Showing posts with label pregnancy. Show all posts
Showing posts with label pregnancy. Show all posts

Thursday, July 25, 2019

Should Mentally Ill Women Have Babies?

There was a time when mentally ill women were sterilized.  People forget history.  If you forget history you’re doomed to repeat it.
Identification with the Agressor is the coping strategy whereby a person claims to say or be something another wants out of fear. A mentally ill woman saying she doesn’t want children may well be identifying with the aggressor, the aggressor being society today.  It’s called ‘internalization’.  
I’m not invested in women having children or not having children.  It’s the reason that counts.  Mentally ill women commonly have major self esteem issues.  Many have been commonly abused.  The consequence of emotional, physical and sexual abuse is a sense of inadequacy.  This can well translate to I’m not ‘good enough’ to have a child or « I could never be a mother ».
RĂ©cent studies have shown that women’s magazines are one of the principle harms to women’s self esteem.  
Having a child I remind women is an athletic event. If you can run, jump, play basketball, soccer, or do a long hike you’re fit. Ironically the larger the ‘hips’ the more likely a woman is to have an ‘easy’ delivery. We have moved a long way from the Twiggy anorexic to the Kardasian butt proud celebrity images. 
Yet there’s still many myths perpetrated on women by the women’s magazine industry.  The myths and ‘politically correct narratives’ push their various sales pitches, backers and propaganda agendas.  Ask your doctor and he/she will tell you if there’s any ‘physical’ reason to not have children?  
When I delivered babies, like every midwife and obstetrician, I liked seeing ‘hips’.  Traditionally ‘female shape’ equates with easy delivery.   That’s it.  Obviously if a woman has heart disease or  a rare  metabolic disorder there is reason for proper prenatal care.  Few conditions are  a contraindication to pregnancy and mental illness in general is not one of them. 
Mood Disorders, Personality Disorders, Thought disorders, and in fact, almost any mental illness is not a reason to avoid having children.  Mental illnesses in general are genetically receptive and the risk of transmission is so minor as to not be an issue.  Really! Really!  
The ‘genetics’ of mental illness is in its infancy and while certain traits ‘run in familie’s’ like alcoholism, the chance of transmission of the traits is incredibly small.  Even schizophrenia which has a strong genetic contribution must have environmental factors to lead to the expression of the schizophrenic genes.. A person can have the risk of schizophrenia because of certain genes but only if, for example, they smoke marijuana in adolescence will the schizophrenia be expressed.  If one identical twin has alcoholism the other twin has a 50% chance of developing alocholism but only if he or she drinks.  
Mental illness is ‘multi factorial’ and commonly ‘recessive’ as opposed to ‘dominant’ which means least likely to be transmitted generation to generation.  Mental illness is therefore not part of the  standard ‘genetic talk’ given to future parents.  If you have huntingdon’s chorea and want boys you might want to talk to a geneticist.  The risk of transmission of a ‘dominant’ trait is significantly higher 
However alot of women who have mental illness have been told they are bad, different, crazy,  all their lives.  She come to  believes this.  She then is likely to translate this to mean that she would not have a good child. A child of hers will be bad like her. The bad ‘seed’ myth.  Further, she believes she will not make a good mother.  Yet motherhood is on of the principle reasons for women ‘changing their life’ around. So many professional women I know used to drink and party other girls but when they became mothers they put on their big girl panties and did a hell of a good job. So women can change and it does not follow that a woman diagnosed with mental illness young will produce a bad child or be a bad mother. 
Dr. Whitaker the famous child psychiatrist also said , If you want to know about how a woman feels about having children ask her how she feels her mother felt about having her.  Self fulfilling prophecies in families can be undone in counselling and routinely are. 
It’s useful to counteract mis information and disinformation with preventative medicine ‘facts’.
My favourite fact regarding child birth that I love to share, to the chagrin and groans of my female friends, is that having children is beneficial biologically for women increasing their health and longevity and reducing disease. This part is true and sadly not shared as wildly as the abortion industry data with its political baggage.  However, here’s what gets the groans, The Amish studies showed that improved health and longevity for women   held true up to 12 children. Therefore, I tell women ‘don’t have the 13th child’ . The data showed no value with having more than 12 children.
Further having children under the age of 30 causes women to have reduced risk of  future cancer and early death.  
Similarly since women have their ‘eggs’ for  life, giving birth young, age 20 to 30 is better than age 50.  As giving birth is an athletic event it’s not surprising that 20 year olds have easier less complicated deliveries than 30 year old and definitely 40 year olds.  However having a baby as a ‘teen ager’ is directly associated with poverty and social problems which translate to future health problems. 
 Probably in western culture and society the ideal time for having a baby is 25 to 30 years of age. It is significant  because men have no such ‘biological clock’.  Given the power of female pheromes and fertility coupled with sociobiology,  reproduction as male defence against fear and denial of death,  casual sex is attractive with this age group of women regardless the age of men.  That doesn’t mean the man consciously wishes to ‘father’ the child or children. It does mean that men and women are vastly different, in a society which wishes often to deny this.  Women  benefit from being ‘informed’.  
