Problematic Substance Use in Pregnancy (PSUP): Optimizing the Epigenetics; A Standard of Care - Ron Abrahams


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This is a presentation that was given at the Lost in Translation 2013: Exploring the Origins of Addiction conference that took place on March 25 - 26, 2013 in Vancouver, British Columbia, Canada.

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Problematic Substance Use in Pregnancy (PSUP): Optimizing the Epigenetics; A Standard of Care - Ron Abrahams

  1. 1. Ron Abrahams MD FCFPProblematic Substance Use In Pregnancy (PSUP)Opitimizing The Epigenetics - A Standard of Care!
  2. 2. “Clinical” Epigenetics“ As health care providers, it isimperative to take into account andadvocate for improving the ‘overall”fitness of the pregnant patient’sparticular “environmental unit.”Poul Sorenson Ron Abrahams
  3. 3. “Integrated Community/HospitalHarm Reduction Program”ShewayFir Square“Trauma InformedCare”A PRIMARY CAREMODELEmpirical/Evidence
  4. 4. Harm Reduction in PregnancyA “CORE PROGRAM”For A Sustainable HealthyCommunity
  5. 5. Goals of the ProgramTo DECREASE THE AMOUNT OF DRUG mothersand babies are exposed to (Trauma InformedCare)To improve social stabilityTo facilitate bonding between mother and babyTo reduce withdrawal and need to treat in thenewbornTo prepare more babies to go HOME with mom
  6. 6. Trauma Informed Care Involves?Pharmaceutical (Pump them with drugs) ?Psychotherapy and/or SelfInterventions Medication ?REMEMBERING!- “NEED TO DECREASE AMOUNT OFDRUG EXPOSURE TO MOM AND FETUS”And it is a long “labour” intensive journey for everyone!!
  7. 7. Salish Seas“Red Lies”“I’ve been lying since I was sevenWhen I knew there was no heavenWhen hell was lying next to me”
  9. 9. “To my Doctor, a believer in meand keeping the family together,Believer in not medicating pain!”
  10. 10. For The Patient Not Ready To Live“Drug Free”/Self MedicatingThe Goal Is“Culturally Sensitive”Integrated/Community/HospitalHarm Reduction programsincorporating“Trauma Informed Care”“Trauma Growth”Minimizing Drug ExposureEpigenetics/Societal Obligation!?
  11. 11. Her Injection SiteHer “Community”
  12. 12. Safe Injection Site
  13. 13. Pregnant andSHE’S INJECTING !!!!!
  14. 14. Her Safe Injection SiteHer “Community”Determines Outcome!!
  15. 15. Social Determinants Of Health“ What is common to these women is that they areexposing themselves and their fetuses to thesame drug.The difference is in their lifestyles.”R. Abrahams MD 1987
  16. 16. NO!-It’s The Drug, STUPID!“Cocaine is popular, glamorous, middleclass and possibly more dangerous toan unborn baby than any other illicitdrug”“Bonding between mother and child ishindered”Dr. Ira Chasnoff 1986
  17. 17. Open Letter To The MediaFeb. 25, 2004These terms, such as “crack babies’,“ice babies” and “meth babies”, lackscientific validity and should not beused.Chasnoff, Koren et al
  18. 18. Partying at Henley“An Open Drug Scene”
  19. 19. Alcohol In Pregnancy“Drinking alcohol in pregnancy is theprimary risk factor for FASD. BUT thelevels and symptoms of damage inthe children emanating from differentdrinking mothers vary significantly,
  20. 20. Alcohol In PregnancyAnd this variation is not fully explainedby the quantity and frequency ofalcohol consumption duringpregnancy. Therefore, risk factorsother than alcohol exist and serve tomediate, moderate or otherwise alterthe effects of alcohol on the fetus.Abel 1998Abel and Hannigan 1995
  21. 21. First Nations Infant MortalityInt. J. Epidemiol. Aug. 04“Post neonatal mortality causes suggest theneed for improved socioeconomic andliving conditions.”“ more culturally oriented maternal andinfant health programs may be helpful.”NOT APPREHENSION AS APREVENTATIVE MEASURE !
  22. 22. “Point Of Entry”The First EncounterEliminate WelcomeBarriers Her In• 
  23. 23. IN THE OFFICE?Don’t Panic !!!!!! Don’t Get On ThePhoneNO LEGAL OBLIGATION TO REPORTTHE UNBORN!
