Women, Children, and Addiction

Loretta Finnegan, Stephen Kandall, Loretta Finnegan, Stephen Kandall, Loretta P. Finnegan, Stephen R. Kandall

• Publisher: Taylor & Francis
• Year: 2014
• Print ISBN: 9780415601030
• eBook ISBN: 9781317982906
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

This proposed book draws on the expertise of 35 experts in the field of Addiction Medicine to provide the reader with a current and comprehensive view of addiction as related to women, pregnancy, newborns, infants and children. The volume begins by placing current attitudes towards addicted women in a historical context, and continues with contributions on the relationship of gender to substance abuse research, addiction as a general health issue in women, and ethical dilemmas faced when approaching drug use during pregnancy.

The volume discusses high-risk pregnancies and HIV infection related to maternal drug abuse. It details specific pharmacotherapy such as methadone and buprenorphine, and assesses society's punitive view toward illicit drug using women. Finally, the book describes outcomes of newborns, infants and children born following intrauterine drug exposure.

Health providers in many related disciplines, specialists in Addiction Medicine, social workers and ethicists are among those who will gain insight into the complex interdisciplinary matrix of abuse in women, its unique relationship to pregnancy, and its impact on drug-exposed children.

This book was published as a special issue in the Journal of Addictive Diseases.

Introduction to Women, Children and Addiction

Loretta P. Finnegan, MD, LLD (Hon), ScD (Hon)

Addiction in women is a major public health problem. Approximately 90% of women using drugs are of reproductive age.¹ Societal moral attitudes have stigmatized and dehumanized women who are drug-dependent, particularly those who become pregnant.² As a result, barriers exist for women who are addicted to drugs when they attempt to obtain optimal and appropriate medical and obstetrical care, as well as gender-specific services for their addiction. These barriers apply to women of all races and socioeconomic status. The best public health result can be obtained once these barriers have been removed, allowing women to find appropriate services in supportive, multidimensional treatment facilities for themselves and their children.³ Much has been learned over the past several decades from research in the field of drug dependence, but continued attention to evidence-based studies is essential to provide the best possible care for women who are addicted, to determine the intricacies of neonatal abstinence syndrome, and to assess the overall immediate and long-term effects of in utero drug exposure. To delineate the multi-factorial aspects of addiction in women and the effects of in utero exposure, it will take many more dedicated researchers and a large funding commitment by government agencies and private foundations.

This supplement will address the major effects of addiction in women and the impact of in utero exposure on their infants and children. Commencing with the history of addiction in women, documents show that female addiction is not a new phenomenon in America, but rather has existed for more than 150 years and was “the result of inappropriate overmedication practices by physicians and pharmacists, media manipulation, or the woman’s own attempts to cope with social or occupational barriers preventing equality and self-fulfillment.”² One could look at current societal mores and practices and see that history truly repeats itself.

Epidemiological and clinical research has indicated that predictors for and progression to drug abuse and dependence are often gender-specific or gender-sensitive. Differences between men and women have been identified in evidence-based studies examining the epidemiology of drug abuse, biological and subjective responses to drugs, patterns of use, progression from use to dependence, gender differences in medical consequences of drug addiction, concomitant psychiatric disorders with drug use, victimization and violence against women, midlife and older women, specific barriers to entry, retention, and completion of treatment.^4,5 In contrast to men, women have a higher vulnerability to the adverse consequences of addiction, show a more rapid progression to entry into treatment despite fewer years of active illicit drug abuse; however, they are underrepresented in addiction treatment.⁶

Significant to women addicted to alcohol, nicotine, opioids or stimulants is the tremendous effect on their health. The medical literature clearly indicates that women progress more rapidly than men into addiction to alcohol and other drugs with the development of serious health consequences. Numerous medical complications occur as a result of addiction in women, including hepatitis, cirrhosis, cardiovascular disease, diabetes mellitus, osteoporosis, lung, breast and endometrial cancer, chronic obstructive pulmonary disease, infections, neurological dysfunctions, and HIV/AIDS.³

