Jovi:
So good evening everyone, and welcome to tonight's webinar Substance Use in Pregnancy - Prevention and Screening. My name Jovi, your host for this evening. Now before we get started, I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay respects to Elders past, present and emerging. I would also like to acknowledge any Aboriginal and Torres Strait Islander colleagues that have joined us online. I myself am joining from Gamaragal Land on Sydney's North Shore.
I would like to introduce to you our speakers for this evening. We have tonight Professor Adrian Dunlop. He is the current Director and Addiction Senior Staff Specialist for the Drug and Alcohol Clinical Services in Hunter New England. Adrian is the Contract Professor with the School of Medicine and Public Health at the University of Newcastle as well as a member and Chair of the New South Wales Drug and Alcohol Clinical Research and Improvement Network. Adrian is also a member of the Centre for Translational Neuroscience and Mental Health at the University of Newcastle at Hunter Medical Research Institute.
Our second speaker, we have got Dr Esther Han. Esther is a GP and a Drug and Alcohol Specialist at the Sydney LHD. Esther is a Clinical Lecturer for the University of Sydney in the Discipline of Addiction Medicine Northern Clinical School at the Facility of Medicine and Health. Her interests include children's health, women's health, drug and alcohol, sexual health and family planning. So welcome to both the presenters tonight.
I would just like to read to you the learning outcomes before I hand you over to our first speaker. So by the end of this online CPD activity, you should be able to identify when and how to ask about AOD use in pregnancy, discuss how to advise, help and reduce harms from AOD use in pregnancy, identify when and how to refer for specialist AOD support, and discuss the role of GPs in providing support for children with prenatal substance exposure.
I would like to hand you over to Dr Esther Han. We will go over to the next slide. Over to you, Esther.
Esther:
Thanks Jovi. So this presentation is going to cover alcohol and other drugs and it will touch on tobacco where it is co-occurring with alcohol and other drug use. We will talk a little bit about other substances including prescribed medications, for example medicinal cannabis. So we have got this pyramid here on the right and on the bottom rung of the pyramid, we have people who are abstaining from any alcohol or drug use, so non-users. And then the second rung, we talk about people who may be using, and this is really patients we might be encountering in our primary care settings, in maternity services at the hospital, the antenatal clinics or through the early childhood kind of centres. These are people who are using substances that are potentially harmful to the foetus. And then the patients who are using harmfully and patients who are using dependently right at the top of the pyramid. And really the top two rungs of the pyramid are those that are probably going to need specialist AOD intervention and for us as GPs, how do we recognise those patients who we need to refer for specialist AOD intervention will be covered later on in this webinar. So next slide please.
So asking. So we have got the 5A framework that we go through with RACGP. So the first A being Ask, and who do we ask and when do we ask? So we ask women, of course, and women of childbearing age. So any woman, even women who are not looking to become pregnant, we should be asking opportunistically as part of our preventive kind of screening and treatment of these people. In terms of other women, women who are trying to conceive, and it may be women who have come off contraception who are maybe not actively trying yet, but kind of, you know, just seeing where things, you know, may land. And that is where we can, you know, start to give some advice and asking about their pre kind of pregnancy alcohol and other drug use patterns. Those are important determinants and risk factors for drug and alcohol use during pregnancy, the pre-pregnancy. And women who are currently pregnant. And so we would ask all women no matter what kind of trimester they are in, as we know that different substances can have different teratogenic effects depending on which trimester the foetus is exposed to that to drug or teratogen. Next slide please.
So women of childbearing age, so a bit of the background. About one in four women in Australia have an unplanned pregnancy. And talking about the risks that, you know, that they can be potentially exposing their foetus to before they know that they are pregnant can just help women start thinking about maybe some of their behaviours, lifestyle, you know, habits that they may want to change, so that it does not have that impact on an unplanned pregnancy. Also it can form the, you know, part of the discussion on contraception options if they are really not wanting to fall pregnant. I often show, you know, women in my general practice that the efficacy of different contraceptive options and you know, combined oral contraceptive pill having 91% efficacy. So still, you know, one in 10 women is falling pregnant on the pill every year when they are just using the pill as contraception. And then looking at some of the long acting reversible contraptions which tend to have better efficacy. So that can be something that we just have in the back of our minds when we are seeing any woman of that kind of reproductive age. Next slide please.
So when we are talking to women who are trying to conceive, we want to yes, ensure that they have optimal kind of preconception health and that would be, you know, obviously we are talking about maybe prenatal vitamins that they might be taking, folic acid and iodine, that would be kind of acceptable to most people and might improve reproductive outcomes, reduce the risk of spinal bifida and cretinism, kind of hypothyroidism. So often women have this period where they do not recognise they are pregnant and they come and they have, you know, done a pregnancy test and you know, I have had the chat where a woman is like, oh, they have, you know, they may be six weeks pregnant and they come into the general practice and they are worried because they said, oh, I went away with some girlfriends the other weekend or I went to a wedding and I drank a lot at that wedding. Have I done my, you know, foetus or baby, any harm? And we do know that alcohol is a teratogen and a lot of the kind of foetal development has already happened in those early weeks, those first few weeks of gestation, first three to six weeks, often before the woman has recognised that she might be pregnant. So we do need to let the women know the risks, especially women who are in this bucket of trying to conceive. And more than half Australian women in one survey was found to have consumed alcohol before they knew they were pregnant. Next slide please.
