substance misuse in pregnancy ipna conference ‘old issues...

Deirdre Carmody, Drug Liaison Midwife

HSE Dublin Mid-Leinster 1

Substance Misuse in Pregnancy

IPNA Conference ‘old issues-

new ideas’ 11-10-13

Deirdre Carmody, RGN, RM, Msc in Nursing (Addictions and Substance related difficulties).

Drug Liaison Midwife (DLM) Clinical Midwifery Specialist (CMS). HSE Addiction Services Dublin Mid-Leinster.

Plan: ‘old issues-new ideas’

Drug use in pregnancy.

The role of the Drug Liaison Midwife

Statitics 2012

Present the findings on Research entitled

: Drug use in pregnancy: challenges for health care workers. and

: An exploratory study into the experiences of pregnant women attending methadone clinics in Dublin who continue to use heroin.'

Discuss the changing drug and alcohol trends in Ireland and the challenges in caring for these women in pregnancy.



Common drugs abused in pregnancy.

Opiates - Heroin

- Methadone

Benzodiazepines

Cocaine

Hypnotics - night sedation

Head Shop Drugs (on-line powders and pills)

Cannabis

Alcohol

Nicotine

Codeine



What’s so different about these pregnancies?

Women are

Reluctant to engage with health services.

Risks of miscarriages, bleeding in pregnancy, spontaneous abortions and IUD.

Newborn –

Risk preterm labour and small for dates.

Risk of Neonatal

Abstinence syndrome (NAS).

Risk of cot death.

Other problems

Recurring admissions to hospital with chest infections.

Risk of Sexual Transmitted Diseases.

Risk of Homelessness.

Risk of Deep Venous Thrombosis.

Vertical transmission of HIV, Hep C and B.



www.drugs.ie



Three Drug Liaison Midwives: Clinical

Midwifery Specialists

Victoire Hurley – HSE Dublin Mid-Leinster

Linked to National Maternity Hospital

Justin Gleeson - HSE Dublin North East.

Linked to Rotunda Hospital

Deirdre Carmody – HSE Dublin Mid-Leinster

Linked to CWIUH

In 2012, 202 (87 +35+80) live babies were born to opiate-dependent women in the 3 main Dublin maternity hospitals.



The role of the DLM

To case manage all pregnant drug dependent women providing education and support during their pregnancy.

To liaise between the obstetric service and the drug treatment service to ensure that the women are followed comprehensively in both services and that good communication exists between both teams.

Give on going support in women in accessing priority drug treatment (methadone treatment) and admission to residential drug treatment centres (Cuan Dara, COH and St Michael’s Ward Beaumount Hospital).

The ability to establish a relationship with this group of women early in their pregnancy has not only improved accessing and attendance to drug treatment and antenatal care but has given women a more positive experience to being pregnant.



CWIUH: Team (A) Dr O’Connell

Specialised Antenatal Team (estd 2008)

A specialised clinic team supporting women with opiate dependency, syphilis and blood borne diseases hepatitis B, hepatitis C and HIV. Every Tuesday morning OPD. GUIDE team St James H attend every second Tuesday.

Liaise with Paediatrics CWIUH, Community Social Workers, Addiction Service, Consultant Psychiatrist, Rainbow Clinic, Crumlin Hospital, Hepatology dep, SJ H and GPs in the community.

The total number of women linked with the DLM who attended the specialised clinic in the CWIUH in 2012 and linked to the DLM was 122 women (85 women delivered + 37 still pregnant on 31-12-12).



In 2012

24% Opiate positive at delivery (heroin).

7 women (8.2%) prescribed benzodiazepine (30% in

2011) and 12 (14%) women (7 in 2011) were

identified as abusing benzodiazepine.

6 women reported taking cocaine four weeks before

delivery and one women earlier in pregnancy. (4 in

2011 at delivery with 11 hx of cocaine use in

pregnancy)

2 women were abusing alcohol (2 in 2011) and one

women earlier in pregnancy.



Out of 87 live babies linked to DLM

It is encouraging that there were no babies born before arrival (BBA) to the CWIUH and all the women were booked into the hospital before delivery.

