Treatment of substance abuse during pregnancy

Supporting the implementation of written exposure therapy for posttraumatic stress disorder in an obstetrics-substance use disorder clinic in the Northeastern United States

Pregnant people with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) constitute a highly vulnerable population. PTSD and SUD confer risks to both the pregnant person and the fetus, including a host of physical and mental health consequences. When PTSD and SUD co-occur, potential negative impacts are amplified, and the symptoms of each may exacerbate and maintain the other. Pregnancy often increases engagement in the healthcare system, presenting a unique and critical opportunity to provide PTSD and SUD treatment to birthing people motivated to mitigate risks of losing custody of their children. This paper presents implementation process outcomes of Written Exposure Therapy (WET), a brief, scalable, and sustainable evidence-based PTSD treatment delivered to pregnant persons receiving care in an integrated obstetrical-addiction recovery program at Boston Medical Center. Trial participants (N = 18) were mostly White, non-Hispanic (61.1%), not currently working (77.8%), had a high school or lower level of education (55.5%), had an annual household income less than $35,000 (94.4%), and were living in a substance use residential program (55.6%). We examined intervention feasibility, acceptability, appropriateness, adoption; barriers and facilitators to implementation; and feedback on supporting uptake and sustainability of the intervention using coded qualitative sources (consultation field notes [N = 47] and semi-structured interviews [N = 5]) from providers involved in trial planning and treatment delivery. Results reflected high acceptability, appropriateness, and adoption of WET. Participants described system-, provider-, and patient-level barriers to implementation, offered suggestions to enhance uptake, but did not raise concerns about core components of the intervention. Findings suggest that WET is an appropriate and acceptable PTSD treatment for this difficult-to-reach, complex population, and has the potential to positively impact pregnant persons and their children.

A qualitative meta-synthesis of pregnant women's experiences of accessing and receiving treatment for opioid use disorder

ISSUES

Addressing opioid use disorder (OUD) among pregnant women is of growing importance, and substance use treatment positively impacts outcomes for mother and baby. Understanding substance use treatment experiences is important to improve access, and retention, and no review or synthesis of research addressing the treatment experiences of pregnant women exists.

APPROACH

Thus, a qualitative meta-synthesis was conducted, which investigated the psychological motivators and barriers of pregnant women with OUD trying to access treatment and their perceptions of treatment.

KEY FINDINGS

A total of 3844 articles were retrieved from the literature search. Nine articles met eligibility criteria, were appraised, then synthesised using a comparative thematic approach. Four themes: (i) Embodied Experiences; (ii) Institutional Pressures; (iii) Social Context; and (iv) Reconstructing Selves; indicate that women with OUD are motivated to engage in treatment to pursue the safety and custody of the unborn baby and to pursue and enact the changes necessary to claim 'normal' parenthood status. Pregnant women describe psychological and relational barriers to engaging in treatment, including anxieties about the baby's health, fears of authorities' involvement, stigma and experiencing relationships with treatment providers as constrictive or invalidating.

IMPLICATIONS

Identity theory's concepts of identity verification, closed environments and master status identities illuminate the findings. Implications include recognising the salience of bodily experiences, providing medication-assisted treatment support groups and promoting validating relationships in treatment using strengths-based approaches.

CONCLUSIONS

Pregnant women face unique psychological challenges in accessing and engaging in substance use treatment for OUD.

“A Window of Opportunity”: Parenting and Addiction in the Context of Pregnancy

Purpose of Review

Maternal prenatal substance use presents a multilevel risk to child development and parenting. Although parenting interventions are increasingly integrated into substance use treatment, prenatal parenting processes have not received equal attention within these interventions. This article aims to synthesize the evidence on the specific prenatal risk factors affecting the development of early parenting of substance-using mothers, as well as interventions focusing on those factors.

