Drug misuse (abuse) is common, but only a minority of misuse is associated with dependence (or addiction). Society currently displays a schizophrenic attitude to drug abuse. We seem to accept alcohol intake and, to a lesser extent, smoking during pregnancy even though we know that these drugs can be addictive, and that regular use can affect the baby. There is a puritanical (and paternalistic) streak, that is particularly strong amongst legislators in America, that would ban all alcohol intake in pregnancy, but there is no evidence that an intake of less than 10 units a week is harmful unless it is consumed in one go (one ‘unit’ of alcohol being a single pub measure of spirits, a small glass of wine or half a pint of ordinary strength beer or cider). In addition, smoking in pregnancy is now seen as one of those ‘facts of life’ that the medical and midwifery professions can do little to change. The attitude to other recreational drug use is more censorious, even though we know that many healthcare professionals occasionally take drugs themselves.

Opiate addiction presents the most serious challenge, and IV injection further increases the risk to the mother’s health. Indeed the main reason for offering these mothers methadone is that it may help them to avoid the hazards associated with giving any drug IV. Access to oral methadone may, by limiting the woman’s urge to acquire other costly drugs of doubtful purity, also help stabilise her lifestyle. Attitudes change over time. Opium and laudanum were widely used by the middle classes in Europe and North America in the 19th century. Opium was even added in many infant ‘soothing syrups’. Now it has been estimated that, when no legal source is available, the average UK addict gets through £20,000 worth of heroin a year. Diet may become inadequate, and alcohol intake may rise. Judgmental attitudes can deter addicts from seeking help until problems escalate. Users may seem to have neglected their condition when the health services have actually, by their attitude, effectively excluded them from care. Despite this, many manage to lead apparently normal lives, running a family or holding down a job.

Few areas of maternity care are more in need of a collaborative, team-based, approach. Little can be achieved until the woman’s trust and confidence have been won. Antenatal care should identify those most in need of support. Intravenous drug users should always be tested, with their informed consent, for sexually transmitted infection, and for hepatitis B, hepatitis C and HIV infection, both to optimise the scope for treatment and to minimise the risk that the baby will also become infected. Plans for post-delivery care should also be made ahead of delivery, and the mother should know what these are.

Many heroin users also take other drugs. While recreational use of drugs such as cannabis, lysergic acid diethylamide (LSD), phencyclidine (PCP), amfetamine (amphetamine), ecstasy or cocaine on their own do not usually cause neonatal withdrawal symptoms serious enough to require treatment, the same is not true for high-dose benzodiazepine use. Transferring from heroin to methadone may actually make matters worse because this does not give the immediate ‘high’ obtained when heroin is smoked, inhaled or injected. Cocaine may then be turned to for the ‘lift’ that it gives and a benzodiazepine, such as temazepam, used to reduce the ‘low’ that tends to follow. Fashions change, but combined addiction to heroin and temazepam is common in the United Kingdom.

Most people who misuse drugs are not drug dependent. The problem only becomes an addiction if abrupt discontinuation causes serious physical and mental symptoms to appear. This is, however, what can happen to the baby after birth. Babies exposed to opiates throughout pregnancy, or to high sustained benzodiazepine usage, often exhibit a range of symptoms (see box) 12–72 hours after birth. None of these, on their own, need treatment, but treatment is called for if sucking is so in-coordinate that tube feeding is required, if there is profuse vomiting, or watery diarrhoea or the baby remains seriously unsettled after two consecutive feeds despite gentle swaddling and the use of a pacifier.

Many units currently admit such babies to special care for observation and then ‘score’ the child’s condition once every 4 hours. However, experience shows that an observer’s views and their ‘attitude’ to drug misuse can influence the score awarded. Scores ask the observer to say how ‘severe’ the symptoms are. If the nurse or doctor has not cared for such a baby before, how can they decide on the severity of the symptoms? Scoring systems, though popular, can also have the perverse effect of suggesting that an increasingly sedated baby is ‘improving’ when the real need is to get the baby feeding normally and sleeping normally.

A better approach is to make the mother aware before delivery that her baby will need to be watched for a period, to involve the mother in this and to care for both mother and baby. Most mothers already feel guilty about their drug habit and fear having their children taken from them. Knowledge of antenatal drug intake (even if accurate) is only of limited value in predicting whether the baby will develop symptoms, and mothers need to be aware of this. If mother and baby have been cared for together, both can be discharged home after 72 hours if no serious symptoms have developed.

If symptoms serious enough to make the baby unwell do develop, then the logical approach is to wean the baby slowly from the drug to which the mother is habituated, rather than introducing yet another drug. Babies of mothers taking an opiate should be weaned using a slowly decreasing dose of morphine or methadone. Morphine is widely used, and the dose can be easily and rapidly adjusted up or down, but methadone may provide smoother control. Weaning should not normally take more than 7–10 days. The same approach can be used where the mother is addicted to buprenorphine, codeine or dihydrocodeine. The use of paregoric for the baby, or tincture of opium, lacks any rational justification. Benzodiazepine dependency is harder to manage using this strategy, because nearly all these drugs have such a long half-life. Some use chloral hydrate in this situation but this can over-sedate the baby, and chlorpromazine may be a better choice. For the occasional mother with barbiturate dependency, phenobarbital should be considered but, while this may provide sedation, it does nothing to control gastrointestinal symptoms.

Although there have been many small controlled trials looking at strategies for managing neonatal withdrawal, assessors have generally merely looked to see how many symptoms there were rather than how distressing and disabling the symptoms were. In addition, the assessors have usually been aware of how the babies were being treated. There is scope for some useful nursing research here.

Breastfeeding can be generally encouraged in the period immediately after birth even if the mother has been taking several drugs, since these babies seem to show fewer features of withdrawal. There is no need to place any arbitrary limit on the length of time the mother is ‘permitted’ to breastfeed. It should, however, be explained that weaning needs to be gradual. No baby should be left in the care of anyone taking a hallucinogen, and few would condone the possible exposure of a baby to such a drug in breast milk. The place of breastfeeding in mothers taking other drugs is summarised in pp. 560–607.

Screening urine, or meconium, for drugs serves little purpose unless serious thought is being given to care proceedings, since it is unlikely to influence management. If you tell the mother you plan to do this, you imply that you do not believe what she has told you about her drug history. If you tell her later, she will merely conclude that you are another person she cannot trust. The decision of any child protection conference, or court, will be influenced purely by what is best for the child, and by the mother’s ability to provide that care. Drug misuse is not in itself a sufficient reason to separate mother and child.

Babies can also become addicted to opiates and benzodiazepines after birth. Fentanyl and midazolam are the drugs that most often cause problems. Continuous use for even a few days can produce tolerance (the need for a progressively larger dose) and dependency (addiction). Management is the same as for addiction acquired in utero – a slow tapered withdrawal of treatment. Perhaps we should do what we tell mothers to do and avoid sustained use all together.