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I have chosen to discuss the physiological and psychological aspects of maternal addiction to heroin, the effects on the foetus and the possible problems related to the attachment of the relationship between mother and child after birth. I will discuss this issue using the biopsychosocial model, and how the use of it affects a patient experience in the hospital setting (Borrell-Carrio et al, 2004). Drug addiction can be described as ‘a number of symptoms or criteria that reflect a loss of control over drug intake and narrowing of the number of different behavioural responses towards drug seeking’ (Koob at al, 1997).
George Engel established the model, where he questioned the use of the biomedical model, which separated body and mind (Borrell-Carrio et al, 2004). Weston (2005) analyzes the model, where he suggests dividing the model where the doctor focuses on the biological factors and other healthcare workers focus on the social and psychological issues. He also raises the point of when psychosocial care is carried out in a patient’s assessment, the patient themselves may become disheartened that we may focus too much on the social and psychological aspect, when they are concerned about their treatment and establishing their illness (Weston, 2005). In the clinical issue I have chosen psychosocial care is so important, as drug abuse, the well being of a child and social issues are involved.
Heroin addiction is a difficult issue for a nurse to plan the care of a patient who is pregnant. Heroin is a very powerful opiate, where it gives a sense of euphoria and high mood elevation (Addiction Science, 2011). The main system of focus is the mesolimbic reward system, which is a branch of the dopamine system. Dopamine is known to control mood levels, and in a normal brain system there is a slow release of dopamine, due to the work of action potentials which then leads to an ordinary level of mood and motivation (Addiction Science, 2011). Food and sex in a normal brain system activate the reward system leading to a feeling of pleasure and satisfaction. In a heroin induced brain system these every day pleasures no longer give the same effect with the drug taking over the role of the mesolimbic reward system (Hyman et al, 2001). Opiate use leads to molecular changes in the brain making it
difficult to control drug addiction (Hyman et al, 2001). These changes increase over time when tolerance develops. Tolerance is when more drug has to be ingested Heroin is very potent due to its pharmacology, once injected it penetrates the lipids in our body and goes straight to the brain giving immediate effect. Heroin increases the work of the action potentials, leading to elevated dopamine levels and giving the effect of euphoria and high motivation levels (Addiction Science, 2011). There is an increasing number of pregnant heroin addicts in our society today (Bashore et al, 1981). It is said that heroin crosses the placenta and into the bloodstream of the foetus within one hour (Keegan et al, 2010). There is also the risk that because the mother is most likely injecting the drug, that there is a possibility of infective diseases such as HIV, Hepatitis B and C etc. If the mother obliges, she will usually be placed on a methadone programme during the pregnancy, which still causes possible intrauterine growth retardation, and foetal withdrawal after birth know as neonatal abstinence syndrome (Oei et al, 2007). Methadone has a slow onset of action (long half life), it does not have a euphoric effect but it prevents opiate withdrawal and blocks cravings for over a day (Goff et al, 2007). If the mother goes through a withdrawal period, it has be know that there is then an increase in movement from the foetus showing signs the baby is also having symptoms . There is a lot of stress put on the mother’s body during pregnancy as she may already be malnourished (due to money spent on buying the heroin), and then the foetal demands for growth and nourishment increases this (Bashore et al, 1981).
In both heroin and methadone addicts there are a noticeable prevalence of abuse of other agents, including tobacco, alcohol, and barbiturates, all of which have a notable effect on the foetus and newborn infant (Bashore et al, 1981). Social context serves as both as a risk factor and a protective factor for substance use, playing an important role in addictions, initiation, escalation, maintenance and relapse ; and conversely in its prevention, treatment and long standing resolution (Gillford & Humphreys, 2007). For a nurse working in the field of midwifery it is important that they have a knowledge and sensitivity about the various co factors associated with addiction and the sociological context in which they occur in order
that they can develop a therapeutic alliance with the patient and assist in developing a programme for the mother that includes both a health promotion, medical intervention and relapse prevention strategy (Westwood, 2002)(Goff et al, 2007). Westwood (2002) concludes that in contrast to the traditional medical model a more inclusive holistic nursing diagnosis appears to be the more conducive to affective identification and management. Various screening devices for example Severity of Dependence Scale (WHO, 2011) can be incorporated into a more general health and lifestyle questionnaire at initial assessment appointment (Westwood, 2002). The nurse can play a key role in encouraging the patients compliance with appropriate further medical screening (for example urinalysis for drug screening, and then blood tests for STI’s etc. ) and subsequent maintenance on a methadone programme by adopting an empathetic and non judgemental approach and the use of motivational interviewing techniques (Westwood, 2002). The mother should be aware of continuous assessment including toxicology screening and referral to child protection social work team for ongoing support and monitoring following the birth of their baby (Goff, 2007)
Methadone is recommended for pregnant women as part of a comprehensive programme of care that has been shown to decrease the incidence of the known neonatal complications of opiate abuse such as prematurity and a low birth weight (Goff, 2007). Neonatal Abstinence Syndrome is the term used to describe a constellation of signs and symptoms that a newborn experiences when withdrawing from opiates (Goff, 2007). The signs of withdrawal most frequently include hyper irritability, GI dysfunction, tremors, jitteriness, high pitched cries and increased muscle tone. Because methadone has a long half signs of neonatal withdrawal may not occur for several days or more after birth (Oei, 2007). Therefore these babies are frequently admitted the Special Care Unit for observation and symptomatic treatment which may include comfort measures, frequent feeding and possible methadone treatment if the symptoms are very severe (Goff, 2007). This period of time during which the baby is in the Special Care Unit, gives the nurse a unique opportunity to assess the mothers motivation to care for her baby and to observe developing patterns of attachment. This is particularly the
