Psychosocial interventions for pregnant women in outpatient illicit drug treatment programs compared to other interventions

Effectiveness of Motivational Interviewing on adult behaviour change in health and social care settings: A systematic review of reviews

BACKGROUND

The challenge of addressing unhealthy lifestyle choice is of global concern. Motivational Interviewing has been widely implemented to help people change their behaviour, but it is unclear for whom it is most beneficial. This overview aims to appraise and synthesise the review evidence for the effectiveness of Motivational Interviewing on health behaviour of adults in health and social care settings.

METHODS

A systematic review of reviews. Methods were pre-specified and documented in a protocol (PROSPERO-CRD42016049278). We systematically searched 7 electronic databases: CDSR; DARE; PROSPERO; MEDLINE; CINAHL; AMED and PsycINFO from 2000 to May 2018. Two reviewers applied pre-defined selection criteria, extracted data using TIDIER guidelines and assessed methodological quality using the ROBIS tool. We used GRADE criteria to rate the strength of the evidence for reviews including meta-analyses.

FINDINGS

Searches identified 5222 records. One hundred and four reviews, including 39 meta-analyses met the inclusion criteria. Most meta-analysis evidence was graded as low or very low (128/155). Moderate quality evidence for mainly short term (<6 months) statistically significant small beneficial effects of Motivational Interviewing were found in 11 of 155 (7%) of meta-analysis comparisons. These outcomes include reducing binge drinking, frequency and quantity of alcohol consumption, substance abuse in people with dependency or addiction, and increasing physical activity participation.

CONCLUSIONS

We have created a comprehensive map of reviews relating to Motivational Interviewing to signpost stakeholders to the best available evidence. More high quality research is needed to be confident about the effectiveness of Motivational Interviewing. We identified a large volume of low quality evidence and many areas of overlapping research. To avoid research waste, it is vital for researchers to be aware of existing research, and the implications arising from that research. In the case of Motivational Interviewing issues relating to monitoring and reporting fidelity of interventions need to be addressed.

Contingency management treatment for substance use disorders: How far has it come, and where does it need to go?

Contingency management (CM) interventions consistently improve substance abuse treatment outcomes, yet CM remains a highly controversial intervention and is rarely implemented in practice settings. This article briefly outlines the evidence base of CM and then describes 4 of the most often-cited concerns about it: philosophical, motivational, durability, and economic. Data supporting and refuting each of these issues are reviewed. The article concludes with suggestions to address these matters and other important areas for CM research and implementation, with the aims of improving uptake of this efficacious intervention in practice settings and outcomes of patients with substance use disorders. (PsycINFO Database Record

Qualitative evaluation of a novel contingency management-related intervention for patients receiving supervised injectable opioid treatment

AIM

To evaluate a novel contingency management (CM)-related intervention for people experiencing complex drug problems, thereby increasing understanding of CM implementation in real-world settings. Objectives are to provide new insights into (i) how context influences intervention delivery; (ii) aspects of intervention delivery that influence outcomes; and (iii) intervention outcomes.

DESIGN

Qualitative realist evaluation of a novel CM-related intervention: conditional budgets (CB).

SETTING

Supervised injectable opioid treatment (IOT) clinic in England (May 2014-March 2015).

PARTICIPANTS

Twenty IOT clinic patients (14 men; six women); 10 IOT clinic staff (seven men; three women).

MEASUREMENTS

Semi-structured interviews systematically coded relating to knowledge and views of the intervention, experiences of delivering/receiving the intervention, and effectiveness of the intervention.

INTERVENTION

Personal budgets provided to patients who reduced their supervised IOT while demonstrating ongoing stability.

FINDINGS

(i) Contextual factors influencing intervention delivery included patient motivation; clarity of intervention information; prior trust in the treatment system; patient and staff involvement in intervention design; stability of the treatment setting. (ii) Aspects of delivery influencing outcomes included transparency of the eligibility criteria, rules and operating processes; rule enforcement; continued verbal information about the intervention; speed of incentive processing and receipt. (iii) Reduced drug use was difficult to attribute to CBs, as patients who did well were those most motivated to change before the intervention started. Unintended outcomes were positive (improved patient psychological wellbeing, staff job satisfaction, staff/patient relationships) and negative (patient relapse, increased staff work-load, tensions in clinic relationships).

