Ron Abrahams MD FCFP Problematic Substance Use In Pregnancy (PSUP) Opitimizing The Epigenetics - A Standard of Care!

“Clinical” Epigenetics

“ As health care providers, it is imperative to take into account and advocate for improving the ‘overall” fitness of the pregnant patient’s particular “environmental unit.”

Poul Sorenson Ron Abrahams

“Integrated Community/Hospital Harm Reduction Program”

Sheway Fir Square “Trauma Informed Care”

A PRIMARY CARE MODEL Empirical/Evidence

Harm Reduction in Pregnancy A “CORE PROGRAM” For A Sustainable Healthy Community

Goals of the Program To DECREASE THE AMOUNT OF DRUG mothers

and babies are exposed to (Trauma Informed Care)

To improve social stability To facilitate bonding between mother and baby To reduce withdrawal and need to treat in the

newborn To prepare more babies to go HOME with mom

Trauma Informed Care Involves? Pharmaceutical (Pump them with drugs) ? Psychotherapy and/or Self Interventions Medication ? REMEMBERING!- “NEED TO DECREASE AMOUNT OF DRUG EXPOSURE TO MOM AND FETUS” And it is a long “labour” intensive journey for everyone!!

Salish Seas “Red Lies”

“I’ve been lying since I was seven When I knew there was no heaven When hell was lying next to me”

SELF MEDICATING because it WORKS BETTER BURIES MY NIGHTMARES !

“To my Doctor, a believer in me and keeping the family together,

Believer in not medicating pain!”

For The Patient Not Ready To Live “Drug Free”/Self Medicating

The Goal Is “Culturally Sensitive” Integrated/Community/Hospital Harm Reduction programs incorporating “Trauma Informed Care” “Trauma Growth” Minimizing Drug Exposure Epigenetics/Societal Obligation!?

Her Injection Site Her “Community”

Safe Injection Site

Pregnant and SHE’S INJECTING !!!!!

Her Safe Injection Site Her “Community”

Determines Outcome!!

Social Determinants Of Health “ What is common to these women is that they are

exposing themselves and their fetuses to the same drug.

The difference is in their lifestyles.” R. Abrahams MD 1987

NO!-It’s The Drug, STUPID!

“Cocaine is popular, glamorous, middle class and possibly more dangerous to an unborn baby than any other illicit drug”

“Bonding between mother and child is hindered” Dr. Ira Chasnoff 1986

Open Letter To The Media Feb. 25, 2004

These terms, such as “crack babies’, “ice babies” and “meth babies”, lack scientific validity and should not be used. Chasnoff, Koren et al

Partying at Henley “An Open Drug Scene”

Alcohol In Pregnancy

“Drinking alcohol in pregnancy is the primary risk factor for FASD. BUT the levels and symptoms of damage in the children emanating from different drinking mothers vary significantly,

Alcohol In Pregnancy

And this variation is not fully explained by the quantity and frequency of alcohol consumption during pregnancy. Therefore, risk factors other than alcohol exist and serve to mediate, moderate or otherwise alter the effects of alcohol on the fetus.

Abel 1998 Abel and Hannigan 1995

First Nations Infant Mortality Int. J. Epidemiol. Aug. 04

“Post neonatal mortality causes suggest the need for improved socioeconomic and living conditions.”

“ more culturally oriented maternal and infant health programs may be helpful.”

NOT APPREHENSION AS A PREVENTATIVE MEASURE !

“Point Of Entry” The First Encounter Eliminate Welcome Barriers Her In • 

IN THE OFFICE? Don’t Panic !!!!!! Don’t Get On The

Phone NO LEGAL OBLIGATION TO REPORT THE UNBORN!

