Managing drug misuse in pregnancy and beyond

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1 Managing drug misuse in pregnancy and beyond Dr Emily Finch Clinical Director Addictions Clinical Academic Group South London and Maudsley NHS Foundation Trust Rachael Evans Policy and Research Officer Adfam

2 Aims of the session Update on management of drug users in pregnancy To review the findings and recommendations of Adfam s reports on tackling risks to children whose parents/carers are prescribed OST To review evidence and learning from serious case reviews (SCRs) and consider evidence for best practice Generate debate: whose responsibility? What about clients who don t engage/disguised compliance? Etc.

3 Management of drug misuse in pregnancy

4 Prevalence % of treatment population who have children ( ) Resident and non resident. Total 55,776 Women 63% Men 51% In women Opiate 68% Alcohol only 58% Non-opiate and alcohol 57% Non-opiate 60%

5 Prevalence Female new presentations to treatment who are pregnant % (42,683) Opiate 4.2% Alcohol only 1.1% Non-opiate and alcohol 2.6% Non-opiate 5.7% But in non-treatment populations prevalence will be much higher Reducing prevalence of opiate use

6 Prevalence evidence 30% of children under-16 years ( million) in the UK lived with at least one binge drinking parent 335,000 children lived with a drug dependent user 72,000 with an injecting drug user 72,000 with a drug user in treatment; and 108,000 with an adult who had overdosed Manning et al 2009

7 Exposure to drugs in pregnancy Hair analysis 16% positivity - third trimester of pregnancy, Cannabis 10.3%, cocaine, 6.4% MDMA 0.9% opiates 0% 1.9% of mothers declared using drugs of abuse Consumption was associated tobacco smoking, mother being Spanish.

8 Cannabis 26.3% previous use of cannabis and 2.6% reported current use. Confounders, include tobacco smoking, alcohol consumption use of other illicit drugs, Low birth weight (odds ratio (OR) = 1.7; 95% (CI): ), Preterm labor (OR = 1.5; 95% CI: ), Small for gestational age (OR = 2.2; 95% CI: ), Admission to neonatal intensive care unit (OR = 2.0; 95% CI: ).

9 Smoking Infants of substance misusing (SM) and/or smoking (S) mothers are at increased risk of sudden infant death syndrome Both nicotine and substance misuse exposure may affect respiratory control Antenatal substance misuse and smoking affect the infant s ventilatory response to a hypoxic Challenge

10 Patterns of drug use Huge range very heterogenous group Dependant opiate users rare but highly problematic Polydrug use cocaine, benzodiazepines, alcohol. Alcohol prevalence unknown Other drugs e.g.mdma, mephadrone, Cannabis OTC opiates Tobacco

11 Revision of clinical guidelines changes since 2007 Publication of NICE guidelines on complex pregnancy WHO guidance 2013

12 NICE on Pregnancy and complex social factors CG 110 Joint working between obstetrics and SM services Multiagency models, co-location, joint care planning Comprehensive assessment Integrated safeguarding Generally exists but some gaps and reduced funding puts good practice at risk Local variations recommended Improves pregnancy outcome (Mayet at al,)

13 WHO guidelines 2013 Evidence based review list of graded recommendations Comprehensive assessment Individualised care OST with maintenance preferable Breastfeeding safe

14 Opiate dependence the evidence Opiate substitution (OST) Good evidence it improves outcomes (Doohan et al 2013) Priority to retain in treatment and reduce chaos and injecting rather than reduce dose May require more OST However often do well and can reduce the dose Need to treat partners

15 Methadone or buprenophine Bup as acceptable as methadone. No difference in outcomes Some suggestion bup may results in lower levels of NAS But evidence very limited.

16 Neonatal abstinence syndrome Buprenorphine may be better than methadone note lower retention Polydrug use increases severity, OST reduces levels Long term effects documented in older children Effects on visual function (McGlone et al 2014, Glasgow)

17 Safeguarding Routine referral for continued drug use Close working and joint protocols with children's social care Huge range of responses Early social care assessment Pre birth conferences if necessary Testing during pregnancy Good joint working improves outcomes? Little follow up evidence Family drug and alcohol courts (FDAC)? effective

18 Screening Routine screening of pregnant women for alcohol e.g. AUDIT Routine history of drug taking Possibly routine urine screening Hepatitis B, C and HIV Comprehensive assessment if needed

19 Brief interventions Routinely offer to all pregnant women identified as being at risk Evidence for alcohol BIs good in non-pregnant populations No evidence for BIs in drugs but likely to be helpful Good outcomes

20 Alcohol dependence DH advice (2016) pregnant women should not drink at all Detox a priority any time in pregnancy Use of long acting benzodiazepines Inpatients may be needed

