Journal of Substance Use, April 2009; 14(2): 124–132
ORIGINAL ARTICLE
Changing patterns of heroin and crack use during pregnancy and beyond
DAVID BEST, JONATHAN SEGAL, & ED DAY Department of Psychiatry, University of Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
Abstract The publication of Hidden Harm [Advisory Counsil on the Misuse of Drugs (ACMD), 2003] was an attempt to increase awareness of the risks to children of parental drug use, and the need for a coherent response across services to this issue, both during pregnancy and after the child has been born. The current study examined a cohort of drug-using mothers who had accessed a specialist ‘mother and baby’ drug treatment service at some point during their pregnancy or in the period immediately after the birth of the child, assessing both their experiences of drug treatment and maternity services and the changes in their drug use. Using a lifetime history instrument (the Lifetime Drug Use History), the study showed reductions in quantity and frequency of heroin use over the course of pregnancy (particularly after month six of pregnancy and in the month after the birth). Although crack use is reduced, there was a less consistent pattern of change. Stigma was reported by some participants with greater dissatisfaction with maternity (and to a lesser extent drug services) linked to higher levels of heroin and crack use. Nonetheless, the study shows that pregnancy is a period of change in the lives of drug using mothers and an opportunity for lasting transitions in the trajectory of the heroin using career.
Keywords: Heroin careers, pregnancy, childbirth, child welfare, treatment effectiveness.
Introduction Opiate injecting has been shown to have a disruptive effect on maternal behaviour (Slamberova, Charousova, & Pometlova, 2005), while substance use during pregnancy provokes public health concerns, consumes health-care resources and contributes to infant mortality and morbidity (Daley, Argeriou, & McCarthy, 1998). Opiate use during pregnancy increases the likelihood of antepartum haemorrhage (Hulse, Milne, & English, 1998), and there is evidence that infants exposed prenatally to drugs are at high risk of developing multiple problems. It has been reported that 55–84% of neonates exposed to opiates in utero suffer from neonatal abstinence syndrome (NAS), and commonly seen
Correspondence: Department of Psychiatry, University of Birmingham, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2QZ, UK. Tel: 0121-678-2356. E-mail:
[email protected] ISSN 1465-9891 print/ISSN 1475-9942 online # 2009 Informa Healthcare USA, Inc. DOI: 10.1080/14659890802658962
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symptoms include irritability, high pitched cry, tremors, hypertonicity, vomiting, diarrhoea, and tachypnoea (American Academy of Pediatrics Committee on Drugs, 1998). Despite this, the UK has a large number of children born to drug using parents. In June 2003 the Advisory Council on the Misuse of Drugs estimated that there were 250,000 to 350,000 children of drug using parents in the UK who were potentially vulnerable as a consequence of the substance use of their parents (ACMD, 2003). About one-third of drug users in treatment in the UK are female and over 90% of these women are of childbearing age (Day & George, 2005). Research has shown that women may enter treatment at an earlier age than men (Hser, Anglin, & Booth, 1987) but that they may have longer addiction careers (Anglin, Hser, & Grella, 1997). Although drug using mothers have been shown to neglect the pre- and postnatal care of their offspring (Slamberova et al., 2005), Barnard has argued that, for some children their parent’s drug problem will not be deleterious to their welfare (Barnard, 2005). While it has been noted that antenatal care is often inadequate in women who misuse drugs because of late presentation to services (Johnson, Gerada, & Greenough, 2003), pregnant woman can derive considerable benefit from addiction treatment services, even when lasting sobriety is not achieved (Daley et al., 1998). Early engagement in treatment can confer a protective effect for mother and child, but many mothers may be unwilling to access treatment due to fear of stigma and being labelled as unfit mothers due to their drug habits (Baker & Carson, 1999). Another major barrier to treatment is the need to care for dependent children, with problems associated with finding child care in order to attend for drug treatment or antenatal support (Swift, Copeland, & Hall, 1996). Pregnancy may be a crucial precipitating factor for change in the life of a drug user and may offer women the chance to resolve housing, social and health problems in order to provide a nurturing environment for the baby (Day, Porter, Clarke, Allen, Moselhy, & Copello, 