When I was doing a  specialty in community medicine and public health I learned that the doctor is a powerful source of health information which people tend to follow.  I believe in ‘informed consent’.  I believe women who have mental illness need to hear that there is no ‘general’ reason for them not to have children.  Of course they can simply not want children but this should be for that reason rather than ‘because I’m mentally ill’. 
There are valid reasons for not wanting to have children. A truly valid reason I heard from a brain injured patient for not having children was « I can not manage my own health needs I don’t believe I would be able to give the time and focus to a child. ».  The question then follows , would you want a child if that was not an impediment?
Underlying any discussion with a mentally ill person may be the idea of ‘worthiness’.   The elite commonly have children.  Justin Trudeau and Sophie have children and nannies.  Donald Trump has children.  Obama has children.  In a world where the elite have control they might simply want to reserve resources for their children and deny mentally ill women children not for their benefit but simply to reduce the competition for resources on their own children, whether they’re mentally ill or not. Power corrupts. Absolutes power corrupts. The mother of the prime minister of Canada was mentally ill and no one discouraged her from having children. Yet if she was poor and nobody would that be the case.   In general the discussion for having a child should be the same for the mentally ill and the not yet diagnosed mentally ill. This is a factor because mental illness often appears later in life. Further the sophistication of diagnosis in western countries is hundred fold beyond the diagnosis of mental illness in other parts of the world.  So many Canadian and American women would simply not have a mental illness diagnosis if they were born elsewhere. By contrast this is not true for heart disease or diabetes.
My friend wanted a PHD rather than have a child. Another friend wanted a house. Children cost money and sometimes only the elite are able to make marriages work in these anti family times.  « I don’t like children. ». Now that’s a good reason not have children. Fortunately in Canada we have a social system with a great deal of support for all women having children so that the mentally ill will as likely have social and economic support having children. Certainly in countries where there isn’t a social network mental illness is a greater stigma.
I enjoyed a mentally ill woman who said she wanted to adopt a child using much the same logic as a person uses who chooses a ‘rescue dog or cat’.  Suffering anxiety about a lot of physical symptoms she had fear of pregnancy but saw that her somewhat delineated fear would make that a challenge but she understood she would make a good parents.  She cared for her dog and her neices and everyone trusted her to baby sit. 
I sometimes hear young people in general say they don’t want children because there are too many people on the planet.  The reason that upsets me is that that was the halcyon cry of the Morgenthaller abortion industry in my youth.  Morgethaller, Jewish,   had three children but aborted so many catholic babies.   That was when the elite were having 3 babies and the ‘peasants’ were told not to reproduce.  Yet thirty years later the government is inviting all and sundry to immigrate to here, saying that there are ‘too few people’ in the west.  
Meanwhile,  the greatest means overall of  reduce third world child birth ,where the women don’t have the education or financial resources,  to ensure optimal parenting, is to address infant mortality.  Maternal education is central to reducing the size of the family which economically is associated with reducing overall the growth of population. .  Women historically have lots of children because children are an old age pension plan.  Boys are especially at risk of dying early but are also the ones who contribute most to the family income.  If children are likely to live women are more willing to have less children. 
Further maternal education regardless of religion, culture, country or race results in reduction of childbirth to the magic ‘three children’. This is the number even the ‘elite’ choose.  Replacement plus a spare. 
The trouble is the most barbaric repressive regimes deny women education . For God knows what reason feminists don’t address this issue.  Women’s liberation did. Women’s Libertation which I marched and fought for  considered female education as the means to female emancipation.  
I believe the stigma against the mentally ill is so great that women with mental illness are at risk of not having children because they feel unworthy or have low self esteem. They are at risk of being marginalized, demonized and denied what clearly the elite persist in having.  The old certainly still see the value of family though Marx and Engles were against family when they planned the communist revolution.    
Most mentally ill women have great pregnancies, easy deliveries and make great mothers.  
UBC Psychiatry Department has a specific division of enlightened brilliant compassionate female psychiatrists who specialize in Prenatal, Perinatal, and Post Natal consultations for Mentally Ill women. If any one has serious questions or concerns they can get the best answer there. Not on Google. Not from Hollywood. Not from Housewives on the Moon.    
I want women with mental illness to have the same ‘true choice’ that other women have in this regard.  I believe in education and informed consent. 

