E. Keenan, A. Dorman, J. O'Connor
Reprinted from Vol. 162, No. 7, July,
1993, pp. 252 - 255.
The Drug Treatment Centre Board, McCarthy Centre, 30/31 Pearse Street,
Dublin 2.
Forty-five pregnant addicts had attended the National Drug Treatment
Centre between 1984 - 1986. At that time they received intensive
counselling, low dose Methadone maintenance and both ante natal
and post natal care. Our aim was to follow these women six years
later focusing on their drug use and outcome of their children.
The women were followed up by chart review, individual interviews
and liaison with the social and probation services. Results indicate
that a high proportion of the women abused chaotically (50%). There
is a worrying high increase of HIV positive patients (53.4%) and
a mortality figure of 15.5% (7). However, only 13 women
(28.6%) have had further children and 22 women (49%) are currently
using some form of contraception. Only 23 women (51.1%) have had
further contact with probation services. Five children (11.3%) are
under formal care order and 4 children have become HIV positive
in their own right. In conclusion, while these women have benefited
in certain areas e.g. family planning, contact with probation services,
in other areas they have remained chaotic e.g. continued drug abuse
or HIV risk taking behaviour. Thus the authors believe that future
programmes should concentrate more directly on detoxification and
rehabilitation after pregnancy. We also believe that because of
the chaotic nature of these women some review of an "at risk"
register for the children should be carried out.
Since the early 1980's opiate addiction in Dublin has been recognized
as a serious problem(1). Due to the fact that a significant
number attending for treatment were females of childbearing age
(25%), the emergence of maternal drug addiction as a problem in
Ireland was recognized as early as 1981(2). These women
are an important group given the medical and obstetrical complications
associated with the abuse of opiates during pregnancy<(3).
As a response to the growing problem of maternal addiction in the
U.K. a number of liaison services were developed within obstetric
departments in London hospitals (4,5). A recent report
focuses on the establishment of a liaison service for pregnant opiate
dependant women as part of a community drug team(6).
In Ireland a service has been in operation for these women as far
back as 1984, thus we find ourselves in a unique position to evaluate
the long term benefit of this type of programme.
The original study by O'Connor et al focused on the two year period
1984 - 1986(7). Over that time 45 pregnant opiate addicts
attended the National Drug Treatment Centre. These women received
low dose Methadone maintenance (20mg) and weekly group therapy with
a psychiatrist and social worker. The women were assigned to a key
worker and attended fortnightly ante-natal clinics also held in
the Centre. After childbirth the women were given advice regarding
family planning and encouraged to address their opiate addiction.
At the time 21 (45%) of the women had a positive response to the
programmed in that they attended regularly, did not abuse other
drugs (as detected by supervised urinalysis), discontinued criminal
life styles and had improved awareness of their children's needs.
The aim of the present study was to follow these
women up six years after the original study. It appeared that this
was a particularly vulnerable and chaotic group thus we were interested
in determining whether the intensive treatment they had received
resulted in any long lasting benefit. Of special interest, in view
of the serious Irish problem with HIV and AIDS, was to discover
whether these women became more responsible in their drug use and
the rate of perinatal viral transmission.
After analysis of the results of the previous study each of the
women were reviewed using the following methods:
1. Chart review of all 45 patients.
2. Individual interview with all patients in contact with drug treatment
services.
3. Interview with Key Workers.
4. Contact with Social Welfare Services, Maternity Hospitals and
Probation Services.
Using this information we then concentrated on
a number of different areas including:
1. Subsequent pattern of drug abuse and attendance for treatment.
2. Physical health including HIV status.
3. Outcome of children (in case, HIV status).
4. Current or any form of contraception and subsequent obstetrical
history.
5. Forensic history.
6. Deaths in target population
The mean age of the mothers in 1992 was 29.3 years. At the time
of follow you only 7 (15%) patients could not be
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Table I - Results
Attendance at the drug treatment
centre - since 1986 (n = 45) |
|
|
|
|
No |
% |
|
|
|
Continued attendance to present day (maintenance) |
5 |
11.1 |
No Further Attendance |
2 |
4.5 |
One Further Attendances |
6 |
13.3 |
Two Further Attendance |
6
(1) |
13.3 |
Three Further Attendances |
1
(1) |
2.2 |
Four Further Attendances |
25
(5) |
55.6 |
|
|
|
() = RIP |
Totals |
45 |
100 (15.5) |
|
|
|
contacted. However five of these had been in contact
with our services at some stage over the past six years. This is
an indication of the fact that the Irish opiate problem is concentrated
in Dublin and there is little permanent movement to the U.K.
All but two of the patients had been in contact with our won service
over the last six years (Table I). In fact over 50% of patients
had attended the Centre on four or more occasions which would indicate
that these women have abused drugs in a chaotic manner over the
six years.