  24. 24. Multi- Disciplinary TeamMUST BECulturally AppropriateUser FriendlyNon-JudgmentalSupportiveTrusted by the patientConfidentialMUST ADVOCATE
  25. 25. Sheway-Philosophy of Servicen  Offers respect and understanding ofFirst Nations culture, history andtraditionn  Takes a harm reduction approach tosubstance usen  Links women and families into anetwork of health-related, social,emotional, cultural, and practicalsupport
  26. 26. SHEWAY – Philosophy of Servicen  Provides women centred services ina flexible, welcoming, non-judgmental, nurturing/acceptingway.n  Supports women’s self-determination, choices, andempowermentn  Be a “helping” hand
  27. 27. Mother The Mother And You WillMother The Child
  28. 28. Sheway Outcomes 1990’sn  91% received pre-natal care by deliveryn  Nutritional concerns decreased from 79%to 4%n  Housing concerns decreased from 27%with no fixed address / 65% at intake vsonly 4% with concerns postpartum
  29. 29. Sheway Outcomes-1990’sn  Birth weight > 2500 gramsINCREASED from 20% to 86% since1993n  In 1993 100% apprehension rateat birth decreased to 5% by 1999
  30. 30. Integrating Community/Hospitaln  To re-orient themanagement ofthese pregnantwomen andfamiliesCulturally Appropriaten  Provide the foundationtowards preparingmothers and babies togo home as a healthyunitTrauma InformedCareR. Abrahams 1986
  31. 31. To Prevent (1980’s)n  Baby separated from mom at birthn  Baby put in “quiet room”n  Observed for withdrawal/no bondingn  Most babies treated for withdrawaln  Mom treated like “sh-t”/JUDGEDn  Baby apprehended! (100% In DTES)n  Mom back on street—MORTALITY!
  32. 32. “Rooming-in Compared WithStandard Care of Mothers UsingMethadone or Heroin”Safe to room in baby and motherLess babies needed treatment forwithdrawalMore babies went home with momR. Abrahams, S. Payne, P. ThiessenCanadian Family Physician Oct 07
  33. 33. 0%10%20%30%40%50%60%70%80%90%100%Jitteriness p =.312Poor suckingp = .078Diarrhea p =.651Vomiting p=.031Cryinginconsolablyp <.002piror to rooming in rooming inBaby’s Behavioural Ratings
  34. 34. Investing In The Future
  35. 35. FIR F amilies I n R ecovery Unitn  Antepartum/UltraSoundsn  Peripartumn  postpartumn  CommunityIntegration
  36. 36. Families In Recovery Unitn  Multidisciplinaryn  Dedicated Nurses/StaffWith the right attitude!n  Continuity of Care
  37. 37. First Day
  38. 38. 9 Years Later
  39. 39. The Perinatal Addiction Service
  40. 40. The Perinatal Addiction Servicen  24/7 On call/Provincialn  Primary Care Physiciansn  Integrated with community andhospitaln  Integrated with multidisciplinaryteams
  41. 41. Observed Trends On FirCuddling/focused moms avoid theneed to treat babies with morphineMultiple drug exposure increases needto treat (illicit/prescribed)Prescribed Meds impact newbornsability to feed, settle, gain weightNB. Don’t Rx with Morphine?1000 plus Women delivered
  42. 42. Fir Square Qualitative Outcomesn  100 % of women felt connected tocommunityn  74% reported decreased use of“problem” drugn  89% reported decreased level ofanxiety
  43. 43. An Evaluation of Rooming-in Amongst Substance-ExposedNewborns in British ColumbiaR. Abrahams et al JOGC, 2010Retrospective comparison of Rooming-in (n=371) vs. Standard care(n=834) using BC Perinatal Heath Program Data.Rooming-in associated with:• Significant decrease in admissions to NICU• Increased likelihood of breastfeeding during hospital stay• Increased odds of baby being discharged home with his/her motherReview supports the finding that rooming-in is both safe andbeneficial for substance-exposed babies.
  44. 44. Probability Methadone/Morphine TxJOGC May 201100. 25 50 75 100 125 150 175 200 225 250Mothers methadone dose (mg)PredictedProbabilityofinfantreceivingmorphineNo breastfeeding and other opiatesBreastfed and other opiatesNo breastfeeding and no other opiatesBreastfed and no other opiates
  45. 45. Sheway/Supportive HousingSociety’s Responsibility
  46. 46. “ In spite of her potentially roughbeginning, Jessie demonstratesnormal movement patterns, has adelightful personality and isaccomplishing all developmentalskills at her age level or beyond.”
