Managing opioid overdose in pregnancy with take-home naloxone.

Programs have recently been established in Australia and internationally to allow wider access to naloxone to people at risk of opioid overdose yet there are no guidelines relating to the administration of naloxone to pregnant women, particularly regarding dose requirements and resuscitative measures peculiar to pregnancy. This paper provides practical guidelines to health workers in relation to any complications that may arise during opioid overdose response (including the administration of naloxone) for pregnant women and the follow up required ensuring best possible outcomes for mother and baby.

Prescription opioid use in pregnancy.

Prescription medications, including opioid analgesics, are increasingly prescribed in Australia and internationally. More women are presenting in pregnancy with prescription opioid use which can potentially cause harm to the mother and fetus. This article outlines the different types of prescription opioids, defines how prescription opioid use disorder presents clinically and suggests a rational clinical approach to assess and manage patients in the context of pregnancy and their infants.

Tobacco treatment incorporating contingency management, nicotine replacement therapy, and behavioral counseling for pregnant women who use substances: a feasibility trial.

Introduction: Most pregnant women with substance use problems smoke, and few will quit during their pregnancy. Tobacco treatment is often overlooked, with the focus usually placed on other substance use. Additionally, few targeted effective treatments for this group exist. To address this, the feasibility of an intensive tobacco treatment incorporating contingency management (CM) that featured non-face-to-face delivery was examined. Methods: A single-arm pre-post design feasibility trial was conducted in three antenatal services that support women who use substances in metropolitan Australia. Participants were over the age of 15, had <33-week gestation, and smoked tobacco daily. They received financial incentives for daily carbon monoxide-verified smoking abstinence or reduction through an internet-based CM programme, nicotine replacement therapy (NRT) posted to women and partners or household members who smoked and telephone-delivered behavioral counseling from study enrolment to birth. Results: Of the 101 referrals, 46 women (46%) consented. The mean (SD) age was 31(±6) years, and the gestation period was 22(±6) weeks. Nineteen (41%) of those enrolled were retained for 12-week postpartum. Of 46 women, 32 (70%) utilized CM; 32 (70%) used NRT for ≥2 weeks; 23 (50%) attended ≥1 counseling session; and 15 (22%) received NRT for partners/household members. Fifteen (33%) were verified abstinent from tobacco at delivery after a median (IQR) period of abstinence of 65(36-128) days. All non-smokers at birth utilized NRT and financial incentives, and 9/15 (60%) utilized counseling. Four (9%) were abstinent at 12-week postpartum. Median cigarettes smoked/day reduced from baseline to delivery (10(6-20) to 1(0-6) p =< 0.001). Women who quit smoking had more education (72% vs. 33% p =< 0.02), completed more CO samples (median (IQR) 101(59-157) vs. 2(0-20) p =< 0.001), and received more incentives (median (IQR) $909($225-$1980) vs. $34($3-$64) p =< 0.001). Intervention acceptability was rated favorably by participants (9 items rated 0-10 with scores >5 considered favorable). Discussion: This study demonstrated the feasibility and acceptability of a consumer-informed, non-face-to-face intensive tobacco treatment, highlighting the potential of remotely delivered technology-based CM to reduce the health impact of tobacco smoking in high-priority populations. The intervention demonstrates scale-up potential. Future studies should extend treatment into the postpartum period, utilizing new technologies to enhance CM delivery and improve counseling provision and partner support. Clinical trial registration: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374196, ACTRN1261800056224.

Barriers and facilitators in antenatal settings to screening and referral of pregnant women who use alcohol or other drugs: A qualitative study of midwives' experience.