Multi- Disciplinary Team MUST BE Culturally Appropriate User Friendly Non-Judgmental Supportive Trusted by the patient Confidential MUST ADVOCATE

Sheway-Philosophy of Service

n  Offers respect and understanding of First Nations culture, history and tradition

n  Takes a harm reduction approach to substance use

n  Links women and families into a network of health-related, social, emotional, cultural, and practical support

SHEWAY – Philosophy of Service

n  Provides women centred services in a flexible, welcoming, non-judgmental, nurturing/accepting way.

n  Supports women’s self-determination, choices, and empowerment

n  Be a “helping” hand

Mother The Mother And You Will Mother The Child

Sheway Outcomes 1990’s

n  91% received pre-natal care by delivery n  Nutritional concerns decreased from 79%

to 4% n  Housing concerns decreased from 27%

with no fixed address / 65% at intake vs only 4% with concerns postpartum

Sheway Outcomes-1990’s n  Birth weight > 2500 grams INCREASED from 20% to 86% since 1993

n  In 1993 100% apprehension rate at birth decreased to 5% by 1999

Integrating Community/Hospital

n  To re-orient the management of these pregnant women and families

Culturally Appropriate

n  Provide the foundation towards preparing mothers and babies to go home as a healthy unit

Trauma Informed Care R. Abrahams 1986

To Prevent (1980’s)

n  Baby separated from mom at birth n  Baby put in “quiet room” n  Observed for withdrawal/no bonding n  Most babies treated for withdrawal n  Mom treated like “sh-t”/JUDGED n  Baby apprehended! (100% In DTES) n  Mom back on street—MORTALITY!

“Rooming-in Compared With Standard Care of Mothers Using

Methadone or Heroin” Safe to room in baby and mother Less babies needed treatment for

withdrawal More babies went home with mom R. Abrahams, S. Payne, P. Thiessen Canadian Family Physician Oct 07

0%10%20%30%40%50%60%70%80%90%

100%

Jitteriness p =.312

Poor suckingp = .078

Diarrhea p =.651

Vomiting p=.031

Cryinginconsolably

p <.002

piror to rooming in rooming in

Baby’s Behavioural Ratings

Investing In The Future

FIR F amilies I n R ecovery Unit

n  Antepartum/Ultra Sounds

n  Peripartum

n  postpartum

n  Community Integration

Families In Recovery Unit

n  Multidisciplinary

n  Dedicated Nurses/Staff With the right attitude!

n  Continuity of Care

First Day

9 Years Later

The Perinatal Addiction Service

The Perinatal Addiction Service

n  24/7 On call/Provincial n  Primary Care Physicians n  Integrated with community and

hospital n  Integrated with multidisciplinary

teams

Observed Trends On Fir

Cuddling/focused moms avoid the need to treat babies with morphine

Multiple drug exposure increases need to treat (illicit/prescribed)

Prescribed Meds impact newborns ability to feed, settle, gain weight NB. Don’t Rx with Morphine?

1000 plus Women delivered

Fir Square Qualitative Outcomes

n  100 % of women felt connected to community

n  74% reported decreased use of “problem” drug

n  89% reported decreased level of anxiety

An Evaluation of Rooming-in Amongst Substance-Exposed Newborns in British Columbia

R. Abrahams et al JOGC, 2010

Retrospective 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 mother

Review supports the finding that rooming-in is both safe and beneficial for substance-exposed babies.

Probability Methadone/Morphine Tx JOGC May 2011

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 25 50 75 100 125 150 175 200 225 250

Mother's methadone dose (mg)

Pred

icte

d Pr

obab

ility

of i

nfan

t rec

eivi

ng

mor

phin

e No breastfeeding and other opiatesBreastfed and other opiatesNo breastfeeding and no other opiatesBreastfed and no other opiates

Sheway/Supportive Housing Society’s Responsibility

“ In spite of her potentially rough beginning, Jessie demonstrates

normal movement patterns, has a delightful personality and is

accomplishing all developmental skills at her age level or beyond.”

Epigenetics-”Cuddle and Hold”

Prof. Meaney-McGill “Good” rat moms produce offspring who explore more, are less fearful and less reactive to stress,

perform better COGNITIVELY, and preserve cognitive skills better into old age- by maternal

behaviour altering gene expression!

“Mother’s affection at 8 months predicts emotional distress in adulthood

J. Maselko et al, JECH July 2010

Study the Epigenetics of

n  Maternal Infant Bonding n  Safe adequate housing n  Nutritional status n  Community/being safe n  Sense of well being/self esteem n  Trauma/childhood abuse/separation

Wanting to hide I swallowed my pride

It was time to care for my baby inside

I could no longer bare being pregnant and scared I took strong advice and stayed at Fir Square

Finally relieved, but pleased

New friends faces tended my needs

The nurses staff and girls that were there Showed me strength, courage and tender care

Safe as can be, I had the right key

Slowly accepting the changes in me

It must have been fate Cause my baby is great

Thank you for helping

Its never too late!!!! A Fir Patient

On The Road To ----

I am happy to say that we continue to make progress.

