recommendations Proposed categories of evidence for observational relationships I: Evidence from large representative population samplesII: Evidence from small, well-designed, but not necessarily representative samplesIII: Evidence from non-representative surveys, case reportsIV: Evidence from expert committee reports or opinions and/or clinical experience of respected authorities
42BAP Recommendations Strength of recommendation A: Directly based on category I evidenceB: Directly based on category II evidence or extrapolated recommendation from category I evidenceC: Directly based on category III evidence or extrapolated recommendation from category I or II evidenceD: Directly based on category IV evidence or extrapolated recommendation from category I, II or III evidenceS:Standard of Care based on expert practical or ethical consensus
44BAP Recommendations Alcohol & pregnancy Women should be advised not to drink alcohol or at most,one drink per day(S)Adequate screening should be routine(S)Psychosocial interventions should be offered & be the mainstay of treatment(B)Patients with symptomatic withdrawal should be offered medical cover for their detoxification ideally, as an in-patient(D)Medication to sustain abstinence should be avoided(D)
45BAP Recommendations Alcohol & pregnancy Key uncertaintiesRisks of alcohol withdrawal versus benzodiazepine prescribed versus continued alcohol consumption to the foetus and whether any trimester carries more risk than at other times?Risk of acamprosate, naltrexone or disulfiram in pregnancy?
46BAP Recommendations Opioids and pregnancy Methadone maintenance results in improved maternal & foetal health & should be offered to opioid dependent pregnant women (B)Less data are available for buprenorphine maintenance but it appears similar benefits are seen for mothers & foetus as for methadone(B)Detoxification should be avoided in the first trimester, is preferred in the second & used with caution in the third.
47BAP Recommendations Opioids and pregnancy Methadone is the best known substitute pharmacotherapy in pregnancy & willusually be the first choice; however, recent experience with buprenorphine is encouraging. Clinicians may therefore consider continuing buprenorphine in patients doing well on established treatment. Potential problems with opioid analgesia during labour must be anticipated
48BAP Recommendations Opioids and pregnancy Key uncertaintiesDoes Methadone or buprenorphine have advantages over the other in terms of maternal or foetal /neonatal outcomes?
49BAP Recommendations Stimulants and pregnancy Limited evidence to make any recommendations except say ‘stop’Substitution therapy is not recommended despite no studies(S)What to offer?
50Lecture SummaryUse and misuse is quantitatively imprecise in terms of foetal drug plasma levels achieved, addictive behaviour/patterns can guide clinicallyThe mainstay of treatment for use, misuse is education and brief interventions.Awareness of the potential risk of teratogenicity poor health in mother leading to poorer neonate outcomes,Advice aimed at the harm reduction that the mother can achieve and working to a hierarchy of health enhancing goals
51Lecture Summary Highest adverse foetal effect of high dose misuse and dependence especially stimulants and alcohol.In the majority of cases pharmacological alcohol detoxification is not required. Inpatient management is recommended.BAP recommendations for high dose Methadone maintenance to improve outcomes for mother and baby, but evidence base for buprenorphine is increasing, but dose effect is unknown.
52REFERENCES:Evidenced based guidelines for the pharmacological management of substance misuse, addiction and comorbidity: recommendations from British Association for Psychopharmacology,Journal of Psychopharmacology(2004)Management of drug misuse in pregnancy Ed Day & Sanju GeorgeAdvances in Psychiatric Treatment, Journal of Continuing Professional Development, The Royal College of Psychiatrists,Vol 11,Issue 4, July 2005, ,http://apt.rcpsych.org
53REFERENCES:- Methadone Neonatal Withdrawal Bell GL,Lau K Pediatr Clin North Amer,1995 Apr;42(2):Drug Misuse in Pregnancy Breastfeeding Project (2003)Breastfeeding and Drug Misuse: An Information Guide for Mothers:University of Plymouth.
54REFERENCE:-The health and development of children whose mothers are on methadone maintenance.Claire Burns , Margaret O'Driscoll , Gem WasonChild Abuse Review Volume 5, Issue 2, Pages (May 1996)Solomon had no evidence but used “clinical” judgement that the mother that acted in the best interest of her child was the true parent
55Case Study Late presenter isolated with partner Stabilisation as in-patient revealed minimisaton of useInformed maternal decision to breast-feedComplicated attitude from partner-previous partner died blamed drug services, he had care of 7 year-old daughter of this relationshipMedical history of this child of congenitalheart disease hiddenSocial services assessed as safe to return home with other child at core meeting
56Further pre-discharge meeting mother determined to breast-feed although duration of stabilisation was short-full risk info givenNeonatal paediatrician found no spcific signs of withdrawal—did not access maternal notes(system now changed)Mother went home and apparently cooperative with community mid-wivesNot informing them nursing baby in bedOver a weekend unilaterally rapidly reduced Methadone dose-pharmacist unaware recently delivered-used heroin, baby rolled off bed died of hypothermia
57Lessons from local perinatal death of continued Maternal Heroin Use whilst prescribed Methadone Post-natallyRisk to baby increased if no evidence of clean urines and/or unstable drug use even though the addiction treatment service philosophy and evidence base is harm reductionbut heroin use must be reduced enough to allow a suitable environment for safe &sustainable child care routines and requires urgent review which may need to be intensive & on-goinge.g. be aware of protracted neonatal methadone withdrawal, twice weekly drug urinalysis during early post-natal period > 14 days, supplemented by further health & social care worker monitoring
58If there is evidence of continued drug use then drug using carer in the household increases risk of harm to the child post natallyRisk management is required of the potential for mother to fall asleep at night whilst feeding baby, due to heroin use on top of methadone, but what should be the child protection consequences of “dirty urines”, in practicesocial services reluctant to implement child removal if mother is “cooperating”with drug & obstetric services and prescribed Methadone
59Should mother & baby be admitted to increase dose of methadone for safe monitoring, what about the risk assessment and management if other children require child carePrevious parenting may not be relevant since past drug misuse may have been more stable & less severe than current drug misuse
60If parents are rejecting of services antenatally and present later in pregnancy more child protection is needed if parental preference is for breast feeding, both in terms of access to the home&/or trying to control the script by altering medication without involvement of keyworker or prescriber, this behaviour increases risk & communication from pharmacist essential
61Proposed Care Pathway developed locally Rapid assessment including health education for harmful use and access into treatment ideally no later than early in middle trimesterPrompt Specialist S/m Cons and liaison nurse involvement, and Cons O&GS/m Specialist 5ml/week reduction or stabilise by 32 week ideally then involve neonatal paediatrician to plan neonatal management at & post-delivery, into puerperium
62Proposed Care Pathway contd Locally developing multiagencyguidelines with social services with 4 weekly core group meetingsFor the future aspirations to more shared care with GPSi and antenatal services but multiagency pathways must first work in practice in specialist services before altering the model of service
63Management of primary dependent stimulant users is a greater issue for amphetamine rather than cocaine in SW England. Polydrug use is the norm. Systematic development of pilot intensive community based psychosocial programmes is required to improve evidence of enhanced foetal outcomesBAP recommendations underscore the experimental evidence base as well as the expert consensus for treatment of pregnant drug misusers which does exist & should be incorporated in routine joint working between obstetric, social & substance misuse services