The mean gestation completed 38 weeks,

range 24 – 41 4/7wks

16% preterm (less than 37 weeks gestation) (21% in 2011)

From DLM knowledge, 9 babies to foster care.



(CWIUH) Babies RIP 2012, 2011,

There were no intrauterine deaths (IUD) or cot deaths among women opioid dependant in 2012.

From the 71 babies born in the

CWIUH linked to the DLM in 2011 there was

Three deaths :

Intrauterine death (IUD) of a girl at 35 6/7 gestation (one IUD in 2010 at 38 5/7).

Preterm delivery of a girl at 23 6/7, lived a few hours,

Preterm delivery of a boy at 21 6/7 died at birth.



(CWIUH) Babies and SCBU over 11 years.

04 05 200

6

200

7

200

8

200

9

201

0

201

1

201

2 No. of

babies

admitted

to SCBU

46/82

56%

46/81

57%

52/8

9

58%

35/76

46%

39/76

51%

48/83

58%

32/64

50%

41/68

60%

44/87

51%

No of

babies

needing

pharmac

ological

treatmen

t for

neonatal

abstinen

ce

syndrom

e (NAS)

29/82

35%

34/81

42%

36/8

9

40%

23/76

30%

22/76

29%

28/83

34%

12/64

19%

17/68

25%

+ 2

late

onset

NAS

Cruml

in

hospit

al

13/87

15%



Research: Drug use in pregnancy:

challenges for health care workers.

A comparative study to examine maternal and neonatal outcomes of pregnant women from a case load of the Drug Liaison Midwife (DLM) over a six year period: 2002 – 2007 with a similar study carried out in 1999 (Scully et al 2004) in the same locality Coombe Women and Infants University Hospital Dublin (CWIUH).

436 women met the inclusion criteria of the study.



Research Results Heroin Use

The age of first experimenting with

heroin has reduced to 17yrs.

There was a small decrease in the

women admitting to taking heroin

30 days prior to DLM initial

assessment

Secondary Drug Use

Although the majority of women

were cigarette smokers, there has

been a 13% decrease in the

number of women smoking.

9% fewer women gave a history of

using benzodiazepines.

There was a significant increase

(13.9%) of women reporting past

cocaine use.

Maternal Characteristics

The mean maternal age at DLM

initial assessment was higher. An

older group of women suggests

potentially a more chronic history

of substance misuse.

There was a slight increase to

more parous women delivering

than primiparous women.

Women are presenting earlier to

CWIUH for booking visit.

The majority of women were found

to have a satisfactory antenatal

attendance.



Research Results

Neonatal Outcomes

The mean birth weight has increased by 66g to 3015g.

The mean gestation at delivery remains at 38 weeks.

There was a substantial increase in neonates needing admission to SCBU and requiring pharmacological treatment for withdrawals.

There was an increase in the mean length of days (2.77 days) neonates were in SCBU.

Maternal Methadone Dose

The majority of women (93.3%) were in treatment on oral methadone at the DLM initial assessment.

The mean methadone dose at both assessment and delivery in this study was 60 mg, which was a marked increase from the 1999-2000 study of 42 mgs on assessment and 39 mgs at delivery.

The upper range of mean maternal methadone doses has substantially increased since 1999.i.e. the upper methadone value moved from 110mgs methadone on initial assessment in 2002 to 145mgs methadone on initial assessment in 2007).



Methodology:

Aim: to explore the experiences of pregnant women who attend a methadone clinic but continue to use heroin.

Objectives: to explore from the drug-using women’s perspectives,

The factors that influence them to continue using heroin in pregnancy while on a methadone programme.

The factors that would assist in the reduction or cessation of heroin use in pregnancy while on a methadone programme.

Seven women, the inclusion criteria for this research were pregnant women who were over 24 weeks gestation, attending a methadone programme for over a four month period and using heroin.



Findings- Themes

Women’s feelings about

- their pregnancy.

- their drug treatment programme.

- their maternity hospital.

