National and international experts´ advisory conference: ”Substitution treatment and pregnancy and the follow-up of the families the following years”

Dear participants, dear experts!

It gives me great pleasure to be here and welcome you to this conference on such an important and challenging topic. Particularly welcome to our colleges from collaborating countries Austria, United States, Denmark and Sweden.

What kind of treatment in order to reduce substance abuse should we offer the women in advance and throughout pregnancy? And what kind of follow-up would be the best for these families? We do not have exact knowledge and experience in these matters, at least not in Norway, in order to set up precise guidelines to the services. By sharing knowledge and experiences, I am sure you all will contribute to elaborate on these challenging questions which will be thoroughly raised and discussed during this conference. Hopefully by the end of this 3-days conference, we will all learn from each other and thus be able to strengthen the services towards the families concerned.

Political focus
Why do we as politicians engage in these matters? It is of course the children we first of all are obliged to give protection and help. They must be of our utmost concern. The Norwegian Government in their political program – “The Soria Moria Declaration” – promised that the children of parents with mental disorders or substance abuse should be ensured follow-up. We know that these children are at a particular risk developing the same problems as their parents. We have no precise figures in Norway how many children should be of our concern. According to our estimations, approximately 130 000 families in Norway struggle with either mental problems or problems because of abuse of drugs or alcohol. No matter how precise our figures are, this indicates the need for focus and action. We believe that children in these families suffer. These kinds of problems in a family often gives a strong sense of shame, and many children will try to hide such problems and – maybe mistakenly – stay loyal to their parents.

Most parents are of course conscious of this. At the same time, those of us who are parents, know this task of giving our children the best possible life, is challenging, and in periods, we all need help and assistance. So we are of course also obliged to offer our interest, our efforts and best services to people suffering from mental problems and/or substance abuse. Opioid addicts and, not to mention, pregnant opioid addicts, must particularly be of our concern. Many are troubled both mentally and socially in addition to – very often - severe medical problems.

Choice of treatment - dilemmas
Furthermore, pregnant opiodid addicts present a dilemma when it comes to choice of treatment. On the one hand, it is scientifically proved that opioids, for example methadone, effects the development of the foetus. Data from several evaluations of the efficacy of substitution treatment show that infants exposed to opioids are born with reduced birth weight, reduced circumference of the head and the length, compared to infants not exposed to opioids. It is also a fact that many of the infants exposed to for instance methadone during pregnancy, are abstinent when born. On the other hand, there is also a severe risk that the foetus will suffer if exposed to uncontrolled drug use, an unhealthy lifestyle and lack of care if the mother is not treated.

I am told that in many western countries, health authorities consider the benefits of substitution treatment to outweigh the disadvantages, both for the mother and child. Accordingly, these countries recommend substitution treatment to pregnant opioid addicts.

Norwegian policy
In Norway we are more restrictive when it comes to medical treatment in pregnancy in general. According to our policy, guidelines and practise, drugs in general are not offered throughout pregnancy, unless the advantages for the mother clearly is considered to exceed the risks for the infant. We have in Norway a tradition for and a wide range of drug-free treatment alternatives towards drug addiction. Accordingly, drug-free treatment is therefore highly recommended to female drug addicts planning to or being pregnant.

At the same time, the services have no easy task when considering the best possible treatment to these women. For instance: What do we recommend pregnant women already receiving substitution treatment when this treatment option proves to have good effect for the woman concerned? Should we always terminate the ongoing substitution treatment and recommend drug-free treatment as an alternative? Furthermore, if the women do not agree with our recommendations of non-medical treatment or fear compulsory admission to drug free treatment as the only alternative? Do we risk not to get in contact with, or even worse, loose contact with pregnant drug addicts? Even though the unborn child should be our first concern, I agree that there are no easy answers to these questions.

As far as I know, Norway is the only European country having legislation which allows compulsory admission and drug free treatment for addicted pregnant women if the health of the foetus is affected by the use of alcohol or drugs. We have little knowledge of the effects of these compulsory rules. Therefore we have started the preparations of a comprehensive evaluation of the set of rules in this area.

More knowledge needed
In Norway these questions have also been discussed politically. Last October our Minister of Health and Care Services, Sylvia Brustad, was asked what kind of drug-free treatment pregnant women were offered as an alternative to substitution treatment. One of the minister´s main messages in her answer to the Parliament was emphasizing the need for more knowledge in order to develop consistent and evidence based guidelines to the services. This conference is partly a result of this and the further work initiated by the Directorate for Health and Social Affairs in order to increase our knowledge in this field, and thus strengthen our services to the best for the women concerned and indeed their children. 

In Norway it is a priority of the Norwegian government and health authorities to expand and improve the quality of substitution treatment to opioid addicts. The present Government has therefore increased the budgets to reduce the number of patients on waiting lists and increase the efforts locally to ensure this target group better follow-up and rehabilitation. Yet, there are still challenges to be solved.

As we increase the number of patients treated with methadone or Buprenorhin, more women and potential pregnant women, will be included in substitution treatment. Approximately one third of today´s patients are women. This means roughly 1500 women according to the latest reports. The need for more precise knowledge in this field should thus be obvious.

Children of parents with mental disorders or substance abuse
In Norway we are particularly concerned with the interests of strengthening the support given to children and young people with mental health problems and young people with drug and alcohol addiction. As I mentioned initially, The Norwegian government in their political program pay particular attention to children suffering from mental problems and drug or alcohol addiction in their families.  Several initiatives are taken towards these groups. It is relevant to mention the action plan on illicit drugs and alcohol policies which the Norwegian Government presented to Parliament in October 2007. The plan contains a wide range of measures in the areas of prevention, treatment and rehabilitation.

Of particular interest in this context I will mention some of our measures according to our Governments action plan against poverty, launched parallel to this Government´s budget of 2007. According to this plan we have initiated several measures to ensure that these children in a more systematic way are identified and ensured follow-up when needed. It is important that our measures directly have an effect to the children concerned. In 2006, the Directorate for Health and Social Affairs presented a circular letter on better identification. Extended guidelines to the relevant public services will be presented next year.

As an extra effort, we this year spend 15 millions Norwegian kroner in order to develop and strengthen services towards these children. This Government has even suggested to increase the funds towards this target group. So if Parliament agree, we can spend 20 mill. Norwegian kroner on this important topic next year. The measures are aimed at increasing competence, research and the ability to identify these children in a more systematic way. Initiatives both locally, in the public health services and in the NGOs are given financially support. Of particular interest I will mention our support of trials of long-term follow-up of children based on a Danish model, namely Familieambulatoriet or the Family Centre in Copenhagen. I am told that the Director of this centre participates in this conference and will share with us their experiences tomorrow. We look forward to listen to her.

Last, but not least, it is important for me to emphasize our efforts to strengthen these children's legal rights. We have started the preparations of a draft document with proposals to amendments to the patients' Rights Act that will contribute to make sure that these children receive necessary help.

Conclusions
As I have already stated, the children, both born and unborn must be of our prior interest and concern. I am sure we all agree. At the same time we have obligations towards the women concerned. Giving them the best possible treatment and follow-up also increases their abilities as a good parent. Of course we should also strengthen our efforts towards these women in order to improve their health and living conditions. Therefore I warmly welcome the initiative to increase knowledge and share experiences in these matters. I am sure you will all contribute during this conference.

Good luck to you all, and thank you for your attention!