Saturday, June 2, 2018

Pregnant Doctor Delivers

Now that I’m older I have the true luxury of remembering. Those who died young didn’t know this.  As a physician I’ve been blessed to be present at so many pivotal, and one might well say ,sacred times.  I’ve heard countless stories and felt the lives of those who have come to me to share.

This morning, for no reason, these memories seem to rise up like that, I don’t even know of a trigger. Yet this one came to mind and I smiled as I so often do remembering work, the colleagues I knew and the patients who brought us together.

This occurred in a busy teaching hospital.  An obstetrics ward in the wee hours of the morning.  We were all gowned and masked.  We had these little paper booties that covered our shoes.  I remember them most.  The white walls and bloody red sheets. The laundry piling in the corner as all were needed for the work at hand. Later there’d be time but at that moment it wasn’t something we could think about.

“There must have been a power outage over the whole city 9 months ago,” the nurse joked.  

I was at the foot of the bed watching as the cervix dilated and the woman pushed. She’d been screaming for an hour before between contractions when the pain should be least. In addition the anesthetist had just given her a spinal block and begun to administer epidural analgesia.  She should be feeling less pain and be screaming less. If anything her screams had grown louder. 

 I’d asked the nurse about that, as an aside, concerned that something might be amiss.  She nodded to the door where a thoroughly terrified young man was there at the window peering in. He’d come to the little square glass then walk away with an older man comforting him.  I’d seen the older one put his arm around the younger man’s shoulder.

Then the father to be would pull back his shoulders, stand tall and return to peer in the little window.  There were tears in his eyes as he waited helplessly, overwrought I presumed with his inability to do anything but wait.   I’d been glancing out at him now and then while waiting, patiently, for the delivery to progress. 

While the anesthesist was speaking to the patient, the nurse was reviewing the continuous monitoring data strips.  In a low voice , beyond the hearing of the patient, who was either  listening to the anesthetist or screaming her lungs out, the nurse shared. 

‘That’s her husband and father,’ the nurse told me. “They’re old school Portuguese.  Our patient is okay but the more she screams the more the men will care for her and the baby after.  They’ll be helping her now for the whole of the coming year,’ she said smiling.  “It’s a good thing. It’s cultural. She’s going to be okay and she and her baby are going to get a lot of well deserved breakfasts in bed.’ She laughed.

I reflected on the aboriginal patients I’d delivered who’d been a different challenge. Their stoicism and silence had been the means to recognition in the family and  community.  As a doctor I had so much to learn about how people express themselves in sickness and in health.  I had to listen for the different cues that something which might be normal had changed to something that might be more concerning. The older nurses especially in Obstetrics were a wealth of experience and insight. Early days I felt like a hamster on a wheel forever playing catch up. 

I was brought back to the present, not by a fresh crescendo of screams but by the door bursting open and another gurney rolling in as it was pushed quickly  in place  by two sweating hurrying orderlies.   

“We’ve run out of anesthetists.” One said smiling as our anesthetist began to busy himself with the new arrival.  “All the delivery rooms are full and we’re  doubling up.”

I was suddenly very anxious. I was very new to this, only a few deliveries under my belt. My lady was almost fully dilated and here was this new lady well on her way by the rate of the her contractions.  

I think the older anesthetist could see I was concerned if not outright terrrifed.  He said, “Her doctor will be on the way. She was just delivering another lady before I came here.  If all else fails I’ll gladly help at your end.  I’ve been there many times before,” he laughed with the infectious confidence of maturity and experience.  My patient screamed. The other patient screamed.  The nurses eyes twinkled.  It was already a long night.

At that moment a very very large young female doctor burst into the delivery room and went to the side of the newest patient taking her hand, speaking kindly and calmly to her as she looked over the monitor.  

“You didn’t think I’d miss this for anything,” she quipped to her tired but smiling patient. “We’ve been planning this for 9 months.  Now we’re going to see that it was all worth it!:

The doctor was 10 months pregnant herself if she was a day.  Bigger than a house and nearly the size of a whale. She’d moved fast into the room but could hardly bend to speak to the patient.

