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Chapter 9 – Medical
management of drug
dependence: reducing
secondary health harms
Provision of healthcare and identification of drug
use as a health issue
This chapter considers the scope of medical practitioners’ involvement in the reductionof drug-related harm, through the provision of healthcare to people using drugs, andthe identification of users, provision of information, and monitoring where drug use is a risk factor for health problems.
Some people who use drugs report experiencing disapproval and frustration in their
interaction with healthcare services,1 and this can be a significant barrier to accessing
healthcare. As discussed in Chapter 8, health professionals who adopt a non-
judgemental, non-stigmatising empathic stance are most likely to be effective in
delivering healthcare for these patients.
There is consistent evidence that in primary care settings, in hospitals, and in mental
health settings, doctors frequently do not address alcohol and drug use.2-5 A history of
alcohol or drug use is seldom documented, even where presenting symptoms or signs
provide an index of suspicion that alcohol or drugs may be involved.2,3 There has been
difficulty engaging doctors in the treatment of problems with addiction in Australia,4
and reports of similar problems in the UK.5 Possible explanations for the reluctance to
explore alcohol and drug use include some doctors’ sense of pessimism about being
able to do anything, avoidance of antagonising patients, and, possibly, reluctance to
work with stigmatised patients (see Section 8.2).
The medical frame of reference is a useful one in which to approach drug use – non-judgemental, factual, professional, accurate diagnosis and provision of informationand referral, monitoring the response. Contrary to pessimism and reluctance to addressdrug use as a health issue, there is evidence that, in relation to the legal drugs alcoholand tobacco, medical management can have significant impact,6-9 but it is unclear howfar this can be extrapolated to illicit drugs. Opportunistic identification of drug use, and provision of brief health advice, may be useful in triggering individuals to reflect on,and sometimes to modify, their use of drugs.
Drugs of dependence: the role of medical professionals If a doctor finds a patient is using illicit drugs, the response should be to undertakean assessment of the extent to which this use is impacting on the person’s healthand their life and the lives of others around them, while acknowledging theimportance of patient autonomy and choice. The appropriate response may involveprovision of information about health risks and harms, or referral for management.
Referral to a specialist service is not always indicated. Screening and brief advicefrom physicians can affect the motivation for change among patients, includingthose with substance dependence.10,11 It is important to identify whether the patient perceives that their health, or otheraspects of their life or that of those around them is negatively impacted by their druguse, whether their family members perceive this to be so, and whether the doctor, onthe basis of the patient’s symptoms and presentation, has identified negative effects oftheir drug use on the person’s life. The doctor must also consider the impact the druguse may be having on children and young people. Guidance published by the GeneralMedical Council (GMC) in 2012 on Protecting children and young people makes it clearthat, while the adult patient must be the doctor’s first concern, the doctor also has aresponsibility to consider whether the patient poses a risk to children or young people.12The new guidance also stresses that, when responding to requests for information forchild protection purposes, the doctor should: ‘include information about the child or young person, their parents and any other relevant people in contact with the child or young person. Relevant information will includefamily risk factors, such as drug and alcohol misuse, orprevious instances of abuse or neglect, but you should notusually share complete records.’12 Opportunistic brief intervention
In the medical response to addictive disorders, prevention is probably better than
treatment – ie opportunistic interventions with people identified as using drugs in
ways that place them at risk. Strategies to prevent drug use are discussed in detail in
Chapter 7. This section looks at strategies to reduce use in those who are already
using drugs.
A review of randomised trials that evaluated an intervention targeting drug use byyoung people under 25 years of age, delivered in a non-school setting, noted thatoverall there is a lack of evidence in this area, so further research is still needed todetermine which interventions can be recommended and which are cost effective.13Some larger studies show promising results, suggesting that, for medicalprofessionals (and other healthcare workers), brief interventions using motivational Drugs of dependence: the role of medical professionals interviewing provide an important means of reducing drug use in young people,including in those who are most vulnerable or most at risk. Some authors haveshown positive impact of brief interventions for use of individual drugs in youngpeople,9,14 while one UK study showed these benefits simultaneously derived acrossa number of different drugs,15 which may also have useful implications for the busyprimary care or emergency department setting.
