This is a presentation that was given at the Lost in Translation 2013: Exploring the Origins of Addiction conference that took place on March 25 - 26, 2013 in Vancouver, British Columbia, Canada.

1. Ron Abrahams MD FCFP
Problematic Substance Use In Pregnancy (PSUP)
Opitimizing The Epigenetics - A Standard of Care!

2. “Clinical” Epigenetics
“ As health care providers, it is
imperative to take into account and
advocate for improving the ‘overall”
fitness of the pregnant patient’s
particular “environmental unit.”
Poul Sorenson Ron Abrahams

3. “Integrated Community/Hospital
Harm Reduction Program”
Sheway
Fir Square
“Trauma Informed
Care”
A PRIMARY CARE
MODEL
Empirical/Evidence

4. Harm Reduction in Pregnancy
A “CORE PROGRAM”
For A Sustainable Healthy
Community

5. Goals of the Program
To DECREASE THE AMOUNT OF DRUG mothers
and babies are exposed to (Trauma Informed
Care)
To improve social stability
To facilitate bonding between mother and baby
To reduce withdrawal and need to treat in the
newborn
To prepare more babies to go HOME with mom

6. Trauma Informed Care Involves?
Pharmaceutical (Pump them with drugs) ?
Psychotherapy and/or Self
Interventions Medication ?
REMEMBERING!- “NEED TO DECREASE AMOUNT OF
DRUG EXPOSURE TO MOM AND FETUS”
And it is a long “labour” intensive journey for everyone!!

7. Salish Seas
“Red Lies”
“I’ve been lying since I was seven
When I knew there was no heaven
When hell was lying next to me”

8. SELF MEDICATING
because it
WORKS
BETTER
BURIES
MY NIGHTMARES !

9. “To my Doctor, a believer in me
and keeping the family together,
Believer in not medicating pain!”

10. For The Patient Not Ready To Live
“Drug Free”/Self Medicating
The Goal Is
“Culturally Sensitive”
Integrated/Community/Hospital
Harm Reduction programs
incorporating
“Trauma Informed Care”
“Trauma Growth”
Minimizing Drug Exposure
Epigenetics/Societal Obligation!?

11. Her Injection Site
Her “Community”

12. Safe Injection Site

13. Pregnant and
SHE’S INJECTING !!!!!

14. Her Safe Injection Site
Her “Community”
Determines Outcome!!

15. Social Determinants Of Health
“ What is common to these women is that they are
exposing themselves and their fetuses to the
same drug.
The difference is in their lifestyles.”
R. Abrahams MD 1987

16. NO!-It’s The Drug, STUPID!
“Cocaine is popular, glamorous, middle
class and possibly more dangerous to
an unborn baby than any other illicit
drug”
“Bonding between mother and child is
hindered”
Dr. Ira Chasnoff 1986

17. Open Letter To The Media
Feb. 25, 2004
These terms, such as “crack babies’,
“ice babies” and “meth babies”, lack
scientific validity and should not be
used.
Chasnoff, Koren et al

18. Partying at Henley
“An Open Drug Scene”

20. Alcohol In Pregnancy
“Drinking alcohol in pregnancy is the
primary risk factor for FASD. BUT the
levels and symptoms of damage in
the children emanating from different
drinking mothers vary significantly,

21. Alcohol In Pregnancy
And this variation is not fully explained
by the quantity and frequency of
alcohol consumption during
pregnancy. Therefore, risk factors
other than alcohol exist and serve to
mediate, moderate or otherwise alter
the effects of alcohol on the fetus.
Abel 1998
Abel and Hannigan 1995

22. First Nations Infant Mortality
Int. J. Epidemiol. Aug. 04
“Post neonatal mortality causes suggest the
need for improved socioeconomic and
living conditions.”
“ more culturally oriented maternal and
infant health programs may be helpful.”
NOT APPREHENSION AS A
PREVENTATIVE MEASURE !

23. “Point Of Entry”
The First Encounter
Eliminate Welcome
Barriers Her In
•

24. IN THE OFFICE?
Don’t Panic !!!!!! Don’t Get On The
Phone
NO LEGAL OBLIGATION TO REPORT
THE UNBORN!

26. Multi- Disciplinary Team
MUST BE
Culturally Appropriate
User Friendly
Non-Judgmental
Supportive
Trusted by the patient
Confidential
MUST ADVOCATE

28. Sheway-Philosophy of Service
n Offers respect and understanding of
First Nations culture, history and
tradition
n Takes a harm reduction approach to
substance use
n Links women and families into a
network of health-related, social,
emotional, cultural, and practical
support

29. SHEWAY – Philosophy of Service
n Provides women centred services in
a flexible, welcoming, non-
judgmental, nurturing/accepting
way.
n Supports women’s self-
determination, choices, and
empowerment
n Be a “helping” hand