Going to the foot of her patients bed she peered down and said to the nurse.  “Already crowning”.  To the patient, she said,   “ We’re doing very well.’ Not much longer now especially given how well your last delivery went. “

“Hi Charley’ she said to the Anesthetist. 

“Hi Annie,” he replied, in the tone of old friends.

“Good morning, Doctor, “ she acknowledged me kindly. 

Looking over my shoulder she saw that my patient was just beginning to crown too.. 

“Primip” she quearied,  smiling at my patient.

“Yes,” I replied

“This is Sarah’s second, could be a close match! ‘ she said looking at her patient and returning to where she could view her.  Turning to me she said, “I’m not going to say it’s a race but if this were Vegas they’re be laying close bets as to which child would come out first.‘ 

“Not much longer now , just a few more pushs Ladies.” She said to both.

It was clear that my patient was more relaxed now that this marvellous woman doctor had arrived, even if she was the size of a house and some at Vegas might be including her in the betting . 

The poor patient  was no longer dependent on me a young doctor obviously wet behind the ears. Her screams had changed  now to more like grunts as she pushed responding to the nurse who’d taken a position right beside her head , letting the patient  hold tight to her hand. 

“Here we go”  Dr. Annie said to her patient just as my patent  became fully dilated and the crown  began to appear.   There was no need for an episiotomy. Everything was going smoothly.  I reached forward as the baby came , cradled the  head, then the shoulders and the bum and finally the legs came too.. The nurse was there beside me taking up the baby in clean linen and, wiping off the amniotic fluid, then giving the beautiful little boy baby to the mother.  The placenta delivered. All the bits were there. The new mother was smiling beautifically, pleased with her little boy. I clamped and  cut  the umbilical cord.  

Normally the father would be invited into the room but with the two deliveries happening and the nurse being more aware than me she’d wheeled this bed out into the hall where the father and mother and family and in laws were all waiting to celebrate the new addition to their family. The nurse returned immediately to be there for the second delivery.  I stood by waiting to be of assistance, not knowing what else to do. 

Just as my lady was being wheeled out, with her baby clutched to her chest, the other baby was delivering.  I’d only glanced over to see the mountain of a pregnant woman doctor between the woman’s legs in stirrups.   She’d been leaning awkwardly forward , stretching out and over the mound in front of her  assisting the delivery.  Her arms had the vague resemblance to the Tyrannasaurus Rex but somehow she managed.   Lifting the baby into the air she exclaimed,  “It’s a girl!”  as she handed the baby to his mother.  

I was about to leave then when the lady doctor said, “I’d appreciate if you ‘d not go  just yet. “

“Sarah” , she said, “Congratulations, but if they don’t get me another bed I might have to ask  to share yours.  My waters broke in all the excitement of your delivery! “ She laughed. It was obvious thought she was  just a bit strained. 

The nurse with the strength of a Sumo wrestler and the speed of a jaguar  muscles  another bed into the room with my helping with the guidance.

 Sarah’s husband had joined her and the two were google gaga over the new baby as the two sweaty orderlies were moving the bed out of the room. I don’t even think they noticed us so caught up in love they were.

Dr. Annie was now  standing partially bent over grabbing hold of her thighs and Lamaze breathing as another contraction passed.  The anesthetist,Charley,  was right by her side. 

“I’m going to have to ask you to help me up on the bed,” she said, “ I don’t think I can stand much longer.”  Together with Charley I helped her onto the stool the nurse had brought forward.  Together we hefted her up onto the bed where she collapsed with a huge sigh.  Lying on her back she looked like an Anaconda who’d swallowed and elephant. I couldn’t believe how far along she’d been and delivered two babies that night before she was about to deliver her own. 

‘Could you tell me how far along I am?” she asked between panting.   Charley was establishing an IV.  The nurse  was spreading the jelly for the  ultrasound monitor.  The baby’s heart rate was suddenly visible and looking just  just fine on the screen.

I examined her then. She was fully dilated and just beginning to crown.    I said so.

“I thought as much, “ she said, between breaths and pants. “I called my own doctor before Sarah. If he doesn’t get here,  I’d appreciate you’d stay and assist. I’m rather occupied myself. “ She smiled and I could see Charley’s eyes twinkling as well.  I really was rather awkward and uncertain in those early years. I stayed of course. Never thought I’d do otherwise. 

“Of course,” I said. 

Her beautiful face was flushed and sweating profusely as another contraction took hold.  The nurse had given her her hand and she was squeezing tightly.