As you know we opened the prenatal clinic at the Family futures

office downtown Pr Albert Dr Egbeyemi runs the clinic once a

week. We continue to have success with our moms rooming in and staying for an extended period

of time (2-3 weeks).

We have had about 7-8 moms since your visit and all have

roomed in. All but one have gone home with mom and the one that didn’t go home with mom did stay with her baby for 16 days until the baby was ready for discharge. We

do consider that a success!

The biggest step has been the supports that family futures put into

place before delivery and then communicated that with us and the

ministry= all with the clients knowledge. That helps us with

having a discharge plan in place. LOVE IT!

TOMSK-SIBERIA

Tomsk-SIBERIA

Downtown Eastside OPEN DRUG SCENE

Who Is Using?

“the Junkie” “The street Entrenched” “high end” cocaine user

nicotine addict “pot” smoker

middle class housewife drinking/valium “The Walking Wounded”

“I’m Not Like Them”

Remove Stereotypes

That they are not all “druggies” prostituting, stealing, incapable of ever being good

mothers

“Yeah BUT”

Can woman who do this to their babies be motivated?

“Most are motivated All feel guilty

Most don’t understand what they are doing All need your help”

What About Diet (Environment)?

Vitamin A deficiency Folic Acid deficiency Choline Deficiency/Ukraine Study “Preventive Intervention To FAS” Ballard et al. Medical Hypotheses Jan/12

So, It Is The Environment

After controlling for covariates neither cocaine nor opiate exposure showed effect on development scores, motor scores or behavioural scores when tested at 1,2, and 3 years.

Mesinger,D.S. et al pediatrics, vol 113 #6, June 2004

Stop Perpetuating the “Crack baby” Myth

“Research now shows that the fetal and

infant health problems previously associated

with crack cocaine are better explained by

malnutrition and a lack of pre-natal care.”

David C. Lewis MD, Oct. 2004

Blame It On The Science!

n  -poorly controlled up to now n  -impossible to control - too many

variables n  inaccurate self reporting- fear of legal

reprisal n  bias in the scientific community! (Scientific Discrimination)

“A difficulty relates to the selection bias in the reporting of positive rather than the negative results in the studies of the effects of intrauterine exposure to cocaine among abstracts submitted to the society for pediatric research. From 1980 - 1989 only 11% of those describing no effect of cocaine were accepted for presentation. As compared to 57% of those describing an effect” J. Volpe N.E.J.M. 1992

“Crystal Meth”

“Limited experience, but it seems that if we control for prenatal care, environment, and diet, we can expect a normal outcome.”

R. Abrahams MD 2004

Clinical Bias

That’s All Wonderful-But!!

THESE WOMEN ARE ALL Dual Diagnosis !

1st European Conference on Drug Addiction 1989

Dual Diagnosis/Abstinence

Avoid SSRIs In Pregnancy?

Increase in: Prematurity! low birth weight! fetal death rate! withdrawal symptoms in newborn! seizures in newborn! AJOG 2006

Among those with a history of early childhood Trauma (emotional,physical,sexual) Psychotherapy alone was superior to antidepressant monotherapy

C. Nemeroff Nov. 2003

Implications For Treatment Approach

Addiction Research Now tells us: correlated with

Dysfunctional families Trauma and/or Abuse/Isolation

Every Strata of Society

“Why Experimentation Becomes Addiction” Isolated rats go back for more and more Rat Park Experiments 1970’s Prof. Bruce Alexander

Potlatch Legislated Racism

A Family Picnic

Childhood Trauma And PTSD Pts With Psychosis

n  “Childhood trauma & its consequences are highly prevalent among pts. With psychosis and severely affect the course and outcome. “

n  “Tx approaches need to be further evaluated for this population”

n  Schafer, Current Opinion Psychiatry 2011

Harm Reduction n  Practical Concept for patients, physicians, Institutions n  Through education and support- the

patient can reduce harm by reducing risks n  A concept that supports “Safe Use” not “Safe Abstinence”

n  Society has the responsibility to reduce harm e.g. provide safe housing, clean needles, drugs legally

n  Improve Social Determinants of Health R. Abrahams 1986

Prescribing Harm Reduction

Opiates- meth/morphine/bupr/heroin trials Iv T’s and R’s- oral talwin Alcohol- benzos/ “managed alcohol program” Cocaine- ativan/valium Crystal meth- dexedrin Smoking patch etc PRAZOSIN? supply needles FOOD! injection sites HOUSING !! naomi trial