Drug use during pregnancy is a major risk factor for maternal morbidity and neonatal complications. To normalize the pregnancy and protect the unborn fetus, considerable challenges exist with regard to identification, assessment, and treatment of woman who addicted while pregnant. The numerous medical and psychosocial complications listed above are compounded during pregnancy with the risk of preterm birth, intrauterine growth restriction, and placental accidents. Infants born to women who are addicted have a higher incidence of morbidity and mortality as a result of prematurity, infection, neonatal abstinence syndrome, and the development of potentially lethal fetal anomalies due to some exposures (i.e., alcohol). Unfortunately, drug abuse treatment providers frequently do not have the facilities or the obstetrical staff available to provide the specialized services that the woman who are addicted while pregnant requires. Pregnancy is an opportune time for women and treatment staff to encourage the woman to seek recovery from an addictive lifestyle.⁷ Both the health care and lay communities need to advocate for the ethical, moral, and just treatment of pregnant women who are addicted and their children.

Women who are addicted contribute to the incidence of HIV infection as a result of their risky behaviors as a result of their injection practices and because of increased engagement in high-risk sexual behaviors. During pregnancy, HIV infection confers the added risk of perinatal transmission, and this transmission accounts for nearly all new HIV infections in children.⁸ Screening, risk reduction interventions, and treatment of the mother and infant represent the current approach to HIV-infected dyads. More specific risk reduction interventions for women are greatly needed.

Medication-assisted treatment has been instituted and used over the past 40 years. Numerous studies have reported on the efficacy, drug-drug interaction, side effects, and dosing issues regarding methadone. Basic clinical research addressing the molecular neurobiological aspects of opiate addiction, as well as human molecular genetic studies by Kreek et al.⁹ and Kreek,¹⁰ have found few differences between males and females. Although women have a different opioid binding capacity than men that will influence dosing regimens in opioid pharmacotherapy,¹¹ both pregnant and non-pregnant women have been successfully treated with methadone.

In recent years in the United States, buprenorphine has been approved for use in medication-assisted treatment in men and non-pregnant women. Buprenorphine has been shown to be well tolerated, and due to its partial agonist properties appears to be a safe therapeutic agent, especially because severe side effects such as respiratory depression develop only with severe over-dosing. It is clinically and scientifically desirable to have treatment options when selecting medication-assisted treatment for opioid dependent individuals.^12,13

Although there has been considerable controversy concerning the use of methadone in pregnancy, it remains both the medication of choice and the standard treatment in the United States. Many studies suggesting that lower methadone doses in pregnancy decrease the incidence and severity of neonatal abstinence have been criticized due to poor research designs and confounding variables. More recent studies have demonstrated that dose is probably not related to the incidence or severity of neonatal methadone abstinence.¹⁴ During pregnancy, significantly more benefits have been identified than risks when methadone and comprehensive services are provided. The main risk is the incidence of neonatal abstinence in 60% of the neonates exposed, equal to that of heroin but with less overall morbidity for the infant.¹⁵ Some studies show that neonatal abstinence in infants exposed to buprenorphine may be less severe than that seen with methadone.¹⁶ Numerous studies in the United States and in Europe have shown the usefulness of buprenorphine in pregnant women; however, we await results from the international MOTHER Study to further support its efficacy and safety in the perinatal period.¹⁷

Of great concern to many in the medical and legal professions is the practice of punishing or prosecuting pregnant women using drugs in several areas of the United States. The plight of the pregnant women who are drug dependent can best be stated by Flavin and Paltrow within their section of the current supplement:

The arrests, detentions, prosecutions and other legal actions taken against drug-dependent pregnant women distract attention from significant social problems such as our lack of universal health care, the dearth of policies to support pregnant and parenting women, the absence of social supports for children, and the overall failure of the drug war. The attempts to “protect the fetus” undertaken through the criminal justice system (as well as in family and drug courts) actually undermine maternal and fetal health and discourage attempts to identify and implement effective strategies for addressing the needs of pregnant drug using women and their families.

Some of the flawed premises on which these arrests, detentions, and prosecutions are based are exposed in their section; the issues viewed through legal, moral, and ethical lenses broaden this volume’s perspective.