McCambridge and Strang tested brief interventions in young people,16 and found that a single session of motivational interviewing (including discussing illicit drug use) ledsuccessfully to reduction in use of these drugs among young people. The interventiontook place across 10 further education colleges across inner London, with 200 youngpeople aged 16-20 years who were currently using illegal drugs. Those randomised tomotivational interviewing reduced their use of cannabis (and cigarettes and alcohol).
Those most at risk benefited the most: for cannabis, the effect was greater amongheavier users. The effect of reduction in cannabis use was also greater among youthusually considered vulnerable or high risk according to other criteria – for exampleyoung male individuals who smoked cannabis the most frequently, were in receipt ofbenefits, and had a prior history of selling drugs.
Relapse prevention CBT (see Section 9.5.2) appears to be effective for cannabis
dependence, compared with a control group awaiting treatment. It appears that
individual therapy may be more effective than group therapy.17
Contingency management (see Section 9.5.2) is associated with much longer
continuous periods of abstinence for cocaine compared with control groups, in both
prize and voucher reinforcement studies.18 This intervention has not been widely used
in the UK, possibly due to training needs.18 Couples-based interventions have also been
found to be effective.18
Individuals with opioid dependence who are in close contact with a non-drug-usingpartner have been found to benefit from behavioural couples therapy, both duringtreatment and at follow-up.19 In order to reduce relapse and the associated increased risk of fatal overdose, servicesproviding residential opioid detoxification should prepare people for admission, strive toretain them in treatment for the full admission period, and actively support their entryinto planned aftercare, in order to improve outcome.20 Drugs of dependence: the role of medical professionals Intravenous drug use and associated risks Opportunistic brief interventions in intravenous drug users have also been shown tohave significant impact. A randomised trial across 15 cities and 4,000 participantsexamined the effect of three sessions of motivation interviewing for intravenous drugusers attending healthcare services for other purposes (HIV testing) compared to HIVtesting alone. The study found that those who received additional counselling hadbetter outcomes than those randomly assigned to receive just HIV testing. In the group that received additional counselling, there was half the rate of drug injection at6-month follow-up, four times the likelihood of abstinence (confirmed by urinalysis),and significantly lower arrest rates.10,11 Safe prescribing
Management of illicit drug users is multifaceted. It requires medical management of thedrug use and its sequelae, but also includes referring to other disciplines, such as socialservices, that can help with the wider aspects of improving quality of life. Medicalmanagement of dependent drug use focuses directly on treating physical and mentalhealth issues and may involve prescribing. This section presents some of the safetyissues that are important in this context. It considers the appropriate and safeprescribing of drugs of dependence and ways to minimise the risks of diversion, misuseand iatrogenic dependence.
Misuse of, and dependence on, prescribed drugs (in particular opioids andbenzodiazepines) is a rapidly growing public health problem in many jurisdictionsinternationally.21,22 There have been well-documented periods in the past whendiversion and misuse of pharmaceuticals was the primary source of street drugs in someUK cities.23 Caution in prescribing, particularly in patients with histories of drugdependence and misuse, is an essential part of minimising diversion and delivering safeand effective medical management. The most effective deterrent to diversion andmisuse is supervised consumption.22 There is clear evidence from the UK that increasingthe level of supervision in patients receiving methadone has been associated with amarked reduction in deaths due to diverted methadone.24 In assessing patients seeking analgesics and/or hypnosedatives, it is appropriate to seeka history and family history of drug use, and to examine for any objective signs of use ofinjected drugs (such as scarred veins), with the patient’s consent. Urine toxicology is alsouseful, to enhance the accuracy of self-report. In addition to minimising misuse,diversion and iatrogenic dependence, the medical professional must consider thephysical safety of the prescribed drugs, as is the case in all prescribing. The impact ofinjudicious prescribing is illustrated in a study from Melbourne, Australia, whereresearchers investigated the medical attendances of young people who had died ofopioid overdoses.25 In the months leading to their deaths, these young people exhibiteda pattern of increasing presentations to doctors, obtaining escalating prescriptions for Drugs of dependence: the role of medical professionals opioids and benzodiazepines – the drug combination that led to their deaths.