2003). Conversely, stresses and discomfort associated with pregnancy may prompt greater usage of drugs to relieve physical symptoms (Daley et al., 1998). It has therefore been suggested that pregnancy itself may represent less a ‘window of opportunity’ than a ‘revolving door’ in which women are torn by conflicting forces, with the power of addiction being the deciding factor (Daley et al., 1998). The current study examines the changes in patterns of heroin use over the course of pregnancy and into the early period of the child’s life, as well as exploring participants’ views about the effectiveness of the treatment they have received from specialist addiction and maternity services. Method The aim of the study was to assess the impact of pregnancy and childbirth on heroin use patterns among clients in contact with specialist addiction treatment services during and after the birth of their child. By recruiting research participants from a specialist ‘mother and baby’ treatment team, the study sought to examine the impact of treatment status on heroin use during pregnancy and in the period after birth. Setting The Birmingham Mother and Baby team is based in central Birmingham and provides a range of community addiction services for drug-dependent women and their partners (Day et al., 2003). Approximately 60 patients attend the clinic at any given time with roughly half
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pregnant drug users and half mothers of babies of less than one year of age. The service was one of the first of its kind to be established in the UK in June 1987. The aims of the service include:
N N N N N
Engaging women in treatment for the duration of their pregnancy Providing practical and emotional support to drug users during pregnancy and early motherhood Encouraging mothers to use antenatal and post-natal services Promoting welfare of their children Supporting parents if they want to withdraw from drugs and providing ongoing support to help them remain drug free
Procedure Following an initial discussion at the clinical team meeting, service users were approached and provided with information about the study when they attended the clinic for routine appointments. Subjects were recruited on a voluntary basis to complete a one-off research interview with a medical student who was independent of clinical process and who was able to guarantee confidentiality to participants. Clients were told that they could withdraw from the study at any point in the interview and that non-participation would not influence the treatment they received. Interviews were conducted on a one to one basis and took 30– 45 min to administer. Participants were given a £10 voucher to compensate them for their time. The project was passed by the South Birmingham Student Ethics Committee (reference number - S/2005/132). Participants A total of 36 women met the inclusion criteria for the study, and 24 (66.7%) were recruited to take part. Two refused to participate and ten did not attend for appointments with the researcher. None of those who started the interview process asked for it to be discontinued. Instruments The Lifetime Drug Use History (LDUH; Day, Best, Cantillano, Gaston, Nambamali, & Keaney, in press) is an instrument used to systematically assess the history of key aspects of opiate-using careers. It allows the retrospective recording of patterns of substance use on a month-by-month basis from the time of initiation to the present day, dividing opiate using careers into phases of use, and recording any periods of abstinence. The instrument also records significant life events such as pregnancies, education, living arrangements, and experiences of community and residential drug treatment. The LDUH instrument allowed the mapping of key life events to opiate use status in order to highlight changes in opiate use around pregnancy. Data collected using the LDUH were supplemented by additional questions about the mothers’ experience of treatment and the support they received during pregnancy and around the time of their most recent birth. In particular, questions were asked about perceptions of being treated differently as a result of their drug using status by maternity and drug services.
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Analysis The primary assessment was based on quantity and frequency of heroin use, measured on a monthly basis in the LDUH. A subsequent calculation was made of the total amount of heroin used each month by multiplying days of use by typical daily quantity used, creating a monthly total (in grams). Measures of association were calculated using bivariate correlations, and group differences by chi-square for categorical variables and Student’s t-tests for continuous variables.
