Two Case Studies Illustrating a Shared Decision-Making Approach to Illicit Methamphetamine Use and Breastfeeding

Abstract

Crystal methamphetamine (MA) is a potent psycho-stimulant that is increasingly used worldwide. It is highly addictive, is often made in clandestine laboratories, and can cause serious health issues in adults. Health professionals caring for women in the perinatal period must counsel women about the health risks to infants if they are exposed to MA in breast milk. Most guidelines recommend that women who have current or recent MA use do not breastfeed. This article explores approaches to breastfeeding advice in the context of MA use. Women who have made lifestyle changes, engaged well with services in the antenatal period, and are committed to drug counseling services after discharge from hospital may be supported to breastfeed if they are assessed as safe to do so. The importance of assessing each woman individually when developing infant feeding plans throughout the perinatal period is advocated.

Background

Street drugs and polysubstance use pose significant challenges for health professionals promoting breastfeeding.¹ Methamphetamine (MA) use varies geographically but in the Oceania region there is a growing number of users of crystalline methamphetamine, as well as increased frequency of use, increased purity, and a decline in purity-adjusted prices.² The recent surge in illicit crystal methamphetamine prevalence is largely due to drugs that are produced in home or backyard laboratories using toxic agents and frequently cut with adulterants.³ In 2013, in Australia, 5.3% of women aged 14 years and older had ever used amphetamine; in the month before the survey, it was used by 1.5% of the female population, the majority being of childbearing age.⁴

This article aims at exploring the issues that are involved with MA use in breastfeeding women by presenting two case studies and describing practical approaches for health professionals. The women in the case studies are polydrug users, as are most MA users⁵; however, MA was the predominant substance of use. A literature review was carried out by using the words “breastfeeding,” “methamphetamine,” “crystal,” “ice,” “pregnancy,” and “infant.” The following databases were searched: PubMed, EMBASE, CINAHL, and Google Scholar. The last search was completed in September 2016.

Physiology and Pharmacology of Methamphetamine

Crystal methamphetamine, commonly known as “ice” in Australia, is the most potent and addictive amphetamine.⁶ It is a powerful stimulant increasing catecholamine and dopamine release and inhibiting neurotransmitter degradation.³ MA produces euphoria for a maximum of 24 hours and has a 10 hour half-life.⁷ Clinical effects of MA are rapid, depending on the administration route. MA can be smoked, snorted, injected, or ingested.⁸ It is present in urine or blood for 46–60 hours depending on the dose and administration route.⁹

Effect of MA on the Body

In adults, MA use may be associated with behavioral changes, particularly aggression and hostility, psychiatric disorders including psychosis, bipolar disorder, anxiety, and major depression,¹⁰ as well as increased energy, reduced need for sleep, and reduced appetite.¹¹ It is also associated with cardiovascular disease¹² and is a recognized withdrawal syndrome.¹³ Methamphetamine is believed to be toxic to the brain, leading to nerve cell death and, although human evidence is limited, changes in the brain can be seen in postmortem studies.¹⁴

Effect of MA on the Fetus/Infant

MA-exposed infants have been found to have a lower birth weight and a smaller head circumference than nonexposed infants¹⁵ and infants exposed to other drugs.¹⁶ Infants exposed to MA during pregnancy are more likely to suck poorly, be sleepy or irritable, and require newborn unit admission.¹⁵ Although infants may show some withdrawal signs after birth, commonly lethargy, only 4% require medication.¹⁶ Infants exposed to MA in breast milk may show irritability, poor sleeping patterns, agitation, and crying.¹⁷

Current Treatment for Methamphetamine Use

There is no effective pharmacological substitution therapy for MA dependence, and psychosocial support is the mainstay of intervention.¹⁸ Pregnant women using MA may be reticent or unaware of how to access help despite services being available.¹⁹ Alternatively, women may experience too many barriers impeding health service attendance, resulting in continued substance abuse²⁰ and sub-optimal antenatal care.