  47. 47. Epigenetics-”Cuddle and Hold”Prof. Meaney-McGill“Good” rat moms produce offspring who exploremore, are less fearful and less reactive to stress,perform better COGNITIVELY, and preservecognitive skills better into old age- by maternalbehaviour altering gene expression!“Mother’s affection at 8 months predicts emotionaldistress in adulthoodJ. Maselko et al, JECH July 2010
  48. 48. Study the Epigenetics ofn  Maternal Infant Bondingn  Safe adequate housingn  Nutritional statusn  Community/being safen  Sense of well being/self esteemn  Trauma/childhood abuse/separation
  49. 49. Wanting to hideI swallowed my prideIt was time to care for my baby insideI could no longer bare being pregnant and scaredI took strong advice and stayed at Fir SquareFinally relieved, but pleasedNew friends faces tended my needsThe nurses staff and girls that were thereShowed me strength, courage and tender careSafe as can be, I had the right keySlowly accepting the changes in meIt must have been fateCause my baby is greatThank you for helpingIts never too late!!!!A Fir Patient
  50. 50. On The Road To ----
  51. 51. I am happy to say that we continueto make progress.As you know we opened theprenatal clinic at the Family futuresoffice downtown Pr AlbertDr Egbeyemi runs the clinic once aweek. We continue to havesuccess with our moms rooming inand staying for an extended periodof time (2-3 weeks).
  52. 52. We have had about 7-8 momssince your visit and all haveroomed in. All but one have gonehome with mom and the one thatdidn’t go home with mom did staywith her baby for 16 days until thebaby was ready for discharge. Wedo consider that a success!
  53. 53. The biggest step has been thesupports that family futures put intoplace before delivery and thencommunicated that with us and theministry= all with the clientsknowledge. That helps us withhaving a discharge plan in place.LOVE IT!
  55. 55. Tomsk-SIBERIA
  56. 56. Downtown EastsideOPEN DRUG SCENE
  57. 57. Who Is Using?“the Junkie”“The street Entrenched”“high end” cocaine usernicotine addict“pot” smokermiddle class housewife drinking/valium“The Walking Wounded”“I’m Not Like Them”
  58. 58. Remove StereotypesThat they are not all “druggies” prostituting,stealing, incapable of ever being goodmothers
  59. 59. “Yeah BUT”Can woman who do this to theirbabies be motivated?
  60. 60. “Most are motivatedAll feel guiltyMost don’t understand what they are doingAll need your help”
  61. 61. What About Diet (Environment)?Vitamin A deficiencyFolic Acid deficiencyCholine Deficiency/Ukraine Study“Preventive Intervention To FAS”Ballard et al. Medical Hypotheses Jan/12
  62. 62. So, It Is The EnvironmentAfter controlling for covariates neithercocaine nor opiate exposure showedeffect on development scores, motorscores or behavioural scores whentested at 1,2, and 3 years.Mesinger,D.S. et alpediatrics, vol 113 #6, June 2004
  63. 63. Stop Perpetuating the “Crackbaby” Myth“Research now shows that the fetalandinfant health problems previouslyassociatedwith crack cocaine are better explainedbymalnutrition and a lack of pre-natalcare.”David C. Lewis MD, Oct. 2004
  64. 64. Blame It On The Science!n  -poorly controlled up to nown  -impossible to control - too manyvariablesn  inaccurate self reporting- fear of legalreprisaln  bias in the scientific community!(Scientific Discrimination)
  65. 65. “A difficulty relates to the selectionbias in the reporting of positive ratherthan the negative results in thestudies of the effects of intrauterineexposure to cocaine among abstractssubmitted to the society for pediatricresearch. From 1980 - 1989 only11% of those describing no effect ofcocaine were accepted forpresentation. As compared to 57% ofthose describing an effect”J. VolpeN.E.J.M. 1992
  66. 66. “Crystal Meth”“Limited experience, but it seems thatif we control for prenatal care,environment, and diet, we canexpect a normal outcome.”R. Abrahams MD 2004
  67. 67. Clinical Bias
  68. 68. That’s All Wonderful-But!!THESE WOMEN ARE ALLDual Diagnosis !
