Drugs of Dependency: The Pregnant Woman and Her Infant

The repercussions of drug abuse are particularly empha-sized when a pregnant woman is a ﬀ ected. Gestational drugexposure is associated with signiﬁcantly increased risks of poor maternal health, adverse perinatal outcomes, and unfavourable psychosocial consequences. Children a ﬀ ected by maternal drug use are at particular risk form their parent’s drug seeking behavior as well as the toxicological e ﬀ ects of the drugs used. Early identiﬁcation is key, and considerably more research is needed to develop the optimum means by which a ﬀ ected mother-infant dyads may be recognized and supported. In this special issue, we present six papers that with the problems caused by gestational drugs of the of Women in substance abuse programs have high rates of smoking. Pregnancy represents a unique opportunity for intervention, but few data exist to guide tailoring of e ﬀ ective interventions. In this study, 44 pregnant and 47 nonpregnant opioid-dependent women enrolled in comprehensive substance abuse treatment received a 6-week smoking cessation intervention based on the 5A’s counseling model. The number of daily cigarettes decreased by 49% for pregnant patients and 32% for nonpregnant patients at the 3-month followup. Length of time in substance abuse treatment did not correlate with smoking cessation or reduction for either group. Factors predicting reduction of cigarette smoking di ﬀ ered for pregnant versus nonpregnant patients. For pregnant patients, lower levels of nicotine use prior to intervention and self-reported cigarette cravings predicted successful reduction in smoking. For nonpregnant patients, lower a ﬃ liative attachment to cigarettes, reliance on cigarettes for cognitive enhancement, and greater sense of control predicted more successful outcomes. Estimates of the prevalence of drug usage during pregnancy vary by region and survey tool used. Clinicians providing care to newborns should be equipped to recognize a newborn who has been exposed to illicit drugs during pregnancy by the e ﬀ ects the exposure might cause at the time of delivery and/or by drug testing of the newborn. The purpose of this paper is to provide an overview of the literature and assess the clinical role of drug testing in the newborn. Accurate recognition of a newborn whose mother has used illicit drugs in pregnancy cannot only impact decisions for healthcare in the nursery around the time of delivery, but can also provide a key opportunity to assess the mother for needed services. While drug use in pregnancy is not an independent predictor of the mother’s ability to provide a safe and nurturing environment for her newborn, other issues that often cooccur in the life of a mother with a substance abuse disorder raise concerns for the safety of the discharge environment and should be assessed. Healthcare providers in these roles should advocate for unbiased and e ﬀ ective treatment services for a ﬀ ected families. Illicit drug use with opiates in pregnancy is a major global health issue with neonatal withdrawal being a common complication. Morphine is the main pharmacological agent administered for the treatment of neonatal withdrawal. In the past, morphine has been considered by and large inert in terms of its long-term e ﬀ ects on the central nervous system. However, recent animal and clinicalstudies have demonstrated that opiates exhibit signiﬁcant e ﬀ ects on the growing brain. This includes direct dose-dependent e ﬀ ects on reduction in brain size and weight, protein, DNA, RNA, and neurotransmitters—possibly as a direct consequence of a number of opiate-mediated systems that inﬂuence neural cell di ﬀ erentiation, proliferation, and apoptosis. At this stage, we are stuck between the devil and the deep blue sea. There are no real alternatives to pharmacological treatment with opiates and other drugs for neonatal opiate withdrawal and opiate addiction in pregnant women. However, pending further rigorous studies examining the potential harmful e ﬀ ects of opiate exposure in utero and the perinatal period, prolonged use of these agents in the neonatal period should be used judiciously, with caution, and avoided where possible. Objective . This paper reports the ﬁndings comparing the obstetrical health, antenatal care, and psychosocial characteristics of pregnant women with a known history of substance dependence ( n = 41) and a comparison group of pregnant women attending a general antenatal clinic ( n = 47). Method . Face-to-face interviews were used to assess obstetrical health, antenatal care, physical and mental functioning, substance use, and exposure to violence. Results . The substance-dependent group had more di ﬃ culty accessing antenatalcare and reported more obstetrical health complicationsduring pregnancy. Womenin the substance-dependent group were more likely to report not wanting to become pregnant and were less likely to report using birth control at the time of conception. Conclusions . The proﬁle of pregnant women (in specialised antenatal care for substance dependence) is one of severe disadvantage and poor health. The challenge is to develop and resource innovative and e ﬀ ective multisectoral systems to educate women and provide e ﬀ ective care for both women and infants. The multiple risks associated with methamphetamine use are of serious concern for women. These risks and consequences are magniﬁed during pregnancy. This secondary analysis of a parent study compared 26 pregnant to 356 nonpregnant women in Cape Town, South Africa, on selected demographic, psychosocial, and HIV-risk domains to identify their treatment service needs. Proportionally, more pregnant than nonpregnant women are using methamphetamine, P = . 