Results Sample characteristics The mean age of the sample was 26.6 years (range519–35¡4.4 years), and 19 (79.2%) were white, two were black (8.3%), one was Asian (4.2%) and two were of mixed ethnicity (8.3%). Participants had on average started using heroin at the age of 19.5 years (range513.5– 32¡4.9 years) and had started using on a daily basis at the age of 20.0 years (range514– 32¡4.9 years). Only seven of the group had ever injected heroin, initiating intravenous use at the age of 20.4 years (range516–27, ¡3.9 years). All of those who had ever injected had gone on to do so daily, first starting daily injecting at a mean age of 20.6 years (range516– 27¡3.9 years). On average, participants in the research had given birth to 2.2 children (range51– 5¡1.1), and seven had one, 10 had two, four had three, two had four, and one had five children. In comparison, the mean number of pregnancies in the group was 2.8 (¡1.4) and the group averaged 0.5 miscarriages (¡0.9). There was a significant positive association between the age of the participant and the number of children they had (r50.49, p,0.05). Heroin using careers The average length of the heroin using career1 was 76.3 months (range512–189¡51.5 months), of which an average of 61.0 months or 81% was spent in active heroin use (range53–153¡48.2). Participants reported that they had used an average total of 1035.3 g of heroin in their lifetime, although this ranged from 36 – 5146 g. There were strong positive associations between the total amount of heroin used and the total length of the heroin using career (r50.56, p,0.01) and with the number of months in active heroin use (r50.56, p,0.05). There was a significant inverse relationship between the number of pregnancies the women had experienced and the percentage of the heroin career that had been in active use (r520.48, p,0.05), suggesting that child birth reduced the total quantities of heroin used. Heroin and crack cocaine use before and after child birth For the most recent pregnancy, participants were asked about the quantity and frequency of their heroin use in three month phases with these data reported in Table I below: Across the whole sample, there was a gradual reduction in frequency of heroin use over the course of pregnancy that continued after the birth of the child. When repeated measures 1 The heroin career was defined as the period between the age of first use (in years and months) and the most recent month in which heroin had been used.
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Table I. Heroin use during each trimester of pregnancy and in the first 3 months after childbirth (total sample) Period
Frequency of heroin use (90 days)
Pregnancy (first 3 months) Pregnancy (second 3 months) Pregnancy (final 3 months) First 3 months after birth
60.5 54.1 40.3 21.2
days days days days
t-tests were used to compare change, there was no significant change from the first to second trimester (t50.93, p50.98), but the reduction in frequency of heroin use from the second to third trimester (t52.20, p,0.05) and the reduction from the last three months of pregnancy to the three months after birth (t52.41, p,0.05) were both statistically significant. There was an overall significant reduction in heroin frequency from the first trimester of the most recent birth to the three months after birth (t53.71, p,0.01). In categorical terms, 17 (70.8%) participants reported using heroin in the first trimester, 16 (66.7%) in the second trimester, 13 (54.2%) in the third trimester and nine (37.5%) reported heroin use in the 3 months after the birth of the child. While six of the 17 who used in the first trimester also used in the 3 months after the child’s birth, 11 had stopped their heroin use. It is perhaps more surprising that three of those who had not used in the first trimester had done so after the child was born. With regard to cocaine use, 11 study participants reported any form of use in the first three months of pregnancy, reducing to nine in the second trimester, eight in the third trimester and six in the 3 months after the child’s birth. There was a strong positive correlation between frequency of heroin use in the 3 months after the child was born and frequency of cocaine use in the same period (r50.59, p,0.01). The overall changes in heroin and crack use are reported in Figure 1. While crack cocaine use reduced significantly in frequency from the first to the second trimester (t52.47, p,0.05), there was a non-significant increase from the second to the third trimester (t50.63, p50.53), and a further significant reduction from the last three months of pregnancy to the three months after birth (t52.68, p,0.05).
Figure 1. Reductions in heroin and crack use during and after most recent pregnancy.