CONCLUSIONS

A 'qualitative realist' evaluation of a contingency management intervention to help address complex substance use disorder problems suggests that the programmes need to have stakeholder input, implement consistent eligibility criteria, rules and processes and be introduced into stable treatment settings where relationships are trusting and patients and staff feel secure.

Psychosocial interventions for pregnant women in outpatient illicit drug treatment programs compared to other interventions

BACKGROUND

Illicit drug use in pregnancy is a complex social and public health problem. The consequences of drug use in pregnancy are high for both the woman and her child. Therefore, it is important to develop and evaluate effective treatments. There is evidence for the effectiveness of psychosocial interventions in drug treatment but it is unclear whether they are effective in pregnant women. This is an update of a Cochrane review originally published in 2007.

OBJECTIVES

To evaluate the effectiveness of psychosocial interventions in pregnant women enrolled in illicit drug treatment programmes on birth and neonatal outcomes, on attendance and retention in treatment, as well as on maternal and neonatal drug abstinence. In short, do psychosocial interventions translate into less illicit drug use, greater abstinence, better birth outcomes, or greater clinic attendance?

SEARCH METHODS

We conducted the original literature search in May 2006 and performed the search update up to January 2015. For both review stages (original and update), we searched the Cochrane Drugs and Alcohol Group Trial's register (May 2006 and January 2015); the Cochrane Central Register of Trials (CENTRAL; the Cochrane Library 2015, Issue 1); PubMed (1996 to January 2015); EMBASE (1996 to January 2015); and CINAHL (1982 to January 2015).

SELECTION CRITERIA

We included randomized controlled trials comparing any psychosocial intervention vs. a control intervention that could include pharmacological treatment, such as methadone maintenance, a different psychosocial intervention, counselling, prenatal care, STD counselling and testing, transportation, or childcare.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration. We performed analyses based on three comparisons: any psychosocial intervention vs. control, contingency management (CM) interventions vs. control, and motivational interviewing based (MIB) interventions vs.

MAIN RESULTS

In total, we included 14 studies with 1298 participants: nine studies (704 participants) compared CM vs. control, and five studies (594 participants) compared MIB interventions vs.

CONTROL

We did not find any studies that assessed other types of psychosocial interventions. For the most part, it was unclear if included studies adequately controlled for biases within their studies as such information was not often reported. We assessed risk of bias in the included studies relating to participant selection, allocation concealment, personnel and outcome assessor blinding, and attrition.The included trials rarely captured maternal and neonatal outcomes. For studies that did measure such outcomes, no difference was observed in pre-term birth rates (RR 0.71, 95% confidence interval (CI) 0.34 to 1.51; three trials, 264 participants, moderate quality evidence), maternal toxicity at delivery (RR 1.18, 95% CI 0.52 to 2.65; two trials, 217 participants, moderate quality evidence), or low birth weight (RR 0.72, 95% CI 0.36 to 1.43; one trial, 160 participants, moderate quality evidence). However, the results did show that neonates remained in hospital for fewer days after delivery in CM intervention groups (RR -1.27, 95% CI -2.52 to -0.03; two trials, 103 participants, moderate quality evidence). There were no differences observed at the end of studies in retention or abstinence (as assessed by positive drug test at the end of treatment) in any psychosocial intervention group compared to control (Retention: RR 0.99, 95% CI 0.93 to 1.06, nine trials, 743 participants, low quality evidence; and Abstinence: RR 1.14, 95% CI 0.75 to 1.73, three trials, 367 participants, low quality evidence). These results held for both CM and MIB combined. Overall, the quality of the evidence was low to moderate.