In a UK-wide 17-year GP dataset of patients also prescribed OST, over one-third ofprescriptions for benzodiazepines exceeded 8 weeks (twice the maximum timeframerecommended by the NICE guidelines).26 In other cases, some patients who may initiallybe prescribed a short-term z-drug or benzodiazepine prescription for sleep problems oran episode of anxiety, but whose symptoms continue, may be at risk of developingdependence.27,28 It is important for medical professionals to conduct regular reviews andconsider the broader care plan options, including a stepped care approach andpsychological interventions.26 Management of withdrawal
It is not unusual for patients to present to emergency departments, or sometimes to
primary care, in acute drug withdrawal. Occasionally withdrawal from drugs that
activate the GABA (gamma-amino butyric acid) system – alcohol, barbiturates and
GHB/GBL can present with very severe and potentially life-threatening seizures.
Such withdrawal is characterised by autonomic overactivity (tachycardia, hypertension,
tremor and sweating), cognitive changes (confusion, agitation, sometimes psychosis)
and perceptual disturbances (formication – a tactile hallucination of insects crawling on
or in the skin, illusions, visual hallucinations). Fits may also occur. One role of therapeutic
detoxification from illicit drugs is management of a clinical emergency, stabilising
the individual and slowing the rate of change to allow their physiology to adapt.
A second role is to decrease the distressing or uncomfortable symptoms of withdrawal,
and, through this, a third role is to enhance engagement and increase the likelihood
of continued abstinence. It is also essential that the medical professional promotes
continued engagement and continues to provide support after the detoxification
process is complete. Relapse prevention is discussed in Section 9.5.
Fits or a paranoid psychosis may also occur on abrupt withdrawal of benzodiazepines.
This is relevant in considering illicit drug use, as it is usual for people who becomedependent on illicit drugs to misuse a range of drugs, including alcohol andbenzodiazepines. Where withdrawal from most illicit drugs is not associated with severemorbidity, withdrawal from benzodiazepines often poses a greater risk. It is moredifficult to recognise, as the onset of withdrawal is often delayed. Withdrawalsymptoms come on within two to three half-lives of the particular benzodiazepine (eg 2-3 days after short- and medium-acting compounds and 7-10 days after long-acting compounds) and usually subside within a few weeks.28,29 Some patients reportsymptoms that have persisted for months or indefinitely.30 This has been described as a ‘post-withdrawal syndrome’,31 and may complicate management of withdrawal from illicit drugs.
Drugs of dependence: the role of medical professionals As with benzodiazepine withdrawal, those with chronic heavy GHB or GBL use canexperience severe withdrawal,32 including delirium and the need for urgent inpatientcare or, in some cases, transfer to an intensive therapy unit. Others can be managed byspecialists, with high-dose diazepam and baclofen, titrated against withdrawal severityin ambulatory settings, but this needs to be backed up with access to inpatienttreatment if required, because of the possible severity of the withdrawal symptoms.33 The distressing symptoms of opioid withdrawal can include dysphoric mood, nausea or
vomiting, muscle aches, lacrimation, rhinorrhoea, sweating, diarrhoea and insomnia.34
In those patients who wish to detoxify from all opioids, withdrawal symptoms are
minimised by the process of opioid detoxification, using the same drug or another
opioid in decreasing doses. This is discussed in more detail in Chapter 8. Methadone or
buprenorphine are offered as the first-line treatment in opioid detoxification.34 As with
other withdrawal syndromes, adjunctive medications at low doses may also be
considered where clinically indicated (for example, to treat diarrhoea), and where the
medication does not interact with the other medications prescribed.
Following successful opioid detoxification, patients should be offered and engaged in
continued support and monitoring designed to maintain abstinence.19 This important
topic is covered in Section 9.5.
The medical professional must also educate the patient regarding the loss of opioid
tolerance following detoxification, and the ensuing increased risk of overdose and
death if opioids are used again during this period. This is addressed in greater detail in
Sections 8.4.5 and 8.6.1.