Adrian:
I might just jump in for a sec there. So great points that you are making, really important at an individual clinical level and obviously at a public health level too. And just, you know, another thing to think about in framing this information to young women, also good to frame it to young men. There is a real shift in thinking that we need to have. But yes, important to talk to young women about it. As you said, a lot of pregnancies are planned and binge drinking is not uncommon, especially in young people, also in older people. But yes, not just women. It is also important to focus on young men. There is there is a program that has not been incredibly well publicised called Pregnant Pause, you know, with the idea if a young woman is trying to get pregnant, then her male partner could be doing something about their alcohol consumption, maybe stopping alcohol for a while too. It will take a lot of work that to really catch on, but something I think you need to be aware of in a primary care setting.
Esther:
Yes, great. Thanks, Adrian. Yes, and definitely I do get young couples kind of come to me in general practice or the woman will come first and then kind of ask, you know, what their partner could be doing also to improve kind of the preconception health. And so, yes, we do need to have this discussion with men who are trying to conceive with their partners around what kind of healthy behaviours they could be engaging in as well. That is great.
So when women are pregnant, you know, what do we want to ask? And whilst each substance kind of differs in its impact on the pregnant woman and the foetus, we know that any kind of substance use in pregnancy can cause serious harm and can even cause lifelong disability to the child. So we know about Foetal Alcohol Spectrum disorders, which is an umbrella term and it describes a spectrum of alcohol effect on the child or the later, you know, to become an adult. And so we know that at each kind of stage of the developing foetus and embryo, depending on when alcohol was consumed, different parts of the body can be affected. So for example if alcohol was consumed quite early on in the pregnancy in those first few weeks when the eyes are developing then that person may have visual problems for the for the rest of their life, and so when a woman first discovers she is pregnant, obviously we are we are the first point of call typically, a GP, and I saw two women today who, yes, you know, found out that they were pregnant in their first trimester. And this early kind of, you know, engagement with the healthcare professional, we do have these kind of opportunities for brief interventions and then, you know, screening recognition of problematic kind of harmful use and then kind of appropriate referrals. And I have definitely made referrals from my general practice to our substance use and pregnancy and parenting services workers in in my local area. Luckily I know them well. But yes, they, you know, they are very open to referrals is what I found.
So nearly one in three Australian women surveyed had consumed alcohol in a pregnancy, including those who before they were aware they were pregnant. So we know that a lot of, yes, part of Australian culture we have got, you know, very kind of cultural beliefs and perceptions and attitudes towards alcohol. We know that alcohol is changing. So what used to be kind of, you know, more men drinking, we know through Australian national surveys that it is now kind of also women who are drinking alcohol at problematic levels, and in my area of Sydney, northern Sydney, we have a high rate of alcohol attributable hospitalisations, especially in this women of reproductive age group. So yes, and we are quite I would say a high affluent kind of, you know, socioeconomic area and it is interesting that in this high socioeconomic area that that women do culturally find it okay, or there is various reasons why women are drinking. And yes, some of them, yes, find out that they are pregnant. So next slide please.
So this graph is from the National Drug Strategy Household Survey, which is run every three years. It surveys tens of thousands of Australians 14 years and up. And it is interesting. So the dark blue line shows the percentage of women who when breastfeeding were abstaining from alcohol. And whilst the percentage of abstainers from 2007 to 2019 has gone up, that is still about 50% of women who whilst breastfeeding, are drinking alcohol. And it is interesting, again in my local area, I would see mothers clubs meeting at the pub and women doing the pump and dump where they kind of, you know, we will have a drink and maybe then you know discard some of the breast milk that they expressed afterwards. There are breastfeeding Apps, Feed Safe is one of them, which kind of help women to recognise when it is safe enough to feed their babies, breastfeed their babies, after they have drunk alcohol. So those are some kind of harm reduction tools that we can let our patients know if they are choosing to drink. And then in that kind of turquoise line with the triangles, that is women who are abstaining from alcohol whilst pregnant. And again, we are we have improved it from 2007, where only 40% of pregnant women were abstaining, up to around kind of 65% in 2019, but that is still one third, roughly one third, of women who are drinking alcohol whilst pregnant. And you know, some of the risk factors or determinants of alcohol use in in pregnancy, are women who would also smoke in pregnancy or plan to smoke in future pregnancies based on past experience. So women who have drank in previous pregnancies, and we will go into this in a case study a bit later on, but women who have had previous abuse or violence exposure are more likely to drink alcohol in pregnancy. So we recognise that drinking in pregnancy happens within this kind of psychosocial context and we need to know more in order to be able to help our patient sitting in front of us. Next slide please.
