The case involves is a 27-year-old white British woman, who lives with her three children (aged 7, 6 and 1) in a council tenancy. She is unemployed and receives state benefits. She was first seen at our drug service in 2004, following a self referral. At initial assessment, she reported a 5 year history of heroin dependence and a 3 year history of cocaine misuse. She was smoking between 2–3 bags (0.4–0.6 g) of heroin and 1–2 ‘shots’ of cocaine a day, but denied ever injecting drugs. She also denied ever misusing any other illicit psychoactive substance or alcohol. Assessment revealed nothing suggestive of underlying psychiatric comorbidity or other medical disorders. At that time she had two children aged 2 and 1. She reported having stayed off drugs (heroin and cocaine) all through her two pregnancies, but relapsed into regular heroin and cocaine use 6 weeks after the birth of her first child and 16 weeks after her second child, respectively. She appeared highly motivated to address her drug problems.
The patient derives from a family of three, with no history of substance dependence in the family. Her parents separated when she was a child, but she maintains excellent relationship with both of them. Her sister is extremely supportive to her; her younger brother is autistic. She was born and raised locally, attended normal mainstream schools, and was average academically. She has no formal educational qualifications and has never been in structured employment. She has committed numerous acquisitive offences (shoplifting) to finance her drug use. Until recently, she was in an abusive relationship with a drug using partner, but is now separated and lives with her three children.
Following the initial assessment, the patient was started on methadone 40 ml daily (1mg/1ml, oral solution). In addition, her treatment package consisted of one-to-one psychological input from her keyworker and further support to address her social needs. She started making progress in treatment and reduced her heroin and cocaine use significantly. Three years into treatment, she was pregnant for a third time, but this went unrecognised until she was 16 weeks pregnant. Soon her care was transferred to our specialist mother and baby nurse. This nurse remained the patient’s keyworker throughout her further treatment and she coordinated her care with other professionals such as antenatal staff, maternity services, general practitioner, and social services. There were regular multidisciplinary reviews of her care and progress in treatment. A comprehensive care plan was drawn up, with the patient’s active participation, with extensive input from all professionals involved in her treatment. She was also informed and educated about the rationale and benefits of methadone treatment and the risk of NAS. Adequate opportunities were provided for her to understand the risk of NAS, its symptoms, and how it could be treated. During the second trimester, at her request, the dose of methadone was gradually reduced to 17 ml daily. At this dose, she remained clean of heroin and denied any craving or withdrawal symptoms. She was receiving regular antenatal care and her pregnancy was uneventful.
At 37 weeks gestation, the patient gave birth normally to a healthy baby. He weighed 8 lbs (3.6 kg) and showed no signs of NAS. They were kept in hospital for 3 days to monitor the baby for NAS, after which they were discharged.
Given below is the patient’s reflections on her pregnancy, drug use and treatment in general:
“When I first found out I was pregnant, it was at 3 months I think, I was still using heroin but soon after I found out I was pregnant I stopped straightaway. I am probably one of the rare ones who can actually stop using heroin quite quickly, if you know what I mean. With me it was more about the people that I was around that were using that tempted me to use. If it wasn’t there in front of my face then it wouldn’t bother me at all. I would not sit there thinking I would love to smoke now. It was when it was there in front of me that was the temptation for me, so once I got rid of it being there in my face I didn’t really have a problem with it. I never have had a problem with it when I’ve been on my own, it’s just people around me.
“I felt guilty about being on methadone and being pregnant so while I was pregnant I was just trying to drop it as much as I could, but do it at a safe level as well because it can harm the baby if you drop too much too quick. I did not want to drop it too much, because then I would have had to smoke heroin. My keyworker explained about dropping methadone as much as we could but slowly and steadily and then we kept it at 17 ml for the last few months so that it was a steady balance. So when he was actually born I was on 17 ml of methadone a day which is not a lot, but he could still have had withdrawal symptoms from that. I was worried about it. I mean, people that I spoke to at the clinic and people who I spoke to at the hospital said you know there is a lot we can do. I was worried because I didn’t want him going through that because knowing how it feels to withdraw myself, I didn’t want my newborn baby to feel that, so I felt bad but I was very relieved when he was born. We were kept in for 3 days because he was monitored closely to make sure he did not show any symptoms which he didn’t, but it was a worry all the way through. I didn’t want him feeling what I felt with withdrawing. It’s not nice is it?
“The clinic was great—definitely. My keyworker was great. I have always got on with her. When I had my hospital (antenatal) appointments, not that anybody said anything or done anything but you know, when they read your notes and they read that you are on methadone, I don’t know, you just feel that they think oh, it is bad to be on methadone or to be smoking heroin when you are pregnant. Just the way they sit there filling out forms and don’t really talk to you like a normal person, do you know what I mean? Just like that. So it did make me feel like people looked down their noses a bit at the fact that I was pregnant and on methadone.
“But it helped my keyworker telling me about NAS, she told me a lot about it. In fact, we did speak a lot about what happens if the baby shows signs and that the baby could be given medication to come out of it. She explained all that to me and how it works and stuff. I mean there have been people that I know that their babies have been born and they have had to be in hospital for 2 to 3 weeks being weaned off it, and I was just glad that after 3 days I was able to take him home and he was OK. I was as happy as I could have been.”