AUTHORS' CONCLUSIONS

The present evidence suggests that there is no difference in treatment outcomes to address drug use in pregnant women with use of psychosocial interventions, when taken in the presence of other comprehensive care options. However, few studies evaluated obstetrical or neonatal outcomes and rarely did so in a systematic way, making it difficult to assess the effect of psychosocial interventions on these clinically important outcomes. It is important to develop a better evidence base to evaluate psychosocial modalities of treatment in this important population.

Compared with what? An analysis of control-group types in Cochrane and Campbell reviews of psychosocial treatment efficacy with substance use disorders

BACKGROUND AND AIMS

A crucial, but under-appreciated, aspect in experimental research on psychosocial treatments of substance use disorders concerns what kinds of control groups are used. This paper examines how the distinction between different control-group designs have been handled by the Cochrane and the Campbell Collaborations in their systematic reviews of psychosocial treatments of substance abuse disorders.

METHODS

We assessed Cochrane and Campbell reviews (n = 8) that were devoted to psychosocial treatments of substance use disorders. We noted what control groups were considered and analysed the extent to which the reviews provided a rationale for chosen comparison conditions. We also analysed whether type of control group in the primary studies influenced how the reviews framed the effects discussed and whether this was related to conclusions drawn.

RESULTS

The reviews covered studies involving widely different control conditions. Overall, little attention was paid to the use of different control groups (e.g. head-to-head comparisons versus untreated controls) and what this implies when interpreting effect sizes. Seven of eight reviews did not provide a rationale for the choice of comparison conditions.

CONCLUSIONS

Cochrane and Campbell reviews of the efficacy of psychosocial interventions with substance use disorders seem to underappreciate that the use of different control-group types yields different effect estimates. Most reviews have not distinguished between different control-group designs and therefore have provided a confused picture regarding absolute and relative treatment efficacy. A systematic approach to treating different control-group designs in research reviews is necessary for meaningful estimates of treatment efficacy.

Characteristics of perinatal women seeking treatment for marijuana abuse in a community-based clinic

In the US, marijuana continues to be the most frequently used illicit drug among women of childbearing age, including pregnant and postpartum women. Given the critical window for treatment during the perinatal period, more information is needed about the characteristics of women who abuse marijuana and about their unique needs with the goal of improving clinical services and outcomes for both women and their infants.

OBJECTIVES

To (1) identify a profile of perinatal women seeking treatment for primarily marijuana abuse and (2) report birth outcomes in a subset of pregnant women with marijuana abuse.

METHODS

This retrospective clinical chart review study examined 67 adult perinatal women patients (54 % ethnic minority) who attended an inner-city, hospital-affiliated outpatient program specializing in substance abuse treatment for women. Of all pregnant women, 26 % reported positive urine screens during the first trimester, 41 % during the second trimester, and 27 % during the third trimester. While the subset of pregnant women was small, exploratory results suggest that infants whose mothers continued to use marijuana during their pregnancies were born at a lower gestational age than mothers who abstained; t(29) = 2.04, p <0.05.

CONCLUSION

Identifying potential barriers to treatment could help improve retention in community-based treatment programs during pregnancy and the postpartum period.

Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users

BACKGROUND

Problem alcohol use is common among illicit drug users and is associated with adverse health outcomes. It is also an important factor in poor prognosis among drug users with hepatitis C virus (HCV) as it impacts on progression to hepatic cirrhosis or opiate overdose in opioid users.

OBJECTIVES

To assess the effects of psychosocial interventions for problem alcohol use in illicit drug users (principally problem drug users of opiates and stimulants).

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group trials register (November 2011), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 11, November 2011), PUBMED (1966 to 2011); EMBASE (1974 to 2011); CINAHL (1982 to 2011); PsycINFO (1872 to 2011) and reference list of articles. We also searched: 1) conference proceedings (online archives only) of the Society for the Study of Addiction (SSA), International Harm Reduction Association (IHRA), International Conference on Alcohol Harm Reduction (ICAHR), and American Association for the Treatment of Opioid Dependence (AATOD); 2) online registers of clinical trials, Current Controlled Trials (CCT), Clinical Trials.org, Center Watch and International Clinical Trials Registry Platform (ICTRP).

