Drug Abuse in Pregnancy - Royal College of Psychiatrists

Drug abuse in pregnancy
Written by Sally Walsh
E-mail address- u9z40@students.keele.ac.uk
Word count 3006
The UK has the highest prevalence of drug misuse in Europe, with approximately one third
of all adults in England and Wales reported to have used drugs at least once in their
lifetime.1 The Office for National Statistics reported that in 2008 there were 2928 drugrelated deaths in England, with heroin being the most frequent cause. Also there were 9,031
alcohol related deaths, which is over double the rate from 19912,3.
Chart showing the alcohol related deaths from 1991 to 2009. Sourced from
http://www.statistics.gov.uk/cci/nugget.asp?id=1091(reference 2)
Addiction is a chronic psychiatric disease where there is dysfunction in the brain reward and
memory system. The addiction forces the individual to pursue reward by substance use. My
case study also reinforces the psychological impact of addiction. Within England in 2001 it
was estimated 118,500 people received treatment from drug misuse agencies4. It is very
difficult to find out exact figures because many do not seek help from health services.
Individuals who abuse drugs tend to receive more stigma than those with a mental illness
because people view drug abuse as a personal choice, and not a medical condition5,6.
Smoking, alcohol and illicit drug use in women of reproductive age is increasing and the
continued use of drugs during pregnancy is common6. In pregnancy, disapproving attitudes
towards drug misusers are heightened, as the welfare of the unborn child is considered.
Assumptions are quickly made about the mother’s ability to be a ‘good mother’ and care
adequately for her child 6,7. Many pregnant women with substance misuse problems do not
seek medical help due to fear of judgemental attitudes. Many people have an addiction,
whether it is coffee, alcohol or heroin, but some addictions are more dangerous and life
changing than others. We all find it difficult to stop taking something we love, and so why
should we judge others and their addictions.
Case study
My case study is based on facts recalled by a patient I spoke to during her alcohol
detoxification. To understand the psychological impact underlying her drug use it is told in
the first person.
“My name is Juliette and I am 31 years old. I live alone in a deprived area of Stoke-on-Trent. I
have two daughters and a baby on the way. My love story started when I was fifteen years
old. I was pregnant with my first child and loved the father Romeo more than words can say.
We were surrounded by poverty, unemployment and drug abuse, but we tried to ignore
these factors and get on with life. All I wanted was the best for our unborn child, and
thought Romeo felt the same. Money stresses started to mount and Romeo would come in
later from work, drinking away most of his earnings and not caring about the consequences.
One day I confronted him about his behaviour, and tried to remind him of his commitment to
me and our baby. Romeo looked at me like I was nothing, and I could see the hatred within
his eyes. Smashing his fist against the wall, he came towards me, never taking his burning
eyes off me. He sent terror through my whole body, as his alcohol smothered words
demoralised me. He talked to my face using his fist, he helped me lie on the floor using the
force of his boot, and he showed his love to me through bruises and broken bones. I
screamed at the excruciating pain and I was silenced with his hands encompassing my throat
and his spit on my face. My love story was crumbling and I was frightened for what the
future would bring.
He threatened to kill me if I tried to run away. Fear and love kept me rooted in this life of
torture and abuse, but at the age of 15 I couldn’t cope. Alcohol helped wash away the
physical pain, but it couldn’t wash away the psychological pain I endured. As the weeks of
abuse turn into months, I leaned on my alcoholic crutch more to help me get through the
It was only six months later when I needed a litre of vodka to help the day go by, and I was
using heroin to distance myself from my chaotic life, that I realised the spiral I was on, and
that there was a mountain to climb to be able to get out of this dark hole.
My daughter was born with fetal alcohol syndrome; she has a thin lip and struggles to
control her emotions. I tried to look after her, but as my heroin addiction increased and
money became low, Romeo forced me into prostitution. My little girl was put under my
mother’s care, and that was when I realised I needed to leave Romeo.
Three years on and I was buying £100 of heroin a day, and using prostitution to pay for it. I
had experienced two miscarriages, had another baby and opted for two abortions. My only
comfort was my drug use, by now I was also using cannabis and occasionally cocaine. I
longed to get my life back on track for my daughter. I went into rehabilitation and started
methadone to try and regain control of my addiction and my life. I didn’t want to go back to
the life I left behind, and I never have done.
Thirteen years on and I am seventeen weeks pregnant, stable on 68 mg methadone and just
finishing an alcohol detoxification. The courts decided both my daughters were better living
with my mother due to my drug misuse. Again it was an abusive relationship that started my
drinking habits, but this time I don’t want it to ruin my future, and the future of my unborn
child. Fear of my baby being taken off me, and determination to provide a stable life for the
two of us will hopefully keep me on track.”