One of the areas in the field of addiction that may evoke a great deal of emotion, controversy, and even anger is the relationship of prenatal drug exposure to the outcome of exposed infants and children. Numerous studies of animals and humans have reported the potential adverse effects on infants and children; however, many have not considered the confounding effects of multiple drugs (licit and illicit) as well as the environment to which the child is exposed. It is acknowledged that some drugs, such as alcohol, are teratogenic; however, the negative impact that nicotine may have on the developing fetus and the child are frequently discounted by the lay public.

After careful research designs were implemented, illicit drugs that had been considered seriously harmful to the offspring are now considered to have only subtle effects. Cocaine and opioids have the potential to affect growth at birth and in the toddler years. In contrast to opioids, which have a high incidence of neonatal abstinence and infant neurobehavioral deficits, prenatal cocaine exposure appears to be associated with subtle decrements in neurobehavioral, cognitive, and language function.^18–20

In older children, numerous studies have cited the effects of prenatal cocaine exposure to include behavior problems and attention, language, and cognition deficits. Follow-up studies of children exposed to opioid (mostly methadone exposed), many that dealt with small numbers of participants, have been unable to adequately control for separate potentially confounding variables. In older children, studies report school behavior problems, disruptive behavior, and a diagnosis of ADHD.²¹ Generally, no differences in children exposed to opioid have been noted on cognitive tests in contrast to comparison groups. However, one important issue in the long-term follow-up of these children is that they grow up in high risk environments. Similar learning and behavior problems have been reported in school-age children not only exposed to drugs in utero,²² but also those living with drug-dependent parents who didn’t have intrauterine exposure.^23,24 A key issue to consider in reporting the outcomes of infants and children is that the children and their families, as well as society in general, would be well served by providing appropriate prevention and intervention services to address the unique needs of drug-abusing pregnant and postpartum women and the developing fetus. These models of treatment have been described in the literature and many currently exist throughout major cities in the United States and abroad.²⁵ Unfortunately, not enough comprehensive services exist to meet the current needs of the vast population of women and children suffering from the disease of addiction.

This compilation of articles on women and children and addiction will provide the reader with up-to-date information prepared by clinicians and scientists who have had extensive clinical experiences and who have done some of the seminal research in this field. The areas covered include historical accounts, the importance of gender, health of the women including HIV risk behaviors and incidence, ethical issues, pregnancy, medication-assisted treatment with methadone and buprenorphine, society’s need to punish women who are addicted and pregnant, and infant and toddler outcomes should provide the reader with an excellent background to deal with the effects of addiction on women and children. Finally, we must strive for excellence in research and in the clinical care of women and children afflicted by addiction. Government agencies and private foundations must recognize their responsibility to provide adequate funding to provide the appropriate and unique services and the needed research for women who are dependent on drugs and their children. Only if this responsibility is taken seriously will this country be able to cope with the pathophysiological and behavioral effects seen in women and children as a result of addiction.

References

1. Kuczkowski K. The effects of drug abuse on pregnancy. Current Opinion in Obstetrics and Gynecology 2007; 19:578–585.

2. Kandall SR. Substance and shadow: women and addiction in the United States. Cambridge, MA: Harvard University Press, 1996.

3. Finnegan LP, Hagan T, Kaltenbach K. Opioid dependence: scientific foundations for clinical practice, pregnancy and sub...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Notes on Contributors
• 1. Introduction to Women, Children and Addiction
• 2. Women and Drug Addiction: A Historical Perspective
• 3. Women and Addiction: The Importance of Gender Issues in Substance Abuse Research
• 4. Substance Use and Women’s Health
• 5. Ethical Issues and Addiction
• 6. Addiction in Pregnancy
• 7. Human Immunodeficiency Virus Risk Behavior Among Female Substance Abusers
• 8. Pharmacotherapy in the Treatment of Addiction: Methadone
• 9. Gender Issues in the Pharmacotherapy of Opioid-Addicted Women: Buprenorphine
• 10. Punishing Pregnant Drug-Using Women: Defying Law, Medicine, and Common Sense
• 11. Prenatal Drug Exposure: Infant and Toddler Outcomes
• 12. Children of Addicted Women
• Index