SUBSTANCE MISUSE

1. SUBSTANCE MISUSE in PREGNANCY

2. Key Issues for Substance Using Pregnant Women • Whether to disclose substance use for fear of stigma • Fear of referral to Social services • Fear and confusion that the baby may be taken into care • Fear that she will be blamed if anything goes wrong with the pregnancy • Fear of been seen as an unfit mother if she doesn’t agree to a detoxification programme or a reduction of her drug use • Unaware or in denial about the effects drugs and alcohol may have on the baby • Unclear about the safe limits of alcohol to be consumed in pregnancy.

3. Good Practice • Important that the woman has access to advice, support and treatment for substance misuse as soon as possible – refer any pregnant drug or alcohol using Mother’s to treatment services for support asap. • Whittington procedure: refer all pregnant illicit drug users to CSCT (Islington CP referral pathway).

4. Safe level of alcohol during pregnancy? • Damage caused depends on level of alcohol, pattern of alcohol exposure and stage of pregnancy when consumed • Just one significant episode of binge drinking can cause harm to the developing foetus • Mothers do not necessarily need to be dependently drinking to cause harm • Other risk factors inc. genetics, nutrition, hormones, other drug use • 1-2 units weekly or no alcohol?-Recent DOH guidelines advise abstinence

5. Monitoring & detecting maternal alcohol consumption • Implementation of evidence-based interventions to reduce risk • “Accurate consumption histories should be taken sequentially, not retrospectively. Use of screening questionnaires will increase the identification of at-risk women, allowing safe drinking advice to be offered.” (Mukherjee, 2006) • Professionals to focus on the substance misuse of the mother and not minimize the risks or substance use due to the mothers social class.

6. Problems with Monitoring & Detecting Alcohol Use • Under-reporting (women may feel afraid or embarrassed to admit they are drinking) • Embarrassment of healthcare professionals (who may view monitoring as intrusive) • Difficulty in ascertaining consumption levels (in early stages of pregnancy) • Inaccurate recording of patient alcohol histories • Poor use of screening techniques & follow-up procedures

7. Neo-Natal Abstinence Syndrome and Foetal Alcohol Syndrome

8. Neonatal Abstinence Syndrome Neonatal abstinence syndrome (NAS) is a condition that some babies experience when withdrawing from certain drugs that the mother has taken during pregnancy. Drugs such as, Heroin, Methadone, Alcohol, Amphetamines and Codeine Once born, the baby is still dependent on the drug; since the drug is no longer available, the baby experiences withdrawal symptoms. The drugs pass through the blood-placenta barrier, into the developing foetus and then cross the blood-brain barrier of the foetus.

9. NAS cont.… Symptoms of withdrawal may include: Excessive, high pitched crying (‘mewling’ cry) Tremor Sleep problems Tight muscle tone Seizures, Fever and Sweating Poor feeding or excessive sucking Vomiting Loose or watery stools Jerky movements Irritable Increased risk of SIDs in first 3-weeks Severe cases need to be treated with morphine

10. Opiates… • Poor foetal growth • Small head size (microcephaly) • Sudden withdrawals can cause foetal death, miscarriage or premature labour • Increased death rates during delivery (due to depression of breathing) • Intrauterine growth restriction • Pre-term delivery (associated with fetal withdrawals in-utero, poor diet and maternal health) • Risks of Transmission of Blood Bourne Viruses if mother an injector • NAS starts 24-72 hours after birth • Can last 3-6 months • Some babies have seizures

11. Cocaine and other Stimulants… • High neonatal blood pressure • Children twice as likely to be delayed at two-years old • Deficits in concentration reported at 6-years • Stimulants may have a permanent effect on brain chemistry and function • Early pregnancy increased risk of miscarriage • Later pregnancy increased risk of premature birth • Cocaine cuts the flow of nutrients and oxygen to the foetus, causing increased risk of Placental Abruption, Intrauterine growth restriction (including reduced brain growth) and Underdevelopment of organs/limbs • May cause an unborn baby to die, or to have a stroke which can result in irreversible brain damage • Babies likely to be born with smaller heads and smaller brains proportionate to body size. • Risk of Transmission of Blood Bourne Viruses if mother an Injector

12. MDMA (Ecstasy) • Animal studies show: • Reduced dopamine and serotonin in parts of brain • Reduced birth weight • Long-term learning and memory impairment • Behavioural alterations in rats • Only been one human study which showed exposure to • ecstasy increased congenital malformations (McElhatton, 2004)

13. Cannabis • Data is unclear about impact although Cannabis usually mixed with tobacco so has same risks as tobacco: • Miscarriage • Pre-term delivery • Still birth • Intrauterine growth restriction • Placental Abruption • Reduction of Breastmilk • Sudden Infant Death Syndrome • Lowers foetal heart rate • Increase of carbon monoxide in foetal blood • Children respond less to light stimuli and ‘self quieted’ themselves less than other infants, such children also had heightened tremor and startle responses (Fried, 1980, 82). • Inattention, hyperactivity, impulsivity in children (Reece, 2009).