SELECTION CRITERIA

Randomised controlled trials comparing psychosocial interventions with another therapy (other psychosocial treatment, including non-pharmacological therapies or placebo) in adult (over the age of 18 years) illicit drug users with concurrent problem alcohol use.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data from included trials.

MAIN RESULTS

Four studies, 594 participants, were included. Half of the trials were rated as having high or unclear risk of bias. They considered six different psychosocial interventions grouped into four comparisons: (1) cognitive-behavioural coping skills training versus 12-step facilitation (N = 41), (2) brief intervention versus treatment as usual (N = 110), (3) hepatitis health promotion versus motivational interviewing (N = 256), and (4) brief motivational intervention versus assessment-only group (N = 187). Differences between studies precluded any pooling of data. Findings are described for each trial individually:comparison 1: no significant difference; comparison 2: higher rates of decreased alcohol use at three months (risk ratio (RR) 0.32; 95% confidence interval (CI) 0.19 to 0.54) and nine months (RR 0.16; 95% CI 0.08 to 0.33) in the treatment as usual group; comparison 3 (group and individual format): no significant difference; comparison 4: more people reduced alcohol use (by seven or more days in the past 30 days at 6 months) in the brief motivational intervention compared to controls (RR 1.67; 95% CI 1.08 to 2.60).

AUTHORS' CONCLUSIONS

Very little evidence exists that there is no difference in the effectiveness between different types of interventions and that brief interventions are not superior to assessment only or treatment as usual. No conclusion can be made because of the paucity of the data and the low quality of the retrieved studies.

The efficacy of escalating and fixed contingency management reinforcement on illicit drug use in opioid-dependent pregnant women

OBJECTIVES: Contingency management (CM), long known to be efficacious in the treatment of substance-dependent men and women, has also been found to be efficacious for substance-dependent pregnant women. However, the specific CM reinforcement parameters in the special population of opioid-dependent pregnant women have been less fully and systematically studied. The Drug Abuse Incentive Systems (DAISY) study, a randomized controlled trial (RCT) of opioid-dependent pregnant patients, found that escalating reinforcement was not superior to a fixed reinforcement CM schedule after a 13-week intervention. To further examine CM's reinforcement parameters in this population, this study aims to test the hypothesis that there is an early treatment response showing an escalating reinforcement schedule to be significantly more efficacious than a fixed schedule after 5 weeks of intervention in opioid-dependent pregnant patients. METHODS: Nine measures of opioid and cocaine abstinence among fixed and escalating CM schedule participants in the DAISY RCT (N=90) were compared over the initial 5 weeks of the intervention. RESULTS: No statistically significant difference in the opioid and cocaine abstinence measures was found between escalating and fixed conditions after 5 weeks (14 opportunities for each participant to leave a urine sample). The mean (SD) number of drug negative urine samples was 8.1 (4.5) and 7.4 (4.3), for escalating and fixed groups, respectively (p=0.46). CONCLUSIONS: These results further the scientific knowledge regarding CM treatment in opioid-dependent pregnant women by supporting the finding that the escalating and fixed CM schedules produce similar amounts of drug negatives urine samples early in treatment.

Motivational enhancement therapy coupled with cognitive behavioral therapy versus brief advice: a randomized trial for treatment of hazardous substance use in pregnancy and after delivery

OBJECTIVE

The objective was to compare the efficacy of motivational enhancement therapy coupled with cognitive behavioral therapy (MET-CBT) to brief advice for treatment of substance use in pregnancy.

METHOD

This was a randomized, parallel, controlled trial that was yoked to prenatal care and delivered at hospital outpatient clinics. We enrolled 168 substance-using women who had not yet completed an estimated 28 weeks of pregnancy. Obstetrical clinicians provided brief advice, and study nurses administered manualized MET-CBT. The primary outcome was percentage of days in the prior 28 days in which alcohol and/or drugs were used immediately before and 3 months postdelivery.

RESULTS

There were no significant differences across groups in terms of self-reported percentage of days in which drugs or alcohol were used prior to and 3 months postdelivery. Biological measures showed similar results. There was a trend (P=.08) for lower risk of preterm birth among those who received MET-CBT.