So asking. So why is it important? We already talked about some of the lifelong disabilities that kind of prenatal alcohol exposure can cause. It helps to prevent and identify some of these risks earlier. And screening can ensure that substance exposure is noted in the medical record, which can be important later when maybe paediatricians are trying to diagnose this child. For alcohol specifically, the NHMRC notes that health professionals in Australia often are not aware of the FASD diagnostic criteria. So that is Foetal Alcohol Spectrum Disorder diagnostic criteria. We do have new guidelines, Australian FASD guidelines, and so often health professionals will not routinely ask pregnant women about their alcohol use, so it can go undiagnosed. And a lot of kids that were previously diagnosed as having ADHD, once they have that history of prenatal alcohol exposure, then get a revised diagnosis of FASD by the paediatricians and the teams, kind of like at the Cicada Centre in Westmead, Elizabeth Elliott's team there who do a lot of the diagnostic assessments for FASD. And the diagnosis, yes, for FASD obviously requires evidence of prenatal alcohol exposure, and I will talk to that a little bit later on in the presentation, what are some of the tools that we use. Next slide please.
So how to engage patients when we are asking. So you know, kind of normalising that drug and alcohol use, you know, well, especially alcohol, it is a common feature of a lot of people's lives and you know, maybe important in social relationships and the culture. And I think we all need to examine our own kind of beliefs and values around drugs and alcohol in order just to be aware that when we talk to patients about it, that it does not necessarily come across in a judgmental way if we have our own personal values and beliefs. Understand which terms may be stigmatising and how stigma can lead to patients disengaging and poor health outcomes. And one of the things that we know is that women who are using, you know, substances or drinking kind of more harmfully and heavily in pregnancy, often feel quite a lot of shame about what they are doing anyhow. So they do not necessarily need healthcare professionals making them feel more ashamed, and really we just come in you know concerned for their health. And so some of the terms that may not be helpful, and we have consulted consumers, so people with lived experience of people who are using drugs and alcohol, around what terms they prefer. So instead of IVDU, you know, the person is not their IV drug use, it is a person who injects drugs. PWID is the acronym. And I would never call somebody an alcoholic. Some of my patients do refer to themselves as alcoholics, and they find that term helpful because it kind of helps in their recovery, but some of them might not find it helpful. So I would never call somebody an alcoholic. I would talk about the diagnosis, alcohol use disorder, mild, moderate, severe, you know, maybe I would refer to alcohol dependence. But again that can be a little bit, you know, vague for some people. And then words like junkie, you know, I would never call somebody a junkie. And try to just reframe it in more objective language around the behaviours, not labelling the person, just talking about the behaviours. So be aware that substance use is not isolated from other mental health issues. As we talked about, often there is a dual diagnosis of mental health and addiction. Psychosocial and cultural factors. And so different cultures obviously, yes, have different attitudes towards different drugs and alcohol.
Adrian:
If I can just jump in. So, like, just to give a couple of very obvious examples, so a really bad way to ask a woman who is pregnant about alcohol use would be, so you are not stupid and ignorant enough to drink alcohol during pregnancy, are you? Like, obviously that leaves no space for a patient to say yes. Another way around it would be to say, oh, did you, you know, before you became pregnant, did you ever drink alcohol, you know, how much would you drink on average? Okay, since you found out you are pregnant, do you still drink any alcohol now? Were you earlier? So not giving the expectation that the answer is yes or no, and giving the permission for the patient to say yes in how you ask the question. The other thing, and you know, this will probably come up in the examples too, is that clearly for women who are pregnant let us put it another way, generally a health practitioner asking a patient about their substance use, generally, doctors, nurses have pretty high respect by most of the community. Generally, people tell you what is going on when you ask them, as long as you ask them sensitively along the lines of what Esther has just said to you. However, if the answer means that there is going to be a really negative outcome for the patient, then people do not tell the truth. That is not surprising. So it comes back to this sort of question of how you ask a question and that there is not necessarily a negative outcome associated with it. So you can imagine, we will get to the more complicated cases, but in pregnancy, a woman might be really worried about what you are going to do with the information that you are asking her. So depending on the situation, we might need to talk a bit more about that. Sorry for jumping in there Esther.
Esther:
That is great. That is right. Yes. So there are some good and less good ways to ask these questions. And definitely, you know, it may be a coping mechanism for trauma, you know, the alcohol or drug use. And for a while there we had a string of women coming into detox, you know, for alcohol detox, and really they were drinking because they were experiencing domestic violence and so domestic violence screening is obviously a part of routine antenatal screening now which is great, that midwives and healthcare professionals are asking these questions to screen for DV, and so I think it is yes, important to kind of yes, also ask about drug and alcohol use, but understand that, you know, it may be happening in that kind of context. And creating an environment that is safe and culturally safe, and that is a hard thing to do, kind of to be aware of obviously all the different cultures and how to approach each culture, you know, respectfully, and I would just ask patients kind of what is appropriate in your culture?
And this privacy and confidential confidentiality thing as Adrian alluded to. Yes, obviously we have doctor-patient confidentiality. But I think it is also important there is a caveat to that in that there are times when we do have to breach patient confidentiality and that is where matters of you know, safety are concerned. And I am pretty upfront with people when I first meet them that every especially with young people, you know, because they think you are going to dob into their parents that they are using you know, drugs and alcohol, and I say look, everything we talk about is confidential. That means I cannot tell anybody, that is protected by the law. The only time I would break that is if I am concerned, seriously concerned, about your safety. Like if you told me you were hurting yourself or planning to end your life, or the safety of others, including in drug and alcohol. Sometimes it is road safety, sometimes it is child protection safety. And so we need to kind of be upfront with people and let them know that these are some of the potential ramifications. But yes, at the GP level I just say, look, everything is kind of confidential, you know, but there are some caveats to that. Next slide please.
