A comparison study of treated and untreated pregnant and postpartum cocaine-abusing women

Effectiveness of psychosocial interventions for reducing parental substance misuse

BACKGROUND

Parental substance use is a substantial public health and safeguarding concern. There have been a number of trials of interventions relating to substance-using parents that have sought to address this risk factor, with potential outcomes for parent and child.

OBJECTIVES

To assess the effectiveness of psychosocial interventions in reducing parental substance use (alcohol and/or illicit drugs, excluding tobacco).

SEARCH METHODS

We searched the following databases from their inception to July 2020: the Cochrane Drugs and Alcohol Group Specialised Register; CENTRAL; MEDLINE; Embase; PsycINFO; CINAHL; Applied Social Science (ASSIA); Sociological Abstracts; Social Science Citation Index (SSCI), Scopus, ClinicalTrials.gov, WHO ICTRP, and TRoPHI. We also searched key journals and the reference lists of included papers and contacted authors publishing in the field.

SELECTION CRITERIA

We included data from trials of complex psychosocial interventions targeting substance use in parents of children under the age of 21 years. Studies were only included if they had a minimum follow-up period of six months from the start of the intervention and compared psychosocial interventions to comparison conditions. The primary outcome of this review was a reduction in the frequency of parental substance use.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 22 unique studies with a total of 2274 participants (mean age of parents ranged from 26.3 to 40.9 years), examining 24 experimental interventions. The majority of studies intervened with mothers only (n = 16; 73%). Heroin, cocaine, and alcohol were the most commonly reported substances used by participants. The interventions targeted either parenting only (n = 13; 59%); drug and alcohol use only (n = 5; 23%); or integrated interventions which addressed both (n = 6; 27%). Half of the studies (n = 11; 50%) compared the experimental intervention to usual treatment. Other comparison groups were minimal intervention, attention controls, and alternative intervention. Eight of the included studies reported data relating to our primary outcome at 6- and/or 12-month follow-up and were included in a meta-analysis. We investigated intervention effectiveness separately for alcohol and drugs. Studies were found to be mostly at low or unclear risk for all 'Risk of bias' domains except blinding of participants and personnel and outcome assessment.  We found moderate-quality evidence that psychosocial interventions are probably more effective at reducing the frequency of parental alcohol misuse than comparison conditions at 6-month (mean difference (MD) -0.32, 95% confidence interval (CI) -0.51 to -0.13; 6 studies, 475 participants) and 12-month follow-up (standardised mean difference (SMD) -0.25, 95% CI -0.47 to -0.03; 4 studies, 366 participants). We found a significant reduction in frequency of use at 12 months only (SMD -0.21, 95% CI -0.41 to -0.01; 6 studies, 514 participants, moderate-quality evidence). We examined the effect of the intervention type. We found low-quality evidence that psychosocial interventions targeting substance use only may not reduce the frequency of alcohol (6 months: SMD -0.35, 95% CI -0.86 to 0.16; 2 studies, 89 participants and 12 months: SMD -0.09, 95% CI -0.86 to 0.61; 1 study, 34 participants) or drug use (6 months: SMD 0.01, 95% CI -0.42 to 0.44; 2 studies; 87 participants and 12 months: SMD -0.08, 95% CI -0.81 to 0.65; 1 study, 32 participants). A parenting intervention only, without an adjunctive substance use component, may not reduce frequency of alcohol misuse (6 months: SMD -0.21, 95% CI -0.46 to 0.04, 3 studies; 273 participants, low-quality evidence and 12 months: SMD -0.11, 95% CI -0.64 to 0.41; 2 studies; 219 participants, very low-quality evidence) or frequency of drug use  (6 months: SMD 0.10, 95% CI -0.11 to 0.30; 4 studies; 407 participants, moderate-quality evidence and 12 months: SMD -0.13, 95% CI -0.52 to 0.26; 3 studies; 351 participants, very low-quality evidence). Parents receiving integrated interventions which combined both parenting- and substance use-targeted components may reduce alcohol misuse with a small effect size (6 months: SMD -0.56, 95% CI -0.96 to -0.16 and 12 months: SMD -0.42, 95% CI -0.82 to -0.03; 2 studies, 113 participants) and drug use (6 months: SMD -0.39, 95% CI -0.75 to -0.03 and 12 months: SMD -0.43, 95% CI -0.80 to -0.07; 2 studies, 131 participants). However, this evidence was of low quality. Psychosocial interventions in which the child was present in the sessions were not effective in reducing the frequency of parental alcohol or drug use, whilst interventions that did not involve children in any of the sessions were found to reduce frequency of alcohol misuse (6 months: SMD -0.47, 95% CI -0.76 to -0.18; 3 studies, 202 participants and 12 months: SMD -0.34, 95% CI -0.69 to 0.00; 2 studies, 147 participants) and drug use at 12-month follow-up (SMD -0.34, 95% CI -0.69 to 0.01; 2 studies, 141 participants). The quality of this evidence was low. Interventions appeared to be more often beneficial for fathers than for mothers. We found low- to very low-quality evidence of a reduction in frequency of alcohol misuse for mothers at six months only (SMD -0.27, 95% CI -0.50 to -0.04; 4 studies, 328 participants), whilst in fathers there was a reduction in frequency of alcohol misuse (6 months: SMD -0.43, 95% CI -0.78 to -0.09; 2 studies, 147 participants and 12 months: SMD -0.34, 95% CI -0.69 to 0.00; 2 studies, 147 participants) and drug use (6 months: SMD -0.31, 95% CI -0.66 to 0.04; 2 studies, 141 participants and 12 months: SMD -0.34, 95% CI -0.69 to 0.01; 2 studies, 141 participants).