At that very moment,  another rather  tall doctor,  burst through the doors. He stopped abruptly beside the patient and said. 

 “I’m glad I’m not late, Annie. I hope you didn’t wait just for me. ” Another contraction came.

“Good to see you, Charley,” he said coming down to the end of the bed beside me. 

“All’s well?” He said, Charley, myself and the nurse nodding. 

I never was more happy to stand aside and let an older doctor take my place.

“I see a head Annie.  Shan’t be long.  Just another push or two if you don’t mind.”  Dr. Annie gave a powerful push and the baby’s face began to slowly appear, the obstetrician carefully guiding.

And sure enough, another baby girl was delivered that morning.  A lovely little girl.  Five fingers and five toes.  

Dr. Annie’s smile was as beautific as the other women’s.  Her husband came in as I began to make myself scarce.  Even as I was leaving, Dr. Annie, turned her beautiful eyes on me, and said,  “Thank you. ” Then her attention was all for her baby and her man.  I looked back over my shoulder at this wonderful family tableau knowing I had been blessed to be there this night. .  

I made my notes at the nursing stations surrounded by the doctors who’d been called in for this most productive night. 

 I will never forget that beautiful lady doctor 9 months pregnant delivering another woman’s baby before giving birth to her own.  That’s a memory I feel  blessed to have. Looking back I’m just thankful to have been there and thankful to have been of some service to all those amazing colleagues and patients and especially Dr. Annie.  Sacred times. 










Thursday, September 26, 2013

Pregnancy and Post Partum Addiction

Dr. Shimi Kang
-Faculty UBC Addiction Psychiatry

I'd heard from Dr. Shaila Misri, world renowned psychiatric authority on Pregnancy and Psychiatric Disorder, that Dr. Shimi Kang was a remarkable addiction psychiatrist who'd been doing incredibly fine work at the BC Women's Hospital.  I was thoroughly delighted to hear her presentation. It was extraordinary. She's an amazing speaker and communicator with tremendous academic and scientific knowledge coupled with obvious clinical experience and skill.  One of the finest presentations I've ever heard, reminiscent, really, of those great presentations I heard by Dr. Misri , beginning decades ago, when she was making the most telling breakthroughs in helping pregnant women. Now here was Dr. Shimi Kang going forward with addressing this 'taboo' subject of addiction and pregnancy with the same deep concern and marvellous clinical acumen. 

I apologize that my rough notes don't do justice to this superb presentation but hopefully they will help someone and should they need more I would most strongly recommend they contact Dr. Shimi Kang or the UBC Department of Addiction Psychiatry. 

Pregnancy and Post Partum Addiction 

Women who use substances have 70% chance of concurrent psychiatric diagnosis
  • often trauma and chronic pain are complicating factors

Concern now with pregnancy that women who have alcohol abuse problems are switching to marijuana in pregnancy because they say it helps with nausea and eating.

Presented a case of a woman who drank heavily in pregnancy and gave birth to a child with Fetal Alcohol Syndrome - she was an internist and the issue of alcohol was never raised in her pregnancy.  Dr. Kang - “I want to bust the Stigma - I work with all kinds of women with addiction issues.

Used of mood altering substances has been an accepted feature of human society for thousands of years

Alcohol Use and Binge Drinking among pregnant women
7.6% of pregnant women reported drinking in the last 30 days - 10 % of these women are college graduates. they report starting drinking in college
1.4% of pregnant women reported binge drinking in the last 30 days

Showed slide of twins - mother drank 10 beer a day in pregnancy - one child appears normal, other appears obviously with fascies of Fetal Alcohol Syndrome.  - same womb, same mother, same amount of alcohol but one thoroughly affected and the other not

Younger population is at higher risk

If a woman is smoking in pregnancy - red flag - likely woman is using another substance

My concern stated, Dr. Kang, is not just addiction in pregnancy but ‘concurrent disorders’.  
Biopsychosocial risk factors for mental illness and addiction run in parallel

Concurrent disorders in Pregnancy - 35% to 60% of patients 

Mood disorder, Mania, Depression, Panic, Agaraphobia, Generalized anxiety,

Opioid prescriptions are going up and up in women - young people
Used to be stimulants
Women present in pain with oxycontin - often with having all kinds of prescriptions from having all kinds of procedures
Prescription use and chronic 

Concurrent Disorders - more relapse - outcomes far worse

Women are different from Men
  • Global context -gender based violence, low income, unremitting responsibility for care of others, socioeconomic disadvantage, 
  • over and over again I see women who can have services but cant take them because they are caring for a mother or children or someone