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Drug use and child birth factors The average birth weight of the babies was 5.3 lbs (range52.5–7.6 lbs) and they were born after an average of 34.4 weeks of gestation (range524–37 weeks). The mothers were in the maternity unit an average of 1.2 days before the birth (range50.4) and remained on the unit for an average of 1.7 days after delivery (range50–20 days). While nine babies received treatment for withdrawal symptoms, five mothers reported that they needed physical treatment in the period after the birth. In 19 of the 21 cases for which information was available, a case conference with social services was held within three months of the child being born, with data on the outcome available for 14 births (two of the women refused to discuss the issue and data were missing in three cases). In five cases, this resulted in the child being taken into care and one child was adopted. Eight children were allowed to stay with their mothers, although three were on the neglect register and two had supervised visits. There were significant positive correlations between quantity of heroin used during the first (r50.50, p,0.05), second (r50.50, p,0.05), third (r50.45, p,0.05) and ninth month of pregnancy and (r50.52, p,0.05) and the baby’s birth weight, and in all nine months the correlation was positive. There was no clear relationship between weeks of gestation and the frequency of heroin use, nor was there a clear relationship between the number of previous children the participant had had and the frequency of heroin use in any month during the pregnancy or after the birth of the child. In nine cases, the mother reported that the child was treated for withdrawal symptoms after birth (from 20 who answered this question, 45%). These children did not have a lower birth weight (5.4 versus 5.2 lbs, t50.36, p50.72) but the gestation periods of the babies treated for withdrawal symptoms were significantly longer (36.1 weeks versus 33.0 weeks, t52.23, p,0.05). There were no differences in the amounts of heroin use in any of the three trimesters for these groups. Total amount of heroin used To calculate the overall change in heroin use during pregnancy and after the birth of the child, for each participant, new values were created for the total quantities of heroin used in each month for each participant (calculated as the frequency of use multiplied by the typical amount used on a using day). The overall effect for the three months prior to pregnancy, over the course of pregnancy and in the three months after the baby was born is shown in Figure 2. This graph shows the change in total quantities of heroin use over the period of pregnancy and after the birth of the child. Two of these changes are statistically significant when paired months are assessed using repeated measures t-tests – from month 5 to month 6 of pregnancy (t52.26, p,0.05) and from the final month of pregnancy to the first month after the child is born (t52.29, p,0.05). Motivation to undergo detoxification 15 (62.5%) women reported that their baby was their main motivation to seek treatment services for their drug use. However, three (12.5%) women voiced concerns about other services being involved, or about the social stigma of being a drug using mother as reasons for seeking treatment.
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Figure 2. Changes in the total amount of heroin used before, during, and after the most recent pregnancy.
Satisfaction with services Participants were also asked how satisfied they had been with their treatment from specialist services and from maternity services before and after the birth of the child with the results reported in Table II below: Although most of the participants were satisfied, opinions about treatment were linked to aspects of heroin use:
N N
A higher frequency of heroin use in the second trimester was associated with greater dissatisfaction with drug services (r50.44, p,0.05). A higher frequency of crack use in the second trimester was associated with greater dissatisfaction with maternity services (r50.58, p,0.01).
Table II. How satisfied participants were with services before and after birth Type of service Specialist Drug services during pregnancy Specialist Drug services after the pregnancy Maternity services during pregnancy Maternity Services after the pregnancy
Very satisfied
Satisfied
Don’t know
Dissatisfied
Very dissatisfied
14(58.3%)
5(20.8%)
1(4.2%)
2(6.5%)
2(6.5%)
10(41.7%)
4(16.7%)
8(33.3%)
2(8.3%)
5(20.8%)
9(37.5%)
9(37.5%)
2(8.3%)
4(16.7%)
4(16.7%)
5(20.8%)
2(6.5%)
5(20.8%)
0
8(33.3%)
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A higher frequency of crack use in the third trimester was associated with greater dissatisfaction with both maternity services (r50.46, p,0.05) and addiction services (r50.44, p,0.05). On average, participants in the study spent just over six months of their pregnancy in substitution treatment, with only one individual stopping methadone before the birth (at month seven in the pregnancy). Nine of the sample were in substitution treatment throughout their pregnancy and two participants received no treatment at any point in their pregnancy. When those who were in substitution treatment for the entire duration of their pregnancy were compared with those spending less time in treatment during pregnancy, there were no significant differences in total amounts of heroin used in any of the months of pregnancy. Similarly, there were no differences in the birth weight of the child or in the number of weeks gestation. There were also no significant correlations between the amount of time in pregnancy spent in treatment and