So how to approach the topic, so asking about use, just like kind of routinely as part of our routine screening questions and bring it to that flow of the normal consultation, the conversation we would have with our patients. And you know, I remember in medical school when we were learning how to ask sexual health, you know, questions, and just practising saying those questions just to make it normal, you know. So can I ask you a few more personal questions about lifestyle? This helps me to decide what tests and investigations we might need to order and what management, you know, we might need to do. And if you are feeling anxious about raising the topic, you can explain to the patient why you are asking. And ask for permission. So do you mind if I ask you a few more questions? Most people do not mind. And you can just relate it back to their health and say, look, I am concerned about the health of you and your baby, and that is why I am asking these questions. So just practising saying those questions. So I remember when we were doing the sexual health history, you know, I just had to practice, you know, asking questions like what kind of sex do you perform? Do you perform, you know, oral sex, anal sex, you know, vaginal sex? Just making it kind of flow off the tongue because patients take their cues from us and if we are awkward, they will also be awkward about it typically. Next slide please.
So asking, which substances to ask about. So we usually just start off with kind of alcohol and tobacco, the two kind of legal substances. And nowadays e-cigarettes obviously are an important thing to ask about. And then I would ask about other substances including prescribed medication, so things like benzodiazepine. So are you on anything like Valium or anything to help you sleep? Are you on any opioids like codeine or any painkillers like Endone, OxyContin, Targin, Palexia, you know, are you prescribed any cannabis, medicinal cannabis? And then asking about any stimulant medication that they might be prescribed for ADHD or, you know, I mean, lisdexamfetamine is also prescribed for binge eating disorder. So asking about those substances, and then asking about the illicit substances after that. So, you know, is there anything else that is not prescribed?
And so when you know somebody discloses that they are prescribed medication, then we do not recommend ceasing that prescribed medication as a default, that obviously needs to be kind of weighed up the risks versus benefits, especially yes, some of the antidepressants that women might be on and other medication that you know, maybe category C or in pregnancy. So that definitely warrants a discussion between the person, the healthcare practitioner who is prescribing that medication to the person, the woman, the GP and the antenatal team. And so there are some meds that, you know, obviously maybe a category D or X that we might kind of consider stopping quite quickly because of the high teratogenic risk. And so, sorry, if you just go back to that previous slide. Yes. And so if you want more support, the Mother Safe phone line is available to answer questions. And yes, you can find that phone number easily online.
Great. And so asking, how to screen. So I mean most of us have Audit C in built into our GP software and it is a you know, good, quick, standardised and validated tool. And so for pregnant women, it is important to ask about alcohol use before they knew they were pregnant and then after they found out they were pregnant. And an Audit C score of zero, obviously there is no alcohol exposure. An Audit C score of 1 to 4 is what we call confirmed prenatal exposure to alcohol, which is part of the guidelines for diagnosing FASD. And then Audit C score of five is confirmed high risk exposure, and that would be somebody that I would probably be referring on for specialist support. So asking about other drug use and with tobacco and e-cigarettes, there is a heaviness of smoking index questionnaire that you can find, but other severity of dependence questionnaires that can help determine how dependent that person is on nicotine. Next slide please.
So these are the case studies.
Adrian:
Yes, thanks. And there is just one point I thought I would add to that before we go through the case study. So generally there is two patterns of substance use that we tend to see in pregnancy. One where before the pregnant woman has come to see us, or maybe, you know, it might be as part of the diagnosis of pregnancy or confirmation of pregnancy, they found out they are pregnant. They have stopped drinking or smoking tobacco or whatever it is, and fantastic, and they do really well generally. And the other where that has not happened for what might be some of the reasons you have already heard from domestic violence, a pre-existing substance dependence, and you know, in a nutshell they are often much more protracted and that is often when you need to seek specialist help. But some of the examples we are going to give you now are more in that sort of earlier, maybe they have just found out or maybe it is not so bad. But seeking advice is always possible.
Anyway, let us go through this case just to start. So this is on alcohol obviously. A 40-year-old woman, G3P2, pregnant with a third baby, currently in a third trimester. So she says to you that she might have a glass of wine or two a day on occasion while pregnant. She has a friend’s wedding upcoming and plans to drink champagne to celebrate. She drank in her two previous pregnancies and the kids are fine. Esther, can I ask you how would you approach somebody presenting like this? What would you say?
Esther:
So, this lady, yes, was a lady I saw in general practice, and I just asked her do you know the current guidelines around, Australian guidelines around, alcohol. So use that kind of opportunity to do a brief intervention and she said no. And then so I said look, yes, our thinking has changed around alcohol. We used to think it was okay in pregnancy, but the current research says it is not. And so for pregnant or breastfeeding women, actually the current guidelines are no alcohol is safe. Yes. So and when she said the kids were fine, I asked, okay and I just asked about any learning difficulties, any behavioural difficulties to kind of suss that out. And yes, I just kind of documented in her notes that, you know, I had informed her of that those risks. She was not drinking in a dependent way so I, you know, recognise that she was just drinking on occasion when she felt that there was a special occasion to celebrate. And yes, I just made sure that I documented that in her notes that she was occasionally having a glass or two of wine.