case when the mother is discharged from hospital and has to prioritise her child’s needs over the temptation to resort to an addictive lifestyle (Butler, 2002). Addiction to drugs involves learnt responses to a drug and to the environment to which drug taking takes place (Gillford et al, 2007). The return of the mother to her home environment provides her with a particular challenge. Psychological theories such as social control theory describe the relationship between social context and individual addictive behaviour. It is therefore very important that the nurse caring for the baby of an addicted mother who has been discharged from hospital is aware of her vulnerability to relapse. Priest (2010) concludes that an unsupported clinical environment and negative attitudes on the part of staff can be a barrier to the effective delivery of psychological care. While the physical dependence on the drug may be controlled by the use of methadone the distinguishing feature of the condition of addiction is the ability of the drug to dominate the individual’s behaviour and where the normal constraints on behaviour are largely ineffective (Addiction Science, 2011). A programme of relapse prevention is therefore essential to ensure that the mother has the opportunity to spend quality time with her new baby in order that the bonds of attachment develops from the earliest opportunity. Gilford et al (2006) refers to more positive treatment outcomes when health service staff behaves in a supportive manner, positively by increasing parent involvement. If an addicted mother is visiting her baby several times a day the nurse can therefore can build up a positive rapport with her and this experience of positive regard may encourage trust to develop with professionals who can facilitate her in her own recovery. The nurse also has the unique opportunity to observe parent-infant interactions and asses the quality of the mother’s response to the infants needs which is the cornerstone of attachment building. Bowlby(1980, 1982) has written extensively of the importance of a child’s strong attachment to its mother for a normal, healthy development. Ainsworth (1979) and her colleagues subsequently did a lot of research on assessing the quality of child- parent attachments. A nurse working with mothers and young infants should familiarise themselves with the work of these therapists.
Family support and friendships are factors that may influence the mothers chances of relapse after birth. Accepting motherhood can be a difficult prospect, the lack of sleep, and the pressure of being a mother and what is expected can lead to temptation (Brudenell, 1997). The fact that the mother is no longer pregnant may also lead to temptation as they would no longer be physically be responsible for giving nutrition to the baby, many mothers choose not to breastfeed their children even though it is known that very little traces or methadone or drugs can be detected in the breast milk (Oei et al, 2007). Breastfeeding is another opportunity for a bonding experience between mother and baby, so if not chosen can lead to a further possibility of poor attachment.
Addiction to opiates affects a person at many levels: physiologically, psychologically and socially. Prevention, intervention and treatment programmes all play a part in response to this issue. When providing a programme for an addictive mother and her baby familiarisation with the theoretical background and evidence based practice in the approach to her treatment must be combined with a working knowledge of the affects of illicit drug use on the development of the foetus and the subsequent implications for the both it’s medical and psychological care following delivery. This issue shows the importance of biopsychosocial care in hospital settings today.
Addiction Science Network (2011) www.addictionscience.net. The Biological Basis of Addiction. Accessed 6thApril 2011.
Ainsworth M. (1979) Infant-Mother Attachment. American Psychologist. 34(10). 932-937.
Bashore R., Ketchum J., Staisch K., Barrett C. & Zimmermann E. (1981) Heroin Addiction and Pregnancy. West journal of Medicine. 134(6). 506-514.
Borrell-Carrio F., Suchman L. & Epstein M. (2004) The biopsychosocial Model 25 Years Later: Principles, Practice and Scientific Enquiry. Annals of Family Medicine. 2. 576-582.
Bowlby J. (1982) Attachment and Loss : Retrospect and Prospect. American Journal of Orthopsychiatry. 52(4). 664-678.
Brudenell I. (1997) A Grounded Theory of Protecting Recovery during Transition to Motherhood. American Journal of Drug and Alcohol Abuse. 23(3). 453-466.
Butler S. (2002) Addiction Problems, Addiction Services, and Social Work in the Republic of Ireland. Journal of Social Work Practice in the Addictions. 2(3/4). 31-48.
Gillford E. & Humphreys K. (2006) The Psychological Science of Addiction. Addiction. 102(3). 352-361.
Goff M. & O’Connor M. (2007) Perinatal Care of Women Maintained on Methadone. Journal of Midwifery and Women’s Health. 52(3). 23-26.
Herbert M. (1996) Bonding: Infantile and Parental Attachments. Parent, Adolescent and Child Training Skills. Blackwell Publishers: Oxford.
Hyman S. & Malenka R. (2001) Addiction and the Brain: The Neurobiology of Compulsion and its Persistence.Nature Reviews: Neuroscience. 2. 695-702.
Keegan J., Parva M., Finnegan M., Gerson A. & Belden M. (2010) Addiction in Pregnancy. Journal of Addictive Diseases. 29(20). 175-191.
Koob G. & Moal M. (1997) Drug Abuse: Hedonic Homeostatic Dysregulation. 278(5335). 52-58.
Nestler E. & Aghajanian G. (1997) Molecular and Cellular Basis of Addiction. Science. 278(5335). 58-62.
Oei J. & Lui K. (2007) Management of the Newborn Infant Affected by Maternal Opiates and Other Drugs During Pregnancy. Journal of Paediatrics and Child Health. 43(1-2). 9-18.
Priest H. (2010) Effective Psychological Care for Physically Ill Patients in Hospital. Nursing Standard. 24(44). 48-56.
Weston W. (2005) Patient-Centered Medicine: A Guide to the Biopsychosocial Model. Families, Systems & Health: The Journal of Collaborative Family Healthcare.23(4). 387-405.
Westwood C. (2002) Strategies for Effective Addiction Management. Practice Nursing. 13(8). 340-342 & 344&345.
World Health Organisation (2011) www.who.int Management of Substance Abuse. Accessed 9th April 2011.
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