CONCLUSIONS

The tested interventions had similar therapeutic effects. Hence, both treatments may be suitable for pregnant substance users, depending on the population, setting and provider availability. Interventions that are intensified after delivery may decrease postpartum "rebound" effects in substance misuse.

BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP

The British Association for Psychopharmacology guidelines for the treatment of substance abuse, harmful use, addiction and comorbidity with psychiatric disorders primarily focus on their pharmacological management. They are based explicitly on the available evidence and presented as recommendations to aid clinical decision making for practitioners alongside a detailed review of the evidence. A consensus meeting, involving experts in the treatment of these disorders, reviewed key areas and considered the strength of the evidence and clinical implications. The guidelines were drawn up after feedback from participants. The guidelines primarily cover the pharmacological management of withdrawal, short- and long-term substitution, maintenance of abstinence and prevention of complications, where appropriate, for substance abuse or harmful use or addiction as well management in pregnancy, comorbidity with psychiatric disorders and in younger and older people.

Treatment of opioid dependence in the setting of pregnancy

Opioid dependence in the setting of pregnancy provides a distinct set of challenges for providers. Treatment plans must take into consideration psychiatric and medical comorbidities while balancing risks and benefits for the maternal-fetal dyad. Treatment is best offered through a comprehensive treatment program designed to effectively deliver opioid agonist maintenance treatment along with psychosocial and obstetric care. As misuse of prescription analgesics increases in the United States, identification of the problem in pregnancy will become more important because this misuse is expected to lead to an increased prevalence of opioid dependence in pregnancy. Buprenorphine as maintenance treatment of opioid dependence during pregnancy has promise and may offer some benefits, but more research is needed, especially regarding induction of actively addicted women during pregnancy. For the present, methadone maintenance remains the standard of care for agonist treatment of opioid dependence in pregnancy against which other treatments must be compared.

Are male neonates more vulnerable to neonatal abstinence syndrome than female neonates?

BACKGROUND

Prior studies have shown an increased vulnerability among males to adverse outcomes during the postnatal period. Most children exposed to opioids and other medications in utero develop neonatal abstinence syndrome (NAS), yet individual predisposition for NAS is poorly understood.

OBJECTIVE

This investigation examined the role of neonatal sex in the postnatal period for neonates exposed to standardized opioid maintenance treatment in utero with a focus on NAS regarding severity, medication requirements, and duration.

METHODS

This was a secondary analysis of data collected in a prospective randomized, double-blind, double-dummy, multicenter trial (MOTHER study) that examined the comparative safety and efficacy of methadone and buprenorphine during pregnancy. A total of 131 neonates born to opioid-dependent women randomized at 6 US sites (n = 74) and 1 European site (n = 37) were analyzed. Sex-based differences in birth weight, length, head circumference, NAS duration, NAS severity, and treatment parameters of full-term neonates were assessed.

RESULTS

Males had a significantly higher birth weight (P = 0.027) and head circumference (P = 0.017) compared with females, with no significant sex difference in rates of preterm delivery. No significant sex-related differences were found for NAS development, severity, or duration, or medication administered, and there were no significant differences in concomitant drug consumption during pregnancy (P = 0.959).

CONCLUSIONS

This unique prospective study shows similar postnatal vulnerability for both sexes, suggesting that factors other than sex are the major determinants of clinically significant NAS. ClinicalTrials.gov identifier: NCT 00271219.