SHE SHOWS UP AT YOUR OFFICE n  Twenty one year old n  -no support/no money n  -no fixed address or affluent (“I’m not like them”) n  - twelve weeks pregnant, confirmed by ultra sound n  -Using heroin and coke daily/smoking-some IV use n  -Alcohol binges n  -Smoking cigarettes n  -Hepatitis C+ n  -HIV Neg

YOU NEED TO ENSURE SHE COMES BACK AGAIN

SHE WANTS TO KNOW n  Will my baby be deformed/addicted n  Should I have an abortion? n  If I decide to keep my baby, should I detox and is it

safe to detox? n  What about methadone? I’ve heard that it is more

addictive than heroin, especially for my baby n  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!

“You Need To Tell her” n  Decrease the amount of drug that you

and your baby are exposed to n  My care is not dependent on

you being abstinent n  You and your baby must have a safe

place to go home to n  Apprehension is not the hidden

agenda n  Don’t f… up!!!/set limits R. Abrahams 1987

Her Physician’s “Referral” To Child Protection

n  Extremely High risk Infant n  Mom probable street worker n  Smokes cocaine and high dose narcotic

thoughout pregnancy. Father has lost two children to MCFD and mom one

n  Mom MRSA pos, dental caries/ unkept n  Requests for follow-up bloodwork not done n  Last baby small for GA n  This baby small also n  “A DISASTER WAITING TO HAPPEN”

MCFD VCH 2 Social Workers 4 Community Health Nurses 1 Nutritionist

1 Alcohol and Drug Counsellor 3 Sessional Family Physicians

1 Coordinator

VNHS YWCA 1 Medical Office Assistant 1 Outreach Worker 1 Receptionist 2 Infant Development Consultants 1 Cook/Peer Support Worker 1 Family Support Worker 1 Aboriginal Community Support Worker 1 Administrative Assistant

The Sheway Team

STAFF MUST HAVE THE RIGHT ATTITUDE!

“Helping” Starts

with

HONORING HER CHOICES to

IMPROVE COMPLIANCE

Improving Compliance

Increases the number of ante-natal visits which is the only consistent variable that improves perinatal outcome

By Reducing Barriers To Care

THE PATIENT IS THE ONE WHO HAS THE RIGHT TO CHOOSE

Moral and Systemic Barriers Scientific bias and a lack of evidence based research Allows the moral/legal/political systems to “justify the implementation of rules/regulations that become BARRIERS TO CARE FOR THE “VULNERABLE “

My Response To My Licensing Authority

“ I recognize the need for the College Of Physicians and Surgeons of BC to monitor the methadone program. I will try to comply with the regulations of the program as long as I feel it does not impinge upon my individual patient’s rights, or interfere with my professional relationship with my patients when they come to me to receive care within the construct of the Harm Reduction Model”

R. Abrahams MD 1996

“it is unconstitutional to prosecute citizens for having drugs for their personal use”

Argentine Supreme Court Sept/09

Illegal To Prescribe Methadone

Neberzhney Chelny

Detox is Safe to Fetus Under Controlled

Conditions

Advise Her That This is True!

Monitoring of the Pregnancy

n  Trust/Compliance increases the number of ante-natal visits

n  Offer regular genetic screening

n  Serial ultra-sounds / clinical suspicion/as a “bonding tool”

n  BE READY For All kinds of complications

Proceed to Labour

If: -decrease drug exposure -stabilize / improve lifestyle -minimize morbidity PROCEED to labour and delivery as normal OTHERWISE manage as “high risk” pregnancy

Induce at or Near Term

Due to: n  Pregnancy failing n  Continued chaotic lifestyle n  Continued risk of drug exposure “Baby Better Off “Out” Than “In”

Barriers To Care n  Woman dealt with the system by

accessing it infrequently, hiding drug use during pregnancy, falling back on uncertain, informal support groups

n  System dealt with woman punitively, apprehended babies and expected them to access “mainstream” services in conventional ways

BECAUSE n  40% of the babies born in the downtown

eastside Vancouver were substance exposed (and low birthweight) n  100% of these children apprehended into care

And Remember!! No Apprehension

With A “Social Cushion”

BC WOMEN’S HOSPITAL •  1980’s- SCN-Babies and Mom Seperated!