BACKGROUND: Screening pregnant women for substance use is highly recommended in antenatal care settings. Although midwives provide routine screening for substance use and referral for treatment in pregnancy, little is known about the barriers and facilitators they experience. AIM: The study explored barriers and facilitators experienced by midwives in antenatal settings to screening and referral of pregnant women who use alcohol or other drugs. DESIGN/SETTING: A semi-structured interview was adopted to explore barriers and facilitators experienced by midwives in screening and referring pregnant women for alcohol or other drugs specialised services. Eighteen midwives were recruited from urban, regional and rural antenatal settings in Victoria. Interviews were tape recorded and transcribed verbatim. Themes were generated by thematic analysis, the process of identifying patterns within the data. FINDINGS: Of the seven themes identified under barriers, five could be categorised as "institution and provider-related", namely: (i) lack of validated screening tool, (ii) inadequate support and training, (iii) discomfort in screening, (iv) lack of multidisciplinary team and specialised treatment in regional and rural areas, and (v) workload and limited consultation time. Conversely, two themes could be classified as 'client-related', namely (i) non- or partial-disclosure of substance use, and (ii) reluctance and non-adherence to referrals. All five themes under facilitators were "institution and provider-related." They are (i) a woman-centred philosophy of care, (ii) evidence of harms from substance use on neonates, (iii) experience and training, (iv) continuity of care, and (v) availability of multidisciplinary team and funding. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: To the best of our knowledge, this is the first study of its kind conducted in Victoria. This study not only adds to the limited body of knowledge on barriers experienced by midwives but also identifies facilitators in antenatal settings that promote screening and referral of pregnant women who use substance. Most of the barriers and facilitators are interrelated. Despite midwives' willingness to screen all pregnant women for substance use and provision of referral, they often felt limited in their capacity. Availability and accessibility to validated screening tool(s), in addition to regular, ongoing training for all midwives to maintain clinical competence and provide effective communication are imperative. Availability of a multidisciplinary team, funds and specialised care facilities such as detoxification and mental health services, especially in regional and rural areas, are necessary to effectively support at-risk pregnant women.

Two Case Studies Illustrating a Shared Decision-Making Approach to Illicit Methamphetamine Use and Breastfeeding.

Crystal methamphetamine (MA) is a potent psycho-stimulant that is increasingly used worldwide. It is highly addictive, is often made in clandestine laboratories, and can cause serious health issues in adults. Health professionals caring for women in the perinatal period must counsel women about the health risks to infants if they are exposed to MA in breast milk. Most guidelines recommend that women who have current or recent MA use do not breastfeed. This article explores approaches to breastfeeding advice in the context of MA use. Women who have made lifestyle changes, engaged well with services in the antenatal period, and are committed to drug counseling services after discharge from hospital may be supported to breastfeed if they are assessed as safe to do so. The importance of assessing each woman individually when developing infant feeding plans throughout the perinatal period is advocated.

Neonatal and maternal outcomes following maternal use of buprenorphine or methadone during pregnancy: findings of a retrospective audit.

BACKGROUND: Substance use in pregnancy is potentially harmful to both the fetus and pregnant woman. At the Royal Women's Hospital, the Women's Alcohol and Drug Service (WADS) provides pregnancy care and counseling for women who have complex drug and/or alcohol issues and psychosocial needs. Women who are stable on pharmacotherapy attend the general pregnancy clinics. RESEARCH QUESTION: What are the maternal characteristics, pregnancy and neonatal outcomes for a group of women attending for pregnancy care who were on pharmacotherapy substitution treatment, being prescribed buprenorphine or methadone? PARTICIPANTS AND METHODS: All women prescribed buprenorphine or methadone from September 2005 to December 2006 were identified by the hospital pharmacy department where prescribing permits are retained during the woman's pregnancy and postnatal period. Data were collected from medical records and a specific Drug and Alcohol Service database and analysed using descriptive statistics. RESULTS: Ninety-eight women were identified; 78 were prescribed methadone and 20 buprenorphine. Of these, 76 women also used other substances: tobacco (63%); cannabis (39%); and heroin (37%). Women who received no antenatal care had poorer outcomes overall. Twenty-four percent of live-born infants ≥33 weeks gestation (22/91) required medication for withdrawal. There was no difference in medication requirement where mothers were polysubstance users (18/70; 26%) compared with those who were not (2/21; 19%) (p=0.78), although these small numbers should be viewed with caution. The mean time until medication was required was 3.47 days. DISCUSSION: A significant proportion of infants whose mothers used buprenorphine or methadone in pregnancy displayed enough symptoms of withdrawal to require medication. This is therefore an important clinical issue of which care providers need to be aware. CONCLUSION: Further prospective research is required to explore whether factors such as specific substances are more likely to be associated with infant withdrawal.