When chronic heavy users abruptly discontinue amphetamine or cocaine use, awithdrawal syndrome occurring within hours to days of their last dose is commonlyreported. While the two syndromes are distinct, they share symptoms, includingdysphoric mood, fatigue, vivid or unpleasant dreams, insomnia or hypersomnia,increased appetite and psychomotor agitation or retardation.33 The degree of severity is a relapse predictor in some individuals.35 This is a distressing experience, and there are reports of suicidal ideation in some during this period.36-38 Research on pharmacotherapies for amphetamine detoxification36,39 and cocainedetoxification35,40,41 are currently ongoing but, as yet, no medications are licensed fordetoxification in stimulant withdrawal. The medical professional’s current focus shouldbe on assessment; engagement; safe means of alleviating distressing symptoms, such asadjunctive medications where appropriate; relapse prevention strategies (discussed in Drugs of dependence: the role of medical professionals Section 9.5); and monitoring for the use of other potentially harmful substances the
patient may be using to self-medicate.
In managing cannabis withdrawal, the medical professional should be aware of thefrequency and presentation of withdrawal symptoms, which are newly listed in theforthcoming Diagnostic and Statistical Manual of Mental Disorders (DSM-V), scheduledfor publication in 2013. The medical professional should also be aware of the possibleresponses of patients aiming to reduce their withdrawal symptoms, includingrelapsing42 and self-medication with other substances.42,43 Symptoms of cannabis withdrawal in those who are dependent include anxiety,irritability, appetite changes, restlessness, sleeping difficulties, tension, thoughts andcravings for cannabis, and twitches and shakes, in both adults42,44 and adolescents,45and commencing typically within hours to days of ceasing cannabis use. From a US general population study, of a sample of 2,613 individuals using cannabis on threeor more days per week, 57.7 per cent (and 59.4% among the subset who did not useother substances) experienced at least one symptom of cannabis withdrawal oncessation, with feeling weak or tired, hypersomnia, anxiety, psychomotor retardationand depressed mood being the commonest symptoms. There was a strong, significantcorrelation between distress experienced during withdrawals and the use of othersubstances to relieve the distress.43 Research on pharmacotherapies for the management of cannabis detoxification is also
ongoing.46,47 In terms of management of withdrawals, the medical professional should
monitor patients for withdrawal; address ways to alleviate significant symptoms to help
avoid relapse and self-medication;42 and engage the patient in other relapse prevention
strategies (see Section 9.5).
Relapse prevention
Drug dependence, in particular in users of heroin, other opioids and cocaine, often
presents as a chronic condition with periods of relapse and remission.48 In the case of
dependence on opioid drugs, relapse after a period of abstinence is associated with an
increased risk of death from overdose due to decreased tolerance (see Section 8.6).49,50
The medical professional has a key role in educating the opioid user51 and their carers52
about these risks and how to respond to them. The medical professional must also
address relapse prevention strategies with those undergoing detoxification.51
Drugs of dependence: the role of medical professionals The role of medication in relapse prevention The use of naltrexone for relapse prevention after opioid detoxification is described in
Section 8.4.6. Its use requires significant motivation for compliance and thus its use
as an effective therapeutic strategy is limited.53
Prescribed OST (described in detail in Chapter 8) is used as treatment in opioid
dependence, to maintain abstinence from illicit opioid use.
A Cochrane review addressing the use of psychostimulants to maintain abstinence from cocaine use found studies in this area to be currently inconclusive.54 The role of psychosocial interventions in relapseprevention Relapse prevention CBT focuses on helping drug users to develop skills to identifysituations or states where they are most vulnerable to drug use, to avoid high-risksituations, and to use a range of cognitive and behavioural strategies to cope moreeffectively with these situations.18,55 Relapse prevention CBT appears to be effective for cannabis dependence, withindividual relapse prevention CBT lasting between four and nine sessions associatedwith greater levels of abstinence and reductions in drug use for people who usecannabis.18,55 In a meta-analysis, contingency management (CM), in the form of voucher-basedreinforcement in the treatment of use and dependence on licit and illicit drugs, hasbeen shown to significantly improve treatment outcomes for all substance use disordersapart from for alcohol.56 Contingency management has not yet been widely used in the UK,18 but has beenshown to increase the likelihood of abstinence in cocaine dependence, using eitherprize- or voucher-based reinforcement,57,58 while relapse prevention CBT and standardCBT have not been shown to be effective for the treatment of cocaine dependence.18As Stulza et al highlight,59 cocaine users are a heterogeneous group, so studying theimpact of psychological therapies on this population as though they are psychologicallyuniform is likely to underestimate the effect size of therapies, which could be moreeffective when tailored to individual cases or if subgroups with shared characteristics arestudied together instead of whole populations.