AUTHORS' CONCLUSIONS

We found moderate-quality evidence that psychosocial interventions probably reduce the frequency at which parents use alcohol and drugs. Integrated psychosocial interventions which combine parenting skills interventions with a substance use component may show the most promise. Whilst it appears that mothers may benefit less than fathers from intervention, caution is advised in the interpretation of this evidence, as the interventions provided to mothers alone typically did not address their substance use and other related needs. We found low-quality evidence from few studies that interventions involving children are not beneficial.

Cannabis use history and characteristics of quit attempts: a comparison study of treatment-seeking and non-treatment-seeking cannabis users

Cannabis is the most commonly used illicit substance worldwide, and cannabis use disorders (CUDs) are correspondingly high. Increased demand for treatment and relatively low rates of positive clinical outcomes has led to a large scientific investment in the development of interventions for the treatment of CUD. Much of this research is conducted with cannabis users who are not seeking treatment at the time of study participation, and it is unknown whether these individuals are representative of those who seek treatment. This study contrasted samples of cannabis users participating in screening interviews for treatment and nontreatment research studies. Several differences between groups emerged: Treatment-seekers were more likely to be female (43% vs. 29%), older (33.4 vs. 29.7 years), and have longer cannabis use histories compared with non-treatment-seekers (p = .007). Treatment-seekers were more likely to report experiencing guilt after using cannabis and to feel that cannabis use has been a problem for them. Additionally, treatment-seekers reported a greater mean number of reasons for making a quit attempt, experiencing a greater number of withdrawal symptoms, and employing more coping strategies during prior quit attempts. Despite the aforementioned differences, the 2 groups were similar on several key characteristics, particularly with regards to current levels of cannabis use and related problems.

Coping strategies of Spanish pregnant women and their impact on anxiety and depression

The aims of this study were to analyze the coping strategies used by women in the first trimester of low-risk pregnancies, their relationships to sociodemographic and pregnancy variables, and their ability to predict anxiety and depression in the third trimester. Participants in the first trimester were 285 Spanish pregnant women, of whom 122 were followed into the third trimester. The use of problem-focused coping was stable, whereas variations occurred in emotion-focused coping. Age, educational level, employment, planned pregnancy, previous childbirth, and previous miscarriage were associated with adaptive coping. Coping strategies predicting anxiety and depressive symptoms were overt emotional expression and social support seeking. Coping through religion predicted anxiety. Coping is a complex process influenced by sociodemographic and obstetric factors that can contribute to the onset of psychological symptoms.

