SUBSTANCE ABUSE IN CANADA 2013 Licit and Illicit Drug Use during Pregnancy: Maternal, Neonatal and Early Childhood Consequences By Loretta Finnegan With A Call to Action by Franco Vaccarino and Colleen Dell This document was published by the Canadian Centre on Substance Abuse (CCSA). CCSA activities and products are made possible through a financial contribution from Health Canada. The views of CCSA do not necessarily represent the views of the Government of Canada. The subjects in the photographs used throughout this publication are models who have no relation to the content. The vignettes are fictional and do not depict any actual person. Suggested citation: Finnegan, L. (2013). Substance abuse in Canada: Licit and illicit drug use during pregnancy: Maternal, neonatal and early childhood consequences. Ottawa, ON: Canadian Centre on Substance Abuse. © Canadian Centre on Substance Abuse 2013. CCSA, 75 Albert St., Suite 500 Ottawa, ON K1P 5E7 Tel.: 613-235-4048 Email: [email protected] This document can also be downloaded as a PDF at www.ccsa.ca. Ce document est également disponible en français sous le titre : Toxicomanie au Canada 2013 : Consommation de drogues licites et illicites pendant la grossesse : Répercussions sur la santé maternelle, néonatale et infantile ISBN 978-1-77178-041-4 Licit and Illicit Drug Use during Pregnancy: Maternal, Neonatal and Early Childhood Consequences Prepared for the Canadian Centre on Substance Abuse Loretta P. Finnegan, M.D., LLD, (Hon.), ScD (Hon.); President, Finnegan Consulting, LLC; Professor of Pediatrics, Psychiatry and Human Behavior, Thomas Jefferson University (Retired); Founder and Former Director of Family Center, Comprehensive Services for Pregnant Drug Dependent Women, Philadelphia, PA; Former Medical Advisor to the Director, Office of Research on Women’s Health, National Institutes of Health, U.S. Department of Health and Human Services (Retired) Table of Contents Foreword by Rita Notarandrea 2 Acknowledgements 3 Foreword by Anthony G. Phillips and Dan Goldowitz 4 Introduction 5 1.0 Epidemiology of Maternal Drug Use 8 2.0 Medical and Obstetrical Consequences of Drug Use in Women 14 3.0 Psychosocial Issues and Victimization in Pregnant Women Using Drugs 26 4.0 Outcomes of Newborns of Pregnant Women Using Drugs 34 5.0 Comprehensive Treatment Approaches for Pregnant Women Using Drugs 62 6.0 Early Childhood Outcomes 90 7.0 A Call to Action by Franco Vaccarino and Colleen Dell 106 Appendices 112 SUBSTANCE ABUSE IN CANADA - Licit and Illicit Drug Use during Pregnancy Foreword Every two years, the Canadian Centre on Substance Abuse was to ensure an up-to-date understanding of this area, as it (CCSA) produces a new report in the Substance Abuse in is vital that professionals providing health care and support to Canada series, with each edition shedding much-needed pregnant women are well-informed about the latest evidence. light on an important drug- and alcohol-related issue. The This perspective is considered as part of the educational, current report is devoted to drug use during pregnancy— motivational and tailored tool kit that treatment providers can more specifically, the maternal, neonatal and early childhood employ to connect with women during their pregnancy — a consequences of using substances ranging from tobacco period when women are more likely to seek care and support and alcohol, to marijuana, cocaine and heroin. Through this from the health community. installment, we hope to bring the challenges faced by pregnant women “out of the shadows” so we can better meet their needs Pregnancy is also a period when women might be more and those of their children. motivated to address the potential harms associated with their drug use. Because of this potential, it was considered important While this latest report covers a variety of topics, an important that the report inform and educate treatment providers about aim for CCSA was to ensure that it summarizes the latest what is happening biologically to the fetus. We also took care knowledge in the biomedical literature pertaining to drug use to provide information about the measures that can be taken on and abuse during pregnancy. Through the work of CCSA’s the part of a pregnant woman and her community to reduce the Scientific Advisory Council (SAC) and the leadership of harms to both the mother and her fetus. Dr. Franco Vaccarino, Professor of Psychiatry and Psychology at the University of Toronto, CCSA had the good fortune to A further catalyst for the approach taken in the present report connect with Dr. Loretta Finnegan, a world-renowned expert derives from learnings in the mental health field. The treatment in the fields of women’s health, pediatrics and perinatal provider can relay information to the mother on the biological addiction. Dr. Finnegan authored the report and took the lead context of substance use in pregnancy. This information in researching it. We are deeply grateful for her contributions can help prevent the mother feeling any sense of blame and and fortunate to