  69. 69. 1st European Conference on DrugAddiction 1989Dual Diagnosis/Abstinence
  70. 70. Avoid SSRIs In Pregnancy?Increase in:Prematurity!low birth weight!fetal death rate!withdrawal symptoms in newborn!seizures in newborn!AJOG 2006
  71. 71. Among those with a history of earlychildhood Trauma(emotional,physical,sexual)Psychotherapy alone was superior toantidepressant monotherapyC. Nemeroff Nov. 2003Implications For TreatmentApproach
  72. 72. Addiction ResearchNow tells us: correlated withDysfunctional familiesTrauma and/or Abuse/IsolationEvery Strata of Society
  73. 73. “Why Experimentation BecomesAddiction”Isolated rats go back formore and moreRat Park Experiments 1970’sProf. Bruce Alexander
  74. 74. PotlatchLegislated Racism
  75. 75. A Family Picnic
  76. 76. Childhood Trauma And PTSDPts With Psychosisn  “Childhood trauma & its consequences arehighly prevalent among pts. Withpsychosis and severely affect the courseand outcome. “n  “Tx approaches need to be furtherevaluated for this population”n  Schafer, Current Opinion Psychiatry 2011
  77. 77. Harm Reductionn  Practical Concept for patients, physicians,Institutionsn  Through education and support- thepatient can reduce harm by reducing risksn  A concept that supports “Safe Use” not“Safe Abstinence”n  Society has the responsibility to reduceharm e.g. provide safe housing, cleanneedles, drugs legallyn  Improve Social Determinants of HealthR. Abrahams 1986
  78. 78. Prescribing HarmReductionOpiates- meth/morphine/bupr/heroin trialsIv T’s and R’s- oral talwinAlcohol- benzos/ “managed alcohol program”Cocaine- ativan/valiumCrystal meth- dexedrinSmoking patch etcPRAZOSIN?supply needles FOOD!injection sites HOUSING !!naomi trial
  79. 79. SHE SHOWS UP AT YOUR OFFICEn  Twenty one year oldn  -no support/no moneyn  -no fixed address or affluent (“I’m not like them”)n  - twelve weeks pregnant, confirmed by ultra soundn  -Using heroin and coke daily/smoking-some IV usen  -Alcohol bingesn  -Smoking cigarettesn  -Hepatitis C+n  -HIV NegYOU NEED TO ENSURE SHE COMES BACK AGAIN
  80. 80. SHE WANTS TO KNOWn  Will my baby be deformed/addictedn  Should I have an abortion?n  If I decide to keep my baby, should I detox and is itsafe to detox?n  What about methadone? I’ve heard that it is moreaddictive than heroin, especially for my babyn  Can I breastfeed?n  Are you / “they” going to take my baby away?n  Will you do drug tests on me? If yes, why?You need to ensure she comes back!
  81. 81. “You Need To Tell her”n  Decrease the amount of drug that youand your baby are exposed ton  My care is not dependent onyou being abstinentn  You and your baby must have a safeplace to go home ton  Apprehension is not the hiddenagendan  Don’t f… up!!!/set limitsR. Abrahams 1987
  82. 82. Her Physician’s “Referral” ToChild Protectionn  Extremely High risk Infantn  Mom probable street workern  Smokes cocaine and high dose narcoticthoughout pregnancy. Father has lost twochildren to MCFD and mom onen  Mom MRSA pos, dental caries/ unkeptn  Requests for follow-up bloodwork not donen  Last baby small for GAn  This baby small alson  “A DISASTER WAITING TO HAPPEN”
  83. 83. MCFD VCH2 Social Workers 4 Community Health Nurses1 Nutritionist1 Alcohol and Drug Counsellor3 Sessional Family Physicians1 CoordinatorVNHS YWCA1 Medical Office Assistant 1 Outreach Worker1 Receptionist 2 Infant Development Consultants1 Cook/Peer Support Worker1 Family Support Worker1 Aboriginal Community Support Worker1 Administrative AssistantThe Sheway Team
  86. 86. Improving ComplianceIncreases the number of ante-natal visitswhich is the only consistent variable thatimproves perinatal outcomeBy Reducing Barriers To Care
  88. 88. Moral and Systemic BarriersScientific bias and a lack of evidence based researchAllows the moral/legal/political systems to“justify the implementation of rules/regulations thatbecomeBARRIERS TO CARE FOR THE“VULNERABLE “
  89. 89. My Response To My LicensingAuthority“ I recognize the need for the College OfPhysicians and Surgeons of BC to monitorthe methadone program. I will try tocomply with the regulations of theprogram as long as I feel it does notimpinge upon my individual patient’srights, or interfere with my professionalrelationship with my patients when theycome to me to receive care within theconstruct of the Harm Reduction Model”R. Abrahams MD 1996
  90. 90. “it is unconstitutional to prosecutecitizens for having drugs for theirpersonal use”Argentine Supreme CourtSept/09
  91. 91. Illegal To Prescribe Methadone
  92. 92. Neberzhney Chelny
  93. 93. Detox is Safe to FetusUnder ControlledConditionsAdvise Her That This isTrue!