•  1990’s- IN- Babies and Mom Seperated! •  2000’s- Rooming IN

Methods “Cuddle and Hold” (avoids withdrawal from Mom?) Measure withdrawal in the newborn using objective criteria:

(eliminates Observer Bias!) WEIGHT GAIN– NB !!! Vital signs G.I. Symptoms e.g. diarrhea, vomiting

2. Percent of babies on morphine p=.016

24.20%

55.30% 52.80%

0%10%20%30%40%50%60%

percentage on morphine

C & W Rooming inC & W Prior to rooming inCommunity hospital without rooming in

1. Mean days on morphine p=.315

23.63

33.71 35.32

0

10

20

30

40

days

C& W Rooming inC & W Prior to rooming inCommunity hospital without rooming in

3. Percent of babies apprehended/ foster care (p=.006)

30.30%

68.40%

52.80%

0%

20%

40%

60%

80%

percentage apprehended/foster care

C & W Rooming inC & W Prior to rooming inCommunity hospital without rooming in

What This Study Adds

• Rooming in is a viable, safe model for providing care for the majority of infants of substance using mothers

Breastfeeding

n  Never tell her “ Your milk is no good” n  Discuss and decide with the patient n  Consider:

• Hep C / HIV • Lifestyle (still using?) • Mom’s motivation to breastfeed

(culture) • “Breast is best” • Cheaper than formula

Morphine Treatment ONLY FOR OPIATE EXPOSED BABIES!! i.e. Not gaining weight/diarrhea/sick!

DX. OF EXCLUSION n  Loading Dose of .03 mg/kg q3hrs n  Decrease .02mg every 2 days when stable n  Generally finish by 14 days

Infants Of Smoking Mothers

Behavioural characteristics are the same as those seen in infants withdrawing from opiates Law, K. et al, Pediatrics June’03

“Triple O Babies” ON (Morphine) OFF (Morphine) and OUT In The Room With MOM !!!

Criteria for Discharge from Hospital

1) Watch for signs of withdrawal 7-8 days of age And 2) Baby gaining weight 2-3 days And 3) Home assessment completed

“Apprehension Free Zone”

n  SW / Ministry gather info , assess,

OFFER SUPPORT n  Consensus Decision Made With

Mom / Family/Team re: Home or to “Place of Safety”

n  Change Legislation

Discharge Home With Baby Mom Stable Supports in place

Weekly Visits to Monitor Use “stability”- not Urine

Drug Screens to Monitor

“drug use is not incompatible with adequate child care”

Baby is Urine Drug Screen!!

Delayed Withdrawal at 3-5 Months?

“PURPLE CRYING”---- P-peak pattern U-unpredictable R-resistant to soothing P-painful face L-long bouts crying E-evening crying

NOT Delayed Withdrawal

Continuity of Care

Critical For: • Fostering compliance / Trust • Providing ongoing care • Improving outcomes • Monitoring family growth • Being there for crisis

Patient Testimonial

“ I just want you to know how much we do appreciate your kindness and dedication”

I came in here all hurt and broken up with not a lot of purpose in life. You guys (gals) have treated me with respect and tenderness.

I once again felt human. After a while, as I became healthier

you made me feel worthy and whole again.

Life started to have purpose and meaning.

“Critical for a Sustainable Community”

Dear Ron-

“I thought you might be interested to know that this child is doing very well. She was in for her one year check up and is walking, has numerous words

and well presented by her parents. Her parents are now clean and sober

and have now moved to Chilliwack.” A Community GP

Don’t throw your hands up in despair

Be prepared for many frustrations

AND MANY REWARDS!!!

Randomized Clinical Trial?

“ I would never accept a return to care standards of the 70’s on so vital an issue as keeping moms and babes together”

P. Thiessen 2004

“THE FAMILY SCHOOL”

Harm Reduction

For Integrated Core Community Programs BE PROUD OF WHAT YOU DO!!

