Breaking the cycle: The role of LARC in substance misuse services. Dr Bernadette Hard Kaleidoscope Drug Project

Transcription

1 Breaking the cycle: The role of LRC in substance misuse services Dr Bernadette Hard Kaleidoscope Drug Project

2 Summary of topic Overview of unintended pregnancy and cycle of deprivation. Relevance to women suffering with active dependence. Service model developed by Kaleidoscope team.

3 Cycle of deprivation Some areas in Wales have highest teen pregnancy rate in Europe. Clear link between unintended pregnancy and cycle of deprivation. Welsh Government has identified key groups of women at increased risk of unintended pregnancy and associated poor pregnancy and parenting outcomes. These include women with active addiction.

4 Background ll women should have easy access to impartial and informed contraceptive advice. NICE guidance supports use of LRC in the female population as the most efficacious and cost effective method of contraception. Evidence suggests that uptake of contraceptive services is lower among opiate using females than non opiate using females. (75% in general female population 16-49) Reasons shown are a lower perceived risk of pregnancy, and a reluctance to access local services.

5 What has previous research shown? UK study, 1995 : 201 opiate dependent women, 44% of nonpregnant sexually active women did not use any contraception, and 43% of those who were using contraception relied on condoms alone The recommendation was that drug dependency units should expand their role to provide educational and preventative services to include aspects of women's sexual health. Study, 2003: semi-structured interview to examine issues surrounding contraception in female opiate dependent service users in-depth. The results showed that women who did not use contraception often had a low perceived risk of pregnancy for a variety of reasons, including past believed infertility, menstrual irregularities and effects of drug use.

6 Impact of active addiction on contraception use Women with active addiction may take part in sexual activity to fund a dependency. cute intoxication makes woman vulnerable to risky sexual practice. Women in abusive relationships may lack control over their contraception Women with active addictions may not prioritize contraceptive/ sexual health needs. Women who have unmet emotional needs may see a baby as a source of love and hope.

7 Effects of maternal drug/alcohol use on pregnancy. FSD - a series of preventable birth defects caused entirely by maternal alcohol during pregnancy. Rates are estimated at between 1% and, in high risk populations, 10% Heroin use in pregnancy is linked with poor pregnancy outcome, with IUGR, prematurity and small for dates babies, also there is inc risk of still birth and SIDS, and neonatal withdrawal syndrome. IVDU exposes fetoes to risk of BBV s. Some viral hepatitis meds are teratogenic. Poor maternal health/ lack of anti natal care/ smoking/ poor diet all are contributory factors to poor outcomes.

8 Effects of parental substance misuse on child s early years. Children in families with substance abuse problems are 3 x more likely to suffer abuse and 4 x more likely to suffer neglect than other children ( Reid, Macchetto & Foster 99) US data shows % of all cases of abuse/ neglect involve parental substance abuse ( including alcohol) Exposure to abuse in 0-3 can lead to Toxic/ Traumatic stress, which results in high levels of cortisol in the brain which can disrupt brain development, leading to anxiety and depression, PTSD, behavioural and learning difficulties in adulthood.

9 Hidden harm- far reaching consequences 2-3 % of children in the UK are affected by parental problem drug use an estimated 64,000 welsh children are affected by parental alcohol use, and 17,500 by parental drug use 1/3 of all child care ss cases involve parental substance misuse Estimated cost via ss alone in Wales in 2007 was 117 million.

10 This is a cycle NOT a victimperpetrator situation Many of our clients have been affected by parental addiction Few clients WNT to be bad parents Most clients are DEVSTTED at having children removed from their care This trauma FUELS further substance use

11 Cycle of deprivation This is where we can clearly see a cycle setting in motion, with children affected by parental addiction, developing with increased vulnerability to addiction in adulthood.

12 Pre-pregnancy Counselling issues We know some of our clients have risky sexual practice. They have an illness which impacts negatively on pregnancy outcomes. Treatment interventions may INCRESE fertility and subsequent risk of pregnancy. Need to include sexual health/contraception advice as part of routine medical assessment.

13 Contraceptive choices and efficacy Barrier methods: Condoms - Highly effective at preventing transmission of some STI s. There are no specific contra-indications to use other than allergy. Failure rate for correct use is around 2%, but rises to 15% for actual use COCP: perfect use - failure rate 0.3% per year. ctual use failure rate between 2-8% per year

14 Features of LRC Methods of Contraception IUD IUS Implanon DPM Duration of action up to 10 years 5 years 3 years 12 weeks Failure rate < 2% over 5 years <1% over 5 years <0.1% over 3 years <0.4% over 2 years

15 Contraceptive choice in client group. Need for highly effective method of contraception. Need to consider risk of oestrogen based methods in clients who smoke, have a history of DVT or liver impairment secondary to alcohol or hepatitis C. Need to consider compliance with contraceptive choice. default position of efficacy. Need to consider quick start and bridging methods.

16 Pre Pilot study of current contraceptive practice in women prescribed ORT in Gwent and RCT To take a snapshot of current contraceptive practice in a sample of female clients in Gwent and RCT. To liaise with local sexual medicine services and develop some a service which allows clients to access LRC in a substance misuse setting. To re evaluate contraceptive practice after service has been put in place to facilitate LRC in the Kaleidoscope service.

17 Initial audit cycle Done over 4 months in summer 2010 Questionnaire based gathering of information, all anonymous. 64 responders Concurrent notes review to look at current parental circumstances of clients.

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19 Current parental situation on a sample of our female client group

20 Kaleidoscope Contraceptive Service. Joint working with local sexual health service consultant, and BHB to develop robust governance framework im to advice/educate clients. lso focus on safe sexual practices. Delivered on the ground by a Health Promotion nurse Include contraceptive needs assessment as part of nursing/medical reviews Offer DMP alongside condoms in the substance misuse clinic setting, and signposting / facilitation of all methods of contraception.

21 Results of second audit cycle 39 responders over a 4 week period in Feb % of clients felt that their substance misuse provider should offer contraceptive services

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23 What next? n independent evaluation of the service offered at present is planned. This will utilize anonymised case notes, and semi structured interviews. Evaluate if the service has led to increased uptake or LRC Look at cost/ benefit analysis of service, and costeffectiveness Determine replicability of the model used.

24 Extending our service We have just started a 1 year pilot project offering CT and GC testing, alongside CT treatment Possibly explore options for PCC and Nexplanon insertion

25 Summary Difficult childhood increases vulnerability to substance abuse Women with active addiction are at high risk of unintended pregnancy with poor outcomes Providing easy access to LRC may offer female clients increased control over their reproductive health Recovery has the power to allow people to BREK FREE of the cycle of addiction. Effective contraception can provide people with space to recover.

26 Thanks for listening. ny questions?...