either total amounts of heroin used or birth weight of the child. Discussion The data show a clear change in heroin use patterns over the course of pregnancy that is sustained into the first three months after the child is born. This treatment sample showed no indication of a rapid reinstatement of drug use in the post-pregnancy period, suggesting that this is a significant opportunity for generating and maintaining lasting change in substance using patterns. Nonetheless, in a population that are well integrated into treatment (all but two of them were in substitute prescribing for at least some of their most recent pregnancy, and 39% for all of it), heroin use continued for a proportion, and there was no added protective effect against ongoing heroin use from additional time in treatment. It is also perhaps surprising that there was no clear relationship between the proportion of pregnancy spent in treatment and the birth weight of the child or the length of gestation for the pregnancy. While the study supports the findings of Gillogley, Evans, & Hansen, (1990) that drug use during pregnancy may be associated with prematurity and consequently low birth weights, the current study does not suggest that the pattern of change of heroin use in drug using mothers’ impacts on the extent of prematurity or low birth-weight. These findings do not support the suggestion that pregnancy is a stressful event that leads to an increase in drug taking (Finkelstein & Piedade, 2003). Although this was a treatment population, residual fears about social services involvement and stigma did arise in the group (Taylor, 1993) and a number of respondents felt they were treated differently by maternity staff. The current study also suggests that the extent of heroin and crack cocaine use during pregnancy was linked to levels of satisfaction with both drug services and maternity services, suggesting that while treatment per se may not result in reductions in substance use, engagement with services that are perceived to address the needs of drugusing mothers may have a more protective effect. Overall, the study is limited both by the small sample size recruited and by the design of the study using retrospective data collection. Furthermore, the data comes from a group of women who had not only remained in treatment after the birth of the child but who had been engaged with treatment services for the majority of their pregnancy. Nonetheless, the study is unique in assessing the trajectory of change in heroin use patterns during and after pregnancy and provides some basis for targeted interventions that address the concerns of pregnant drug users, and which aim to sustain and enhance the ‘natural recovery’ process
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that is associated with pregnancy and child birth for a substantial proportion of the drug using mothers in the current cohort. Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. References Advisory Counsil on the Misuse of Drugs. (2003). Hidden Harm – Responding to the needs of problem drug users. London: HMSO. American Academy of Pediatrics Committee on Drugs. (1998). Neonatal drug withdrawal. Pediatrics, 101, 1079–1088. Anglin, M. D., Hser, Y. I., & Grella, C. E. (1997). Drug addiction and treatment careers among clients in the drug abuse treatment outcome study (DATOS). Psychology of Addictive Behaviours, 11, 308–323. Baker, P., & Carson, A. (1999). ‘I take care of my kids’: Mothering practices of substance abusing women. Gender and Society, 13, 347–363. Barnard, M. (2005). Discomforting research: colliding moralities and looking for ’truth’ in a study of parental drug problems. Sociology of Health & Illness, 27, 1–19. Daley, M., Argeriou, M., & McCarthy, D. (1998). Substance abuse treatment for pregnant women: A window of opportunity? Addictive Behaviours, 23(2), 239–249. Day, E., Best, D., Cantillano, V., Gaston, R., Nambamali, A., & Keaney, F. (2008). Measuring the use and career histories of drug users in treatment: Reliability of the Lifetime Drug Use History (LDUH) and its data yield relative to clinical case notes. Drug and Alcohol Review, 27(2), 175–181. Day, E. J., & George, S. (2005). Management of drug misuse in pregnancy. Advances in Psychiatric Treatment, 11, 253–261. Day, E., Porter, L., Clarke, A., Allen, D., Moselhy, H., & Copello, A. (2003). Drug misuse in pregnancy: The impact of a specialist treatment service. Psychiatric Bulletin, 27, 99–101. Finkelstein, N., & Piedade, E. (1993). The relational model and the treatment of addiction in women. The Counsellor, 8–10. Gillogley, K. M., Evans, A. T., & Hansen, R. L. (1990). The perinatal impact of cocaine, amphetamine and opiate use detected by universal intrapartum screening. American Journal of Obstetrics and Gynecology, 163, 1535–1542. Johnson, K., Gerada, C., & Greenough, A. (2003). Substance misuse during pregnancy. British Journal of Psychiatry, 183, 187–189. Hser, Y. I., Anglin, M. D., & Booth, M. W. (1987). Sex differences in addict careers. American Journal of Drug and Alcohol Abuse, 13(3), 231–251. Hulse, G. K., Milne, E., & English, D. R. (1998). Assessing the relationship between maternal use of opiate use and antepartim haemorrhage. Addiction, 93, 1553–1558. Slamberova, R., Charousova, P., & Pometlova, M. (2005). Methamphetamine administration during gestation impairs maternal behavior. Developmental Psychobiology, 46, 57–65. Swift, W., Copeland, J., & Hall, W. (1996). Characteristics of women with alcohol and other drug problems: findings for an Australian national survey. Addiction, 91, 1141–1150. Taylor, A. (1993). Women drug users: An ethnography of a female injecting community. Oxford: Clarendon Press.
