Kathryn Webb and Laurie Meschke explore the trends and characteristics of breastfeeding for women in treatment for opioid use and the factors associated with breastfeeding among opiate users.
Trends and characteristics
Addiction to opioids, including heroin and the misuse of prescription medications, such as morphine and oxycodone, is oftentimes treated with the use of methadone or buprenorphine to reduce withdrawal effects and reduce the likelihood of relapse. Of women, ages 15 to 44, 5.2% have used illicit drugs in the past month (Bauer et al., 2002), and 4.4% of pregnant women have reported illicit drug use in the past 30 days (Substance Abuse and Mental Health Services Administration, 2011).
Neonatal abstinence syndrome (NAS) is a diagnosable condition associated with prenatal exposure to illegal or prescription drugs (Jansson & Velez, 2012). Symptoms can vary by type of drug used, duration, and severity of drug use, maternal metabolism, infant metabolism, and duration of gestation.
Symptoms of NAS include:
- neurological excitability
- gastrointestinal dysfunction
- autonomic signs (American Academy of Pediatrics, 1998).
The infant withdrawal can last from 48 hours to 4 weeks (Kandall et al., 1977). Annually, about 50,000 infants receive inpatient pharmacotherapy as NAS treatment associated with withdrawal (Backes et al., 2011). In relation to pharmacotherapy, human milk of mothers who are in treatment for opioid addiction has been related to reduced NAS symptoms for infants, although methadone in human milk is low (McCarthy & Posey, 2000) regardless of treatment dosage (Jansson et al., 2008).
Factors affecting breastfeeding
The decision to breastfeed, among women in treatment for opioid use is complicated by personal challenges, social barriers, and cultural stigma. We shall highlight specific factors in all three areas.
Among opiate users, low confidence and low levels of education are common and interfere with seeking prenatal care and assistance for substance abuse (Alto & O’Connor, 2011). Both low self-esteem and low education are negatively correlated with breastfeeding success. Similarly, social disadvantage and economic hardship negatively impact breastfeeding. Women in treatment for opioid use often incur the cost of missed work days in order to attend therapy sessions (Alto & O’Connor, 2011). With low financial resources, they may temporarily live with family or friends who further expose them to the harmful drug culture. Formula-fed infants are more likely than breastfed infants to have younger, unemployed mothers, and live in socially disadvantaged situations (Abdel-Latif et al., 2006).
Personal challenges affecting mothers’ ability to breastfeed also include medical contraindications to breastfeeding. Drug abusing women, and women in treatment for opioid use, are at an increased risk for HIV and Hepatitis C. While Hepatitis C is not contraindicated with breastfeeding, health professionals strongly discourage women with HIV living in developed countries from breastfeeding (ABM Clinical Protocol #21, 2009). Like HIV, polysubstance use is also a contraindication to breastfeeding. Cigarette smoking and relapse to illicit substance abuse are common among women in treatment for opioid use (Abdel-Latif et al., 2006; Abrahams et al., 2007). Also common are psychiatric disorders, which often require medications not conducive to breastfeeding (Abdel-Latif et al., 2006; ABM Clinical Protocol #21, 2009).
Quality and quantity of prenatal care is another personal factor affecting breastfeeding outcomes. Lack of prenatal care and/or failure to adhere to prenatal recommendations lowers breastfeeding education and success among women in treatment for opioid use. Low prenatal care also increases the likelihood of NAS in infants born to mothers in treatment (American College of Obstetricians and Gynecologists, 2012). There is evidence to suggest that breastfeeding reduces NAS symptoms; the two factors also seem to work bi-directionally. Infants with mild NAS may be more successful at breastfeeding than infants with severe NAS, who exhibit breathing, sucking, and swallowing difficulties.
Social factors affecting breastfeeding among women in treatment for opioid use include:
- partner and peer drug abuse
- domestic violence
- separation from partner or spouse.
Living among friends and family who use illicit drugs increases a woman’s risk for relapsing into opioid abuse. Drug abusing women are also more likely to experience domestic violence and single parenthood (Abdel-Latif et al., 2006). Breastfeeding rates are significantly lower among women without partner support than among women who have the approval and encouragement of their partners (Giugliani, Caiaffa, Vogelhut, Witter, & Perman, 1994).
The cultural stigma, and associated guilt and shame of drug addiction during pregnancy, may result in attempts to hide the drug use and/or hide the pregnancy until delivery. Women in treatment for opioid use may fear that seeking prenatal care will result in the loss of custody of their child or the monitoring of their homes, partners, children, etc. (Alto & O’Connor, 2011). Because low prenatal care is associated with low breastfeeding rates, societal pressures that keep women from seeking care may prevent mothers in treatment for opioid use from breastfeeding successfully.
Factors affecting breastfeeding among women in treatment for opioid use is a complex issue with many possible directions for future research. Further investigation into the decision to breastfeed among women in treatment for opioid use is needed in order to effectively promote breastfeeding among this population. Currently, most of the research seems to describe breastfeeding among drug abusing women, but not specifically opioid dependent women. Further research is also needed to examine the relationship between human milk from a bottle and NAS severity. If human milk from a bottle has the same beneficial effects as breastfeeding, more women in treatment for opioid use may be able to breastfeed exclusively.