Breastfeeding and Substance Use

A woman's desire to be a “good mother” frequently includes a strong intention to breastfeed.²¹ There are very few contraindications to breastfeeding; however, the situation for women using illicit substances requires careful consideration.¹

Methamphetamine passes freely into breast milk. One study examined breast milk from two recreational intravenous MA users, who injected “a point” in a single dose.²² Dose purity was unknown, although a urine sample after injection confirmed that the predominant compound was MA.²² Milk samples were collected 2–6 hourly over 24 hours. Peak and average MA milk concentrations were 160 and 111 μg/L in case 1 and 610 and 281 μg/L in case 2. The authors concluded that MA concentrations may be a maximum of 2.5 times higher in breast milk than maternal serum levels and breastfeeding should be withheld for 48 hours after an MA dose.²²

Little data exist about breastfeeding and illicit drugs, and guidelines are largely based on expert opinion.^1,23 Pregnancy and motherhood can be considered powerful motivators to cease or reduce substance use.²⁴ For women who are not dependent on substances, pregnancy provides sufficient reason for abstinence. For substance-dependent women, this is more difficult. Both powerful neurobiological circuits and past psychosocial trauma drive ongoing substance use. We present two case studies (using pseudonyms) illustrating some of these practical complexities.

Case Studies

Case study 1

Sophie is a 33 year-old woman referred to Women's Alcohol and Drugs Service (WADS, see Box) by her general practitioner at 22 weeks gestation of her recently discovered, unplanned first pregnancy. Sophie stated that she smoked 1 g of cannabis daily, smoked 0.1–0.3 g of methamphetamine daily, two cigarettes daily, and ingested 20 mg of diazepam daily prescribed for 5 years for anxiety. Before her pregnancy, Sophie reported four standard drinks of wine three to four times a week.

Box 1.

Model of Care at the Women's Alcohol and Drug Service, Royal Women's Hospital, Melbourne

The Women's Alcohol and Drug Service (WADS) provides specialist clinical services and professional support in the care of pregnant women with complex substance use and alcohol dependence. It utilizes a multidisciplinary team approach to advance the health and well-being of women and their infants.

The WADS model of care is woman centered and focuses on continuity of care throughout the antenatal and postnatal period. Women are allocated a social worker and midwife who work closely with the family throughout the pregnancy and postnatal period. The WADS team aims at building a strong therapeutic relationship with women to ensure that both mother and infant have the best health and social outcomes.

Women are seen as required, with fortnightly pregnancy reviews until 30 weeks and then weekly until birth. Women have access to specialist support, including drug and alcohol counselors, an addiction specialist, a psychiatrist, a pediatrician, a midwife and an obstetrician, a dietician, and housing and legal support. Individual childbirth education is provided by the midwife, including a tour of the maternity wards and the Newborn Intensive Care Unit.

WADS routinely undertakes an assessment of each woman, to ensure an accurate understanding of her drug and/or alcohol use, obstetric history, her experiences of physical, psychological harm and socioeconomic history to determine specific treatment plans. Assessment is a fluid process undertaken throughout the course of treatment and care.

The Royal Women's Hospital recognizes that breastfeeding is the best method of infant feeding and actively encourages breastfeeding. The hospital has been accredited seven times as a Baby Friendly Health Initiative (BFHI) hospital and has a dedicated guideline for breastfeeding and substance use. The positive aspects of breastfeeding are discussed with the women early in pregnancy and continue into the postnatal period and community setting after discharge. Discussion centers on how breastfeeding is beneficial for mother and infant and addresses the issues of transfer of substances in breast milk, and the known/suspected risks that this may or may not pose to the infant and parenting. Where medications are prescribed, a senior pharmacist will be involved with the woman and the extended WADS team in assessing the safety of breastfeeding. Lactation consultant support is available in the postnatal wards and in the outpatient setting.

During high school, Sophie experienced bullying and mental health problems, including diagnoses of anxiety, depression, and obsessive compulsive disorder. Sophie's parents divorced when she was a teenager but both supported her.

Sophie worked briefly as a hairdresser but was unable to work for 3 years due to her poor mental health. Tom, Sophie's partner of 1 year, had a history of 5 years MA use, smoking 0.1 g three times a week. He denied other drug use but reported problematic gambling. Tom and Sophie lived together, and both were estranged from families and friends due to drug use. There were frequent violent attacks toward Sophie. Tom's family was legally granted an intervention (restraining) order against him. At 30 weeks into the pregnancy, Tom was incarcerated and Sophie moved in with her mother. Prebirth child protection notification was made due to ongoing drug use and family violence. The situation was mostly resolved by the postnatal period, and Child Protection closed the case.

Sophie attended all but three antenatal appointments, appearing alert and engaging well with staff. She expressed considerable regret at using drugs and alcohol during pregnancy. After Tom's incarceration, Sophie could focus on her health and baby's health and was less inclined to use MA. Sophie reconnected with her family and friends and commenced a routine of walking and yoga.