30. Mother The Mother And You Will
Mother The Child

32. Sheway Outcomes 1990’s
n 91% received pre-natal care by delivery
n Nutritional concerns decreased from 79%
to 4%
n Housing concerns decreased from 27%
with no fixed address / 65% at intake vs
only 4% with concerns postpartum

33. Sheway Outcomes-1990’s
n Birth weight > 2500 grams
INCREASED from 20% to 86% since
1993
n In 1993 100% apprehension rate
at birth decreased to 5% by 1999

34. Integrating Community/Hospital
n To re-orient the
management of
these pregnant
women and
families
Culturally Appropriate
n Provide the foundation
towards preparing
mothers and babies to
go home as a healthy
unit
Trauma Informed
Care
R. Abrahams 1986

35. To Prevent (1980’s)
n Baby separated from mom at birth
n Baby put in “quiet room”
n Observed for withdrawal/no bonding
n Most babies treated for withdrawal
n Mom treated like “sh-t”/JUDGED
n Baby apprehended! (100% In DTES)
n Mom back on street—MORTALITY!

36. “Rooming-in Compared With
Standard Care of Mothers Using
Methadone or Heroin”
Safe to room in baby and mother
Less babies needed treatment for
withdrawal
More babies went home with mom
R. Abrahams, S. Payne, P. Thiessen
Canadian Family Physician Oct 07

37. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jitteriness p =
.312
Poor sucking
p = .078
Diarrhea p =
.651
Vomiting p=
.031
Crying
inconsolably
p <.002
piror to rooming in rooming in
Baby’s Behavioural Ratings

38. Investing In The Future

39. FIR F amilies I n R ecovery Unit
n Antepartum/Ultra
Sounds
n Peripartum
n postpartum
n Community
Integration

40. Families In Recovery Unit
n Multidisciplinary
n Dedicated Nurses/Staff
With the right attitude!
n Continuity of Care

41. First Day

42. 9 Years Later

43. The Perinatal Addiction Service

44. The Perinatal Addiction Service
n 24/7 On call/Provincial
n Primary Care Physicians
n Integrated with community and
hospital
n Integrated with multidisciplinary
teams

45. Observed Trends On Fir
Cuddling/focused moms avoid the
need to treat babies with morphine
Multiple drug exposure increases need
to treat (illicit/prescribed)
Prescribed Meds impact newborns
ability to feed, settle, gain weight
NB. Don’t Rx with Morphine?
1000 plus Women delivered

46. Fir Square Qualitative Outcomes
n 100 % of women felt connected to
community
n 74% reported decreased use of
“problem” drug
n 89% reported decreased level of
anxiety

47. An Evaluation of Rooming-in Amongst Substance-Exposed
Newborns in British Columbia
R. Abrahams et al JOGC, 2010
Retrospective comparison of Rooming-in (n=371) vs. Standard care
(n=834) using BC Perinatal Heath Program Data.
Rooming-in associated with:
• Significant decrease in admissions to NICU
• Increased likelihood of breastfeeding during hospital stay
• Increased odds of baby being discharged home with his/her mother
Review supports the finding that rooming-in is both safe and
beneficial for substance-exposed babies.

48. Probability Methadone/Morphine Tx
JOGC May 2011
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0 25 50 75 100 125 150 175 200 225 250
Mother's methadone dose (mg)
PredictedProbabilityofinfantreceiving
morphine
No breastfeeding and other opiates
Breastfed and other opiates
No breastfeeding and no other opiates
Breastfed and no other opiates

49. Sheway/Supportive Housing
Society’s Responsibility

50. “ In spite of her potentially rough
beginning, Jessie demonstrates
normal movement patterns, has a
delightful personality and is
accomplishing all developmental
skills at her age level or beyond.”

51. Epigenetics-”Cuddle and Hold”
Prof. Meaney-McGill
“Good” rat moms produce offspring who explore
more, are less fearful and less reactive to stress,
perform better COGNITIVELY, and preserve
cognitive skills better into old age- by maternal
behaviour altering gene expression!
“Mother’s affection at 8 months predicts emotional
distress in adulthood
J. Maselko et al, JECH July 2010

52. Study the Epigenetics of
n Maternal Infant Bonding
n Safe adequate housing
n Nutritional status
n Community/being safe
n Sense of well being/self esteem
n Trauma/childhood abuse/separation

53. Wanting to hide
I swallowed my pride
It was time to care for my baby inside
I could no longer bare being pregnant and scared
I took strong advice and stayed at Fir Square
Finally relieved, but pleased
New friends faces tended my needs
The nurses staff and girls that were there
Showed me strength, courage and tender care
Safe as can be, I had the right key
Slowly accepting the changes in me
It must have been fate
Cause my baby is great
Thank you for helping
Its never too late!!!!
A Fir Patient

54. On The Road To ----

55. I am happy to say that we continue
to make progress.
As you know we opened the
prenatal clinic at the Family futures
office downtown Pr Albert
Dr Egbeyemi runs the clinic once a
week. We continue to have
success with our moms rooming in
and staying for an extended period
of time (2-3 weeks).