Juliette was drinking eight cans of 7% strength beer a day, and has now successfully
completed her alcohol detoxification. She attends the antenatal clinic for drug users every
Tuesday, where at her twenty week scan, she was told her baby had signs of fetal alcohol
syndrome. At the moment she has a daily prescription of 68 mg methadone and 10 mg
diazepam, and smokes twenty cigarettes a day. She has no significant past medical history,
but had a forensic history for drug possession, public order offence and shoplifting. Her aims
for the near future are to find a house in a better area of Stoke-on-Trent and with the help
of the ADSIS team, remain alcohol free. Long term she wants to try and gain custody of her
children and to maintain a stable home life for her family.
My case study is based on alcohol and opiate use, for this reason I am going to focus on the
effects of these in pregnancy. From 2003 to 2005 there were 295 women out of two million
who died from pregnancy related complications, and 11% of these women had alcohol or
drug misuse problems8. Approximately one third of pregnant women smoke and 60%
consume alcohol
Pregnancy is a significant life event, and for women who have drug
misuse problems, it offers opportunities to change their life, as well as risks within
pregnancy. These women have the same hopes and aspirations for family life, and are
anxious about pregnancy and what motherhood brings 9,6.
It has been found that most patients who receive treatment for drug misuse are using
opiates or crack cocaine 16. Tolerance and physical dependence develops with regular use,
but surprisingly the physiological effects on the body are minimal when taken below
overdose levels. Abrupt withdrawal of opiates is rarely life-threatening and is less dangerous
than alcohol withdrawal, however withdrawal symptoms cause intense cravings therefore
making abstinence very difficult 6.
Chart from the National Drug treatment Monitoring System, showing the main drugs misused by patients who
seek treatment for their drug addiction. (Reference 16)
Many opiate users have menstrual irregularities and it can therefore be a huge shock when
they discover they are pregnant
From my experience many of these women feel guilty
about their addiction, but feel unable to stop using. The combination of shock and guilt
combined with fear that their child may be taken off them, may result in late presentation
to health services during pregnancy.
The stigmatisation and negativity directed at drug abusers causes an increased risk of social
avoidance, resulting in many drug misusers having a reduced supportive network around
them when trying to battle through their cravings and refrain from use. Pregnant women
misusing drugs need more support and monitoring, and so it is vital as health professionals
we work through these discriminatory boundaries, and try to establish early contact by
reassuring these women11. This can be done through a professional non-judgemental
attitude we can enhance their care6.
The drug using parents policy guidelines make it clear that drug misuse in itself is not a good
enough reason to separate a child from their mother. In court it has to be shown that it is in
the child’s best interests to be separated from their mother, due to the risk of harm the
child may be exposed to if left in their environment
I think it is important to reassure
mothers that their child will be able to stay with them if the child safety standards are met.
Within pregnancy, abrupt withdrawal of opiates is dangerous for the foetus, as it is
associated with miscarriage in the 1st trimester, and stillbirth or pre-term labour in the 3rd
trimester 17,6. The use of opiates like heroin increases the risk of injecting behaviour, which
can cause infection and the transmission of HIV, Hepatitis B and C, as well as increased risk
of drug related deaths from uncontrolled drug use 17,6.
Methadone is a prescribed medication which is used as a substitute for heroin, so patients
can stop abusing drugs and gain control of their life. The patients taking methadone have
regular checks and usually want to become drug free. A pregnant woman on methadone
receives more antenatal checks to monitor her and the foetus. Too many people are quick
to judge these mothers, and see them as unfit because of their methadone use. It is time
society offers support to mothers who are trying to get their life back on track, and
remember that a mother on methadone is not automatically a bad mother.
The Department of Health recommends the use of methadone for the management of
opioid dependence. It has a longer half life than heroin and so creates stable levels of the
drug within the mother and foetus
Opiates are not thought to cause congenital
abnormalities during pregnancy, but may cause prematurity, low birth weight, sudden
infant death syndrome and Neonatal Abstinence Syndrome 14, 18. Studies show that larger
maternal methadone dosages in late pregnancy are associated with increased risk of
neonatal abstinence syndrome14. As a result, methadone should be reduced within the
second trimester to the smallest tolerated dose. Neonates born to mothers receiving
methadone have a higher incidence of drug withdrawal, with more severe symptoms when
compared with those born to heroin addicts19. Symptoms typically appear within 48-72
hours but may not start until the infant is aged 3 weeks. Benefits of methadone use
compared to heroin are increased foetal growth and higher birth weights.
Neonatal abstinence syndrome is characterised by central nervous system irritability,
gastrointestinal dysfunction and autonomic hyperactivity, however on rare occasions
seizures have been reported. Due to the risks of the baby developing neonatal abstinence
syndrome, drug dependent women and their baby should stay in hospital for observation
for at least 72 hours after birth. To assess the severity of the neonatal abstinence syndrome,
the ‘Lipsitz tool’ or a modified version of the Finnegan chart is used. A high score may
indicate the need for supportive therapy, or pharmaceutical intervention. The most
effective and most used medication for opiate withdrawal is morphine. The hospital stay for
a neonate with severe symptoms is usually between 10-14 days.6
The medical intervention that may be required with neonatal abstinence syndrome can be
distressing for the mother, and so at their 32 week review, midwives should give these
mothers a leaflet called ‘Caring for a baby with drug withdrawal symptoms’, which explains
what they can expect when their baby is born6.