Adrian:
I guess just going back into, you know, just to what we understand about alcohol exposure, FASD, there is a dose response relationship. So a much bigger dose and there is a much bigger risk. There is also differences in how alcohol effects pregnancy, early in pregnancy compared to later in pregnancy. And yes, there is concerns about early, but there are also concerns about later use in pregnancy. There is not a safe level of alcohol that we can quantify from the literature to say, okay, this amount is safe. Now the flip side is we should not misunderstand it. So it does not mean that if somebody has ever had any alcohol exposure then automatically that means the kid is going to have FASD or you know, it is a serious problem. Somebody typed a question, a Q and A question Esther while you were talking, which is, with heavier alcohol use should the woman have a termination, or they actually ask you about a termination? So I would not jump to immediately thinking yes, there is definitely harm if there is any alcohol exposure, and that concept of because we do not know a safe limit, we therefore recommend not to drink alcohol, can be a bit complicated if you do not have a medical or scientific sort of background of understanding risk and risk exposure. So can I ask Esther, maybe just, yes, that sort of scenario. So a woman comes in and says, look, I have been drinking and then I found out I was pregnant. What should I do, doctors? Is my baby going to have FASD or you know, what should I do? How would you respond?
Esther:
Yes, I typically say, look if you stop drinking from now, you know, the likelihood is that the risks are pretty small. And you know, I kind of show them the foetal development and just say look, this is what we know is happening at the foetus at these early weeks of pregnancy. And that is something that we can monitor and review after the baby is born. But you know most, most babies generally are fine if they have had that kind of limited exposure, you know and then kind of early earlier on. And so you are right, yes most of the women I see in general practice kind of where I am currently working, you know, they are in some ways the worried well, you know, and yes they kind of are able to stop. But then on the other hand the women that I do see in the clinic, in drug and alcohol clinic, are the ones, yes, that are probably, like they were dependent pre-pregnancy and still experiencing a lot of trauma and violence and that makes it more difficult to stop. Yes. So thanks, that was a good one.
Adrian:
Thanks. Can we go on to the next slide, please.
Jovi:
There is just a question that has just come up from Dr Chen. I will just read it out. So patient asked if they should consider ToP when they had alcohol 4 to 5 drinks every night for three weeks before she found out her pregnancy. How would you advise her?
Adrian:
Yes, that is what we just discussed, Jovi. On its own, that is not a reason for termination.
And so there is another question there. If there is alcohol dependency in pregnancy with a pregnant woman who has been unable to proceed with detox, is it justified to apply for the involuntary treatment. Is it possible to? Yes. Is it necessarily going to happen? It depends on more like there is a lot more information that is required, so there is only a small number of involuntary treatment beds. It is much, much harder to access than involuntary mental health treatment. So it would not be the first thing I would jump to. There is a lot of steps before trying to encourage somebody to be able to access alcohol withdrawal treatment in pregnancy.
Esther:
I actually work at one of the involuntary drug and alcohol treatment centres. I work at Royal North Shore. I do not take the IDAT patients, but I take care of the voluntary patients. But yes, look, I mean, definitely a pregnant woman would be high on the list. They triage their referrals and yes, a pregnant woman would be high on the list and we have definitely had pregnant IDAT patients before. But almost sometimes the threat of the stick of involuntary treatment is enough to make people engage in voluntary treatment because they do get a lot of their rights taken away when they come in involuntary, so that is as Adrian said, other options.
So let's move on to the next case study. So this is about e-cigarettes. So Adrian, if a 28-year-old woman who is 16 weeks pregnant presents to your surgery as part of antenatal shared care, and she discloses that she has been vaping nicotine for the past six months to stop cigarette smoking, and has stopped smoking tobacco for the past three or four months, she is currently using a 3000 puff vape every five to seven days. What would you recommend to her? And the second question being, is vaping less dangerous than tobacco use in this context?
Adrian:
I think our routine recommendation, because we do not have adequate data on the safety of vaporised nicotine in pregnancy would be to say to her, would you consider trying nicotine replacement patches, gum, lozenges, et cetera, a combination as the next step, given that you are pregnant now? And yes, you might get a yes or no. The issue with her vaporising nicotine, so another question would be, so what sort of nicotine are you are getting and is it prescribed or non-prescribed? So a problem with the majority of vaporised nicotine in Australia is that it is non-prescribed and not authorised through any mechanism. Essentially illegal, but not yet controlled in Australia and so quality control, we have got no idea of the concentration, if there is any adulterants. Probably most of it is nicotine, but may be very potent nicotine. So yes, I think that the step would be to see if she would consider that. If she would not consider that, you could consider, would you prescribe vaporised nicotine with a plan to get it a stock during pregnancy? You could consider that. There is a single randomised control trial published in Nature Medicine, so a very reputable journal, of NRT compared to vaporised nicotine during pregnancy did not find a difference in tobacco cessation, but did find higher birth weight in the group that was randomised to e-cigarettes. Now, do not jump from that to saying that therefore all cigarettes are safer than NRT, because all of those issues about non-prescribed products need to be considered. So yes, that is essentially how I approach it. And I guess related, but probably a more common presentation you would see, it as they are in the pregnancy clinic that you do, would be women who cannot stop smoking tobacco during pregnancy. So that is, of women who can stop, they stopped generally before they come to see you and they stay stopped in the main. But women who cannot stop, what do we do? Combination NRT, counselling, that is the best, but we do not have fantastic outcomes with it.