Randomized controlled trials in pregnancy: scientific and ethical aspects. Exposure to different opioid medications during pregnancy in an intra-individual comparison

BACKGROUND

Chronic medical conditions such as opioid dependence require evidence-based treatment recommendations. However, pregnant women are under-represented in clinical trials. We describe the first within-subject comparison of maternal and neonatal outcomes for methadone- versus buprenorphine-exposed pregnancies. Although methadone is the established treatment of pregnant opioid-dependent women, recent investigations have shown a trend for a milder neonatal abstinence syndrome (NAS) under buprenorphine. However, it is not only the choice of maintenance medication that determines the occurrence of NAS; other factors such as maternal metabolism, illicit substance abuse and nicotine consumption also influence its severity and duration and represent confounding factors in the assessment of randomized clinical trials. CASE SERIES DESCRIPTION: Three women who were part of the European cohort of a randomized, double-blind multi-center trial with a contingency management tool [the Maternal Opioid Treatment: Human Experimental Research (MOTHER) study], each had two consecutive pregnancies and were maintained on either methadone or buprenorphine for their first and then the respective opposite, still-blinded medication for their second pregnancy. Birth measurements, the total neonatal abstinence score, the total amounts of medication used to treat NAS and the days of NAS treatment duration were assessed.

RESULTS

Both medications were effective and safe in reducing illicit opioid relapse and avoiding preterm labor. Methadone maintenance yielded to a significantly higher neonatal birth weight. Data patterns suggest that buprenorphine exposure was associated with lower neonatal abstinence syndrome (NAS) scores. Findings from this unique case series are consistent with earlier reports using between-group analyses.

CONCLUSIONS

Buprenorphine has the potential to become an established treatment alternative to methadone for pregnant opioid-dependent women. Under special consideration of ethical boundaries, psychopharmacological treatment during pregnancy must be addressed as an integral part of clinical research projects in order to optimize treatment for women and neonates.

Health-Led Interventions in the Early Years to Enhance Infant and Maternal Mental Health: A Review of Reviews

BACKGROUND

  Increasing recognition of the importance of maternal mental health and early parenting in optimising the later mental health of the child has given rise to new ways of working during the perinatal period.

AIMS

  The objective of this review is to identify effective health-led interventions to support parents, parenting and the parent-infant relationship during the perinatal period,¹ and beyond.

METHOD

  A systematic search of key electronic databases was undertaken to identify secondary and primary sources of data addressing the research question. Twenty-four reviews addressed the effectiveness of interventions delivered during the postnatal period in promoting closeness and sensitive parenting, infant sensory and perceptual capabilities, and positive parenting, and in addressing infant regulatory problems, maternal mental health problems, and parent-infant relationship problems.

CONCLUSIONS

  A number of methods of working are recommended as part of a model of progressive-universalism beginning ante-natally and continuing through the first two post-natal years, and beyond. The implications for universal, targeted and specialist healthcare services are explored, alongside the role and contribution of CAMHS practitioners.

Treatment of cocaine abuse during pregnancy: translating research to clinical practice

In the late-1980s and early-1990s, much attention in America was focused on cocaine abuse. In particular, the effects of prenatal cocaine use on mothers and infants were in the news spotlight. Risks of adverse effects prompted funding for novel treatment programs. More recently, media attention has shifted elsewhere, and specialized treatment resources have grown scarce. This redirection of funding is unfortunate, as social stigma and fear of legal consequences continue to encourage cocaine-abusing pregnant women to hide drug use and avoid prenatal care. The purpose of this article is to summarize the most prominent adverse maternal and fetal/infant effects associated with prenatal cocaine use; review treatment options, focusing on comprehensive care programs of the 1990s as well as recent research on evidence-based practices and their applicability to pregnant women; and highlight the population of prenatal cocaine-abusing women uninterested in treatment, with a focus on promising strategies to promote drug abstinence and other positive health behaviors.

Pharmacologic interventions for pregnant women enrolled in alcohol treatment

BACKGROUND

Excessive alcohol use during pregnancy has been associated with adverse maternal and neonatal effects. It is therefore important to develop and evaluate effective interventions during this important time in a woman's life. To our knowledge there have been no systematic reviews of randomised control trials (RCT) in this population.

OBJECTIVES

To evaluate the effectiveness of pharmacologic interventions in pregnant women enrolled in alcohol treatment programs for improving birth and neonatal outcomes, maternal abstinence and treatment retention.

SEARCH STRATEGY

We searched the Cochrane Drugs and Alcohol Group's Trial register (August 2008) ; MEDLINE (1.1950 to 6.2008) ; EMBASE (1.1974 - 8.2008); CINAHL (1.1982-6.2008); PsycInfo (1.1806-6.2008), and reference lists of articles.

