Managing drug misuse in pregnancy and beyond

Transcription

1 Managing drug misuse in pregnancy and beyond Dr Emily Finch Clinical Director Addictions CAG, South London and Maudsley Foundation NHS Trust Rachel Evans, Adfam 1 /

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. Aims of the session 2 /

3 Management of drug misuse in pregnancy An update 3 /

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% 4 /

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 5 /

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 /

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. 7 /

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: ). 8 /

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. 9 /

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 10 /

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

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???) 12 /

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

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 14 /

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. 15 /

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) 16 /

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 17 /

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 18 /

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 19 /

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 20 /

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 21 /

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

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 23 /

24 Questions? 24 /