Esther:
Yes. Yes, that is right. And I mean I know Colin Mendelsohn, who is the, you know, Australian Head of Australian Tobacco Harm Reduction Association talks about kind of using a nicotine patch as harm reduction for people vaping and if they are going to vape, take longer puffs and kind of hold it for longer as part of harm reduction. So you know, those would be some kind of basic counselling things. When people wear a nicotine patch, they are less, even when they are kind of smoking tobacco cigarettes, they are less likely to suck as hard on each cigarette, because really what they are trying to suck out of the cigarette is the nicotine. And it is more when they are sucking so hard on they are cigarettes or vapes, they are kind of sucking the other dangerous chemicals in. And so we actually see their carbon monoxide, you know, scores go up even though they have halved their cigarettes from 20 to 10, because they are sucking each cigarette down to the nub. So just putting on a nicotine patch to kind of curb the background cravings might be also good to yes, reduce their harm. All right.
Adrian:
Thank you. I am sorry I am asking this one. So it is a 25-year-old woman stable on 80 milligrams of methadone. So for those of you unfamiliar, methadone is are long term opiate treatment for opiate dependence. This woman has had previous opiate dependence. She is pregnant. G1P0. Must be, we have got it the wrong way around. Six weeks. She is excited about being pregnant. Her partner is also on an opiate treatment program and worried about being on methadone whilst pregnant. Worried about potential harms to her baby. What would you say to her?
Esther:
Yes, so this is, a lady, again another lady that I did see in general practice, and she did very well in her pregnancy. So, I mean it is very common that women on opioid replacement therapy are very nervous about being on it when they are pregnant. And the reality is, it is less harmful for them to be on it than risk relapsing to using, you know, other opioids whether they be prescription or heroin where kind of, you know, they are they are really kind of up and down with that opioid use. They are at risk of overdose, they are at risk of withdrawal, whereas both methadone and buprenorphine are long acting and kind of, you know, reduce those risks of withdrawal and overdose. And typically women do need to go up on their dose of their opioid replacement therapy during pregnancy as the circulation and the hemodynamics of their body change. And so I would say that if they are feeling opioid withdrawal, then they need to go up on their dose in order to stabilise. Their foetus will also feel kind of those effects of opioid withdrawal. And you know, luckily we have neonatal intensive care units that can manage the neonatal abstinence syndrome that sometimes results from the babies that are born to mums who are on opioids when they are pregnant and they can manage these babies really, really well. Interestingly, this lady, her baby did not develop neonatal abstinence syndrome at all. And I think she went up to about 100 milligrams of methadone by the end of her pregnancy. And then we, yes, kind of reduced that back down again after she delivered. She did really well. She was very stable on her methadone during the pregnancy. That stopped her from using any heroin. And yes, the outcomes were really good for mum and bub. So I would counsel her to stay on the methadone and that she may need to go up in the dose, depending on how her symptoms went.
Adrian:
Great. And often that anxiety about, you know, withdrawal is much worse than what withdrawal might be. The reason women generally are really reluctant about it is because it marks them as somebody who has had opiates in pregnancy and the stigma associated with that is a disincentive. But yes absolutely very strong evidence base for methadone and buprenorphine in pregnancy. If somebody was not already in treatment but was opiate dependent, I think these days I would probably suggest they try buprenorphine first before methadone, because I think there is probably adequate evidence now to say that the risk of withdrawal requiring treatment and the severity of the withdrawal is a little bit less with buprenorphine than with methadone, but of somebody is already on methadone, I agree, I would not ask them to swap, I would just say stay on methadone. Great, can we go to the next slide, please.
Esther:
So, Adrian this is a 36-year-old female, G4P2T1, in her second trimester of pregnancy. She has a three-year-old son at home with her and she separated from her son's dad. She is smoking 3 grams of cannabis a day via bong, and how would you start to manage this patient?
Adrian:
Sure. Great question, and probably more in the sort of substance use and pregnancy clinic, this is a common presentation. Quite common. Specifically for people who are not super familiar with cannabis, 3 grams is a lot. You have got to smoke a lot of water pipes or bongs of cannabis to get through 3 grams a day. That is going to be probably something like 30 bongs. So you can imagine, that is like every half hour or more in the waking day of having a pipe of cannabis. So yes, it is a significant amount. Although not here in the brief history, but almost for certain, she is smoking the equivalent of four or five cigarettes mixed with the cannabis, because that is how Australian cannabis users smoke cannabis, mixed with tobacco. So you have got to think about trying to manage the tobacco dependence as well, and you know, tobacco, we clearly know is associated with low birth weight, prematurity and a bunch of other complications and trying to address that is really important. So I would definitely be talking about tobacco as well as just the cannabis. What would I do? So like two approaches. One, first thing, ask her if she has sort of has a sense of concern about that, is it a goal to cut down? Does she want to cut down? Does she think she can cut down? And some women can and are really keen to and will try to do that, and I will get them to do that. Some women really cannot, and we might bring them in to have an inpatient stay in the antenatal ward where they can have monitoring. It might be not just be about drug withdrawal, but about the environment, if they are an environment that is unsupportive, if their partner smokes cannabis, then having some separation from them, trying to address other social issues. Often in a patient with this sort of presentation, there is lots of mental health problems. Axis 1, Axis 2, often not well treated so making sure there is adequate mental health treatment, assessment, may need medication, may need further investigations, et cetera. And so they are all the things I try to do, and ask her what her sense of the risk of cannabis is. Now, once you take away that tobacco risk, there is some evidence of long term learning difficulties but in my mind, far from being really conclusive, and really hard to be absolutely clear, I do not think we can say that prenatal cannabis exposure definitely causes learning difficulties. Growing up in an unsupportive, unstable housing environment with, you know, a poorly supported parent, that has links to learning difficulties for sure. So a conversation about, you know, what her social situation is, is really important, and trying to, with a multidisciplinary team, try to manage that. So this is probably the sort of patient if she showed up in primary care you would be wanting to refer to your local drugs in pregnancy services and if you do not know how to access that, we should make sure we talk about that before the end of the webinar.