Recent Findings

Both neurobiological and psychosocial risk factors affect the prenatal development of parenting in the context of maternal substance use. Maternal–fetal attachment, mentalization, self-regulation, and psychosocial risks are important in treatment and highly intertwined with abstinence. Although parenting interventions seem to be highly beneficial, most studies have not differentiated between pre- and postnatal interventions or described pregnancy-specific intervention elements.

Summary

Due to the salience of pregnancy in treating substance-using parents, interventions should begin prenatally and include pregnancy-specific parenting focus. Further research on prenatal interventions is warranted.

Cannabis Use in Pregnant and Breastfeeding Women: Behavioral and Neurobiological Consequences

Nowadays, cannabis is the most consumed illicit drug. The global prevalence of the use of cannabis in 2017 was estimated in 188 million of people, 3.8% of worldwide population. Importantly, the legalization of cannabis in different countries, together with the increase in the apparent safety perception, may result in a great variety of health problems. Indeed, an important concern is the increase in cannabis use among pregnant and breastfeeding women, especially since the content of delta9-tetrahidrocannabinol (THC) is currently around 2-fold higher than it was 15-20 years ago. The purpose of this study was to review cannabis use during pregnancy and breastfeeding including epidemiological aspects, therapeutic or preventive strategies, and experimental considerations and results from animal models of perinatal cannabis exposure to analyze the underlying neurobiological mechanisms and to identify new therapeutic approaches. A recent report revealed that among pregnant women aged 15-44, last month cannabis use prevalence was over 4.9%, raising to 8.5% in the 18-25-year-old age range. Pre- and post-natal exposure to cannabis may be associated with critical alterations in the newborn infants that are prolonged throughout childhood and adolescence. Briefly, several reports revealed that perinatal cannabis exposure was associated with low birth weight, reduction in the head circumference, cognitive deficits (attention, learning, and memory), disturbances in emotional response leading to aggressiveness, high impulsivity, or affective disorders, and higher risk to develop a substance use disorder. Furthermore, important neurobiological alterations in different neuromodulatory and neurotransmission systems have been associated with cannabis consumption during pregnancy and lactation. In spite of the evidences pointing out the negative behavioral and neurobiological consequences of cannabis use in pregnant and breastfeeding women, there are still limitations to identify biomarkers that could help to establish preventive or therapeutic approaches. It is difficult to define the direct association specifically with cannabis, avoiding other confusing factors, co-occurrence of other drugs consumption (mainly nicotine and alcohol), lifestyle, or socioeconomic factors. Therefore, it is necessary to progress in the characterization of short- and long-term cannabis exposure-related disturbances.

Attachment Theory and Maternal Drug Addiction: The Contribution to Parenting Interventions

Children's emotional and relational development can be negatively influenced by maternal substance abuse, particularly through a dysfunctional caregiving environment. Attachment Theory offers a privileged framework to analyze how drug addiction can affect the quality of adult attachment style, parenting attitudes and behaviors toward the child, and how it can have a detrimental effect on the co-construction of the attachment bond by the mother and the infant. Several studies, as a matter of fact, have identified a prevalence of insecure patterns among drug-abusing mothers and their children. Many interventions for mothers with Substance Use Disorders have focused on enhancing parental skills, but they have often overlooked the emotional and relational features of the mother-infant bond. Instead, in recent years, a number of protocols have been developed in order to strengthen the relationship between drug-abusing mothers and their children, drawing lessons from Attachment Theory. The present study reviews the literature on the adult and infant attachment style in the context of drug addiction, describing currently available treatment programs that address parenting and specifically focus on the mother-infant bond, relying on Attachment Theory.

First time's a charm: Maternal problem drinking around the birth of a child in primiparous and multiparous women at risk for child maltreatment

OBJECTIVE

The birth of a child may represent a turning point in alcohol and other drug (AOD) use trajectories, particularly for families exposed to cumulative early adversity. This prospective longitudinal study aimed to examine differences in the problem drinking trajectories of primiparous and multiparous mothers around the birth of a child. A history of AOD problems was examined as a predictor of change in problem drinking.