COERCION AND DRUG TREATMENT FOR POSTPARTUM WOMEN

This research examined the extent to which various indicators of coercion were related to treatment retention in a gender-specific treatment program and a traditional outpatient program for pregnant and postpartum women who were mandated to enter treatment. Women who were given custody of their infant stayed in treatment longer than women who did not have custody. There was an interaction effect with women who had custody and were in the intensive day treatment program completing treatment at a much higher rate than those in the traditional program. Implications for social work professionals and policy makers are discussed.

Treatment barriers identified by substance abusers assessed at a centralized intake unit

The 59-item Barriers to Treatment Inventory (BTI) was administered to 312 substance abusers at a centralized intake unit following assessment but before treatment entry to assess their views on barriers to treatment. Factor analysis identified 25 items in 7 well-defined latent constructs: Absence of Problem, Negative Social Support, Fear of Treatment, Privacy Concerns, Time Conflict, Poor Treatment Availability, and Admission Difficulty. The factorial structure of the barriers is consistent with the findings of other studies that asked substance abusers about barriers to treatment and is conceptually compatible with Andersen's model of health care utilization. Factors were moderately to highly correlated, suggesting that they interact with one another. Selected characteristics were generally not predictive of barrier factors. Overall, results indicate that the BTI has good content validity and is a reliable instrument for assessing barriers to drug treatment. The potential utility of the BTI in assessment settings is discussed.

Factors associated with lifetime history of drug treatment among substance dependent women

There is extensive research on factors related to substance use treatment retention and completion but less is known about factors related to treatment initiation, particularly for women. This paper examines factors associated with a lifetime history of substance abuse treatment among women with drug abuse or dependence. Baseline interview data, using the Addiction Severity Index (ASI) that obtained during a randomized clinical trial was analyzed comparing women with no history of drug treatment with women with a history at least one drug treatment episode. Of the 153 women, 47.4% had a lifetime history of drug treatment compared to 52.6% who have never enrolled in drug treatment. After multiple logistic regression, craving drugs at least 15 days in the past month, using cocaine at least 15 days in the past month, ASI alcohol composite score, perceived seriousness of legal problems, history of at least 3 pregnancies, and history of physical abuse by a known person, were independently associated with drug treatment.

Psychopathology and treatment outcome of drug dependent women in a perinatal program

One hundred and five drug-dependent women in outpatient perinatal addiction treatment were classified by cluster analysis of the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) profiles into high and low psychopathology (HP and LP) groups that differed on three validation measures. The HP group (n=29, 27.6%) had elevations on MMPI-2 Scales F, 2, 4, 6, 7, and 8, while the LP group (n=76, 72.4%) generated a normal range profile with elevations on Scales F and 4. Psychological outcomes differed by group. HP participants showed reduced alcohol, family, and psychiatric severity, and reduced depressive symptoms, while LP subjects showed reduced drug, self-debasing, and acting-out problems. Data suggest the need for lower intensity services for the majority of the perinatal drug dependent population with LP.

Drug dependence, parenting responsibilities, and treatment history: why doesn't mom go for help?

Despite longstanding concern that the presence of children deters drug-dependent women from entering treatment, there have been few empirical tests of the relationship between parenting responsibilities and treatment-seeking behavior. In this study, the relationship between number of biological children and treatment history was examined in a cohort of 153 women seeking methadone maintenance treatment. In a standard multiple regression analysis that also allowed for the potential influence of (a) age, (b) education, (c) ethnic minority status, (d) cohabitation with a sexual partner, (e) chronicity of opioid use, and (f) knowledge of HIV infection, there was a significant, negative relationship between number of children and number of earlier contacts for drug abuse treatment. Ethnic minority status and cohabitation with a sexual partner were also associated with fewer earlier contacts; greater chronicity and knowledge of HIV infection were associated with more earlier contacts. Moreover, there was significant moderation of the negative relationship between parenting responsibilities and treatment history by (a) ethnic minority status, (b) cohabitation, and (c) chronicity of use. Within a cross-sectional research design, the findings highlight ways parenting responsibilities may interact with other factors over time to influence the treatment-seeking behavior of drug-dependent women.