So in a nutshell, that is what I would try to do and then there is a second part of the question.
Esther:
Yes. So how would it be different if the patient was being prescribed medicinal cannabis?
Adrian:
So I guess the first thing I want to do is talk to her cannabis prescriber and talk to them about what is their plan, what are they prescribing for? Did they know the patient was pregnant, and what do they want to do? Because yes, there is there is a range of practice in medical cannabis prescribing. I think it would be pretty hard to justify saying, yes, 3 grams of cannabis is fantastic for this patient. Unless they were really unwell before and whatever symptom they have been prescribed cannabis for was much, much better and the patient is a lot better, then that becomes pretty complicated. So yes, that is where I start and look for more. Certainly really confusing for the patient if you have got Doctor A saying do this and Doctor B saying no, do not do that, that is not good.
Jovi:
This is for you, Adrian.
Adrian:
Yes. So the next thing we are going to talk about is Advise. So, in terms of three As, what should you be doing? Advising of the potential health risks on the mother of child. So this is across all of the substances we are talking about, alcohol risks, opioid risk, tobacco risk et cetera, cannabis risks, both short and long term, noting the specific known risks regarding alcohol exposure. And no, I am not sorry to harp on, I should harp on a little bit about that. So when you see another substance use, always think about tobacco use, because people who use any other sort of substances, tobacco, alcohol regularly, opioids regularly, cannabis regularly, tend to use tobacco too. And we know the risks of tobacco in pregnancy. So that is really important to try to address. The ideal is to be substance free. Not always achievable. Encourage as you do with your motivation interviewing the benefits of quitting or reducing. Try to get the patient to, and make sure you understand what the patient’s understanding is and the patient's goals are, because if we tell patients to do things and they do not want to do them, they usually do not. And discuss ways to quit or reduce. Next slide please.
Esther:
So what can GPs do? We can do a lot. We get these kind of repeated multiple kind of episodes with our patients. So for those not looking to become pregnant, ask about contraception, if they are interested in contraception. And as I said before, yes, I kind of talk about the efficacy of the different contraptions. But yes, finding contraception that fits into their life, and you know, you may kill two birds with one stone if they have got some acne and, you know, or they have got irregular periods, they might want to go on something like the pill. And some of those anti-androgenic pills. But otherwise, yes, things like Implanon the Mirena IUD and again you know, kill two birds with one stone for women who have painful heavy periods, and now they have got Kyleena for younger women, which is a smaller version of my Mirena for women who have not had babies and vaginal deliveries before whose cervix has not dilated. The Kyleena is just for contraception. It is not for menorrhagia or dysmenorrhea. And Depo Provera which is obviously the injections. And yes, so you know, women kind of figure out which one they obviously want to go on or have heard about from other friends and things. Next slide thanks.
So for those who are trying to conceive or pregnant and using substances. Yes, well, I mean pregnancy is a great, I know Di Russell from our substance use in pregnancy parenting services, talks about kind of, often the window of motivation for change is pretty small in addiction. But pregnancy makes that window much bigger. And so you know, what women might not do for themselves when there is a baby in the picture, they are much more willing to change, you know, and kids are a great motivator for people to want to, yes, live life differently. So, recognising their strengths and yes, a lot of them have survived a lot, and then kind of positively affirming and you know, recognising that they have got a lot of strengths to them. Assessing any barriers, you know, any problems that might get in the way, like Adrian talked about kind of if they are in an unsupportive kind of environment at home, it might be worth bringing them in for a detox if they need to detox and assisting them with problem solving to help overcome some of these reasons why they are using. So one of the common reasons why people use drugs, often it is to relieve negative affect and mood. And so you know, are there healthier ways that we can help them do that? Have they optimised, you know, other parts of their treatment? So for tobacco and e-cigarette kind of cessation, definitely referring to some kind of behavioural counselling greatly increases that person's chance of quitting or reducing, and so referrals to Quitline online or nicotine replacement therapies for people, using tobacco and e-cigarettes can be quite helpful. Next slide please.
