• Summary
• Introduction
• Pregnant women
• Young people
• Clients with responsibility for young people
• People who have HIV
• Minority ethnic groups
• People who ‘use on top’
• People who ‘don’t get better’
• People with mental health problems
• People dependent on injection practice

Summary

• Antenatal care should include input from a drug worker, and should aim to be as normal as possible.

• Babies of opiate-using mothers can normally be cared for in the normal maternity environment.

• The Children Act makes care of young people at risk a priority over all other considerations.

• Parental drug use is not, in itself, sufficient cause for children to be placed on the register of children at risk.

• Use of illicit opiates in addition to methadone should not normally lead to automatic removal from a methadone prescribing regime.

• Problematic opiate use is often a long-term activity that is seldom quickly and completely resolved.

Introduction
Although the majority of people who are prescribed methadone are white Anglo-Saxon males between 25 and 40 years old, they are not a homogenous group with the same needs nor are they the only group who receive or need methadone treatment. This section looks at the groups of clients with special needs who use, or could benefit from, but avoid, methadone prescribing services.

Pregnant women
Guilt and anxiety are often features of pregnancy in opiate-using women. People often assume that opiates and methadone in themselves will cause congenital abnormalities in the foetus. However there is no evidence to support this assertion. A booklet called Drugs, Pregnancy and Childcare, published in 1992 by ISDD and available direct from them, is useful further reading.

For a full discussion of the effects of methadone on the foetus see Section 4: Physiology and pharmacology of methadone.

The risks to the mother and baby that services can have some influence over are:

• Lack of ante-natal care
• Maternal withdrawal syndrome triggering premature labour
• Multiple drug use which includes drugs which can cause damage to the foetus (such as alcohol)
• Fatal overdose from injected illicit heroin
• Infection through unsafe injection practices
• Poor nutrition
• Smoking tobacco
• Sudden cessation of methadone treatment.

Interagency co-operation
Pregnant opiate-using women should be assessed by a drugs worker, in addition to medical and midwife assessment.

Where necessary interagency co-operation should help ensure that the mother receives the best possible care and treatment.

The following liaison procedure has been suggested as good practice.⁹² However its potential for raising anxieties unnecessarily should be recognised. The aim should be for as normal a pregnancy and birth as possible, and in the absence of concern about the safety of the child or mother, it is often sufficient for the prescriber or drug service to liaise with the GP, community midwife and health visitor, and with the hospital.

Procedure where there is concern
A ‘booking meeting’ should be held after pregnancy is confirmed which involves all the workers concerned and the mother (and partner or significant other). The presence of a nominated obstetrician and a member of the maternity unit staff can help allay any anxieties of the staff, as well as that of the client, that she will not receive sufficient analgesia.

The purpose of this meeting is to:

• Identify pre-birth key worker
• Share information
• Discuss drug treatment options (see below)
• Decide on whether or not a child protection case conference needs to be held.

A second meeting of the same staff should be planned for 2 weeks before the expected date of delivery. The possibility of premature labour must be considered and the date of this meeting brought forward, if necessary. The purpose of this meeting is to:

• Share the key worker’s current assessment
• Discuss long and short-term plans
• Decide whether a child protection case conference needs to be held prior to discharge.

Following the birth there should be a pre-discharge meeting with membership as above and including a paediatrician to:

• Assess bonding and parenting
• Ensure that appropriate care will be provided in the community
• Confirm the identity of the key worker
• Decide whether a review meeting will be needed at 3 months.

The purpose of the review meeting at 3 months is:

• Formal feedback and liaison.

Methadone treatment in pregnancy
The methadone treatment of choice with a pregnant woman is often thought to be detoxification. However this is not always the case. In particular withdrawal symptoms should be avoided in the first 3 months of pregnancy because of the increased risk of miscarriage. Withdrawal symptoms can also induce premature labour during the last 3 months of pregnancy.

Pregnancy is a time when many women are able to make changes such as giving up drugs because of the added motivation of being pregnant. Where this is possible it should be encouraged and supported by the workers involved.

However many women find that during pregnancy they experience an increase in:

• Stress
• Pressure from family, friends, drug users and drug workers
• Feelings of inability to cope and lack of control over life
  – all of which can lead to increased drug use.

Skilled, careful and non-judgmental assessment of the situation is therefore essential prior to a treatment plan being formulated.

If detoxification is chosen it is important that contingency plans are made for the prevention and management of relapse following the birth.

The optimal time to detox is the second 3-month period of the pregnancy. The normal maximum reduction in the daily dose in any week is 10mg. The final, slower part of a detox is often carried out (under close medical supervision) in the final 3 months of pregnancy without risk to the baby.

However only a proportion of women will be able to achieve abstinence because of either relapse or obstetric complications. Short or long-term methadone maintenance will be the treatment chosen by most pregnant women.⁹¹

As what is best for the mother is best for the foetus the dose should be adequate to enable the mother to avoid illicit heroin use.

Babies withdrawing from opiates

Care of the withdrawing infant
Although one study found it to be ineffective, a quiet, darkened room and close wrapping may calm the baby and remove the need for drug treatment. Babies can usually be cared for in the normal maternity environment provided they can be moved to special care units if necessary.