- their heroin use in pregnancy.

Women’s concerns

- for their unborn baby.

- regarding their ability to mother.

Influences to continued heroin use

- Vomiting in pregnancy.

- The need to escape reality and their environment.

- The influence of male partners.

- Environment.

Factors in their treatment that would help them stop using heroin.



Discussion of findings

Women’s feelings

Positive feelings about their pregnancy.

A false belief that heroin use caused infertility.

Liked a non judgmental attitude by staff.

Feelings of guilt and shame at their heroin use.

Heroin use was part of the fabric of their lives.




Women’s concerns Drug using pregnant women shared the same concerns as the

normal population of pregnant women regarding labour and motherhood.

Concern for their pregnancy. Pregnancy was a motive to enter drug treatment. Entering drug treatment was described as being quick and smooth.

Fetal movements were both a comfort and concern to the women. They reported that feeling fetal movements helped them to accept they were pregnant but also excessive movements caused them concern that the baby (intero) was withdrawing from methadone and/or heroin.

Motherhood.




Influences to continued heroin use.

- The findings of this research suggests that in pregnancy, although women continue to use heroin, there was an attempt to reduce their heroin intake indicating that pregnancy itself can be a motive to change drug behaviour.


Partners using heroin appeared to be a critical contributor to heroin use. Some partners continued to use heroin but insisted that the women to come off their drugs. Also evident was how sensitivity women were to their partner’s comments and criticisms of their heroin use.

-





Partners not in treatment.

Partners who are not prioritised onto a methadone treatment programme and put on long waiting lists, can influence pregnant women to continue using heroin. Results showed the frustration and difficulties within a relationship when one member of the relationship is denied treatment.




Influences to continued heroin use.

Substituting heroin was found as a general coping strategy for relieving the stress of life and feelings of depression.

Violence in the form of physical and emotional abuse by their partners.

Accommodation problems.

Having a drug-using social network.



Conclusions

That drug use in pregnancy is complex and that there are no simple predictors of pregnant women’s continued heroin use while on a methadone programme.

Most of the pregnancies were unplanned and the women had a false perception that heroin use caused infertility.

In general, women had a positive experience regarding their interactions with professionals both in the drug service and maternity service.

Women were happy with their dose of methadone and the only complaints were the taste of methadone and being unable to tolerate the methadone due to vomiting in pregnancy.

Feelings of guilt were common among this group of women both to being on methadone and using heroin in pregnancy.



Discuss the changing drug and alcohol

trends in Ireland

Ageing heroin population

No waiting list for methadone

treatment in Dublin.

Drug use increasing outside

Dublin particularly commuter

towns.

New generation of women in

childbearing age with addiction

to newer drugs.

Internet: the new drug dealer,

Online shops selling legal

highs (693 online shops) and

the rise of powders and pills,

Hash replaced by ‘skunk’ (stronger)

in Ireland.

Alcohol and home drinking…always

the bigger problem!!!!

Problems with self disclosure of

drug use in pregnancy.



External review of methadone treatment

protocol 2010 Main reason for waiting lists

outside of Dublin is lack of

level 2 GPs (enables doctors

to initiate treatment). Late 2008

on-line training module

covering level 1 for GPs.

Recommended for level 2 GPs

changing cap for number of

patients from 35 to 50 and

abolishing a cap for level 1.

Recommends the introduction

of a model of GP nurse

practitioners who work to both

support and move patients on

from clinics to community GPs.



Close to home: a study on the misuse of drugs and

alcohol in the Midland region. 2010

Midland regional drugs task force

covers 4 counties Offaly, Laois,

Longford and Westmeath.

Geographical distances were both

a barrier and a burden to service

users. Recommendation: A

service close to a persons home

and a decentralised approach to

the addiction services i.e.

community GPs and pharmacies.

Also recommends nurse

specialists in the community

supervised by addiction

psychiatrist similar to UK and

Australia



2012: HIV in Ireland Report, HSE-Health

protection surveillance centre www.hpsc.ie From a total 341 new

diagnosis HIV in Ireland 2012,

there was a decrease in new

diagnosis of HIV from 74 in

2004 to 13 in 2012 (down

82%) among IDUs.