Currently 10 (22%) of the patients are on a Methadone maintenance
programme at this centre, and 18 (40%) are either attending another
service for treatment or abusing chaotically. Only 3 patients became
completely drug free over the six year period (Table II).
Regarding the physical status f these women and their HIV status
in particular we see that a disturbingly large number are HIV positive
(Table III). Twenty-four (53.4%) are HIV positive as compared with
fifteen (33.3%) in 1986. This is not wholly accounted for by women
who were not tested in 1986 being subsequently tested and in fact
a number have seroconverted over the years, two as recently as 1991,
having been negative in 1986.
Another worrying fact is that 14 out of the 18 HIV positive women
still alive are not attending a medical service on a regular basis.
Other medical problems show more encouraging
|
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Table II
Current Status
(n = 45)
|
|
|
|
|
No |
% |
|
|
|
Currently Attending The Drug Treatment Centre |
10 |
22.2 |
Currently Attending G.P. / Other Agency |
9 |
20.0 |
Currently Using Chaotically |
9 |
20.0 |
Drug Free |
3 |
6.7 |
Unsure of Whereabouts |
7 |
15.6 |
R.I.P. |
7 |
15.5 |
|
|
|
|
|
|
|
|
Table
III
HIV Status |
|
|
|
|
|
|
Pre 1986 |
Post 1986 |
|
|
|
|
|
|
No |
% |
No |
% |
HIV +ve |
15 |
33.3 |
24 |
53.4 |
HIV -ve |
18 |
40.0 |
15 |
33.3 |
No Test |
12 |
26.7 |
6 |
13.3 |
|
45 |
100% |
45 |
100% |
|
|
|
|
|
|
|
|
Table IV
Current form of contraception or at time of death
(n = 45)
|
|
|
|
|
No |
% |
|
|
|
Depo Provera |
13 |
28.9 |
I.U.C.D |
4 |
9.0 |
Pill |
2 |
4.5 |
Condoms |
2 |
4.5 |
Tubal Ligation |
1 |
2.2 |
No Contraception |
13 |
28.9 |
Unsure |
10 |
22.3 |
|
|
|
() = RIP |
Totals |
45 |
100% |
|
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|
figures. Since 1986 only 3 women (6.6%) have had
hepatitis B, as compared to 20 women (45%) pre 1986. Also there
has been a very low incidence of sexually transmitted diseases since
1986 with only 2 women (4.5%) requiring treatment.
Advice given on the programme regarding family
planning appears to have been successful given that 22 women (49%)
are using some form of contraception(Table IV). Also seven women
have attended gynaecology clinics for colposcopy.
Information obtained from probation services shows a marked drop
in the number of women involved in criminal activity. Prior to 1986,
44 women (97.8%) had a forensic
|
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Table V
Children
|
|
|
|
Up
to 1986 - 105 children born to 45 women
Since 1986 - 17 children born to 13 women
Since 1986
(n = 45) |
|
|
|
|
No |
% |
|
|
|
Women with Further Children |
13(6) |
28.9 |
Women with No Further Children |
25 |
55.5 |
Uncertain |
7 |
15.6 |
Miscarriage |
5(4) |
11.1 |
Termination |
3 |
6.7 |
|
3 |
6.7 |
|
|
|
() = HIV +
Mothers |
|
|
|
|
|
|
|
|
|
Table VI
Whereabouts of children
n = 44 (one child miscarriaged) |
|
|
|
|
No |
% |
|
|
|
Mother looking after child |
19 |
43.3 |
Child in care of family member |
13 (6) |
29.5 |
Care order |
5 (1) |
11.3 |
Unsure |
7 |
15.9 |
|
|
|
() = Mother RIP |
|
|
|
|
|
history but since 1986 only 23 women (51.1%)
have any further dealings with the justice system.
The number of children born since 1986 also shows a marked reduction
(Table V). Prior to 1986 only 17 children have been born to 13 mothers.
In all, 25 women (55.5%) that we definitely know of have had no
further children.
Focusing our attention on the children born in the original study
period we see that 19 (43.3%) children have remained with their
mother. Of the remaining children that we now of only 5 (11.3%)
have been placed under a formal care order (Table VI).
Of the 15 children who had been born to HIV positive mothers re
1986, 4 (26.6%) became HIV positive in their own right and 2 of
these are currently on AZT.
Finally a mention is made of the high mortality in this group. Seven
15.9% women have died since 1986, four of these have died of AIDS
related deaths, usually due to Pneumocystis Carnii Pneumonia (P.C.P).
The other three deaths were caused by drug overdoses, two accidental
and one deliberate.
Other studies on an Irish population have
found that narcotic addiction presented a wide range of physical
and social hurdles to both the mother and baby(8). The
previous study by O'Connor et al highlighted the unstable nature
of this group of women and as such an intensive treatment programme
was established(7).