Women are more likely to use pharmaceutical drugs
May become dependent on some illicity substance faster
greater rates of concurrent mental health problems
More likely to have suffered sexual and/or physical abuse
May engage in more HIV risk behavior
Higher mortality and advances to AIDS from HIV
Poly-substance use is often present

Freeze, Flight or Fight - depression/addiction/acting out - I explain your brain grew up with adrenaline - when you grew up with trauma - cortisol is linked
I give this explanation so they know there is a biology as well as a psychology
It is normal to be anxious to being chased by axe murderer but not to go to buy milk

Women are more stigmatized and less likely to be acknowledged
More severe problems at start of treatment
More likely to be introduced to and carry on using with partner
Less resources (education,employment,income)
Care for dependent children

Women versus men
  • more concurrent diagnosis
  • more rates of violence
  • more difficulty accessing treatment

75% of women in treatment for addiction report childhood sexual abuse
Severity of SUD related to trauma

Menstrual cycle, fertility and substance use
  • substance disrupt menstrual cycle
  • asking about pms and relapse and craving - looking for patterns 
-Fertility -substances can effect fertility, cocaine and opioids cause secondary amenorrhea and risk of unplanned pregnancy
-can have no period but still be ovulating

Risk factors for substance use in pregnancy and postpartum
-past history Substance Use Disorder

Pregnancy red flags
  • missed or inadequate prenatal care
  • recurrent somatic complaints
  • psychiatric condition
  • trauam
  • nicotine and /or alcohol
  • failure to gain adequate weight
  • intra-uterine growth delay/retardation
  • withdrawal signs (eg. delivery)

Window of Opportunity
-for many women first time in health care system
in prenatal period women more liekly to engage with care and abstain or reduce their substance use, without treatment will relapse

****90% of those who remain abstinent for 2 years will be substance free for at 10 years******NIDA 1995- Vaillant et al 1988

-requires integrated approach to treatment of mental health and substance use disorder


Perinatal consequences of Substance Use
In general - LBW (less than 2500 g), prematurity, small head circumference, poor nutritional status, infections, withdrawal issues
Substance specific
-Alcohol - fetal alcohol syndrome/effects
-Marijuana - behavioural problems - impaired decision making, memory and attentiveness, tremors and altered visual responsiveness
-Stimulants

Breast Feeing
Contradindicated
-active substance use - eg heroin, cocaine
-breast pump 

Child protection
-professional responsibility
  • encourage self - referral
  • physical harm, sexual abuse or exploitation, emotional harm, deprivation, parental refusal of needed treatment, death and abandonment, 

Female vs Mixed Gender Services
  • treament engagement and adherences
  • children are 5x less likely to be put in care if woman goes to gender specific service

Tools
Motivational Therapy
Importance Confidence Ruler
  • smoking woman
  • on scale 1-10 if you could wish on a star what would be number
  • in general we get, 7-8 10
  • in general women don’t want to be using in pregnancy

Next question
On same scale , how confident are you you can quit smoking today
-tends to be 2 or 3

I then say I don’t need to tell you the risk, you’re there - importance , and we can shift to building confidence 
‘Ask how do we build your confidence?”

if they say 3
Then ask why did you say 3 instead of 1
Then they will give you reasons to quit
  • i quit before, ministry on my back
  • we are evoking their reasons to quit

Questions
-Methadone Prescriber
dilemna prescribing SSRI’s and Antipsychotics
-half of doctors are saying don’t prescribe i npregnancy
Answer
-I say to women you don’t want to take anything in pregnancy - say this is tough - I don’t like prescribing to women - our principal is not prescribing and if we do we use lowest dose - then we said all associations, pediatricians, obstetricians, family physicians - got to gether and said - maternal health must be guiding principal - so we prescribe medication for asthma and diabetes despite those medications having risks in pregnancy
  • I give them the risks and ‘motherrisk.com
  • I tell them risks of treatment and the risks of not being treated
  • I say what can happen to you - when you last quit smoking you relapsed to cocaine because of anxiety

If all else is equal we go with SERTRALINE for anxiety and depression
For schizoprhenia SEROQUEL