56. We have had about 7-8 moms
since your visit and all have
roomed in. All but one have gone
home with mom and the one that
didn’t go home with mom did stay
with her baby for 16 days until the
baby was ready for discharge. We
do consider that a success!

57. The biggest step has been the
supports that family futures put into
place before delivery and then
communicated that with us and the
ministry= all with the clients
knowledge. That helps us with
having a discharge plan in place.
LOVE IT!

58. TOMSK-SIBERIA

59. Tomsk-SIBERIA

60. Downtown Eastside
OPEN DRUG SCENE

61. Who Is Using?
“the Junkie”
“The street Entrenched”
“high end” cocaine user
nicotine addict
“pot” smoker
middle class housewife drinking/valium
“The Walking Wounded”
“I’m Not Like Them”

62. Remove Stereotypes
That they are not all “druggies” prostituting,
stealing, incapable of ever being good
mothers

63. “Yeah BUT”
Can woman who do this to their
babies be motivated?

64. “Most are motivated
All feel guilty
Most don’t understand what they are doing
All need your help”

65. What About Diet (Environment)?
Vitamin A deficiency
Folic Acid deficiency
Choline Deficiency/Ukraine Study
“Preventive Intervention To FAS”
Ballard et al. Medical Hypotheses Jan/12

66. So, It Is The Environment
After controlling for covariates neither
cocaine nor opiate exposure showed
effect on development scores, motor
scores or behavioural scores when
tested at 1,2, and 3 years.
Mesinger,D.S. et al
pediatrics, vol 113 #6, June 2004

67. Stop Perpetuating the “Crack
baby” Myth
“Research now shows that the fetal
and
infant health problems previously
associated
with crack cocaine are better explained
by
malnutrition and a lack of pre-natal
care.”
David C. Lewis MD, Oct. 2004

68. Blame It On The Science!
n -poorly controlled up to now
n -impossible to control - too many
variables
n inaccurate self reporting- fear of legal
reprisal
n bias in the scientific community!
(Scientific Discrimination)

69. “A difficulty relates to the selection
bias in the reporting of positive rather
than the negative results in the
studies of the effects of intrauterine
exposure to cocaine among abstracts
submitted to the society for pediatric
research. From 1980 - 1989 only
11% of those describing no effect of
cocaine were accepted for
presentation. As compared to 57% of
those describing an effect”
J. Volpe
N.E.J.M. 1992

70. “Crystal Meth”
“Limited experience, but it seems that
if we control for prenatal care,
environment, and diet, we can
expect a normal outcome.”
R. Abrahams MD 2004

71. Clinical Bias

72. That’s All Wonderful-But!!
THESE WOMEN ARE ALL
Dual Diagnosis !

73. 1st European Conference on Drug
Addiction 1989
Dual Diagnosis/Abstinence

75. Avoid SSRIs In Pregnancy?
Increase in:
Prematurity!
low birth weight!
fetal death rate!
withdrawal symptoms in newborn!
seizures in newborn!
AJOG 2006

76. Among those with a history of early
childhood Trauma
(emotional,physical,sexual)
Psychotherapy alone was superior to
antidepressant monotherapy
C. Nemeroff Nov. 2003
Implications For Treatment
Approach

77. Addiction Research
Now tells us: correlated with
Dysfunctional families
Trauma and/or Abuse/Isolation
Every Strata of Society

78. “Why Experimentation Becomes
Addiction”
Isolated rats go back for
more and more
Rat Park Experiments 1970’s
Prof. Bruce Alexander

79. Potlatch
Legislated Racism

80. A Family Picnic

81. Childhood Trauma And PTSD
Pts With Psychosis
n “Childhood trauma & its consequences are
highly prevalent among pts. With
psychosis and severely affect the course
and outcome. “
n “Tx approaches need to be further
evaluated for this population”
n Schafer, Current Opinion Psychiatry 2011

82. Harm Reduction
n Practical Concept for patients, physicians,
Institutions
n Through education and support- the
patient can reduce harm by reducing risks
n A concept that supports “Safe Use” not
“Safe Abstinence”
n Society has the responsibility to reduce
harm e.g. provide safe housing, clean
needles, drugs legally
n Improve Social Determinants of Health
R. Abrahams 1986