  94. 94. Monitoring of the Pregnancyn  Trust/Compliance increases thenumber of ante-natal visitsn  Offer regular genetic screeningn  Serial ultra-sounds / clinicalsuspicion/as a “bonding tool”n  BE READY For All kinds ofcomplications
  95. 95. Proceed to LabourIf:-decrease drug exposure-stabilize / improve lifestyle-minimize morbidityPROCEED to labour and delivery asnormalOTHERWISE manage as “high risk”pregnancy
  96. 96. Induce at or Near TermDue to:n  Pregnancy failingn  Continued chaotic lifestylen  Continued risk of drugexposure“Baby Better Off “Out” Than “In”
  97. 97. Barriers To Caren  Woman dealt with the system byaccessing it infrequently, hiding druguse during pregnancy, falling back onuncertain, informal support groupsn  System dealt with woman punitively,apprehended babies and expectedthem to access “mainstream” servicesin conventional ways
  98. 98. BECAUSEn  40% of the babies born in the downtowneastside Vancouver were substance exposed(and low birthweight)n  100% of these children apprehended into care
  99. 99. And Remember!!No ApprehensionWith A“Social Cushion”
  100. 100. BC WOMEN’S HOSPITAL•  1980’s- SCN-Babies and Mom Seperated!•  1990’s- IN- Babies and Mom Seperated!•  2000’s- Rooming IN
  101. 101. Methods“Cuddle and Hold” (avoids withdrawal fromMom?)Measure withdrawal in the newbornusing objective criteria:(eliminates Observer Bias!)WEIGHT GAIN– NB !!!Vital signsG.I. Symptoms e.g. diarrhea, vomiting
  102. 102. 2. Percent of babies on morphinep=.01624.20%55.30% 52.80%0%10%20%30%40%50%60%percentage on morphineC & W Rooming inC & W Prior to rooming inCommunity hospital without rooming in
  103. 103. 1. Mean days on morphine p=.31523.6333.71 35.32010203040daysC& W Rooming inC & W Prior to rooming inCommunity hospital without rooming in
  104. 104. 3. Percent of babies apprehended/foster care (p=.006)30.30%68.40%52.80%0%20%40%60%80%percentage apprehended/foster careC & W Rooming inC & W Prior to rooming inCommunity hospital without rooming in
  105. 105. What This Study Adds• Rooming in is a viable, safe modelfor providing care for the majorityof infants of substance usingmothers
  106. 106. Breastfeedingn  Never tell her “ Your milk is no good”n  Discuss and decide with the patientn  Consider:• Hep C / HIV• Lifestyle (still using?)• Mom’s motivation to breastfeed(culture)• “Breast is best”• Cheaper than formula
  107. 107. Morphine TreatmentONLY FOR OPIATE EXPOSED BABIES!!i.e. Not gaining weight/diarrhea/sick!DX. OF EXCLUSIONn  Loading Dose of .03 mg/kg q3hrsn  Decrease .02mg every 2 days when stablen  Generally finish by 14 days
  108. 108. Infants Of Smoking MothersBehavioural characteristics are thesame as those seen in infantswithdrawing from opiatesLaw, K. et al, Pediatrics June’03
  109. 109. “Triple O Babies”ON (Morphine)OFF (Morphine)andOUTIn The Room With MOM !!!
  110. 110. Criteria for Discharge fromHospital1) Watch for signs of withdrawal7-8 days of ageAnd2) Baby gaining weight 2-3 daysAnd3) Home assessment completed
  111. 111. “Apprehension Free Zone”n  SW / Ministry gather info , assess,OFFER SUPPORTn  Consensus Decision Made WithMom / Family/Team re: Home orto “Place of Safety”n  Change Legislation
  112. 112. Discharge Home With BabyMom StableSupports in placeWeekly Visits to MonitorUse “stability”- not UrineDrug Screens toMonitor“drug use is notincompatible withadequate child care”Baby is Urine DrugScreen!!
  113. 113. Delayed Withdrawal at 3-5 Months?“PURPLE CRYING”----P-peak patternU-unpredictableR-resistant to soothingP-painful faceL-long bouts cryingE-evening cryingNOTDelayed Withdrawal
  114. 114. Continuity of CareCritical For:• Fostering compliance / Trust• Providing ongoing care• Improving outcomes• Monitoring family growth• Being there for crisis
  115. 115. Patient Testimonial“ I just want you to know how muchwe do appreciate your kindness anddedication”I came in here all hurt and broken upwith not a lot of purpose in life.You guys (gals) have treated me withrespect and tenderness.
  116. 116. I once again felt human.After a while, as I became healthieryou made me feel worthy andwhole again.Life started to have purpose andmeaning.“Critical for a SustainableCommunity”
  117. 117. Dear Ron-“I thought you might be interested toknow that this child is doing very well.She was in for her one year check upand is walking, has numerous wordsand well presented by her parents. Herparents are now clean and soberand have now moved to Chilliwack.”A Community GP
  118. 118. Don’t throw your hands up in despairBe prepared for many frustrationsAND MANY REWARDS!!!
  119. 119. Randomized Clinical Trial?“ I would never accept a return to carestandards of the 70’s on so vital anissue as keeping moms and babestogether”P. Thiessen 2004
  120. 120. “THE FAMILY SCHOOL”
  121. 121. Harm ReductionFor Integrated CoreCommunity ProgramsBE PROUD OF WHAT YOU DO!!