Methadone treatment during pregnancy is associated with earlier antenatal care and
improved neonatal outcomes. Follow-up studies suggest that women who enter a
methadone treatment programme during pregnancy have a better long-term outcome in
terms of their pregnancy, childbirth and infant development.17
I was happy to see that within North Staffordshire Hospital patients on Methadone
attended reviews each week, therefore enhancing the access to health services and ability
to pick up problems early on. It was good to see that these patients were seen at the
pregnant drug users clinic within the maternity building, which reinforced that these were
pregnant women who misuse drugs, and not drug misusers who were pregnant 10. I feel that
opiate users are one of the most stigmatised groups within society, and so can easily feel
secluded. With opiate addiction being so strong it is essential these women are given
enhanced support. These women need to be treated the same as other pregnant women,
with enhanced support, rather than letting their drug misuse cloud the most vital issues.
Alcohol is a legal and readily available within society, and so may be viewed as a safe
substance to use. Alcohol can have detrimental effects on the foetus, and has one of the
strongest associations with teratogenesis. During pregnancy a ‘safe’ level of alcohol use has
not yet been established, with literature providing a range from 1 unit a day, to 1-2 units a
week13,7. Women who drink heavily during conception are more likely to continue drinking,
and so it is crucial these women are identified and offered help. There is good evidence that
screening questionnaires can improve detection of drinking problems in pregnancy. These
screening tools are quick and easy to complete, and so should be encouraged in all
antenatal clinics 13,6.
Alcohol is associated with an increased risk of miscarriage in the 1st trimester, as well as
strong association with teratogenesis, and foetal alcohol syndrome12. Complications of
foetal alcohol syndrome are reduced foetal growth, central nervous system problems,
including cognitive dysfunction and neurological abnormalities, and
abnormalities. Studies have also shown that foetal alcohol syndrome causes delays in
language and mental development, impairment in learning and memory, and that up to 63%
develop hyperkinetic disorders later in life 14. Juliette described her daughter as having a
thin lip, and said that she had uncontrolled emotional outbursts, as well as poor
development at school. Studies into neurological changes associated with prenatal alcohol
exposure have shown that alcohol causes cortical atrophy and enlargement of the
ventricles, with the parietal lobe being the most affected region of brain14.
Due to the risks to the foetus associated with alcohol use, alcohol detoxification should be
considered at any time throughout pregnancy. It is essential to remember that sudden
cessation of high alcohol consumption is potentially dangerous to the mother due to the risk
of seizures, and may cause foetal distress; therefore it is imperative a safe alcohol
detoxification can be started. A pregnant woman receiving an alcohol detoxification has
increased risk of complications and therefore detoxification is usually within an inpatient
setting, where close medical monitoring from both obstetric and alcohol specialist teams
are available. The collaboration of these teams is crucial when dealing with these high risk
pregnancies 15,6.
It is all too easy to focus on the drug as the only risk during pregnancy, and forget about
other key issues. Juliet lived in poverty and had been forced into prostitution. A number of
drug users do not maintain good physical health, easily become dietary deficient and may
use other drugs such as tobacco. Many are unemployed and living in areas of social
deprivation, all of which further complicate the patient’s care. When a patient is undergoing
a detoxification it is important that these other issues are also addressed by the
involvement of many different professionals and agencies to help provide the best standard
of care for the mother and baby 15,6.
Alcohol abuse during pregnancy is a serious issue that needs to be addressed so that the
least harm possible is done to the foetus, however it is easy to forget about care to the
mother after the child is born. It has been found that relapse is more common after the
baby is born, because the mother is no longer able to cause direct harm to the foetus
through placental transmission, and because the mother has increased anxieties about
motherhood3. Relapse prevention services should be available for the mother as part of the
detoxification support so they can care for their child when they are most vulnerable. From
talking to pregnant women with drug misuse problems it became clear that they felt there
were not enough services available to them. One lady commented that she would have liked
to go to rehabilitation after her alcohol detoxification, but there were no rehabilitation
services that would take pregnant women.
It is evident that alcohol and substance misuse is a problem within the UK, and that
pregnant drug misusers are more at risk of obstetric complications. It is easy enough to see
a substance as safe, when it is legal and widely used within society, but with the increased
risk of teratogenesis public awareness of these risks needs to be heightened. I believe there
should be increased monitoring of alcohol and further guidance on the safe levels of
consumption, to make women more aware of the problems this accepted substance can
Pregnant women using opiates are one of the most stigmatised groups within society. We
should support these patients and encourage them to come to the services provided
specifically for them, and remember that opiate users cause less foetal harm than patients
who abuse alcohol.
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