83. Prescribing Harm
Reduction
Opiates- meth/morphine/bupr/heroin trials
Iv T’s and R’s- oral talwin
Alcohol- benzos/ “managed alcohol program”
Cocaine- ativan/valium
Crystal meth- dexedrin
Smoking patch etc
PRAZOSIN?
supply needles FOOD!
injection sites HOUSING !!
naomi trial

84. SHE SHOWS UP AT YOUR OFFICE
n Twenty one year old
n -no support/no money
n -no fixed address or affluent (“I’m not like them”)
n - twelve weeks pregnant, confirmed by ultra sound
n -Using heroin and coke daily/smoking-some IV use
n -Alcohol binges
n -Smoking cigarettes
n -Hepatitis C+
n -HIV Neg
YOU NEED TO ENSURE SHE COMES BACK AGAIN

85. SHE WANTS TO KNOW
n Will my baby be deformed/addicted
n Should I have an abortion?
n If I decide to keep my baby, should I detox and is it
safe to detox?
n What about methadone? I’ve heard that it is more
addictive than heroin, especially for my baby
n Can I breastfeed?
n Are you / “they” going to take my baby away?
n Will you do drug tests on me? If yes, why?
You need to ensure she comes back!

86. “You Need To Tell her”
n Decrease the amount of drug that you
and your baby are exposed to
n My care is not dependent on
you being abstinent
n You and your baby must have a safe
place to go home to
n Apprehension is not the hidden
agenda
n Don’t f… up!!!/set limits
R. Abrahams 1987

87. Her Physician’s “Referral” To
Child Protection
n Extremely High risk Infant
n Mom probable street worker
n Smokes cocaine and high dose narcotic
thoughout pregnancy. Father has lost two
children to MCFD and mom one
n Mom MRSA pos, dental caries/ unkept
n Requests for follow-up bloodwork not done
n Last baby small for GA
n This baby small also
n “A DISASTER WAITING TO HAPPEN”

88. MCFD VCH
2 Social Workers 4 Community Health Nurses
1 Nutritionist
1 Alcohol and Drug Counsellor
3 Sessional Family Physicians
1 Coordinator
VNHS YWCA
1 Medical Office Assistant 1 Outreach Worker
1 Receptionist 2 Infant Development Consultants
1 Cook/Peer Support Worker
1 Family Support Worker
1 Aboriginal Community Support Worker
1 Administrative Assistant
The Sheway Team

89. STAFF MUST HAVE
THE RIGHT ATTITUDE!

90. “Helping” Starts
with
HONORING HER CHOICES
to
IMPROVE COMPLIANCE

91. Improving Compliance
Increases the number of ante-natal visits
which is the only consistent variable that
improves perinatal outcome
By Reducing Barriers To Care

92. THE PATIENT IS THE ONE WHO
HAS THE RIGHT TO CHOOSE

93. Moral and Systemic Barriers
Scientific bias and a lack of evidence based research
Allows the moral/legal/political systems to
“justify the implementation of rules/regulations that
become
BARRIERS TO CARE FOR THE
“VULNERABLE “

94. My Response To My Licensing
Authority
“ I recognize the need for the College Of
Physicians and Surgeons of BC to monitor
the methadone program. I will try to
comply with the regulations of the
program as long as I feel it does not
impinge upon my individual patient’s
rights, or interfere with my professional
relationship with my patients when they
come to me to receive care within the
construct of the Harm Reduction Model”
R. Abrahams MD 1996

95. “it is unconstitutional to prosecute
citizens for having drugs for their
personal use”
Argentine Supreme Court
Sept/09

96. Illegal To Prescribe Methadone

97. Neberzhney Chelny

99. Detox is Safe to Fetus
Under Controlled
Conditions
Advise Her That This is
True!

100. Monitoring of the Pregnancy
n Trust/Compliance increases the
number of ante-natal visits
n Offer regular genetic screening
n Serial ultra-sounds / clinical
suspicion/as a “bonding tool”
n BE READY For All kinds of
complications

101. Proceed to Labour
If:
-decrease drug exposure
-stabilize / improve lifestyle
-minimize morbidity
PROCEED to labour and delivery as
normal
OTHERWISE manage as “high risk”
pregnancy

102. Induce at or Near Term
Due to:
n Pregnancy failing
n Continued chaotic lifestyle
n Continued risk of drug
exposure
“Baby Better Off “Out” Than “In”

103. Barriers To Care
n Woman dealt with the system by
accessing it infrequently, hiding drug
use during pregnancy, falling back on
uncertain, informal support groups
n System dealt with woman punitively,
apprehended babies and expected
them to access “mainstream” services
in conventional ways

104. BECAUSE
n 40% of the babies born in the downtown
eastside Vancouver were substance exposed
(and low birthweight)
n 100% of these children apprehended into care