  122. 122. “Every public action which is notcustomary, either is wrong, or if itis right, is a dangerous precedent.It follows that nothing should everbe done for the first time”
  123. 123. Canadian MedicalAssociation Journal 1996“ I’d like to see heroin legalized andprescribed legally. It would save a lotof lives and illicit activity.”R. Abrahams MD
  124. 124. FIR SQUARELeading Practice -2004Canadian Council HealthAccreditationInnovative Service Award OfExcellence-2008BC Representative For ChildrenAnd Youth
  125. 125. SummaryPregnancy is a 9 month luv affairn  You have time to:n  Go slown  Educaten  Set Goals / Limitsn  Supportn  Helpn  Monitorn  Evaluaten  Be There
  126. 126. Every BCCommunity
  127. 127. Community Hospital ProgramPatient CentredMultidisciplinary Harm ReductionResearch Education
  128. 128. Higher Aboriginal HIV Ratesn  Social Isolationn  Povertyn  Discrimination“ It has roots inpoverty,unemployment,lack of housing,and dislocationthat plague manyaboriginalcommunities”
  129. 129. “Among those with a history of earlychildhood trauma ( emotional, physical,sexual) psychotherapy alone wassuperior to antidepressantmonotherapy.”C. Nemeroff PNAS Nov.2003
  130. 130. Supportive HousingSOCIETY’S RESONSIBILITY
  131. 131. EPIGENETICS“His research suggests that amother’s touch may not onlycomfort her child, but may alsotrigger genes involved in shaping thechild’s response to stress”Globe and Mail Jan. 24, 07
  132. 132. Sheway Testamonialn  My son was born in 1998 and wewere in the Sheway program. Eventhough he was born with someeffects of my drug abuse I wanted tosay he is now a very healthy 9 y.o.boy. He was taken into care but Iworked very hard to regain custodyof him, straighten out and create apositive environment for my son and
  133. 133. Create a positive nurturing environment.It was rough, it was shameful, but mymemories were that Sheway was alwaysthere supporting with the food andvitamins that helped him be born ashealthy as he was. I just want to send anencouraging word to any mother who isstruggling. It can be done, be strong andthanks Sheway for being there when noone else was.
  134. 134. With the team and patient look atn  “Predictors” / Co-morbidity factorsn  Motivationn  Support systemsn  Spouse/Maten  Age / Entrenchment / parityn  Personality / drug use / psychiatric disorder
  135. 135. AREAS FOR FUTURE RESEARCH /SYSTEM DEVELOPMENTFor concept of family bonding to work we need todevelop support systems for the men as well as thewomanensure continuity of care and parenting support systemsare in place beyond 2 years of age
  136. 136. “I just want you to know how much we do appreciateyour kindness and dedication.I came in here all hurt and broken-up with not alot of purpose in life. You guys (Gal’s) have treatedme with respect and tenderness. I once again felthuman. After a while as I became healthier youmade me feel worthy and whole again. Life startedto have purpose and meaning.”
  137. 137. Principles of Perinatal care for Substanceusing Women and their Newborns.n  All individuals, from a variety of social,economic, educational, racial and culturalbackgrounds are at risk for substance useduring pregnancy.n  It is important that women who arepregnant and using substances beinformed by their health care and otherservice providers of their choices andrights at all steps of the process.
  138. 138. n  It is important to highlight the strengthsand protective factors of women, infants,their families and their comunities.n  There is a continuum of help that can beoffered to women, children and theirfamilies. Harm reduction approaches needto be encouraged.n  Optimal care is consistent with IntegratedCase Management, which is a sharedcommunity process and should begin assoon as the pregnancy is known.
  139. 139. Process components of IntegragtedCase Management1.  A holistic approach for working withclients.2.  Advocacy3.  Respectful and consistentinvolvement of clients4.  Development of trustingrelationships5.  Common goals
  140. 140. 6.  Clarity of roles7.  Information sharing and frankcommunication.8.  Shared responsibility andaccountability to other professionalsand to clients.9.  A mechanism for resolving conflict.10.  Aboriginal involvement in planningservices for their community.
  141. 141. “ In my experience, if you stayfocused with your baby, provide agood home, talk and play with yourbaby
  142. 142. Then you have done what you haveto do!
  143. 143. Can woman you do this to theirbabies be motivated?
  144. 144. Most are motivatedAll feel guiltyMost don’t understand what they are doingAll need your help
  145. 145. Major Areas of Pediatric Concernn  Birth defectsn  Neonatal effectsn  Long term effects- growth anddevelopmentn  Social risk- neglect abuse
  147. 147. Methodsn  3 groups of mothers and infants were studied1) Tertiary care maternity hospital-rooming in(n=38)2) Tertiary care maternity care hospitalnot rooming in, (n=33)3) Community hospital-not rooming in (n=36)
  148. 148. What About the Genetics?“ There is a 10 fold difference insusceptibility of genetic strains toalcohol”Dr. K. Sulik11th Annual Western PerinatalResearch MeetingBanff 2003
  149. 149. Sheway Outcomes-2004n  77 babies born/70% aboriginaln  70% BW above 2500gmsn  10% premature/normal birthweightn  25% premature/low birthweightn  Average 115 open clients/families
  150. 150. Science & Beyond IIIBanff Alberta 2004“the question of the mother’s lifestyleand the possible effect on thegrowing baby is a sensitive issue thatwill be addressed from the scientific,ethical and legal perspective”
  151. 151. Barker HypothesisSub-optimal nutrition in utero leads tofetal adaptations that permanentlyalter the physiology and metabolismof the body and leads to diseases inadult life.