By the end of the pregnancy, Sophie had considerably reduced her substance use, ceasing cigarettes, smoking 2–3 “joints” of cannabis at night and MA 0.1 g every 6–8 weeks. Diazepam was reduced to 5 mg three times a week, as needed. Escitalopram 10 mg daily was prescribed but not taken. Hypertension developed in late pregnancy, and Sophie commenced labetalol 200 mg BD.

After spontaneous term labor, Sophie birthed a male infant weighing 3,110 g with Apgar scores of 8 and 9, at 1 and 5 minutes, respectively. Baby Harry sucked at the breast within the first hour of life. He was reviewed by the pediatrician daily. Harry was transferred to the Neonatal Intensive and Special Care (NISC) unit on day 3 with unstable temperature (38°) and hypoglycemia and commenced intravenous dextrose 10% and a 5 day intravenous antibiotic course. Sophie continued to breastfeed in NISC, and feeds were complemented with expressed milk and infant formula. Harry returned to the postnatal ward where Sophie fully breastfed him. He gained weight and was discharged with Sophie on day 7.

A safety feeding plan was developed. If Sophie used MA at home, she would express and store milk in advance. If this was not possible, Sophie would provide infant formula. She learned about correct formula preparation. To maintain her milk supply, Sophie was advised to express and discard milk at least eight times every 24 hours until 48 hours after MA use. A responsible adult would care for Harry while Sophie was drug affected.

A community organization provided ongoing parenting, drug and alcohol counseling, and outreach support. Sophie was linked with Enhanced Maternal and Child Health Nursing for breastfeeding and parenting support. Baby Harry was reviewed on day 12 in the pediatric clinic; he was fully breastfeeding, gaining weight, and settling well. When seen at 5 months, Harry remained fully breastfed, thriving, and planning to start solids with normal development. Sophie was now living alone, but her mother continued to visit her three to four times a week. Sophie continued contact with the WADS psychiatrist until 8 weeks postpartum. She had no psychiatric symptoms on discharge but was referred to a local psychologist for ongoing counseling and support.

Case study 2

Chi is a 40 year-old G5 P2 Vietnamese woman who initially presented to the hospital between Christmas and New Year in established labor at 39 weeks gestation. She reported smoking MA during her pregnancy. Her urine drug screen was positive for methamphetamine, amphetamines, and cannabis. She birthed a daughter weighing 3,836 g with Apgar scores of 6 and 9, at 1 and 5 minutes, respectively, who was admitted to NISC due to respiratory distress. The baby was returned to her mother's care in the postnatal ward on day 3.

After further discussion, Chi reported smoking at least 0.1 g MA every second day, occasional cannabis, and about 10 cigarettes daily throughout her pregnancy. Chi stated that she had not received any antenatal care as she “was lazy” and did not have access to a car. She felt the baby “would be fine.” Chi had no contact with her children, aged 5 and 15 years, who resided with their respective fathers since she was incarcerated for 10 months for cannabis cultivation 3 years earlier. Hospital medical files confirmed antenatal attendance and no recorded substance use in previous pregnancies. After prison release, Chi met her current partner, Paul, who had a long history of daily intravenous heroin and MA use. Paul was in police custody at the time of the birth, which distressed Chi greatly, and he was subsequently incarcerated.

Postnatally, Chi developed hypertension for which no cause could be found and she required three doses of labetalol.

Chi had smoked MA on the day of delivery and was advised not to breastfeed until her urine was clear of MA. The transfer of MA at high concentrations into breast milk was explained, and Chi expressed and discarded milk until day 3. Her baby was noted to have a fractured clavicle, consistent with birth trauma, and was assessed for neonatal withdrawal but did not require medication. After multidisciplinary team discussion, the likelihood of Chi abstaining from MA use and safely feeding her baby was considered low and Chi was advised not to breastfeed.

Chi understood the potential risks but stated that she had breastfed her other children and wanted to breastfeed this child. She stated that she would be abstinent because her baby's well-being was important. Despite the WADS team's concerns, Chi insisted that she breastfeed. At discharge on day 10, Chi was breastfeeding with additional infant formula for ∼50% of feeds. Chi had lost family contact. With Child Protection Service's assistance, Chi and her baby were discharged to live with Chi's mother. She was referred to a local family doctor, and Enhanced Maternal and Child Health Nursing provided additional support through daily visits. Child protection remained involved.