105. And Remember!!
No Apprehension
With A
“Social Cushion”

106. BC WOMEN’S HOSPITAL
• 1980’s- SCN-Babies and Mom Seperated!
• 1990’s- IN- Babies and Mom Seperated!
• 2000’s- Rooming IN

107. Methods
“Cuddle and Hold” (avoids withdrawal from
Mom?)
Measure withdrawal in the newborn
using objective criteria:
(eliminates Observer Bias!)
WEIGHT GAIN– NB !!!
Vital signs
G.I. Symptoms e.g. diarrhea, vomiting

108. 2. Percent of babies on morphine
p=.016
24.20%
55.30% 52.80%
0%
10%
20%
30%
40%
50%
60%
percentage on morphine
C & W Rooming in
C & W Prior to rooming in
Community hospital without rooming in

109. 1. Mean days on morphine p=.
315
23.63
33.71 35.32
0
10
20
30
40
days
C& W Rooming in
C & W Prior to rooming in
Community hospital without rooming in

110. 3. Percent of babies apprehended/
foster care (p=.006)
30.30%
68.40%
52.80%
0%
20%
40%
60%
80%
percentage apprehended/foster care
C & W Rooming in
C & W Prior to rooming in
Community hospital without rooming in

111. What This Study Adds
• Rooming in is a viable, safe model
for providing care for the majority
of infants of substance using
mothers

112. Breastfeeding
n Never tell her “ Your milk is no good”
n Discuss and decide with the patient
n Consider:
• Hep C / HIV
• Lifestyle (still using?)
• Mom’s motivation to breastfeed
(culture)
• “Breast is best”
• Cheaper than formula

116. Morphine Treatment
ONLY FOR OPIATE EXPOSED BABIES!!
i.e. Not gaining weight/diarrhea/sick!
DX. OF EXCLUSION
n Loading Dose of .03 mg/kg q3hrs
n Decrease .02mg every 2 days when stable
n Generally finish by 14 days

117. Infants Of Smoking Mothers
Behavioural characteristics are the
same as those seen in infants
withdrawing from opiates
Law, K. et al, Pediatrics June’03

118. “Triple O Babies”
ON (Morphine)
OFF (Morphine)
and
OUT
In The Room With MOM !!!

119. Criteria for Discharge from
Hospital
1) Watch for signs of withdrawal
7-8 days of age
And
2) Baby gaining weight 2-3 days
And
3) Home assessment completed

120. “Apprehension Free Zone”
n SW / Ministry gather info , assess,
OFFER SUPPORT
n Consensus Decision Made With
Mom / Family/Team re: Home or
to “Place of Safety”
n Change Legislation

121. Discharge Home With Baby
Mom Stable
Supports in place
Weekly Visits to Monitor
Use “stability”- not Urine
Drug Screens to
Monitor
“drug use is not
incompatible with
adequate child care”
Baby is Urine Drug
Screen!!

122. Delayed Withdrawal at 3-5 Months?
“PURPLE CRYING”----
P-peak pattern
U-unpredictable
R-resistant to soothing
P-painful face
L-long bouts crying
E-evening crying
NOT
Delayed Withdrawal

123. Continuity of Care
Critical For:
• Fostering compliance / Trust
• Providing ongoing care
• Improving outcomes
• Monitoring family growth
• Being there for crisis

125. Patient Testimonial
“ I just want you to know how much
we do appreciate your kindness and
dedication”
I came in here all hurt and broken up
with not a lot of purpose in life.
You guys (gals) have treated me with
respect and tenderness.

126. I once again felt human.
After a while, as I became healthier
you made me feel worthy and
whole again.
Life started to have purpose and
meaning.
“Critical for a Sustainable
Community”

127. Dear Ron-
“I thought you might be interested to
know that this child is doing very well.
She was in for her one year check up
and is walking, has numerous words
and well presented by her parents. Her
parents are now clean and sober
and have now moved to Chilliwack.”
A Community GP

128. Don’t throw your hands up in despair
Be prepared for many frustrations
AND MANY REWARDS!!!

129. Randomized Clinical Trial?
“ I would never accept a return to care
standards of the 70’s on so vital an
issue as keeping moms and babes
together”
P. Thiessen 2004

130. “THE FAMILY SCHOOL”

131. Harm Reduction
For Integrated Core
Community Programs
BE PROUD OF WHAT YOU DO!!

132. “Every public action which is not
customary, either is wrong, or if it
is right, is a dangerous precedent.
It follows that nothing should ever
be done for the first time”

133. Canadian Medical
Association Journal 1996
“ I’d like to see heroin legalized and
prescribed legally. It would save a lot
of lives and illicit activity.”
R. Abrahams MD

134. FIR SQUARE
Leading Practice -2004
Canadian Council Health
Accreditation
Innovative Service Award Of
Excellence-2008
BC Representative For Children
And Youth