Interventions and programs that promote breastfeeding
While the cultural stigma of opioid abuse prevents many women from seeking prenatal care, pregnancy can also serve as motivation for some to seek help for their addictions (Ballard, 2002). These women typically undergo methadone or buprenorphine maintenance therapies to manage their drug addictions during pregnancy. Research has shown that these treatments decrease the mother’s use of illicit drugs and other opiates, while also lowering maternal morbidity and mortality rates (Pritham, Paul, & Hayes, 2012). Opiate maintenance therapies increase the mother’s adherence to prenatal care and advice, furthermore protecting the fetus by promoting fetal stability and growth (Pritham et al., 2012; Pritham, 2013). Methadone Maintenance Therapies (MMT) and Buprenorphine Maintenance Therapies are associated with factors that are beneficial to the mother and the infant. Therefore, opioid-maintenance therapies are not deemed contraindications to breastfeeding (Wong, Ordean, & Kahan, 2011).
For infants of opioid-dependent mothers in treatment, breastfeeding serves as an appropriate treatment for managing infant withdrawal and has been associated with a decreased need for treatment of NAS (Welle-Strand et al., 2013). Breastfeeding also promotes responsibility and structure for the mother, raising the mother’s self-esteem (Williams, 1985). Although breastfeeding is beneficial for this population of women, the Academy of Breastfeeding and Medicine suggests a criterion be used when determining which of these women should be encouraged to breastfeed (ABM Clinical Protocol #21, 2009). Specific breastfeeding policies for chemically dependent mothers vary between hospital settings. Though policies may be added that make breastfeeding eligibility requirements contingent upon the mother’s substance use in the third trimester, or promote increased urine surveillance of these women in MMT. In the case of most hospital policies, if a woman tests positive for any substance other than methadone, she will not be recommended to breastfeed (Williams, 1985).
Some of the challenges of promoting breastfeeding among this group of mothers stem from the lack of evidence-based guidelines for chemically dependent women wishing to breastfeed. Without the continuity of guidelines and policies, medical professionals may be inadequately trained on how to manage breastfeeding for opioid-addicted women in MMT (Schanler, O’Connor, & Lawrence, 1999). However, there are interventions that are beneficial for the promotion of breastfeeding.
For healthy women, peer support is advantageous to breastfeeding. These peer supporters serve breastfeeding moms as role models familiar with the challenges of breastfeeding. Peer support/counseling increases breastfeeding duration and exclusivity (Demirtas, 2012; Wambach et al., 2005). An informal, personalized approach to prenatal health education, as well as physician encouragement, increases breastfeeding initiation among women of low income and low education (Demirtas, 2012; Dyson, McCormick, & Renfrew, 2005; Wambach et al., 2005). In addition, breastfeeding initiation and duration rates among low income women have increased through participation in lactation programs that include motivational videos during prenatal care and one year of follow-up with a lactation consultant (Demirtas, 2012).
Policies regarding breastfeeding and opiate-dependent mothers are not consistent across hospitals. However, several breastfeeding interventions in hospitals look promising for this population of women (Pritham, 2013). One such intervention is rooming-in. Infants of chemically dependent mothers are most at risk for attachment and abandonment issues. The early postpartum separation of the opioid-addicted mother and infant can be detrimental to the mother-infant bond. The rooming-in intervention allows the infant and the mother to remain in the same room, which as a result, increases breastfeeding rates during the hospital stay (Abrahams et al., 2007; Pritham et al., 2012). Another successful intervention is early postpartum skin-to-skin contact between the drug-dependent mother and infant. This intervention increases infant awareness, has positive effects on maternal feelings, and also increases breastfeeding initiation (Pritham, 2013).
Integrated medical and behavioral program interventions are also advantageous due to the frequency of psychiatric issues among women in treatment for opioid use. In these programs, mothers are encouraged to bring their infants to sessions facilitated by psychologists. Resident physicians, nurse practitioners, and lactation consultants also attend the group. Mothers receive patient education on the risks and symptoms of NAS, and breastfeeding is modeled by the health professionals. Integrated programs have demonstrated an increase in breastfeeding initiation and duration rates among participants (O’Connor, Collett, William, & O’Brien, 2013).
Education and collaboration
As research has shown, breastfeeding is beneficial for the chemically dependent mother and her infant. For this reason, further exploration of techniques and interventions used to increase breastfeeding among this population is needed. Increasing the quality of professional training and education among health professionals so that they are fully equipped to understand and manage such a complex group of women is another vital step. The collaboration between health professionals and the community is also important, since both are an integral part of pre- and post-natal care. Future research should analyze the continuity of support messages from the community and the health professionals who care for these women. These preliminary results are promising medical strides made to help opioid-addicted women and their infants through breastfeeding. However, future work is necessary.
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Kathryn M. Webb is a first year Master’s student in Public Health at the University of Tennessee, Knoxville, where she also received her undergraduate degree in Child and Family Studies. With a strong interest in child development, Kathryn has a great deal of work and volunteer experience with children. Last spring, she interned at Knox County Health Department and worked alongside health educators to create, implement, and evaluate nutritional lessons for after-school centers in Knox County. Currently, Kathryn works under the direction of Dr. Laurie L. Meschke as a graduate research assistant exploring breastfeeding among mothers in treatment for opioid use.
Laurie L. Meschke, MS, PhD, is an Associate Professor in the Department of Public Health at the University of Tennessee, Knoxville. Laurie has over a decade of experience in conducting and disseminating research in the area of prenatal substance use and infant outcomes. While in Minnesota she examined statewide prenatal substance use, the diagnosis of Fetal Alcohol Syndrome, and the design and evaluation of a randomized-control, treatment-group evaluation of a substance abuse treatment program for high-risk women. Since moving to Tennessee in 2012, Laurie has initiated the examination of prenatal opioid use and its effects on infants.