Chi and her baby were seen by the pediatrician at day 18 postpartum. The fractured clavicle was healing, and Chi continued combination feeding with breast and infant formula. The baby was well and gained weight. The baby did not attend the scheduled 8 month appointment. There was no further contact with WADS. It is likely that the baby was removed from Chi's care. Further information was unavailable from child protection for privacy reasons.

Discussion

For regular users of MA, the Academy of Breastfeeding Medicine (ABM) guidelines state that women who have used substances in the previous 30 days should be discouraged from breastfeeding, particularly if they have positive urine drug screens and have not engaged with pregnancy services or alcohol and drug treatment services.¹

In case study 1, Sophie continued to use MA and cannabis until 2 weeks before delivery and had significant prior psychosocial factors, but she also demonstrated protective factors. Her mother provided consistent support despite rebukes and aggression when Sophie was MA affected. Her partner, Tom, who had introduced Sophie to methamphetamine and caused significant family violence, was incarcerated, enabling Sophie to address her drug use and to actively engage with WADS. Although Sophie did not fully cease MA use, she reduced both cannabis and MA use and ceased tobacco before delivery.

Therapeutic relationships are central to change. Regular multidisciplinary team care in a nonjudgmental environment facilitated her engagement in antenatal and substance use care. Sophie's interest in breastfeeding and wanting to do the best for her infant were motivators to address substance use.²⁴

Since complete abstinence is rare and “lapses” (brief substance use episodes) are common, a breastfeeding safety plan is essential.

Small amounts of cannabis can be found in breast milk, but the effect that this has on the infant is unclear.^25,26 However, since cannabis use can sedate and affect parenting, a backup plan is important for infant safety. Sophie was encouraged to cease use, although she probably continued to smoke at low levels.

Although Sophie stated that she did not intend to use drugs after birthing, safety planning remains important, which fits with the harm reduction approach to drug use.²⁷

In case study 2, there had been no antenatal care and substance use occurred up until, and on, the day of childbirth. Chi also demonstrated multiple risk factors. Despite a recommendation not to breastfeed, Chi insisted on breastfeeding. After a discussion with Chi about the transfer of MA into breast milk, she was compliant to express and discard milk until the urine drug screen was clear. Despite advice not to breastfeed, Chi was very committed to breastfeed, believing that this was important for her baby. Breastfeeding was supported with ongoing education, including the effects and transfer of MA on breastfed infants. A safety plan was developed with Chi on discharge.

Recommended Therapeutic Intervention

Not all substance-using women have the same pattern of MA use; consequently, advice about breastfeeding will vary.

Recommendations for women wishing to breastfeed are:

• Antenatal assessment of mental health and parenting and breastfeeding ability is best performed early, with an ongoing review occurring given the risk of deteriorating mental health postpartum.

• Urine drug screen(s) may assist clinical decisions regarding breastfeeding but should not be relied on without considering the entire clinical picture. Depending on the assay, urine drug screens for amphetamines may be positive for 2–5 days after use. False positives that are secondary to prescription drugs (e.g., antidepressants, H2 receptor antagonists such as ranitidine) may occur.⁹ Drug screens may cause some women to disengage from care.²⁸

• Regular, nonintoxicated attendance at scheduled antenatal appointments indicates good engagement with pregnancy care. Retention and engagement in substance use treatment antenatally and continuing after delivery is important due to the chronic relapsing nature of substance abuse. The woman should be aware that withdrawal from MA can persist for several months⁷ and be associated with anhedonia, making abstinence goals challenging. A support network, both professional and social, is critical.

• If MA use is ongoing at or shortly after birth, breastfeeding is actively discouraged. Child protection service notification is mandatory if child welfare concerns exist.

Conclusion

Methamphetamine use in pregnancy poses challenges to health professionals regarding what is best advice. Not all women should be automatically discouraged from breastfeeding, as mother-infant dyads can benefit in many ways from breastfeeding. Factors favoring breastfeeding include early engagement in antenatal care and in substance use intervention. These support the woman increasing chances of MA abstinence and lifestyle improvement. Clinicians must evaluate the risks and benefits of using clinical skills and best evidence as it becomes available to assess breastfeeding safety on a case-by-case basis. However, for ongoing MA use, breastfeeding should not occur and this should be clearly communicated to the woman and all her caregivers. Services caring for women with complex substance use are encouraged to consider developing a documented policy regarding breastfeeding and MA use.

Disclosure Statement

No competing financial interests exist.

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