135. Summary
Pregnancy is a 9 month luv affair
n You have time to:
n Go slow
n Educate
n Set Goals / Limits
n Support
n Help
n Monitor
n Evaluate
n Be There

141. Every BC
Community

142. Community Hospital Program
Patient Centred
Multidisciplinary Harm Reduction
Research Education

144. Higher Aboriginal HIV Rates
n Social Isolation
n Poverty
n Discrimination
“ It has roots in
poverty,
unemployment,
lack of housing,
and dislocation
that plague many
aboriginal
communities”

145. “Among those with a history of early
childhood trauma ( emotional, physical,
sexual) psychotherapy alone was
superior to antidepressant
monotherapy.”
C. Nemeroff PNAS Nov.2003

147. Supportive Housing
SOCIETY’S RESONSIBILITY

148. EPIGENETICS
“His research suggests that a
mother’s touch may not only
comfort her child, but may also
trigger genes involved in shaping the
child’s response to stress”
Globe and Mail Jan. 24, 07

149. Sheway Testamonial
n My son was born in 1998 and we
were in the Sheway program. Even
though he was born with some
effects of my drug abuse I wanted to
say he is now a very healthy 9 y.o.
boy. He was taken into care but I
worked very hard to regain custody
of him, straighten out and create a
positive environment for my son and

150. Create a positive nurturing environment.
It was rough, it was shameful, but my
memories were that Sheway was always
there supporting with the food and
vitamins that helped him be born as
healthy as he was. I just want to send an
encouraging word to any mother who is
struggling. It can be done, be strong and
thanks Sheway for being there when no
one else was.

151. With the team and patient look at
n “Predictors” / Co-morbidity factors
n Motivation
n Support systems
n Spouse/Mate
n Age / Entrenchment / parity
n Personality / drug use / psychiatric disorder

152. AREAS FOR FUTURE RESEARCH /
SYSTEM DEVELOPMENT
For concept of family bonding to work we need to
develop support systems for the men as well as the
woman
ensure continuity of care and parenting support systems
are in place beyond 2 years of age

153. “I just want you to know how much we do appreciate
your kindness and dedication.
I came in here all hurt and broken-up with not a
lot of purpose in life. You guys (Gal’s) have treated
me with respect and tenderness. I once again felt
human. After a while as I became healthier you
made me feel worthy and whole again. Life started
to have purpose and meaning.”

154. Principles of Perinatal care for Substance
using Women and their Newborns.
n All individuals, from a variety of social,
economic, educational, racial and cultural
backgrounds are at risk for substance use
during pregnancy.
n It is important that women who are
pregnant and using substances be
informed by their health care and other
service providers of their choices and
rights at all steps of the process.

155. n It is important to highlight the strengths
and protective factors of women, infants,
their families and their comunities.
n There is a continuum of help that can be
offered to women, children and their
families. Harm reduction approaches need
to be encouraged.
n Optimal care is consistent with Integrated
Case Management, which is a shared
community process and should begin as
soon as the pregnancy is known.

156. Process components of Integragted
Case Management
1. A holistic approach for working with
clients.
2. Advocacy
3. Respectful and consistent
involvement of clients
4. Development of trusting
relationships
5. Common goals

157. 6. Clarity of roles
7. Information sharing and frank
communication.
8. Shared responsibility and
accountability to other professionals
and to clients.
9. A mechanism for resolving conflict.
10. Aboriginal involvement in planning
services for their community.

158. “ In my experience, if you stay
focused with your baby, provide a
good home, talk and play with your
baby

159. Then you have done what you have
to do!

160. Can woman you do this to their
babies be motivated?

161. Most are motivated
All feel guilty
Most don’t understand what they are doing
All need your help

162. Major Areas of Pediatric Concern
n Birth defects
n Neonatal effects
n Long term effects- growth and
development
n Social risk- neglect abuse

163. RELAPSE/CRISIS!!!
BE THERE

164. Methods
n 3 groups of mothers and infants were studied
1) Tertiary care maternity hospital-rooming in
(n=38)
2) Tertiary care maternity care hospital
not rooming in, (n=33)
3) Community hospital-not rooming in (n=36)

165. What About the Genetics?
“ There is a 10 fold difference in
susceptibility of genetic strains to
alcohol”
Dr. K. Sulik
11th Annual Western Perinatal
Research Meeting
Banff 2003

167. Sheway Outcomes-2004
n 77 babies born/70% aboriginal
n 70% BW above 2500gms
n 10% premature/normal birthweight
n 25% premature/low birthweight
n Average 115 open clients/families

168. Science & Beyond III
Banff Alberta 2004
“the question of the mother’s lifestyle
and the possible effect on the
growing baby is a sensitive issue that
will be addressed from the scientific,
ethical and legal perspective”

169. Barker Hypothesis
Sub-optimal nutrition in utero leads to
fetal adaptations that permanently
alter the physiology and metabolism
of the body and leads to diseases in
adult life.