Fetal effects of cocaine: an updated meta-analysis

BACKGROUND

A very large number of women in the reproductive age group consume cocaine, leading to grave concerns regarding the long term health of millions of children after in utero exposure. The results of controlled studies have been contradictory, leading to confusion, and, possible, misinformation and misperception of teratogenic risk.

OBJECTIVE

To systematically review available data on pregnancy outcome when the mother consumed cocaine.

METHODS

A meta-analysis of all epidemiologic studies based on a priori criteria was conducted. Comparisons of adverse events in subgroups of exposed vs. unexposed children were performed. Analyses were based on several exposure groups: mainly cocaine, cocaine plus polydrug, polydrug but no cocaine, and drug free.

RESULTS

Thirty three studies met our inclusion criteria. For all end points of interest (rates of major malformations, low birth weight, prematurity, placental abruption, premature rupture of membrane [PROM], and mean birth weight, length and head circumference), cocaine-exposed infants had higher risks than children of women not exposed to any drug. However, most of these adverse effects were nullified when cocaine exposed children were compared to children exposed to polydrug but no cocaine. Only the risk of placental abruption and premature rupture of membranes were statistically associated with cocaine use itself.

CONCLUSIONS

Many of the perinatal adverse effects commonly attributed to cocaine may be caused by the multiple confounders that can occur in a cocaine using mother. Only the risk for placental abruption and PROM could be statistically related to cocaine. For other adverse effects, additional studies will be needed to ensure adequate statistical power.

Women Injection Drug Users Who Have Sex with Women Exhibit Increased HIV Infection and Risk Behaviors

This article is a comprehensive review of published research on HIV seroprevalence and HIV-related risk behaviors among women injection drug users (IDUs) who have sex with women (WSW). At least 14 studies since the late 1980s converge into a consistent pattern: compared to other IDUs, WSW IDUs report higher levels of HIV-related risk behaviors and in many cases exhibit higher rates of HIV seroconversion or seroprevalence. Data from these and additional studies also indicate that large numbers of women IDUs are WSWs. Since information regarding WSW IDUs are widely collected but infrequently analyzed and reported, we suggest promising research and analysis strategies for exploring the meaning behind this pattern of increased vulnerability to HIV. Finally, we assert that enough is currently known to warrant significant investment in targeted prevention and intervention programs to address the critical HIV-related needs of lesbian, bisexual, and other WSW IDUs.

Attentional response at eight weeks in prenatally drug-exposed and preterm infants

To evaluate the effect of prenatal polydrug exposure on infant attention, 105 8-week-old African-American infants were presented a series of stimuli and their heart rates (HRs) were recorded. Infants were identified postnatally based on mothers' substance use. Four groups were tested: 1) preterm drug-exposed infants (n = 25); 2) full-term, drug-exposed (n = 32); 3) preterm nonexposed (n = 22); and 4) full-term, nonexposed (n = 26). Preterm infants' ages were corrected. Infant's baseline HRs were recorded and then stimuli presented in the following order: auditory (rattle), visual (red ring), and social (examiner's face and voice). There were no HR differences at baseline or in auditory or visual conditions. However, significant differences (F(2, 103) = 6.54, p < 0.01) were seen in response to social stimuli. Drug-exposed infants showed an acceleratory HR indicating distress or arousal and control infants showed a deceleratory response indicating focused attention and there was an interaction due to greater HR response in preterms. Hierarchical regression indicated cocaine (R2 = 0.034, p < 0.05) but not other drug use and instability in parenting (R2 = 0.137, p < 0.001) accounted for the observed differences.