Wednesday, August 8, 2012

Cannibis Addicted Fetus

"It's so sad to hear their wee high pitches cries," when they're born addicted to marijuana, he told me.  They're shaking and go into withdrawal.  He was a pediatrician at a conference I was attending.  We knew smoking was harmful to the fetus. Nicotine is a teratogen but now it was evident that marijuana was causing fetal distress.
Child abuse by drug addiction is a concern with 12 to 24% of mothers using drugs and alcohol in pregnancy.  With marijuana though the 'withdrawal phase' post delivery is particularly unnerving. The babies shake just like opiate withdrawing infants, an obstetrician described.
I am on a plane right now and hope when I've time to investigate this more.  The difficulty I recently had with searching information regarding the increasing dangers to physical and mental health associated with marijuana use was that a very poor small number unsupported outdated research on marijuana was dominating the servers. Clearly there are reputable studies documenting the dangers and risks which are well known to us in the medical community who observe the problems and show more caution than the mercantile business and political interests.  The spam in favour of marijuana simply swamps the google servers so that I am forced to use medical and university sites to find research that is not of the most spurious kind.  Given the influx of pharmaceutical marijuania too there is less interest in the industry which has hopped on board big money marijuana.
http://emedicine.medscape.com/article/978492-overview
 

Sunday, August 5, 2012

Pregnancy and Addiction - Dr. Stacy Seikel

Dr. Stacy Seikel ( http://stacyseikelmd.com/biography/) presented at the IDAA 2012 Medical Conference in Orlando Florida on the topic of Addiction and Pregnancy.  Her slides were remarkable and her presentation one of the most informative and engaging presentations I've been priviledged to hear.  Given the importance of her message regarding the future generation and the unborn child, universal screening is the very least that can be considered.  The hundreds present were equally impressed given the level of applause. Dr. Seikel's work is not only cutting edge technologically but she had done amazing networking to ensure that women and families can access the treatments that are needed for the betterment of individuals and society.  It was clear that she was motivated by a deep spiritual and ethical moral system of concern for pregnant women suffering from addiction.  She demonstrated the compassion and empathy for these women who are so commonly ashamed and carry such stigma with their addiction when they simply can't say 'no' without the help of doctors and society when pregnant they want to change.  Dr. Seikel is clearly there for her patients.
The following are the rough notes I took during the presentation with just a few highlights taken from many slides in which she simply wanted to point to one aspect of the problem or the solution. I was unable to get all the information but know that her slides and notes are available through the www.idaa.org.  International Doctors in Alcoholics Anonymous was very fortunate indeed to have someone of Dr. Seikel's training, experience and high level of functioning in the system where it counts, most to come to the conference to present in the Continuing Medical Education in Addiction Medicine portion of the conference. I would strongly recommend her as one of the finest lecturers I've heard on a terribly important topic in our present day.
Pregnancy and Addiction
  • Dr. Stacy Seikel 
IDAA - Orlando - 2012

Prevalence

12 to 24% women use drug and alcohol during pregnancy
1 of every 3-4 women expose fetus to alcohol

Risk Factors
Family history of addiction
Experienced violence in childhood

Clues in medical history
No prenatal care
-fear of discovery of addiction
-secondary to general chaos in her life

Tattoos or self scarring
-seconary to IVDU or skin popping

Burns on hands and clothing

Positive hepatitis

Nicotine abuse

Screening
All pregnant women should be screened for drug and alcohol use
-T-Ace
-TWEAK
A positive test indicates need for a further evaluation

Elements of the history and physical may indicate need for drug screen

Immunoassay Drug Screens (not test)
  • POC UDS = immunoassay
  • semi quantitative immunoassay - not confirmation test
  • lab screen UDS = immunoassay
  • GCMS= Confirmation test
  • LCMSMS = Confirmation test
  • It’s important to know that a second immunoassay isn’t a ‘confirmation test’, must order a ‘confirmation test’ to know.

E-Forcse
Florida’s Prescription Drug Monitoring Program 

PMP - shows every controlled substance prescribed and where from - helps get around the denial, 

Patient advisory reports - used by the methadone maintenance program

We know that relapse is harmful to the fetus hence methadone is better.
Taper isn’t as good but will work with those who want a as a plan b.