170. “Mental Ilness as a Response
to an Insane World”
The Evolution of
Psychotherapy Conference
Anaheim, Cal./ Dec. 2005

171. Cuddling Moms = Decreased Need
To Treat
So
Introduce Extended Family/Volunteer
Cuddlers

172. “Holistic understanding of Drug
Addiction determines our
Primary Care
approach/treatment!”
For the Fetus as well as Mom!
“To Decrease the Amount of Drug that
Mom and Fetus are Exposed To”

173. 2 Years later

174. “Cuddle and Hold”

175. “DRUG USE IS NOT NECESSARILY
INCOMPATIBLE WITH ADEQUATE
CHILDCARE.” ?????????

176. Rooming In

177. Why Do They Use
Social Dislocation/Racism
AND

178. Identify the Population/Community
Who is using?
What are they using?

181. n Dysfunctional Family
n She was a ‘problem’ in school
n Left school in grade six
n Started drinking and Drugs age 12

182. Ron Abrahams MD FCFP POGO 2008

183. Multiple Drug Exposure (With
Opiates) Increases Need Treat
So
Decrease number and amount of drugs
mom and fetus exposed to

184. Prescribed Meds Impact Newborns
Ability to Feed, Settle, Gain Weight
So
balance risks/benefit of
antidepressants/mood stabilizers
and don’t treat as opiate withdrawal

185. Ron- if you think it is bad here (DES)
Go to Regina- IT IS SCARY
I left after three days
Pills / alcohol / violence
They even have gated communities

186. EUREKA !
“We Need to try rooming in
the babies
with
the moms”

187. Rooming In? – Let’s Do It
n To compare outcomes of newborns of
pregnant women maintained on
methadone who were admitted to a
rooming in program compared to
“usual care” in the special care
nursery.

188. Consequences of Drugs Are Specific
As a teratogen
On fetal growth / pregnancy
To Use-IV or Snorting or Orally
To Newborn Withdrawal
In breastfeeding
On long term development
HEROIN/COCAINE/ALCOHOL/

189. Prescribing Methadone
n Patient has “right” to choose (detox)
n Dose needs to be individualized
n “Rooming in” decreases withdrawal
n Can Breastfeed at any dose!
n Studies show small amount in
Breast milk

190. “I DON’T WANT MY KID TO
GO
INTO CARE, And I WANT
HELP”

191. Monitoring Drug Use
Trust the Patient ???
Depend on Clinical Suspicion
Not urine drug screens
“THE CHILD IS THE URINE DRUG
SCREEN”

193. Identify the Population/Community
“The Environmental Unit”
TO REDUCE HARM

194. Outcomes Dependent On
The
SOCIAL DETERMINATS
Of
HEALTH

195. Social Discrimination
Scientific Discrimination
“UNFIT TO PARENT”
Translates Into Apprehension

196. Foster Care “Graduates’
Consistently will tell you that
I AM NOT CRAZY
but
I AM TRAUMATIZED
and
DISLOCATED

197. “Work With The Patient”
BE Flexible
Be Safe

198. “Pandora’s Box Of Addiction ”
Experimentation Recreational
Trauma
Wounded

199. Clinical Discrimination

201. Chavaesk-Samara

206. Retrospective comparison of Rooming-in vs. Standard care
using BC Perinatal Services data
An Evaluation of Rooming-in amongst Substance-exposed
Newborns in British Columbia
Rooming In
(n = 355)
Standard Care
(n = 597)
Admitted to NICU * 138 (38.9%) 231 (45.0%)
Term newborn NICU
days (mean (SD)) *
1.1 (3.1) 3.1 (8.3)
Received breast milk
during hospital stay *
225 (63.7%) 263 (45.4%)
Presence of neonatal
withdrawal
97 (27.3%) 156 (26.1%)
Discharged home
with mother *
228 (69.9%) 326 (58.7%)
* p < 0.001
*P < 0.001

207. Rooming-in associated with:
• Significant decrease in admissions to NICU
• Decreased NICU length of stay for term infants
• Increased likelihood of breastfeeding during hospital stay
• Increased odds of baby being discharged home with
his/her mother
Review supports the finding that rooming-in is both safe and
beneficial for substance-exposed babies
An Evaluation of Rooming-in Amongst Substance-exposed
Newborns in British Columbia (cont.)

208. “ She thoroughly enjoys the play
situation and approaches people and
toys with much enthusiasm. Her
grandmother reports enjoying her
granddaughter and is to be
congratulated for providing the
stability Jessie needed to progress so
well.”