METHOD

Primiparous (n = 245) and multiparous (n = 243) women were recruited on the basis of risk for child maltreatment. Past-year maternal problem drinking was assessed with the CAGE screener (cut down, annoyed, guilty, eye opener) at childbirth and child ages 12, 24, and 36 months. Latent growth modeling was used to estimate changes in CAGE scores over the four time points.

RESULTS

Although maternal CAGE symptoms decreased linearly from the year before the child's birth to age 36 months at the sample level, substantial differences emerged when trajectories of primiparous and multiparous mothers were examined separately. CAGE trajectories of primiparous mothers decreased sharply from the year before the child's birth to age 12 months, whereas no change was observed among multiparous mothers. Of note, an equal proportion of primiparous and multiparous women consumed any alcohol during pregnancy. In addition, a history of AOD problems predicted a slower decline in CAGE symptoms across the transition to parenthood for primiparous mothers.

CONCLUSIONS

Parity may be an important dimension of maternal identity for AOD-focused health professionals to consider in working with mothers at risk for child maltreatment because of their problem drinking.

Predictors of inadequate prenatal care in methamphetamine-using mothers in New Zealand and the United States

This study compared patterns of prenatal care among mothers who used methamphetamine (MA) during pregnancy and non-using mothers in the US and New Zealand (NZ), and evaluated associations among maternal drug use, child protective services (CPS) referral, and inadequate prenatal care in both countries. The sample consisted of 182 mothers in the MA-Exposed and 196 in the Comparison groups in the US, and 107 mothers in the MA-Exposed and 112 in the Comparison groups in NZ. Positive toxicology results and/or maternal report of MA use during pregnancy were used to identify MA use. Information about sociodemographics, prenatal care and prenatal substance use was collected by maternal interview. MA-use during pregnancy is associated with lower socioeconomic status, single marital status, and CPS referral in both NZ and the US. Compared to their non-using counterparts, MA-using mothers in the US had significantly higher rates of inadequate prenatal care. No association was found between inadequate care and MA-use in NZ. In the US, inadequate prenatal care was associated with CPS referral, but not in NZ. Referral to CPS for drug use only composed 40 % of all referrals in the US, but only 15 % of referrals in NZ. In our study population, prenatal MA-use and CPS referral eclipse maternal sociodemographics in explanatory power for inadequate prenatal care. The predominant effect of CPS referral in the US is especially interesting, and should encourage further research on whether the US policy of mandatory reporting discourages drug-using mothers from seeking antenatal care.

Services used by perinatal substance-users with child welfare involvement: a descriptive study

Background

Substance use during pregnancy often leads to involvement in the child welfare system, resulting in multiple social service systems and service providers working with families to achieve successful child welfare outcomes. The Vulnerable Infants Program of Rhode Island (VIP-RI) is a care coordination program developed to work with perinatal substance-users to optimize opportunities for reunification and promote permanency for substance-exposed infants. This paper describes services used by VIP-RI participants and child welfare outcomes.

Methods

Data collected during the first four years of VIP-RI were used to identify characteristics of program participants, services received, and child welfare outcomes: closed child welfare cases, reunification with biological mothers and identified infant permanent placements.

Descriptive Results

Medical and financial services were associated with positive child welfare outcomes. Medical services included family planning, pre- and post-natal care and HIV test counseling. Financial services included assistance with obtaining entitlement benefits and receiving tangible support such as food and clothing.

Conclusions

Findings from this study suggest services that address basic family needs were related to positive child welfare outcomes. The provision of basic services, such as health care and financial assistance through entitlement benefits and tangible donations, may help to establish a foundation so mothers can concentrate on recovery and parenting skills. Identification of services for perinatal substance users that are associated with more successful child welfare outcomes has implications for the child welfare system, treatment providers, courts and families.