“Every public action which is not customary, either is wrong, or if it is right, is a dangerous precedent. It follows that nothing should ever

be done for the first time”

Canadian Medical Association Journal 1996

“ I’d like to see heroin legalized and prescribed legally. It would save a lot of lives and illicit activity.”

R. Abrahams MD

FIR SQUARE

Leading Practice -2004 Canadian Council Health Accreditation Innovative Service Award Of Excellence-2008 BC Representative For Children And Youth

Summary Pregnancy is a 9 month luv affair

n  You have time to: n  Go slow n  Educate

n  Set Goals / Limits n  Support

n  Help n  Monitor n  Evaluate n  Be There

Every BC Community

Community Hospital Program Patient Centred

Multidisciplinary Harm Reduction Research Education

Higher Aboriginal HIV Rates

n  Social Isolation n  Poverty n  Discrimination

“ It has roots in poverty,

unemployment, lack of housing, and dislocation that plague many aboriginal communities”

“Among those with a history of early childhood trauma ( emotional, physical, sexual) psychotherapy alone was superior to antidepressant monotherapy.”

C. Nemeroff PNAS Nov.2003

Supportive Housing

SOCIETY’S RESONSIBILITY

EPIGENETICS “His research suggests that a

mother’s touch may not only comfort her child, but may also trigger genes involved in shaping the child’s response to stress”

Globe and Mail Jan. 24, 07

Sheway Testamonial

n  My son was born in 1998 and we were in the Sheway program. Even though he was born with some effects of my drug abuse I wanted to say he is now a very healthy 9 y.o. boy. He was taken into care but I worked very hard to regain custody of him, straighten out and create a positive environment for my son and

Create a positive nurturing environment. It was rough, it was shameful, but my

memories were that Sheway was always there supporting with the food and vitamins that helped him be born as healthy as he was. I just want to send an encouraging word to any mother who is struggling. It can be done, be strong and thanks Sheway for being there when no one else was.

With the team and patient look at

n  “Predictors” / Co-morbidity factors n  Motivation

n  Support systems n  Spouse/Mate

n  Age / Entrenchment / parity n  Personality / drug use / psychiatric disorder

AREAS FOR FUTURE RESEARCH / SYSTEM DEVELOPMENT

For concept of family bonding to work we need to develop support systems for the men as well as the woman

ensure continuity of care and parenting support systems

are in place beyond 2 years of age

“I just want you to know how much we do appreciate your kindness and dedication. I came in here all hurt and broken-up with not a lot of purpose in life. You guys (Gal’s) have treated me with respect and tenderness. I once again felt human. After a while as I became healthier you made me feel worthy and whole again. Life started to have purpose and meaning.”

Principles of Perinatal care for Substance using Women and their Newborns.

n  All individuals, from a variety of social, economic, educational, racial and cultural backgrounds are at risk for substance use during pregnancy.

n  It is important that women who are pregnant and using substances be informed by their health care and other service providers of their choices and rights at all steps of the process.

n  It is important to highlight the strengths and protective factors of women, infants, their families and their comunities.

n  There is a continuum of help that can be offered to women, children and their families. Harm reduction approaches need to be encouraged.

n  Optimal care is consistent with Integrated Case Management, which is a shared community process and should begin as soon as the pregnancy is known.

Process components of Integragted Case Management

1.  A holistic approach for working with clients.

2.  Advocacy 3.  Respectful and consistent

involvement of clients 4.  Development of trusting

relationships 5.  Common goals

6.  Clarity of roles 7.  Information sharing and frank

communication. 8.  Shared responsibility and

accountability to other professionals and to clients.

9.  A mechanism for resolving conflict. 10.  Aboriginal involvement in planning

services for their community.

“ In my experience, if you stay focused with your baby, provide a

good home, talk and play with your baby

Then you have done what you have to do!

Can woman you do this to their babies be motivated?

Most are motivated All feel guilty

Most don’t understand what they are doing All need your help

Major Areas of Pediatric Concern

n  Birth defects n  Neonatal effects n  Long term effects- growth and

development n  Social risk- neglect abuse

RELAPSE/CRISIS!!! BE THERE

Methods n  3 groups of mothers and infants were studied 1) Tertiary care maternity hospital-rooming in (n=38) 2) Tertiary care maternity care hospital not rooming in, (n=33) 3) Community hospital-not rooming in (n=36)

What About the Genetics?