  152. 152. “Mental Ilness as a Responseto an Insane World”The Evolution ofPsychotherapy ConferenceAnaheim, Cal./ Dec. 2005
  153. 153. Cuddling Moms = Decreased NeedTo TreatSoIntroduce Extended Family/VolunteerCuddlers
  154. 154. “Holistic understanding of DrugAddiction determines ourPrimary Careapproach/treatment!”For the Fetus as well as Mom!“To Decrease the Amount of Drug thatMom and Fetus are Exposed To”
  155. 155. 2 Years later
  156. 156. “Cuddle and Hold”
  158. 158. Rooming In
  159. 159. Why Do They UseSocial Dislocation/RacismAND
  160. 160. Identify the Population/CommunityWho is using?What are they using?
  161. 161. n  Dysfunctional Familyn  She was a ‘problem’ in schooln  Left school in grade sixn  Started drinking and Drugs age 12
  162. 162. Ron Abrahams MD FCFP POGO 2008
  163. 163. Multiple Drug Exposure (WithOpiates) Increases Need TreatSoDecrease number and amount of drugsmom and fetus exposed to
  164. 164. Prescribed Meds Impact NewbornsAbility to Feed, Settle, Gain WeightSobalance risks/benefit ofantidepressants/mood stabilizersand don’t treat as opiate withdrawal
  165. 165. Ron- if you think it is bad here (DES)Go to Regina- IT IS SCARYI left after three daysPills / alcohol / violenceThey even have gated communities
  166. 166. EUREKA !“We Need to try rooming inthe babieswiththe moms”
  167. 167. Rooming In? – Let’s Do Itn  To compare outcomes of newborns ofpregnant women maintained onmethadone who were admitted to arooming in program compared to“usual care” in the special carenursery.
  168. 168. Consequences of Drugs Are SpecificAs a teratogenOn fetal growth / pregnancyTo Use-IV or Snorting or OrallyTo Newborn WithdrawalIn breastfeedingOn long term developmentHEROIN/COCAINE/ALCOHOL/
  169. 169. Prescribing Methadonen  Patient has “right” to choose (detox)n  Dose needs to be individualizedn  “Rooming in” decreases withdrawaln  Can Breastfeed at any dose!n  Studies show small amount inBreast milk
  171. 171. Monitoring Drug UseTrust the Patient ???Depend on Clinical SuspicionNot urine drug screens“THE CHILD IS THE URINE DRUGSCREEN”
  172. 172. Identify the Population/Community“The Environmental Unit”TO REDUCE HARM
  173. 173. Outcomes Dependent OnTheSOCIAL DETERMINATSOfHEALTH
  174. 174. Social DiscriminationScientific Discrimination“UNFIT TO PARENT”Translates Into Apprehension
  175. 175. Foster Care “Graduates’Consistently will tell you thatI AM NOT CRAZYbutI AM TRAUMATIZEDandDISLOCATED
  176. 176. “Work With The Patient”BE FlexibleBe Safe
  177. 177. “Pandora’s Box Of Addiction ”Experimentation RecreationalTraumaWounded
  178. 178. Clinical Discrimination
  179. 179. Chavaesk-Samara
  180. 180. Retrospective comparison of Rooming-in vs. Standard careusing BC Perinatal Services dataAn Evaluation of Rooming-in amongst Substance-exposedNewborns in British ColumbiaRooming In(n = 355)Standard Care(n = 597)Admitted to NICU * 138 (38.9%) 231 (45.0%)Term newborn NICUdays (mean (SD)) *1.1 (3.1) 3.1 (8.3)Received breast milkduring hospital stay *225 (63.7%) 263 (45.4%)Presence of neonatalwithdrawal97 (27.3%) 156 (26.1%)Discharged homewith mother *228 (69.9%) 326 (58.7%)* p < 0.001*P < 0.001
  181. 181. Rooming-in associated with:• Significant decrease in admissions to NICU• Decreased NICU length of stay for term infants• Increased likelihood of breastfeeding during hospital stay• Increased odds of baby being discharged home withhis/her motherReview supports the finding that rooming-in is both safe andbeneficial for substance-exposed babiesAn Evaluation of Rooming-in Amongst Substance-exposedNewborns in British Columbia (cont.)
  182. 182. “ She thoroughly enjoys the playsituation and approaches people andtoys with much enthusiasm. Hergrandmother reports enjoying hergranddaughter and is to becongratulated for providing thestability Jessie needed to progress sowell.”