have been able to draw on her decades of judgment, which feeling could lead to her inaction. experience on this complex issue. The biomedical focus of the report did not permit a Women who use drugs, alcohol and tobacco already face comprehensive, in-depth analysis of the many complex many health and social challenges. These challenges are psychosocial factors associated with drug use during further compounded during pregnancy, when substance use pregnancy. The report does, however, include an important can profoundly affect the earliest stages of human development chapter relating to psychosocial issues, as well as a section and have adverse outcomes that carry into early childhood and highlighting the value of a setting that provides a more holistic beyond. Clearly, we know that drug use has impacts on many and comprehensive approach to care. This information on the lives. During pregnancy it affects the lives of the mother and setting for care underscores the importance of psychosocial child. Drug use also affects — and is affected by — their family, themes such as those related to victimization that were included the larger community in which they live and even society as in the report. It also stresses the central role played by the family a whole through interactions with our healthcare and social and community in any treatment response or prevention effort. systems. This report explores the full spectrum of impacts. The Call to Action found at the end of the report encourages ongoing efforts to integrate biomedical and psychosocial One of the important — but arguably less broadly recognized — approaches to care for women’s drug use, particularly during impacts pertains to the biomedical consequences of drug use pregnancy. and abuse during pregnancy. An important driver for this report 21 Canadian Centre on Substance Abuse SUBSTANCE ABUSE IN CANADA - Licit and Illicit Drug Use during Pregnancy Acknowledgements To meet our goals of producing a report with a broad-based Beyond the invaluable work performed by Dr. Finnegan and international perspective, the report was not designed to Dr. Vaccarino, an initiative of this scope would not be possible be country-specific or to focus only on the state of affairs in without the contributions of many knowledgeable researchers Canada, although it does highlight some Canadian data. For and clinical experts. I would like to take this opportunity to this reason, Dr. Finnegan, the report’s author, was a strong thank the members of CCSA’s SAC for their review of this fit in her capacity as a world expert and she has provided a report and their contributions to it; as well as Dr. Colleen Anne comprehensive, globally relevant report on the impacts of drug Dell, Research Chair in Substance Abuse at the University use during pregnancy on the fetus and on the infant. of Saskatchewan, who co-authored the recommendations outlined in the Call to Action chapter together with Dr. Vaccarino. There are a number of actions we need to take to address the I must also acknowledge the external reviewers who helped challenges. This report is an important reminder of the need finalize the report, including Dr. Peter Selby, Clinical Director of to continue to build our knowledge base as it pertains to the the Addictions Program at the Centre for Addiction and Mental Canadian context. Some of this work will involve closing gaps Health, and Dr. Gideon Koren, Director of the Motherisk Program in the knowledge pertaining to Canada-specific issues and at Toronto’s Hospital for Sick Children. Finally, it goes without some of it will involve adapting the knowledge derived from the saying that CCSA is indebted to Dr. Amy Porath-Waller, Senior international context to a Canadian context. But by concentrating Research and Policy Analyst, for her exceptional leadership and our efforts on the areas identified in the Call to Action — among management of this report together with Dr. Vaccarino, from them, ensuring clinicians and their clients have access to the inception to completion, and to everyone involved in the design latest evidence and adopting a more holistic and multidisciplinary and production of this report. approach to treatment and prevention — we will be able to bring real change to frontline practices and to community responses, Their contributions were invaluable. and we will help countless lives in the process. Rita Notarandrea Deputy Chief Executive Officer Canadian Centre on Substance Abuse Canadian Centre on Substance Abuse 13 SUBSTANCE ABUSE IN CANADA - Licit and Illicit Drug Use during Pregnancy Foreword Non-medical abuse of drugs can occur at any stage of life. Clearly, simple approaches to this most complex form of human When such exposure occurs during pregnancy and in the post- disorder are destined to failure. natal phase, it raises understandable concern about the impact on the health of the mother and child, as well as possible long- The Canadian Institutes of Health Research and NeuroDevNet, term consequences for brain development in the new infant.