21 Other factors Psychiatric diagnosis PD plus others, rarely psychosis Social issues e.g. homelessness, refugee status IPV Multiple pregnancies. PAUSE project FDAC has good outcomes

22 Outcomes Very variable Good evidence pregnant opiate users do well from NDTMS data analysis

23 Changes since 2007 Clinical guidelines - summary Evidence that pregnancy is a positive outcome factor Multidisciplinary management, coordination, care planning Heterogeneity of presentation Effectiveness of OST (methadone alone better that methadone plus illicit) Increased evidence for LT damage in the baby Possible reduced NAS with buprenorphine (marginal) DH recommendation of abstinence from alcohol Breastfeeding safe (even in HCV) may reduce NAS

24 Questions?

25 MEDICATIONS IN DRUG TREATMENT: TACKLING THE RISKS TO CHILDREN

26 Background to the project Adfam published Medications in Drug Treatment: Tackling the risks to children in April Aim: to examine the incidence of child ingestion of OST drugs and assess how the risks to children can be minimised during the provision of OST to their parents/carers. Medications in Drug Treatment: Tackling the risks to children One year on was published in November Aim: to describe and assess the progress made in implementing the recommendations of the original report, provide practice examples and up-to-date information, data and evidence. National training project 19 LAs

27 Key Findings In 2012/13, the number of people with parental responsibility receiving an OST prescribing intervention totalled 61,928 (a rise from 60,596 in 2011/12) (FOI request) The first report found that between , there were 20 SCRs (23 children) in England and Wales involving a child s ingestion of OST drugs. By the time next report was published, two more and one underway Between , at least 328 children (0-17) were hospitalised due to methadone poisoning (HSCIC) Between , 110 people up to the age of 18 inclusive died in the UK due to methadone or buprenorphine poisoning (only 3 confirmed buprenorphine deaths)*

28 SCR Findings 23 SCRs since 2003 involving child s ingestion of OST (26 children) 19 fatalities 21 involved methadone, 1 buprenorphine (other: heroin and other drugs ) Intentional administration: SCRs reveal dangerous practice where parents use methadone to pacify or soothe children 6 confirmed cases of parental administration, 8 accidental, 6 unclear and 3 deliberately taken by teenagers Age bias towards younger children (two years old) because SCR more likely if younger? Most commonly prescribed to the mother (11 cases)

29 Why might a child ingest OST? Unsafe storage Child finds OST him/herself and ingests without parents knowledge Parent/carer/other accidentally given child OST, mistaken for another liquid Use of baby bottles as measuring receptacle for medication Unsafe disposal droplets left over in empty bottles Single, Methadone poisoning in young children: deliberate or accidental?

30 Why would a carer give methadone to a child? It would be naïve to believe that parents who use drugs to treat their own physical and emotional distress, may not sometimes do the same for their children. (Bays, 1994) Small doses to settle child or for pain relief. User feedback suggests this might be common Underestimating the toxicity of OST, as they themselves use in large quantities Belief child is tolerant after in utero exposure Belief child will sleep it off Reluctance to present to hospital until symptoms are severe Child K, Bristol

31 What would raise concerns about a child s welfare? Change in level of appointment attendance, including child s appointments (e.g. vaccinations) Disengagement with services Starting/increasing illicit substance use Another OST using adult residing with child Unknown adults residing at home Unsafe OST storage Concerns expressed by others (professionals/other family members) Child has non-age appropriate routine Noticing signs of ingestion (sleepy, nausea, lowered heart rate, shallow breath, pinpoint pupils etc )

32 Best Practice evidence from SCRs and local examples The research found an insufficient awareness of both the impact of parental substance use generally and the specific risks posed to children by OST medications.

33 Safety and intentional administration Safe storage: not consistently discussed with parents/boxes not provided/parents not using. Professionals not seeing it as their responsibility to check Recommendation: safety boxes should be provided to all clients prescribed take-home OST if they have contact/living with children, with discussion of safe storage and checks. This should be a shared responsibility Intentional Administration: little evidence it is being addressed by services, with few tackling issue explicitly in leaflets/safety advice e.g. Never give your baby or child even a tiny amount of methadone or other drug to soothe them or help them to sleep. Messages around safe storage futile if parents deliberately administering Interviews and discussions with practitioners suggest this may be a difficult possibility to accept over optimism and wanting to see the best in their clients More research to estimate prevalence and what can be done to prevent it is needed

34 Prescribing and dispensing practice: Guidance Are clinical decisions to relax, drop or reinstate supervised consumption regularly reviewed and based on individual users present circumstances, taking into account their level of stability, work commitments and level of risk (especially to children)? (PHE) High mortality risk associated with methadone in opioid naïve people; clinicians should estimate the benefits of prescribing methadone or buprenorphine, taking account of the person s lifestyle and family situation (for example, whether they are considered chaotic and might put children and other opioid naïve individuals at risk. (NICE, Technology Appraisal 114) the Committee was mindful that methadone is cheaper than buprenorphine and therefore concluded that, if both drugs are equally suitable for a person, methadone should be prescribed as first choice.