  183. 183. An Evaluation of Rooming-in amongst Substance-exposedNewborns in British ColumbiaManuscript accepted to JOGCRetrospective comparison of Rooming-in (n=371) vs. Standard care(n=834) using BC Perinatal Heath Program data.Rooming-in associated with:• Significant decrease in admissions to NICU• Increased likelihood of breastfeeding during hospital stay• Increased odds of baby being discharged home with his/her motherReview supports the finding that rooming-in is both safe andbeneficial for substance-exposed babies.
  184. 184. Rooming in ProgramDecision to treat determined bynewborns inability to gain weightELIMINATES OBSERVER BIAS
  185. 185. Chart review: Interim Analysis (174 pairs)Most Common Maternal Drug Use: Cocaine used by 103 (59%)Methadone used by 58 (33%)Heroin used by 48 (28%)Alcohol used by 26 (15%)Crystal Meth. used by 20 (11%)165 babies: 36 (22%) babies were prescribed morphine at birthLength of morphine treatment: Mean = 18 days (SD = 9.6; min = 6 days, max = 55 days, Median = 15.5days)The higher the dose of maternal methadone, the more likely the baby was to receivemorphine (t = 2.18, p = 0.03), with a tendency for an increased duration of treatment (r = 0.31, p =0.08)A threshold of 100mg maternal methadone was significantly associated with whether a babyreceived morphine treatment (F(1, 161)= 12.93, p < 0.0001). Of the mothers who received less than100mg methadone, 122 (83.6%) babies did not receive morphine treatment. Of the motherswho received 100mg or more of methadone, 11 (57.9%) babies received morphinetreatment. Whether a baby roomed in was significantly associated with whether or not it receivedmorphine. 94% of babies who ROOMED IN did not receive morphine, whereas 41% of babieswho DID NOT room-in received morphine (F(1, 161)= 17.51, p < 0.0001).
  186. 186. DRUG ADDICTIONIf we say it is a psychiatric disease (DualDiagnosis) then we tend to ‘misdiagnose”the cause- TRAUMASocial DysfunctionWe are then unable to focus on the real“needs” of this populationR.Abrahams 1987
  187. 187. “Prescribing” Harm ReductionBE FLEXIBLE/BE SAFEDO NO HARM!!
  188. 188. WHO IS USING ?
  189. 189. THC and Standard of Living“ Prenatal Marijuana Exposure AndNeonatal Outcomes In Jamaica”Dreher M.C., Pediatrics Feb. 94
  190. 190. “Heroin Addicted Babies/RDS33 consecutive prems had no RDScompared to controlsGlass et al, Lancet 1971Heroin injected rabbit lungs increased rabbitlung surfactantTaeusch, Carson et alPaediatrics 1973.Morphine withdrawal releases steroids
  191. 191. Methadone vs HeroinNo controlled studies comparing the two!except for:Naomi TrialHigher Retention RatesHealth ImprovementsDecreased criminal activity
  192. 192. Indices For Tx Opiate Withdrawaln  174 mother baby pairsn  Length of tx—median = 15.5 daysn  Maternal meth dose>100 mg=60%n  Maternal meth dose <100 mg=17%
  193. 193. To Minimize Racism/SocialBiasThe Native “jittery” babyversusThe Norwegian “jittery” baby
  194. 194. Vancouver’s Downtown Eastsiden  Canada’s poorest neighborhoodn  Area of only 10 square blocksn  Densely populated - dilapidated singleroom hotelsn  Concentration of community serviceorganizationsn  Estimated 4700 injection drug usersn  Open drug scenen  Open prostitution scenen  Severe health consequences
  195. 195. Wilson’s Principles#1- Susceptibility to teratogenesisdepends on the genotype of theconceptus and the manner in whichthis interacts with adverseenvironmental factors.
  196. 196. Fir Square Outcomes 20046 monthsn  58 term babiesn  29 opiate exposedn  26% (of 29)treated withmorphinen  16 day averagetreatmentn  58 babies roomedinn  60% home withmomn  7% with familyn  33% to foster
  197. 197. Dual Diagnosis 1980’sbecameCo – Occurring 1990’sThenPost Traumatic Stress DisorderNow“Trauma Informed Care”
  198. 198. Drug EffectsIndependent of Lifestyle(1) Cocaine – pregnancy harm??(2) Opiates/Methadone - newborn withdrawal(3) Nicotine – small babiesnewborn withdrawal(4) Alcohol – fetal alcohol syndromeRemember - it is the legal drugs that do the mostDamage
  199. 199. “Improvement Of Trauma Care”n  Trauma trainingn  Short Trauma Interventionn  Development Web Based Tools forTrauma Informed CarePlus Research:Necessary Length of Stages OfSupportSocial and Biological Factors Of RecoveryAN EFFECTIVENESS TRIAL