Psychological impact of emergency cesarean section in comparison with elective cesarean section, instrumental and normal vaginal delivery

The purpose of the study was to compare the psychological reactions of women after emergency Cesarean section (EmCS), elective Cesarean section (ElCS), instrumental vaginal delivery (IVD) and normal vaginal delivery (NVD). The participants (EmCS, n = 71, ElCS, n = 70, IVD, n = 89, and NVD, n = 96) answered questionnaires a few days postpartum and 1 month postpartum. The EmCS group reported the most negative delivery experience at both times, followed by the IVD group. At a few days postpartum the EmCS group experienced more general mental distress than the NVD group, but not when compared with the ElCS or the IVD groups. At 1 month postpartum the EmCS group showed more symptoms of post-traumatic stress than the ElCS and NVD groups, but not when compared to the IVD group. An unplanned instrumental delivery (EmCS or IVD) should be regarded as a pointer with respect to possible post-traumatic stress.

Who drops out of drug-user treatment research on women?

Attrition or dropping out is an important methodological issue in drug-user treatment research. The purpose of this study was to describe and explain the degree of subject attrition-more specifically, postinclusion attrition-within the context of a research demonstration project which focused on a women's sensitive approach to drug-user treatment. Demographic variables, psychosocial outcome measures, and two treatment variables were examined as possible predictors of attrition from research participation. Findings showed attrition rates increased from admission, peaked at 3-month follow-up, and then declined substantially by the 12-month follow-up period. A logistic regression analysis showed only treatment discharge status to significantly predict subject attrition.

Behavioral Interventions: Effective and Adaptable for the Treatment of Pregnant Cocaine-Dependent Women

We examined the effectiveness of behavioral interventions in the treatment of cocaine-dependent pregnant women. The study was carried out in four stages: (1) the unique needs of substance-abusing women were examined to identify effective treatment factors, (2) behavioral interventions found to be effective in other cocaine-dependent populations were identified, (3) strategies from these two elements were combined in an ongoing treatment-study of cocaine-dependent pregnant women (the Pregnancy Project), and (4) outcome data in a group of 35 women who participated in the Pregnancy Project were examined. The rate of retention in treatment was high, as was compliance with prenatal care for those women who remained in treatment. A high rate of compliance with prenatal care was associated with good perinatal outcome. There was a relatively high rate of cocaine abstinence during treatment, at birth, and in the early period following birth of the baby. Many of the patients especially appreciated the individually based, self-empowering aspects of the behavioral counseling interventions. We concluded that behavioral interventions, within a woman-friendly treatment program, are an important treatment option to consider.

Women and Children in Residential Treatment: Outcomes for Mothers and Their Infants

This paper examines the relationship between the living arrangement of mother and baby in a residential treatment center and measures of self-esteem, depression and parenting sense of competence and a woman's length of stay and completion or non-completion of treatment. Scores on the Bayley Scales of Infant Development (Bayley 1969) are also examined by the amount of time the baby spent with mother, an arrangement that affords the opportunity for the child to participate in the facility's therapeutic child care center. Findings suggest that the earlier a mother's infant resides with her in the treatment setting, the longer her length of stay will be, with an increased opportunity for program completion. In addition, measures of depression were lower and measures of self-esteem were higher for women with their babies than for clients who did not have their infant in the treatment facility. Scores on the Bayley Scales of Infant Development were within normal limits for all infants living with their mothers in treatment.

A five-factor model of personality and addiction, psychiatric, and AIDS risk severity in pregnant and postpartum cocaine misusers

The relationship between addiction severity, psychiatric symptoms, AIDS risk behaviors, and an alternative five-factor measure of personality, the Zuckerman-Kuhlman Personality Questionnaire, was assessed in 92 cocaine-misusing pregnant and postpartum women in an inner city outpatient treatment program. Three of the personality traits (Neuroticism-Anxiety, Impulsive Sensation Seeking, Aggression-Hostility) were significantly related to different subscales of the Addiction Severity Index, Beck Depression Inventory, various psychiatric symptoms, and high HIV risk sexual activity. Of these traits, Neuroticism-Anxiety seemed to be the most powerful predictor of symptom severity for this sample of women. Scores on the personality dimensions were not related to recency, frequency, amount, or duration of drug use or to treatment outcomes.