14. Benzodiazepines • Little evidence although some reports of : Facial abnormalities (i.e, cleft lip and palate) • Withdrawal Symptoms (dependant women advised to do a gradual reduction during pregnancy )

15. Hallucinogens and Solvents • Again little evidence regarding the effects of hallucinogens • Inhaled solvents may reduce oxygen supply to the foetus • Neonatal Withdrawals reported in heavy users of Solvents • Solvent users run the risk of sudden death

16. Methadone • Prescribed Opioid substitute • Prevents mother and foetus experiencing withdrawals once dose is stabilised • Reduces the risks of injecting behaviour • Reduces risks of taking unknown substances • Helps mother withdraw from other drug users • Reduces involvement in crime related to drug use • Provides stability and engagement with services • Usually improves nutritional intake and general health of mother

17. Treatment Options • Ideally abstinence • Stabilise opiate users on methadone • REFER ALL PREGNANT DRUG or ALCOHOL USERS TO LOCAL COMPLEX NEEDS TREATMENT SERVICE:

18. Foetal Alcohol Syndrome • Alcohol is a teratogen; a substance that can cause birth defects. • Foetal Alcohol Syndrome (FAS) affects the way a baby’s brain develops. • Ethanol readily crosses the blood-placenta barrier and then passes through the baby’s blood-brain barrier. • Children with FAS have distinct facial features including: small and narrow eyes, a small head, a smooth area between the nose and the lips and a thin upper lip.

19. Effects of alcohol on the foetus • Increases the risk of miscarriage • Premature birth • Effects CNS dysfunction - brain impairment leading to intellectual/developmental disabilities, attention deficits, poor social skills, hyperactivity, memory problems etc • Facial dysmorphology – abnormal facial features • Pre- and post-natal growth deficiency (FAS babies tend to be smaller)

20. Physical Impairments • Facial features • Heart defects • Limb damage • Bone formation defects • Kidney damage • Smaller brain and damage to the structure of the brain • Eye and visual problems • Ear and hearing problems

21. Babies livers aren’t formed and so can’t process the alcohol • Babies are born with more alcohol/drugs in system than parents • Alcohol causes more harm to the developing foetus than any other substance, including cannabis, heroin and cocaine Institute of medicine, 1996.

22. Foetal Alcohol Spectrum Disorder (FASD) • FASD is the term used to describe a wide spectrum of adverse effects of prenatal alcohol exposure to the developing foetus • These include FAS, PFAS, ARBD and ARND • They usually include structural anomalies as well as behavioural and neurocognitive impairments

23. Foetal Alcohol Spectrum Disorder It is more difficult for a specialist to diagnose FASD than it is FAS. This is because children with FASD may not have facial deformities. It might not be until they start going to school and interacting with others that the following symptoms (which also affect children with foetal alcohol syndrome) show up: • Learning difficulties/ ADHD/ Autistic spectrum behaviours • Difficulties with socialisation • Poor short term memory • Failure to learn from the consequences of their actions • Hyperactivity and poor attention • Dyspraxia • Difficulty with abstract concepts e.g. Maths

24. Table 01: An overview of the cognitive effects of damage to different regions of the brain commonly compromised by FASD (Blackburn 2009, from Kellerman 2008, Blaschke et al, 2009, Mukherjee 2009).

26. Brain of baby with no exposure to alcohol Brain of baby with heavy prenatal exposure to alcohol Damage can occur in various regions of the brain. The areas that might be affected by alcohol exposure depend on which areas are developing at the time the alcohol is consumed. Since the brain and the central nervous system are developing throughout the entire pregnancy, the baby's brain is always vulnerable to damage from alcohol exposure. The brain is the most sensitive organ to alcohol damage. [Dr. Edward Riley Lecture at San Diego State University, September 25, 2002]

27. Epidemiology • No reliable evidence on the incidence of FASD in the UK • Data only collected on FAS (not whole spectrum) • According to hospital episode statistics from the HSCIC (Health and Social Care Information Centre), in England 252 people were recorded as receiving a diagnosis of FAS in 2012-13. • Not common, but a leading cause of non-genetic intellectual disability in Western World (Abel & Sokel, 1987)

28. nofas-uk.org • National Organisation for Foetal Alcohol Syndrome – UK. • Online resources: • FAS - Information for professionals • nofas-uk.org - egg video