General aims of managing the pregnant drug user

• Maintain contact with the patient.

• Promote the health and well being of the mother and fetus.

• Aim to reduce risk-taking behaviours (sharing needles, prostitution).

• Stabilize on non-injectable alternatives such as methadone.

• If considering detoxification, this should be done in the middle trimester.

• Provide good primary health (nutrition) and psychological care.

• Liaise with obstetric, midwifery, and paediatric teams, and with social services where appropriate.

• Social stability and provisions for motherhood.

• Social work/parenting assessment.

• Ensure that other drug and alcohol behaviours are assessed.

• HIV and hepatitis screening (vaccination where appropriate).

Stabilization of the mother on an oral substitute drug should always be the initial aim. Where possible, the mother should be encouraged to become abstinent prior to delivery—indeed this is often what both doctor and mother want. However, such a move may not always be in the best interests of the infant and mother, and it may often be more appropriate to keep the mother in contact with services on low-dose maintenance. The long-term outcome in women who enter methadone treatment programmes during pregnancy is better in terms of their pregnancy, childbirth, and infant development, irrespective of continuing illicit drug use. (2Z>

Although there is no clear relationship between maternal methadone dose and the intensity of neonatal withdrawal (or likelihood of experiencing it), the pregnant opiate user should be encouraged to try and reduce the dose since lower doses (15 mg) are probably associated with a reduction in severity of neonatal withdrawals. Benzodiazepines and opiates are slowly metabolized by the newborn infant, so that peridelivery administration may result in hypotonia and respiratory depression. Both opiate and benzodiazepine dependence in the mother may be associated with protracted withdrawal syndromes in the infant, with the risk of seizures. There is some evidence to suggest that transferring the pregnant mother onto buprenorphine during the second trimester is associated with lower rates of neonatal withdrawal. Methadone is not a contraindication to breast feeding, although there is wide variation in local recommendations. Issues such as maternal nutritional and viral status also need to be taken into account when deciding whether breast feeding is appropriate.

Prisoners

About one-third of remand prisoners have a substance abuse dependency problem, most commonly alcohol and opiates. Access to illicit substances is not prevented by imprisonment; indeed some users may increase their 'habit' while in prison. Poor levels of identification on screening at entry and as yet inadequate prison treatment services and court diversion schemes for drug-dependent offenders mean that their considerable needs will continue to be unmet. Education and good primary health care are vital. Recent interest in drug treatment and testing orders may allow those dependent users who are convicted of crimes associated with acquisitive offending to receive a treatment order as opposed to a custodial sentence.

Comorbid clients

There are high rates of comorbidity of personality disorders, depression, and anxiety disorders among opiate users, with the severity of premorbid pathology being an important determinate of outcome.(32> Appropriate assessment and treatment of depressive disorders is important in reducing relapse rates and maintaining engagement, remembering that suicide accounts for a high percentage of deaths in opiate users. Again, liaison with adult mental health teams is important.

HIV-positive addicts

Reducing high-risk behaviours by those with HIV is important in limiting the spread of the disease. Stabilization on methadone with abstinence from injecting, needle-sharing, and unprotected sex should be encouraged. Liaison with medical and psychiatric services is important.

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