Of the 22 pregnant women

newly diagnosed HIV only 3

women were IDUs.



New guidelines for GP practice

Three DLMs contributed to the National Guidelines Pregnancy and neonatal care re pregnant drug users for the Irish College of General Practioners (ICGP). Requested by Denis O’Driscoll (on board) and Joseph Doyle 17-1-12, Chair of the working group established by the HSE to progress recommendations from The Introduction of the Opioid Treatment Protocol.

'Methadone Prescribing and Administration in Pregnancy' accepted as a national document with the Institute of Obstetricians and Gynaecologists Royal College of Physicians of Ireland and the Directorate of Strategy and Clinical Care Health Service Executive. Will improve communication between GPs and pharmacies and maternity hospital regarding methadone dispensing.



Title of Guideline: Methadone

Prescribing and Administration

1. GUIDELINE STATEMENT:

2. GUIDELINE PURPOSE:

3. SCOPE OF GUIDELINE:

4. DEFINITIONS:

5. GUIDELINE:

5.1 Background

5.2 Care of Opiate-Dependent Women

5.3 Symptoms and Signs of Overdose

5.4 Clinical Scenario 1: Patient admitted and known to be on prescribed methadone from case notes information or from verbal history

5.5 Clinical Scenario 2: Patients admitted with a ‘take–away’ methadone supply.

5.6 Clinical Scenario 3: Patients admitted to hospital self-reporting heroin use but not registered with the addiction services or a prescribing GP

5.7 Clinical Scenario 4: Patients admitted looking for a prescribed dose of methadone out of hours and known to be on prescribed methadone from case notes information or from verbal history

5.8 Intoxicated patients

5.9 Management of vomiting in pregnant women on MMT

5.10 Discharge of methadone- maintained women

6. PRODUCTION/CONSULTATION TRAIL

7. REFERENCES/BIBLIOGRAPHY



A window of opportunity.

As long as women abuse

drugs in pregnancy we will

be challenged with treating

them appropriately.

Pregnancy can be a great

motivator and offers a

window of opportunity for

women to engage in

services and stabilise their

drug use



Recent publications

Carmody, D., Gleeson, J. & Hurley, V., (2009) ‘Drug Use in Pregnancy’ at www.drugs.ie

Carmody, D., Geoghegan, N., Sheppard, R., Scully, M., Keenan, E., O’Connell, M. (2010) Drug use in pregnancy: challenges for health care workers: Midirs Digest 20:4.

Cleary B.J., Donnelly J., Strawbridge J.D., Gallagher P.J., Fahey T., Clarke M. & Murphy D.J. (2010a) Methadone dose and neonatal abstinence syndrome—systematic review and meta-analysis. Addiction;105 (12):2071-84.

Cleary B.J., Donnelly J., Strawbridge J.D., Gallagher P.J., Fahey T., Clarke M. & Murphy D.J. (2010b) Methadone and perinatal outcomes: a retrospective cohort study. American Journal of Obstetrics & Gynecology, doi: 10.1016/jajog.

Cleary, B. J., Eogan, M., O’ Connell, M. P., Fahey, T., Gallagher, P. J., Clarke, T., White, M. J., Mc Dermott, C., O'Sullivan, A., Carmody, D., Gleeson, J. & Murphy, D. J. (2012a) Methadone and perinatal outcomes: a prospective cohort study. Addiction, 107, 1482-1492.

Cleary, B. J., Reynolds, K., Eogan, M., O’ Connell, M. P., Fahey, T., Gallagher, P. J., Clarke, T., White, M. J., Mc Dermott, C., O'Sullivan, A., Carmody, D., Gleeson, J. & Murphy, D. J. (2012b) Methadone dosing and prescribed medication use in a prospective cohort of opioid-dependent pregnant women.. Addiction, doi:1111/add.12078.

http://www.drugs.ie/

substance misuse in pregnancy ipna conference ‘old issues...

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