35 Prescribing and dispensing practice cont. Wide variation in local prescribing/dispensing practice but appears common to automatically allow take-home doses after the initial three month period of supervision comes to an end Local example: We offer a more gradual regime: once the three months end, clients have to wait another 12 weeks before weekly dispensing is considered, to allow for a more controlled treatment pathway. Practitioners felt there was a lack of specific guidance on what safe prescribing for parents looks like and called for best practice examples Local example: Two local areas reported implementing a policy where buprenorphine is prescribed as the first choice for parents in treatment one if child under 5, other child of any age. Both reported positive results, with little resistance from clients. No evidence on respective benefits of methadone and buprenorphine specifically to parents in treatment. NB treatment in itself is a protective factor for the child

36 Prescribing and dispensing practice cont. Issue: Despite clinical guidelines, safeguarding concerns are not sufficiently prioritised in reality Recommendations: guidance on the implementation of NICE must reemphasise safeguarding children as a primary factor in decisions around OST, including which drug to prescribe and whether to permit take-home doses. Further research into the relative safety of buprenorphine and methadone specifically in the context of child ingestions is warranted. Clinical guidelines should clarify the circumstances under which both drugs will not be considered equally suitable * Lack of engagement should be seen as a significant risk factor in regard to children; and serious consideration should be given to the suspension of prescribing and a return to supervised consumption of methadone (Birmingham SCR, 2015)

37 Joint working, information sharing and professional competency Issue: lack of consistency in knowledge and involvement of professionals outside drug treatment agencies in recognising, communicating and acting on risks of OST. SCRs identify number of missed opportunities as a result of failures in communication and inter-agency working. Local efforts to improve this: multi-agency meetings, joint assessments, multi-disciplinary training, joint protocols. Issue: SCRs found risk factors often missed by professionals. Some find difficult conversations hard to raise, and tendency towards over optimism and lack of professional challenge. Recommendation: Training for drug services, pharmacies and GPs must highlight the dangers of OST drugs to children. Workers should be able to address intentional administration with service users and promote positive parenting practices. Other professionals working with vulnerable families, especially those undertaking home visits, need to be alert and vigilant about the dangers of OST drugs.

38 Disguised compliance Disguised compliance involves a parent or carer giving the appearance of cooperating with [agencies] to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention. (NSPCC) Signs of disguised compliance Out of character run of attendance at appointments Sudden compliance with practitioner requests Unexpected agreement with sanctions Eagerness to overstate engagement withy other professionals No change in outcomes, despite considerable intervention Changes agreed but not carried out Actions speak louder than words

39 Identifying disguised compliance conflicting accounts of family life from family members conflicting evidence from different professionals persistently unmet needs of children presentation and behaviour of children conflicts with adult accounts repeat incidents of harm/neglect to children analysis of detailed, multi-agency chronology observation of parent child interaction (there is convincing evidence that simulated sensitive parenting is very difficult to sustain - C4EO 2010) Working with disguised compliance and resistant families, presentation by Sue Woolmore

40 Seeing the child Drug services still too adult-focused, must recognise safeguarding children is their responsibility Some services don t allow children into the service are there home visits? Professionals working with parents prescribed OST should receive training in noticing the signs of ingestion in children Pharmacists have a key role to play they are the ones most likely to see the child most often SHARED RESPONSIBILITY all agencies working with the family must be aware of and vigilant about risks to children. Consider: is the child behaving normally for their age? Does the child present a change in behaviour? Is the child showing signs of distress/suffering? Are they always asleep? Are they clean and dressed appropriately?

41 Thank you! Any questions?

42 Discussion questions: What can be done to prevent OST poisoning in children? What are the elements of a good risk assessment? What do you think are the pros and cons of stopping unsupervised consumption or take home medications for parents prescribed OST? Think about: Safe storage; Disguised compliance; Client satisfaction What would you do to ensure that your clients understand the risks of methadone and to reduce the likelihood of ingestion by a child? Think about: Welfare checks; Professional curiosity; Multi-agency working; Risk assessment How would you say problem drug use compromises parenting capacity? What s been your experience?

43 Exercise: Look at the SCRs you ve been given and discuss the following questions 1. What risks can you identify from the chronology? 2. What prevented further action from being taken? 3. What positive action was taken by practitioners working with the family? 4. What could you learn from this?