210. An Evaluation of Rooming-in amongst Substance-exposed
Newborns in British Columbia
Manuscript accepted to JOGC
Retrospective comparison of Rooming-in (n=371) vs. Standard care
(n=834) using BC Perinatal Heath Program data.
Rooming-in associated with:
• Significant decrease in admissions to NICU
• Increased likelihood of breastfeeding during hospital stay
• Increased odds of baby being discharged home with his/her mother
Review supports the finding that rooming-in is both safe and
beneficial for substance-exposed babies.

211. Rooming in Program
Decision to treat determined by
newborns inability to gain weight
ELIMINATES OBSERVER BIAS

212. Chart review: Interim Analysis (174 pairs)
Most Common Maternal Drug Use: Cocaine used by 103 (59%)
Methadone used by 58 (33%)
Heroin used by 48 (28%)
Alcohol used by 26 (15%)
Crystal Meth. used by 20 (11%)
165 babies: 36 (22%) babies were prescribed morphine at birth
Length of morphine treatment: Mean = 18 days (SD = 9.6; min = 6 days, max = 55 days, Median = 15.5
days)
The higher the dose of maternal methadone, the more likely the baby was to receive
morphine (t = 2.18, p = 0.03), with a tendency for an increased duration of treatment (r = 0.31, p =
0.08)
A threshold of 100mg maternal methadone was significantly associated with whether a baby
received morphine treatment (F(1, 161)= 12.93, p < 0.0001). Of the mothers who received less than
100mg methadone, 122 (83.6%) babies did not receive morphine treatment. Of the mothers
who received 100mg or more of methadone, 11 (57.9%) babies received morphine
treatment.
Whether a baby roomed in was significantly associated with whether or not it received
morphine. 94% of babies who ROOMED IN did not receive morphine, whereas 41% of babies
who DID NOT room-in received morphine (F(1, 161)= 17.51, p < 0.0001).

213. DRUG ADDICTION
If we say it is a psychiatric disease (Dual
Diagnosis) then we tend to ‘misdiagnose”
the cause- TRAUMA
Social Dysfunction
We are then unable to focus on the real
“needs” of this population
R.Abrahams 1987

214. “Prescribing” Harm Reduction
BE FLEXIBLE/BE SAFE
DO NO HARM!!

215. WHO IS USING ?

216. THC and Standard of Living
“ Prenatal Marijuana Exposure And
Neonatal Outcomes In Jamaica”
Dreher M.C., Pediatrics Feb. 94

217. “Heroin Addicted Babies/RDS
33 consecutive prems had no RDS
compared to controls
Glass et al, Lancet 1971
Heroin injected rabbit lungs increased rabbit
lung surfactant
Taeusch, Carson et al
Paediatrics 1973.
Morphine withdrawal releases steroids

218. Methadone vs Heroin
No controlled studies comparing the two!
except for:
Naomi Trial
Higher Retention Rates
Health Improvements
Decreased criminal activity

219. Indices For Tx Opiate Withdrawal
n 174 mother baby pairs
n Length of tx—median = 15.5 days
n Maternal meth dose>100 mg=60%
n Maternal meth dose <100 mg=17%

220. To Minimize Racism/Social
Bias
The Native “jittery” baby
versus
The Norwegian “jittery” baby

221. Vancouver’s Downtown Eastside
n Canada’s poorest neighborhood
n Area of only 10 square blocks
n Densely populated - dilapidated single
room hotels
n Concentration of community service
organizations
n Estimated 4700 injection drug users
n Open drug scene
n Open prostitution scene
n Severe health consequences

222. Wilson’s Principles
#1- Susceptibility to teratogenesis
depends on the genotype of the
conceptus and the manner in which
this interacts with adverse
environmental factors.

223. Fir Square Outcomes 2004
6 months
n 58 term babies
n 29 opiate exposed
n 26% (of 29)
treated with
morphine
n 16 day average
treatment
n 58 babies roomed
in
n 60% home with
mom
n 7% with family
n 33% to foster

224. Dual Diagnosis 1980’s
became
Co – Occurring 1990’s
Then
Post Traumatic Stress Disorder
Now
“Trauma Informed Care”

225. Drug Effects
Independent of Lifestyle
(1) Cocaine – pregnancy harm??
(2) Opiates/Methadone - newborn withdrawal
(3) Nicotine – small babies
newborn withdrawal
(4) Alcohol – fetal alcohol syndrome
Remember - it is the legal drugs that do the most
Damage

226. “Improvement Of Trauma Care”
n Trauma training
n Short Trauma Intervention
n Development Web Based Tools for
Trauma Informed Care
Plus Research:
Necessary Length of Stages Of
Support
Social and Biological Factors Of Recovery
AN EFFECTIVENESS TRIAL