Methadone maintenance was provided for two main reasons. Firstly
in an effort to reduce the intravenous opiate misuse during pregnancy.
Detoxification is contraindicted in the first trimester because
of the risk of spontansous abortion and in the third trimester because
of the risk of premature labour. Secondly from the point of view
of the fetus if the mother is on a low dose of controlled opiates
during pregnancy then the risk of withdrawals in the immediate post
natal period is substantially reduced (9). More recent
evidence has suggested that detoxification during pregnancy may
in fact be a feasible option (10).
Our results indicate that in certain areas these women remain chaotic.
If we take attendance at the National Drug Treatment Centre as an
indication of continued involvement with illicit drugs all but 2
women (4.5%) re-attended or continued to attend. In fact 25 women
(55.6%) attended four or more times, showing a high degree of chronicity.
Examining their current pattern of drug use we see that only 3 (6.7%)
became drug free and to our knowledge 28 (62.2%) are currently using
drugs in some form. Given that 7 women (15.5%) are now dead, their
drug taking is a very serious ongoing problem.
Examining sero conversion as an indicator of patients indulging
in "at risk behaviour" the number of patients so doing
since 1986 (20%) is a worrying one. Overall the figure of 24 patients
being HIV positive out of 39 tested (61.5%) shows again the instability
of this group and their poor compliance with advice and treatment.
It is interesting to compare these figures with those from a similar
group of pregnant addicts in the U.K. Out of forty-five pregnant
women attending a community drug team/ liaison service only seven
reported being tested for HIV and these negative (6).
Of our own patients the fact that 14 of the 18 HIV positive patients
still alive do not attend regularly at any medical clinic does not
augur well for the future.
The low incidence of Hepatitis B since 1986 indicates that the Hepatitis
epidemic in Dublin did peak in the early 1980's (11)
and the continued low incidence of S.T.D. would imply that these
women have remained monogamous and are not involved in prostitution.
Other studies have indicated incidences of S.T.D. at 20% in drug
addicted mothers (12). The HIV and Hepatitis B were considered
separately from the figures for S.T.D.'s because of the extra risk
factor involved of sharing contaminated needles in this population.
In some areas the patients have benefited. Twenty-two women out
of thirty-five (%) are using some form of contraception. This is
reflected in the fact that only 13 women (28.9%) have had further
children. The worrying aspect is that six of these women were HIV
positive and as can be seen from the figures for children born HIV
positive mothers pre 1986 approximately one quarter went on to develop
the virus in their own right. Transmission rates of between 13 -
40 % have been reported with more recent European studies tending
towards the lower figure (13).
In Ireland it appears that opiate dependent women are determined
to keep their children (14) and in our study 20 mothers
(45.5%) that we know of are still looking after their children.
However in a sizable number of cases where the mother is no longer
caring for the child, it is in care of a family member, 12 (27.3%).
In only five cases is the child under a formal care order. This
is markedly different from the U.K. where in one study almost half
the cases had been placed under some form of statutory supervision
and in another where 90% of the babies were placed on the Child
Protection Register (15). Perhaps in Ireland some review
of an "at risk" register should be carried out as courts
do seem unwilling to place formal care orders on children.
It was gratifying to note the marked reduction in involvement in
criminal activities. The drop from 44 patients (97.8%)
pre 1986 to 23 patients (51.1%) reflects either that group intervention
was beneficial or else a shift in the legal system from prosecution
towards helping this group by referral for treatment.
The final figures of 7 deaths (15.5%), 6 in people who were HIV
positive, although not entirely unexpected is however an indication
of the instability of this particular population. As time goes on
this figure will rise and the authors are aware of a further 2 patients
who are currently very seriously ill.
Our study highlights the fact that this group of patients is a very
chaotic and unstable group, requiring major input from the medical
and psychiatric services. They have continued to abuse drugs and
to indulge in at risk behaviour regarding the HIV virus. This is
worrying form the patients point of view and that of their children.
On the positive side treatment during pregnancy seemed to result
in a more responsible attitude towards further children. The large
number of patients using contraception should be taken as a considerable
achievement. Also a change in lifestyle is apparent from the fact
that many fewer patients were involved in criminal activity than
before 1986.
Thus the programme appeared to be of benefit to the patients in
both improving responsibility regarding contraception and decreasing
criminal activity. In the absence of a control group however other
explanations remain to be tested. For example with age some patients
do mature out of illicit drug misuse and criminal activity. Also
there may be a possible therapeutic effect of having children and
need to care for them. The continued abuse of drugs and their risk
taking behaviour indicates a need for an extra emphasis in this
area.
The authors believe that future treatment programmes should concentrate
more directly on detoxification and rehabilitation after pregnancy
while not ignoring the important areas of individual lifestyle and
social circumstances.
Thanks to Siobhan Fisher for her secretarial assistance.
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