01, although a very high rate of women used methamphetamine. Women reported similar monthly rates of sexual intercourse, but pregnant women were signiﬁcantly less likely to report condom use, P < . 0001, maintaining their risky behavior. Both groups reported elevated Center for Epidemiological Studies Depression Scale CES-D means, suggesting a need for depression treatment. Results demonstrate a pervasive need for women’s comprehensive treatment, regardless of pregnancy status. Moreover, ﬁndings support the urgent need for women-focused and pregnancy-speciﬁc treatment services for methamphetamine use. Finally, a job-skills training/employment component focus is suggested. African-American women who use crack are vulnerable to HIV because of the complex social circumstances in which they live. Drug-abuse treatment for these women during pregnancy may provide time for changing risk behaviors. This paper examines the initial 6-month feasibility of a women-focused HIV intervention, the Women’s CoOp, adapted for pregnant women, relative to treatment-as-usual among 59 pregnant African-American women enrolled in drug-abuse treatment. At treatment entry, the women were largely homeless, unemployed, practicing unsafe sex, and involved in violence. Results indicated marked reductions in homelessness, use of cocaine and illegal drugs, involvement in physical violence, and an increase in knowledge of HIV from baseline to 6-month followup for both conditions. Findings suggest that the Women’s CoOp intervention could be successfully adapted to treat this hard-to-reach population. Future studies should examine the e ﬃ cacy of the pregnancy-adapted Women’s CoOp for women not enrolled in drug-abuse treatment.

The repercussions of drug abuse are particularly emphasized when a pregnant woman is affected. Gestational drugexposure is associated with significantly increased risks of poor maternal health, adverse perinatal outcomes, and unfavourable psychosocial consequences. Children affected by maternal drug use are at particular risk form their parent's drug seeking behavior as well as the toxicological effects of the drugs used. Early identification is key, and considerably more research is needed to develop the optimum means by which affected mother-infant dyads may be recognized and supported. In this special issue, we present six papers that deal with the problems caused by gestational drugs of dependency.
"Pregnant and non-pregnant women in cape town, South Africa: drug use, sexual behavior, and the need for comprehensive services" deals with the problem of methamphetamine use in pregnant women in South Africa, a country where poverty and HIV risk are high. The authors find that methamphetamine, a drug highly associated with adverse psychosocial sequelae, is proportionally used by more pregnant than non-pregnant women, a practice that could have far-reaching effects on their families.
"Drug testing for newborn exposure to illicit substances in pregnancy: pitfalls and pearls" in this special issue provides an overview of drug testing of newborns. Accurate recognition of a newborn whose mother has used illicit drugs during pregnancy influences decisions regarding healthcare of mother and infant whilst in hospital and following discharge. The difference between screening and confirmatory drug testing and the potential for false-positive results by immunoassay screening are discussed. Testing of newborns for illicit drugs can be done on urine, blood, meconium, hair, and umbilical cord blood or tissue samples. The implications and limitations of drug testing are presented. The authors caution that illicit drug use in pregnancy is not an independent predictor of a mother's ability to adequately care for her child but needs to be considered in health care planning.
"Initial feasibility of a woman-focused intervention for pregnant African-American women" reports on the difficulties faced by drug-using women in accessing antenatal care and contraception compared to the general pregnant population. The authors discuss challenges faced in the development of innovative and effective systems to educate affected women and to provide adequate care for the women and their children.
"Pharmacological treatment of neonatal opiate withdrawal: between the devil and the deep blue sea" deals with the issues faced by clinicians on how to optimize treatment of the newborn infant withdrawing from maternal opiates. They emphasize that current clinical research and evidence on the long term development of children affected by in utero opiate exposure is limited as are the effects of pharmacological treatment on these infants, especially when there is an increasing body of evidence suggesting that opiates may not have a benign influence on fetal or, indeed, neonatal neurodevelopment.
"Psychosocial characteristics and obstetric health of women attending a specialist substance use antenatal clinic in a large metropolitan hospital" investigates the outcomes of a community-based intervention to improve drug-use behavior and social circumstances of crack-using African-American women. It highlights, in particular, the benefits of training in social skills such as relationship support to alleviate lifestyle issues associated with highly dependent drug-use behaviors.
"Effectiveness of a smoking cessation intervention for methadone-maintained women: a comparison of pregnant and parenting women" examines the effects of an intervention aimed to reduce cigarette smoking for women in substance abuse programs. This is particularly important as cigarette smoking compounds the risk of adverse perinatal and neonatal outcomes in this population, and the paper highlights the benefits of addressing what would often be considered a trivial problem for the drug-using woman.