From nucleus - November 2018 - distinctives: addiction in pregnancy
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Edinburgh is famous for its iconic skyline, the festival and its important place in Scottish history. However, in the city also famous for Trainspotting, you don't have to journey far to come face-to-face with the harsh reality that faces many of its residents.
A 25 minute bus journey from where I lived as a student, takes you from one of the wealthiest areas in Scotland to one of the most deprived and yet most of Edinburgh's middle class population are unaware of the deprivation and poverty that is on their doorstep. These areas have higher rates of crime, lower life expectancy, poorer health and are less educated. There are also much higher rates of drug misuse and dependency. (1) Life here is chaotic and breaking the cycle of poverty is difficult.
It was amongst this population that I found myself, in my fourth year of medicine, undertaking a project looking into drug addiction in pregnancy. Although this was primarily a research project, I found that the people I met and things I learnt really challenged me: around 1 in 80 women in Edinburgh between the ages of 15 and 69 have an illicit drug problem. (2)
I joined the PrePare team, an integrated pregnancy and parenting support team established in 2006 to reduce maternal drug use, improve pregnancy and neonatal outcomes and protect children from harm. They work primarily with pregnant drug users. These women are amongst the most chaotic and regularly do not attend appointments or engage with services. The team aim to break the cycle of poverty and addiction. They run parenting classes, provide financial advice and educate on the harms of drug use, all in a supportive and blame-free environment.
The aim of this study was to determine whether women with benzodiazepine dependence were receiving a gradual dose reduction of long acting benzodiazepines in accordance with guidelines. (3) It also aimed to explore the barriers to reducing drug use. I found that diazepam prescriptions were not being reduced in accordance with guidelines but that there were many barriers to doing so. These barriers included chaotic lifestyles, complex family relationships, the use of drugs as a coping mechanism and lack of education. Reducing the prescription couldn't be done without tackling some of these issues, and keeping the patients engaged. All the women felt they benefited from PrePare's work and I was struck by the commitment of the staff to working relentlessly to bring about change in these women's lives.
Addiction is a very powerful vice. It has a psychological and physical grip on people and completely controls their lives. This often results in manipulative drug-seeking behaviour as people look to get the next fix. Perhaps understandably this doesn't endear them to others. However, we can often fail to see past the addiction to the person.
I spoke to women about their lives, their families and how they started using drugs. Many attributed the start of their drug use to 'getting in with the wrong crowd.' However, around half of the women I interviewed disclosed experiencing significant childhood trauma, including childhood abuse, exposure to parental domestic violence, parental addiction and family members in prison. There is strong evidence that exposure to violence as a child increases behavioural problems in children and leads to domestic violence in their own relationships as adults. (4) Childhood trauma also increases the likelihood of drug addiction, earlier drug use, depression and suicidal intention, all of which negatively impact parenting ability. (5)
In my study, two-thirds of the women were in abusive relationships. Two-thirds of their partners had previous convictions or prison sentences. To cope with their unstable home environment, many women turned to drugs such as diazepam, methamphetamines and heroin. These women were now bringing children into the same environment that they themselves had been brought up in.
All the children in the study were put onto the child protection register before birth — 60% of babies went straight into care; the remaining 40% went home with their families with input from social work and other services. Over three-quarters of these women already had other children in care. Sadly, many of these babies were born with neonatal abstinence syndrome which can have long term effects. (6),(7) The separation of a mother from her child is always painful but particularly so when these women are left with a sense of shame and failure in their role as parents.
These mothers were hurting deeply. One woman cried throughout the interview because all she wanted was her children back home. She desperately wanted to stop taking drugs and be free from the control her drug dependence had on her.
Through these conversations, I began to understand the depths of pain and suffering that many of these mothers had experienced and been exposed to throughout their lives. When you begin to realise this and share in someone's pain, you see a hurting and broken woman trapped in a situation that she grew up in, instead of the addict who brought it upon herself.
Drug users are amongst the most stigmatised in our society, particularly in healthcare settings. This stigma is often left unchallenged because of an underlying belief that the addicts are to blame for their addiction. I'm sure we have all heard the way that staff talk about 'the IVDU in bed four', or the scepticism surrounding requests for pain relief. It seems that the stigma is even greater towards drug-using pregnant women because the drug use harms both mother and baby. One woman told me she was refused analgesia during labour by staff who thought she was drug-seeking.
When we call a woman by a label such as 'the IVDU in bed four', we define them by that. This becomes her identity. As Christians, our identity is in Christ and we believe that all human beings are created in God's image - this is our call to treat everybody equally. The Bible tells us that we are all broken and sinful and in need of grace. (8) The Bible also tells us to love one another as ourselves. (9) This is not an instruction to love the people that we like or the people that are easy to love, but an instruction to love each and every person that we meet. Loving someone who is addicted to drugs is often difficult, but these are people who need love the most. Jesus loved people that no one else did and who were despised by society, such as the tax collectors, prostitutes and criminals. (10),(11)
As Christians, we are called to be more like Jesus and to love those who society ignores or neglects. Working in the NHS we see many people who fall into that category, which includes people with addictions. As Christian healthcare professionals, we should be on the front line in challenging attitudes and stigmas towards some of the most vulnerable people in society. We are called to reach out to these people, to believe that their lives can be different and to show them a glimpse of a love that they have never experienced, pointing them to the Father who loves them more than we ever could.
What does it look like to show love to a drug user? Don't be afraid to talk about their drug use; it shouldn't be a taboo subject. Let them tell their story. Be interested in them and their lives without judgement.
The biggest lesson I learnt through this project was not to give up on people in seemingly hopeless situations. I met people who had stopped using drugs after years of addiction and who were slowly breaking the cycle of poverty that they had been trapped in with help from healthcare and social workers. We can't always predict how lives can change, but God can transform lives no matter the situation.
Eilidh Urquhart is a junior doctor in Scotland
1. Scottish Index of Multiple Deprivation 2016 bit.ly/2xcS2tR
2. Estimating the National and Local Prevalence of Problem Drug Use in Scotland 2012/13. Information Services Division Scotland bit.ly/2QrG7By
3. Guidelines for the identification and management of substance use and substance use disorders in pregnancy. World Health Organization 2014
4. Watson K, O'Brien JA, Groff JY, McFarlane JM. Behaviors of children who are exposed and not exposed to intimate partner violence: an analysis of 330 black, white and Hispanic children. Pediatrics 2003;112(3 Pt 1): e202-7
5. Rastam M, Tedgard E. Vulnerable parenting among mothers with substance abuse in their family of origin: a cross-sectional comparative study of mothers in an infant and toddler program. Springerplus 2016 5(1):1540 bit.ly/2Qr8Vdd
6. Wikner BN, Stiller CO, Bergman U, Asker C, Källén B. Use of benzodiazepines and benzodiazepine receptor agonists during pregnancy: neonatal outcome and congenital malformation. Pharmacoepidemiol Drug Safety 2007;16(11):1203-10.
7. Ban L, West J, Gibson J E, Fiaschi L, Sokal R, Doyle P, Hubbard R, Smeeth L, Tata L J. First Trimester Exposure to Anxiolytic and Hypnotic Drugs and the Risks of Major Congenital Anomalies: A United Kingdom Population-Based Cohort Study. PLoS One 2014; 9(6) bit.ly/2NcfAdq
8. Romans 3:23-24
9. Mark 12:31
10. Luke 19:1-10
11. Luke 7:36-50