SELECTION CRITERIA

We sought to include randomised or quasi-randomised studies comparing any pharmacologic intervention versus other pharmacologic treatment alone or in association with psychosocial treatment, placebo, non-intervention or psychosocial intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion in the review. Included studies were to be assessed using standardized data extraction and quality assessment forms. No suitable trials were identified.

MAIN RESULTS

The search strategy identified 793 citations. Twenty-three citations were deemed relevant for full text review; an additional ten articles were retrieved through hand searching references, for a total of thirty-three articles. Following full text review no articles met the inclusion criteria. Data extraction and assessment of methodological quality were therefore not possible.

AUTHORS' CONCLUSIONS

The review question remains unanswered as there were no randomised control trials found relevant to the topic. There is a need for high quality research to determine the effectiveness of pharmacologic interventions in pregnant women enrolled in alcohol treatment program.

Incentives for retention of pregnant substance users: a secondary analysis

Retention of pregnant substance users in treatment is challenging. In a multisite clinical trial, 200 pregnant substance users entering outpatient treatment at one of four programs were randomized to either three individual sessions of Motivational Enhancement Therapy for Pregnant Substance users or three individual sessions normally provided. Retail scrip from $25 to $30 was provided for attendance of research visits but not treatment visits. A post hoc analysis of the non-methadone-maintained participants (n = 175) evaluated the hypotheses that monetary reinforcement for attendance would result in more consecutive, and overall, weeks of attendance of research versus nonincentivized treatment visits. Findings indicate participants were nearly three times as likely to attend 4 consecutive weeks of research visits versus treatment sessions. There was no effect for income while fewer dependents were associated with more consecutive weeks of attendance. Incentives in the $25-to-$30 range may serve to significantly increase attendance and retention.

SUBSTANCE MISUSE DURING PREGNANCY: ITS EFFECTS AND TREATMENT

Prenatal care reduces the impact of illicit drug use on perinatal outcomes. Women who misuse substances are often excluded from mainstream society and, on becoming pregnant, feel guilty about their drug misuse and the potential effects this could have on their unborn baby. These women are vulnerable in many ways and agencies must ensure that they are not excluded from antenatal care. The latest enquiry into maternal deaths published in the UK (CEMACH report) highlights how women with socially complex lives who died were far less likely to have sought antenatal care early in pregnancy or to remain in regular contact with maternity services. Of the women who died from any cause, 11% had problems with substance abuse of whom 60% were registered addicts. Gaps in communication between agencies was highlighted as a particular problem.

Treating pregnant women dependent on opioids is not the same as treating pregnancy and opioid dependence: a knowledge synthesis for better treatment for women and neonates

AIMS

Through a novel synthesis of the literature and our own clinical experience, we have derived a set of evidence-based recommendations for consideration as guidance in the management of opioid-dependent pregnant women and infants.

METHODS

PubMed literature searches were carried out to identify recent key publications in the areas of pregnancy and opioid dependence, neonatal abstinence syndrome (NAS) prevention and treatment, multiple substance abuse and psychiatric comorbidity.

RESULTS

Pregnant women dependent on opioids require careful treatment to minimize harm to the fetus and neonate and improve maternal health. Applying multi-disciplinary treatment as early as possible, allowing medication maintenance and regular monitoring, benefits mother and child both in the short and the long term. However, there is a need for randomized clinical trials with sufficient sample sizes.

RECOMMENDATIONS

Opioid maintenance therapy is the recommended treatment approach during pregnancy. Treatment decisions must encompass the full clinical picture, with respect to frequent complications arising from psychiatric comorbidities and the concomitant consumption of other drugs. In addition to standardized approaches to pregnancy, equivalent attention must be given to the treatment of NAS, which occurs frequently after opioid medication.

CONCLUSION

Methodological flaws and inconsistencies confound interpretation of today's literature. Based on this synthesis of available evidence and our clinical experience, we propose recommendations for further discussion.