Predicting treatment retention of women dependent on cocaine

The purpose of this research was (a) to assess differences in retention patterns and discharge status across three program settings; and (b) to examine selected pretreatment characteristics that might help predict treatment retention, which was operationalized as length of time in treatment. Three groups of pretreatment characteristics were examined. They included demographic factors, drug use and treatment history, and psychological status and symptomology. Clients in the intensive day treatment program tended to stay longer and were more likely to successfully complete the program than either clients in the outpatient or the traditional residential programs. In general, pretreatment client characteristics were not helpful in predicting length of time in treatment regardless of program type. Few pretreatment characteristics were related to retention within programs and significant predictors differed across treatment settings.

The impact of outpatient drug services on abstinence among pregnant and parenting women

Although there is an increasing number of outpatient drug programs, there remains little consensus on which service components are most effective for pregnant and parenting women seeking treatment. In this investigation, we studied 48 women who remained in treatment for 5 consecutive months to: (1) examine differences between clients who maintained 30 to 90 days of abstinence and those who did not and (2) test the association between services and abstinence. Although we found no demographic differences between abstinent and nonabstinent women, we did find that significantly more abstinent women received family therapy services compared to nonabstinent women as they remained in treatment. Furthermore, we found that clients who were abstinent tended to receive more services overall than those who were not. Providers need to consider their population when deciding on which service components will be included: and family therapy is one service component that should be available to pregnant and parenting women.

Access to substance abuse treatment for homeless women of reproductive age

Homeless women in the United States comprise a subpopulation at high risk for substance abuse, with rates of substance use disorder ranging from 16% to 67%. Despite the need for treatment that such high rates imply, relatively few substance-abusing homeless women avail themselves of formal treatment. The fact that they tend not to utilize formal treatment services is especially problematic among homeless women of reproductive age, who are not only themselves at risk of health-related problems but who place their fetuses and children in danger of multiple negative consequences. The imbalance between treatment need and treatment access suggests that homeless, substance-abusing women are facing severe barriers to care. Although identifying barriers to their treatment access is crucial if this imbalance is to be remedied, very little empirical research has been done in this area. This article presents an overview of current knowledge about barriers to substance abuse treatment for women generally and for homeless women specifically, and proposes a comprehensive empirical strategy for redressing the lack of information on homeless women's access to substance abuse treatment.

Perceived need for treatment among pregnant and nonpregnant women arrestees

Previous research has noted a high rate of drug use by women arrestees. Not only are women arrestees more likely to be found drug positive by urinalysis than are men arrestees, but in recent years, in part because of drug use, women have constituted the fastest growing population segment involved with the criminal justice system. One small but important subgroup of women arrestees are those who are pregnant and, thus, who particularly need intervention. This article utilizes Drug Use Forecasting (DUF) data from Los Angeles jails to examine whether or not pregnant drug-abusing women arrestees differ from nonpregnant drug-abusing women arrestees in terms of perceived need for treatment. Bivariate analyses and multivariate logistic regression show that pregnant drug-using women are not more likely than nonpregnant women to perceive a need for treatment. Although pregnancy status is not related to perceived need, a number of other factors are related, including being single, Euro-American ethnicity, using cocaine or opioids for more than three days in the past 30 days, being self-identified as currently drug dependent, having a substance abuse treatment history, and having lower legal incomes. Interventions with drug-using women arrestees should be made early in their drug use and criminal careers and should target both pregnant and nonpregnant women.

Treatment needs of drug-addicted mothers. Integrated parenting psychotherapy interventions

Substance abuse among women is associated with several negative maternal as well as child outcomes. This article reviews the theoretical and empirical literature on salient domains of risk and vulnerability among addicted mothers, with a view toward identifying critical components of effective intervention programs.

Behavioral development in children prenatally exposed to drugs and alcohol

Empirical research on the behavioral consequences to the offspring of use of recreational and addictive drugs and alcohol by pregnant women is reviewed. The current epidemic of cocaine use has raised the specter of a host of "cocaine babies" whose prenatally induced impairments will interfere with social and academic functioning and constitute an immense social burden. In fact, examination of effects of drug exposure on infant behavior and subsequent development suggests a much more subtle and complicated process which must take into account not only the child's prenatal exposure but the various other environmental factors which contribute to eventual outcome. These other factors include caregiving competence and social environment.