“ There is a 10 fold difference in susceptibility of genetic strains to alcohol”

Dr. K. Sulik 11th Annual Western Perinatal Research Meeting Banff 2003

Sheway Outcomes-2004

n  77 babies born/70% aboriginal n  70% BW above 2500gms n  10% premature/normal birthweight n  25% premature/low birthweight n  Average 115 open clients/families

Science & Beyond III Banff Alberta 2004

“the question of the mother’s lifestyle and the possible effect on the growing baby is a sensitive issue that will be addressed from the scientific, ethical and legal perspective”

Barker Hypothesis

Sub-optimal nutrition in utero leads to fetal adaptations that permanently alter the physiology and metabolism of the body and leads to diseases in adult life.

“Mental Ilness as a Response to an Insane World”

The Evolution of Psychotherapy Conference Anaheim, Cal./ Dec. 2005

Cuddling Moms = Decreased Need To Treat

So

Introduce Extended Family/Volunteer Cuddlers

“Holistic understanding of Drug Addiction determines our

Primary Care approach/treatment!”

For the Fetus as well as Mom!

“To Decrease the Amount of Drug that

Mom and Fetus are Exposed To”

2 Years later

“Cuddle and Hold”

“DRUG USE IS NOT NECESSARILY INCOMPATIBLE WITH ADEQUATE CHILDCARE.” ?????????

Rooming In

Why Do They Use

Social Dislocation/Racism AND

Identify the Population/Community

Who is using? What are they using?

n  Dysfunctional Family n  She was a ‘problem’ in school

n  Left school in grade six n  Started drinking and Drugs age 12

Ron Abrahams MD FCFP POGO 2008

Multiple Drug Exposure (With Opiates) Increases Need Treat

So

Decrease number and amount of drugs mom and fetus exposed to

Prescribed Meds Impact Newborns Ability to Feed, Settle, Gain Weight

So

balance risks/benefit of antidepressants/mood stabilizers

and don’t treat as opiate withdrawal

Ron- if you think it is bad here (DES) Go to Regina- IT IS SCARY

I left after three days Pills / alcohol / violence They even have gated communities

EUREKA !

“We Need to try rooming in the babies with the moms”

Rooming In? – Let’s Do It

n  To compare outcomes of newborns of pregnant women maintained on methadone who were admitted to a rooming in program compared to “usual care” in the special care nursery.

Consequences of Drugs Are Specific

As a teratogen On fetal growth / pregnancy

To Use-IV or Snorting or Orally To Newborn Withdrawal

In breastfeeding On long term development

HEROIN/COCAINE/ALCOHOL/

Prescribing Methadone n  Patient has “right” to choose (detox) n  Dose needs to be individualized n  “Rooming in” decreases withdrawal n  Can Breastfeed at any dose! n  Studies show small amount in Breast milk

“I DON’T WANT MY KID TO GO

INTO CARE, And I WANT HELP”

Monitoring Drug Use

Trust the Patient ??? Depend on Clinical Suspicion

Not urine drug screens

“THE CHILD IS THE URINE DRUG SCREEN”

Identify the Population/Community

“The Environmental Unit”

TO REDUCE HARM

Outcomes Dependent On

The

SOCIAL DETERMINATS

Of

HEALTH

Social Discrimination Scientific Discrimination “UNFIT TO PARENT”

Translates Into Apprehension

Foster Care “Graduates’

Consistently will tell you that I AM NOT CRAZY but I AM TRAUMATIZED and DISLOCATED

“Work With The Patient”

BE Flexible

Be Safe

“Pandora’s Box Of Addiction ”

Experimentation Recreational Trauma Wounded

Clinical Discrimination

Chavaesk-Samara

Retrospective comparison of Rooming-in vs. Standard care using BC Perinatal Services data

An Evaluation of Rooming-in amongst Substance-exposed Newborns in British Columbia

Rooming In (n = 355)

Standard Care (n = 597)

Admitted to NICU * 138 (38.9%) 231 (45.0%)

Term newborn NICU days (mean (SD)) *

1.1 (3.1) 3.1 (8.3)

Received breast milk during hospital stay *

225 (63.7%) 263 (45.4%)

Presence of neonatal withdrawal

97 (27.3%) 156 (26.1%)

Discharged home with mother *

228 (69.9%) 326 (58.7%)

* p < 0.001

*P < 0.001

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 with

his/her mother

Review supports the finding that rooming-in is both safe and beneficial for substance-exposed babies

An Evaluation of Rooming-in Amongst Substance-exposed Newborns in British Columbia (cont.)