Treatment Barriers
Fear, shame and guilt about use
-will she lose children if in treatment
-does she have family support
-attitudes of medical providers
Lack of comprehensive clinical care for all the problems of pregnancy and addiction
  • can she get treatment?  Transportation problems?
  • Care is fragment
  • lack of childcare in treatment
  • basic needs must be met for her to engage in treatment
Co morbid diagnois impacting ability to access services
  • multiple problems associated with co morbidity, ex psychiatric symptons

Alcohol
-known teratogen
-no safe level of drinking in pregnancy


New Alcohol Biomarker in cord blood
=3-4 week retrospective of alcohol use

Medical Complications of Drug Abuse in Pregnancy
Same as in regualar patients

Obstetrical complications of opiate abuse
-Polysubstance abuse is the norm
-increase in spontaneous abortion, esp first trimester
-amnionitis
-intrauterine growth retardation
-placental insufficiency
-postpartum hemorrhage
-preeclampsia, eclampsia
-premature labor/membrane ruptures
-septic thrombo

Opioid Dependence (DSM IV) Aka Addiction
Opioid Addiction
-chronic progressive, relapsing
-neurobiolgic changes
 -pharmacologica treatments are effective in normalizing neurobiology

There is a big difference between short acting and long acting opiates.
  • animal studies show long acting opiates can cause healing of the mu receptors which can go back to normal state
  • brain makes new endorphins - so when I ‘m tapering off buprenorphines I encourage my patients to ‘go make endorphins’ - walk the dog, eat chocolate, take a bubble bath etc.

90 meetings in 90 days, is said in AA but it’s no coincidence because the first 90 days has so much healing that is going on.  

Medication assisted treament is one option for people to engage in a treatment program to develop psychosocial skills to be able to tolerate a taper when they have some relapse prevention skills

Drug addiction is a brain disease
  • prefrontal cortex mri studies show ‘disruption of brain circuits involved in reward and punishment’
  • prefrontal cortex is the executive function


Morphine has a jack hammer on and off mu effect
  • altered gene expression - you no longer are the person you were before you used drugs
  • limbic system in overdrive
  • prefrontal cortex not working
  • “You have to use to survive”
-this is why a pregnant woman will use and she is so ashamed, because there’s nothing worse in her eyes and in the eyes of others than a woman who uses drugs
Because relapse is high in this population we have found maintaining women on methadone 

Various Discipline see the Maternal Fetal Dyad differently
-obstetricians
-therapists
-addiction specialists
-psychaitrists
-pediatricians
-corrections officers

“Those in recovery who have themselves experienced loss of control will hopefully have some compassion for these women who get very little compassion from anyone else”
In Florida Orange County have developed an interdisciplinary program involving methadone treatment, hospital, high risk obstetric unit, outpatients and jail

Methadone and Pregnancy
-Methadone is only agonist therapy recognised for use in pregnancy,  Supported by 30 years of research

Federal Laws Governing Addiction Treatment

-requires special federal license
-rules and rules and rules

Opiod agonist maintenance in pregnancy
  • maintenance with methadone during pregnancy produces the same benefits as treatment in non pregnant 
  • The studies  (Jones H, 2008) are really poor by evidence based medicine for taper because of the high risk of relapse.  But if patient individually demands this despite the evidence against it, taper in second trimester - make sure though that there is no significant abstinence syndrome (Luty,J, Nilodeau V, Bearn J 2004) 

Pregnancy patients receive all the same results methadone treatment programs for non pregnant

Clinical Study last year showed buprenorphine may have less abstinence but can have complications for c section 

 Methadone Induction
-start low - go slow
5 days until steady state obtained
  • peaks 2-3 hour after dosing
  • Consider dosing in office and observing patient for 3 hours

Opiate intolerant (or someone you’re not sure) Day 1 10-15 mg max
Opiate tolerant day 1 25 to 40 mg max
Increase every 5 days

The right dose throughout pregnancy is the dose that stops withdrawal

Buprenorphine
not fda approved, methadone gold standard in pregnancy but can be used and is widely used in Europe
NEJM Dec 2011 study

Suboxone can be changed directly to Subutex

Induction is very tricky because you are supposed to give suboxone when people are in withdrawn but this is contraindicated so while it can be done it’s 

I don’t go from methadone to buprenorphine because of the withdrawal problems

Ongoing illicit or polysubstance use
Perioperative pain management for patients on buprenorphine
anesthetists need to know last dose, 
-continue dose tid or qid (don’t stop because we must avoid withdrawal for fetus in pregnancy
-use non narcotic pain medications
-Fentanyl with it’s high affinity may over ride antagonist effect

With methadone in pregnancy dose once a day and realize post op may need 10 to 20% more narcotic because of pain

Discharge Pain Meds should be a fixed amount - tend to give ‘excess’ medications especially the post op patients who give too much - teen agers are dying from pills in medicine cabinet

Breast Feeding on Methadone
  • it’s okay to breast feed - came from American Academy of Pediatrics