And so how to reduce harm for women who are trying to conceive or pregnant. So as Adrian talked about, there is this dose response curve with all the drugs, so including alcohol. So the risk of harm increases with higher levels of use and more frequent use. So any kind of reduction might be beneficial to both the woman and their baby. And so helping them, you know, use less and less risky use of substances, we do a lot of, you know, harm reduction stuff around people who are injecting, if they are going to inject make sure they are not injecting alone. If they are using opioids, let us give them naloxone, let's do blood-borne virus screening and testing if they are injecting drugs. And with alcohol, it might be things like making sure they have something to eat, you know, spacing out their drinks, having non-alcoholic drinks in between, you know, do not have salty foods because you are probably much more likely to drink more when you are out. So, next slide.
Adrian:
Yes, so when to refer to a specialist. I guess essentially whenever you think that it is a difficult problem is the answer. So the alcohol, if you find someone is having trouble with cutting down, if they have got medium or high risk use, but you essentially anybody who is not able to cut down, and same with other drugs, anybody who is having difficulty trying to cut back, I think that is an appropriate reason. The next slide.
How to do so. So, there is a Get Healthy in Pregnancy module available through the State as part of the screening program that Esther was just talking about, so you can refer to that. There is Get Healthy and Get Healthy in Pregnancy website.
Alcohol, so any of the other substances, all of the teaching hospitals have a substance use in pregnancy service. I know that is not where every pregnancy is delivered, but all of the specialist services across the states, all the major teaching hospitals, will have a substance use in pregnancy service. Sometimes they get called other names, chemical use in pregnancy or sups or cups or wups or yes, a few other acronyms, but these days they tend to be kept being all called substance use in pregnancy. So if you ask for that when you call up a hospital, usually you can find that. Also through DASAS, the Drug and Alcohol Specialist line 24/7, 365, for health professionals. So you can call up and speak to a consultant about that who will have some familiarity with use in pregnancy. So that is another sort of 24/7. I think we should post the number, I should read it off to you right now, and of course I cannot remember it off the top of my head, but the number is 1800 023 687. That is 1800 023 687 and we can post it at the end of the night. So yes, that is how I seek help. So essentially anybody who is not responding and we have not got a slide on other drugs too, but it is the same.
And what do these services do? So they are there to support women throughout their pregnancy, but also post birth. So to up to two years post birth. And they typically have a case manager and multidisciplinary team to try to help support women. So it might be a community nurse, social worker, et cetera. And they usually have links to medical staff. So Esther works in one in North Sydney. I work in one up here at the Hunter. And it is a way to help navigate the healthcare system because we know unfortunately a lot of this group drops out of care and does not get the sort of treatment that they need. But also importantly the paediatric follow up that sometimes is really important falls off. So that is the aim of these services. So they are not everywhere in the state but generally at teaching hospitals and you know, also good for helping re-link women into treatment because part of nature of dependence is relapses, it goes hand in hand with having a dependence. So sometimes treatment and retreatment and retreatment is there. Thank you.
Esther:
So long term support for children. So obviously early identification of developmental issues and intervention for kids who we know have a prenatal exposure, can help to improve their long term outcomes. So we always talk about early intervention. So what kind of types of follow-up might they need? So maybe ongoing support from a multidisciplinary team, the child and family health kind of nursing programs and home visiting program. And so that would usually be until age, the kid is aged one. And you know, some of them provide up to age two and they do things like the ages and stages questionnaire, the ASQ or the PEDs, the Parent’s Evaluation of Developmental Status, questionnaires to assess the kid’s development, health and wellbeing. And the teams, the early childhood nurses, are really great at recognising kind of when they need to refer to a paediatrician, but also as GPs, if we are doing the blue book checks, the childhood checks, when the kids are coming in for their vaccinations, then we should refer to a paediatrician without delay if we see that this child has delays in one or more areas of development. Paediatric review every six to 12 months to identify, prevent and treat potential kind of health issues, mental health, neurodevelopmental and behavioural issues, usually until, you know, age seven. And this can be kind of undertaken by early childhood nurses in collaboration with paediatricians and usually be reviewed by a developmental paediatrician as needed. And where we know that there is this case of prenatal alcohol exposure then a developmental paediatrician might liaise with one of the FASD specialists as needed. Next slide, please.
Then other kind of follow ups for kids. So ophthalmology review, eye reviews until age one or sooner if we kind of see any abnormalities. Neurodevelopmental screening for example, like general movements assessment screening usually until age one as well. And if the mum has had a blood-borne infection, a review by a paediatric infectious disease specialist might be needed until age one. So I had a woman who had hepatitis C, which was untreated and she discovered she was pregnant and so we linked her up with the paediatric ID specialist. And if indicated things like referral to allied health like speech pathology and physiotherapy until around age seven. Thank you.
So these are the references and resources available for GPs to access.
Jovi:
We will be sending out a copy of the slides. You will have all these resources to your email tomorrow. Just any more questions like to come through?
Adrian:
I did answer one just in the chat box that somebody asked. Can you refer through Health Pathways? And yes, but I do not know to every hospital, but I know it is certainly in Hunter and I am pretty sure on Central Coast and I imagine that is the case in Sydney, too.
Jovi:
If there are any more questions, you can send it to that email just on the website now on the screen. So that is all that we have time for this evening. So I would like to thank our presenters Esther and Adrian and for everyone that has joined us online, we hope you enjoyed the presentation. Thank you everyone and have a good evening.
Adrian:
And thanks everyone for your interest in the area. It is great to have so many people interested, we really need it.
Esther:
Definitely. Thanks everybody.
Adrian:
Thanks.