“ She thoroughly enjoys the play situation and approaches people and toys with much enthusiasm. Her grandmother reports enjoying her granddaughter and is to be congratulated for providing the stability Jessie needed to progress so well.”

An Evaluation of Rooming-in amongst Substance-exposed Newborns in British Columbia

Manuscript accepted to JOGC

Retrospective 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 mother

Review supports the finding that rooming-in is both safe and beneficial for substance-exposed babies.

Rooming in Program

Decision to treat determined by

newborns inability to gain weight ELIMINATES OBSERVER BIAS

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 birth Length of morphine treatment: Mean = 18 days (SD = 9.6; min = 6 days, max = 55 days, Median = 15.5 days) The higher the dose of maternal methadone, the more likely the baby was to receive morphine (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 baby received morphine treatment (F(1, 161)= 12.93, p < 0.0001). Of the mothers who received less than 100mg methadone, 122 (83.6%) babies did not receive morphine treatment. Of the mothers who received 100mg or more of methadone, 11 (57.9%) babies received morphine treatment.   Whether a baby roomed in was significantly associated with whether or not it received morphine. 94% of babies who ROOMED IN did not receive morphine, whereas 41% of babies who DID NOT room-in received morphine (F(1, 161)= 17.51, p < 0.0001).

DRUG ADDICTION If we say it is a psychiatric disease (Dual

Diagnosis) then we tend to ‘misdiagnose” the cause- TRAUMA

Social Dysfunction We are then unable to focus on the real

“needs” of this population R.Abrahams 1987

“Prescribing” Harm Reduction

BE FLEXIBLE/BE SAFE DO NO HARM!!

WHO IS USING ?

THC and Standard of Living

“ Prenatal Marijuana Exposure And Neonatal Outcomes In Jamaica”

Dreher M.C., Pediatrics Feb. 94

“Heroin Addicted Babies/RDS 33 consecutive prems had no RDS compared to controls Glass et al, Lancet 1971 Heroin injected rabbit lungs increased rabbit

lung surfactant Taeusch, Carson et al Paediatrics 1973. Morphine withdrawal releases steroids

Methadone vs Heroin No controlled studies comparing the two! except for:

Naomi Trial Higher Retention Rates Health Improvements Decreased criminal activity

Indices For Tx Opiate Withdrawal

n  174 mother baby pairs n  Length of tx—median = 15.5 days n  Maternal meth dose>100 mg=60% n  Maternal meth dose <100 mg=17%

To Minimize Racism/Social Bias

The Native “jittery” baby versus The Norwegian “jittery” baby

Vancouver’s Downtown Eastside n  Canada’s poorest neighborhood n  Area of only 10 square blocks n  Densely populated - dilapidated single

room hotels n  Concentration of community service

organizations n  Estimated 4700 injection drug users n  Open drug scene n  Open prostitution scene n  Severe health consequences

Wilson’s Principles

#1- Susceptibility to teratogenesis depends on the genotype of the conceptus and the manner in which this interacts with adverse environmental factors.

Fir Square Outcomes 2004 6 months

n  58 term babies n  29 opiate exposed n  26% (of 29)

treated with morphine

n  16 day average treatment

n  58 babies roomed in

n  60% home with mom

n  7% with family n  33% to foster

Dual Diagnosis 1980’s became

Co – Occurring 1990’s Then

Post Traumatic Stress Disorder Now

“Trauma Informed Care”

Drug Effects Independent of Lifestyle

(1) Cocaine – pregnancy harm?? (2) Opiates/Methadone - newborn withdrawal (3) Nicotine – small babies newborn withdrawal (4) Alcohol – fetal alcohol syndrome Remember - it is the legal drugs that do the most Damage

“Improvement Of Trauma Care” n  Trauma training n  Short Trauma Intervention n  Development Web Based Tools for Trauma Informed Care Plus Research: Necessary Length of Stages Of Support Social and Biological Factors Of Recovery AN EFFECTIVENESS TRIAL