In the UK, if treatment is required, chlorpromazine is usually used with a regime such as the following:

• Chlorpromazine 1–3mg/Kg/24 hours in 4 divided doses for 5–10 days then gradual withdrawal over 14–21 days.

The literature also includes withdrawal regimes using other non-opioid drugs such as phenobarbitone, clonidine and the benzodiazepine diazepam, opiate drugs such as camphorated opium tincture (Paregoric) and methadone.

Breast-feeding
There is no conclusive evidence about how much, or indeed whether, methadone passes from mother to baby in breast-feeding. If there is transfer of methadone the doses will be very low. Therefore the general advantages of breast-feeding, and the fact that if it is passed to the baby it may help to reduce any withdrawals, mean that breast-feeding can be encouraged.

Care of the parents of a withdrawing infant
Most mothers of babies who suffer opiate withdrawals feel very guilty and therefore censure from staff is unlikely to be a helpful intervention.

It is important for staff to deal with their feelings about a mother’s drug use separately from their care of her and the baby – especially if the mother requires extra help in learning to care for her child. Drug service staff can often be of assistance in the process of helping maternity staff understand the drug-related issues and their feelings towards drug-using mothers.

The rationale for prescribing to the baby should be explained to the parents. It may be necessary to tell parents that they must never administer opiates to the child – even if it displays distress similar to withdrawal symptoms.

If admission to a special care baby unit is required it is helpful for the parents to be introduced to the staff as soon as possible.

Young people

The Children Act 1989
The Children Act enshrined in law the principle that in all care the interests of the child are paramount. This means that a worker has a responsibility to inform the appropriate authorities if they believe a young person (whether directly their client or not) may be at serious risk from any of the following:

• Physical harm
• Psychological harm
• Sexual harm
• Neglect.

This will usually be the line manager in the first instance and then social services. It is not possible for workers to argue that the drug user, not the child, is their client and that therefore they should do nothing, or that it is the responsibility of other workers to identify these issues.

Because of this it is good practice for workers to explain to the client at the outset their responsibilities with regard to confidentiality and child protection. It is useful to explain to clients what ‘serious harm’ means as well as informing them of the factors that might cause concern regarding care of a child. However this must be done sensitively and the client must be reassured that ‘at risk’ is not synonymous with ‘in the care of a parent who is prescribed methadone’.

Methadone treatment for young people
Methadone is unlikely to be an appropriate treatment for young people (usually taken to mean under 16s – but possibly including immature 17 year olds) because they are unlikely to have:

• Long-term opiate use
• Significant tolerance
• Heroin using problems that are not amenable to other forms of help and treatment.

Parental consent to treatment will almost always be required. If a skilled assessment has ascertained that the young person is mature enough to be able to give informed consent to treatment, the Scarman ruling in the Victoria Gillick case would appear to make treatment without parental consent a legal option. In such cases the whole decision –making process needs to be very carefully documented.

In-patient assessment and specialist consultant prescribing are strongly indicated if methadone treatment is considered for a young person.

Clients with responsibility for young people
The vast majority of drug users do take adequate care of their children and drug use alone is not necessarily a cause for concern and is certainly not reason enough to initiate care proceedings.

If the client has responsibility for children the Children Act 1989 is clear that as far as the worker is concerned the needs of the child are paramount.

If it appears that there are times when there are no suitable arrangements for the care of children who are at risk of serious physical, psychological or emotional harm or at risk through neglect, a skilled and full assessment should be carried out. The local authority has a responsibility to offer help and support to the parents or carers and child. This must be done sensitively and with the long-term aim of helping the family stay together where this is in the best interests of the child.

It is important that people working with parents or carers understand the Children Act and have immediate access to supervision and specialist social work support if child care becomes an issue.

People who have HIV
Methadone treatment can reduce behaviours which compromise the immune system such as injecting, and can reduce stress and improve diet and other factors which are likely to accelerate the progression of HIV disease.

In prescribing methadone for clients who have HIV it is important to:

• Encourage a multi-agency approach to treatment of symptomatic HIV infection
• Discuss hepatitis B and/or C infection with the client as they are more likely to have these infections as well
• Maintain close liaison with the client’s HIV physician and be aware of the other services involved in providing care
• Observe for reducing tolerance to methadone during periods of illness and weight loss
• Ensure that if the client has memory loss they are not at risk from accidental overdose through forgetting they have taken the medication
• Ensure that the client fully understands transmission routes.

Only prescribe drugs for the treatment of HIV-related illness as a last resort if the client refuses to see a specialist doctor. Prescribing treatment for symptomatic HIV is best done in conjunction with a specialist, as methadone interactions with drugs used in the treatment of HIV such as AZT, are not yet fully researched or understood.

Drug users who have had a positive HIV test will have a variety of responses and needs. A positive test in itself may not change drug-using behaviour. Although for some it will lead to positive changes for others it may trigger a period of chaotic drug use.

The process of adjusting to living with HIV may involve not only coming to terms with feelings of loss and grief but also a discovery of life or rediscovery of a purpose to live, in the knowledge that they cannot become uninfected.

Treatment options are the same for opiate users, regardless of HIV status, and a full assessment needs to be carried out to weigh up the pros and cons of the available treatments.

Some drug users who are living with HIV may avoid dealing with the many feelings they experience by using prescribed and illicit drugs in a dangerous and chaotic way. This can be exacerbated by the knowledge that as there are serious health consequences in being discharged from a methadone prescribing programme, termination of the prescription may be less likely, possibly leading to disruptive behaviour and refusal to comply with the prescribing contract.

Minority ethnic groups
Traditionally drug services have been managed, staffed and run overwhelmingly by and for the white population. There is often a perception among ethnic groups that the services are not for them.

It is incumbent upon services not only to have equal opportunities policies and to employ staff from ethnic backgrounds but also to offer culturally appropriate services to ethnic communities as a whole, and to the drug users within those communities.

People who ‘use on top’
Most opiate users continue to use cannabis in addition to their methadone prescription and where this is not interfering with the primary treatment aims it is tolerated by most drug services.

Clearly in order to be able to deal with additional drug use the worker must first be aware of it. This means either forming a therapeutic relationship with the client in which these issues can be discussed (which will normally mean that the threat of removal of prescribing on discovery of illicit drug use is not a useful part of the agreement) or having effective urine screening procedures which, as discussed in Section 10, is difficult and expensive.

It is important to assess the scale, nature and motivation of illicit drug use before taking action. There is a world of difference between using heroin every other ‘giro day’ and using it on a daily basis, and frequently selling the methadone, and while the latter may require action the former may be enough of an improvement to continue with no change to the programme.

People take heroin in addition to their methadone for a number of reasons which include:

• It ‘feels better’ to take heroin than methadone
• They enjoy feeling out of control
• They are experiencing withdrawal symptoms
• Their partner is using heroin
• They find injecting a ritual that is difficult to live without
• They believe that recreational heroin use is possible and relatively harmless
• As a way of coping with problems
• They have used up the take-home dose of methadone.

If it is identified that illicit drug use is occurring and jeopardising the treatment aims appropriate strategies should be employed to reduce risk behaviour.

Treatment options include increasing:

• Daily methadone dose
• Frequency of methadone collection
• Supervised consumption
• Time spent with the client by counselling staff

and:

• Appropriate offers of ‘rewards’ following achievement of realistic treatment goals
• Drug-free residential rehabilitation
• Suspension of prescribing.

People who ‘don’t get better’
Frustration at the ‘failure’ of opiate users to ‘recover’ and become drug-free quickly following efforts to help them is a feeling experienced by many workers. The answer to this feeling of frustration usually lies in reducing expectations rather than increasing pressure on the client to ‘do better’. Opiate dependence, once established, is a long-term problem characterised by:

• The desire to take opiates as a central part of life
• Tolerance of many adverse consequences of drug use
• Long periods of time spent contemplating change
• Periods of greater and lesser use
• Periods of abstinence followed by relapse.

Towards the end of an ‘opiate-using career’ these periods of abstinence usually become longer and the periods of relapse shorter.

Demoralising the client by constantly admonishing their failures is unlikely to help them move forward or use help constructively. An approach which recognises where the client is, sets appropriate goals, and offers appropriate help will be more successful.

People with mental health problems
Prevalence of some mental health problems has been found to be significantly higher in opiate users than in the general population.⁹¹ For many of these people opiates may be a way of self-medicating the feelings caused by their mental health problems.

Rates of depression in opiate users have been found to be five times higher than in the general population.⁹⁴

Careful history taking at initial assessment will pick up whether there is an increased likelihood of mental health problems and careful monitoring, particularly during detox, will detect the emergence of underlying mental health problems as the dose is reduced.

Most people who are being treated for mental health problems can be treated concurrently with methadone for their drug dependence. Some disorders such as depression and anxiety are likely to be improved by the increased stability and access to professional help afforded by methadone prescribing.

Some people use opiates as medication for paranoid or other psychotic ideas, and as such may become more ill as they stabilize or reduce their opiate intake.

Inappropriate referrals
Mental health services and other referring agencies may refer all clients with mental health problems and any history of drug use to the local drug service and expect them to deal with both. Liaison between drug and mental health services is vital in ensuring appropriate sharing of care for drug users with mental health problems.

People dependent on injection practice
Intravenous heroin users often change the frequency and level of risk of their injecting practice over time, and these changes may be encouraged or facilitated by drug services.⁹⁵

For those clients who find injecting a powerful ritual, stopping altogether can be as hard to achieve as abstinence from drug use itself. Services must recognise that clients who achieve abstinence from compulsive injecting will feel frustration and support should be offered accordingly.

Reducing the harm associated with injecting may be helped by:

• Working with the client to improve injection technique and reducing the frequency with which they inject
• Higher doses of oral methadone
• Prescribing injectable drugs
• Discussing the rituals involved
• Promoting insight into the motivations and triggers for injecting.