Individuals with cocaine and/or opioid dependence and who are in close contact with a non-drug-using partner benefit from behavioural couples therapy, both duringtreatment and at follow-up.18 Drugs of dependence: the role of medical professionals Narcotics Anonymous (NA) and Cocaine Anonymous (CA) are mutual-help groups that offer a recovery programme based on the 12-step approach that began with AA – ‘a non-profit fellowship or society of men and women for whom drugs hadbecome a major problem’, which ‘encourages its members to abstain completely from all drugs’.60 Although there are still only very few UK studies in this area,61a longitudinal, prospective cohort study of 142 drug-dependent clients interviewed at intake to residential treatment in the UK, and again at 1-year, 2-year and 4-5-yearfollow-up, found that those who attended NA/AA, in particular those who attended atleast weekly, were more likely to be abstinent of opioid drugs at all follow-up pointsthan those who did not.15 This study showed reduced stimulant use at 1-year follow-upin those who attend NA/AA following residential treatment, but not at other follow-uppoints.61 Other studies have shown that active participation rather than just attendance,at 12-step groups was associated with reduced cocaine use.15 This is consistent withfindings that the efficacy of certain psychosocial treatments, including 12-stepprogrammes, is dependent on individual patient characteristics of cocaine-usingpopulations, which can be subdivided based on personal characteristics, such as belief in the 12-step programme.59 This emphasises the importance of the medicalprofessional tailoring a treatment package to the individual patient in order to optimise outcomes.
Illicit drug use in pregnancy
Medical professionals have a responsibility to identify pregnant women who are usingillicit drugs, and to engage them in treatment. The earlier members of this populationare able to access treatment services, the better the outcome will be for their generalphysical health, the pregnancy and the neonate.
A sensitive, non-judgemental approach is essential in engaging this population andoptimising treatment effectiveness. Medical professionals have a role to play not only inportraying this through their own clinical care and manner, but in leading their clinicalteams to be approachable, non-judgemental and patient centred in this situation. Thiswill include attention not only to physical healthcare and management of drug use, butsensitive attention to the coexistent psychological difficulties and social concerns thatthe patient may be experiencing. The medical professional and the full multidisciplinaryteam will need to address the woman’s fears about the involvement of children’sservices; anxiety and guilt about the potential impact of their drug use on their baby;62and concerns the patient may have about finances, support networks, and copingstrategies during pregnancy and their forthcoming parenthood. The NICE guidelines onPregnancy and complex social factors62 recommend that the first time a woman whouses substances discloses that she is pregnant, she should be offered referral to anappropriate substance use programme. They also recommend that a variety of methods(eg text messaging) should be used to maintain contact and engagement, and toremind women of upcoming and missed appointments.62 Drugs of dependence: the role of medical professionals The medical professional must ensure high-quality effective interagencycommunication. Multiagency team work is also essential, working with social careprofessionals and ensuring seamless communication between general practice andthe specialist services involved in the patient’s antenatal care, including obstetrics,specialist drug services and any other specialist healthcare services. Multiagency caseconferences, with prospective parents invited as participating attendees, willfacilitate good inter-team communication and optimise clinical care.63 The following case study illustrates some of the additional issues to be considered in pregnancy.
Case study: Illicit drug use in pregnancy
Ms B is 23 years old. She is smoking about £30 of heroin and £10 of crack per day. She does not drink any alcohol. She has presented for treatment and is 14 weekspregnant for the second time.
Ms B was brought up in a small isolated community and was one of six children. Herfamily were very strict and she was not allowed to have friends outside the community.
Between the ages of 10 and 13 she was subjected to regular sexual abuse by an unclewho lived with the family. She once told her mother about the abuse but was told tokeep it quiet and not tell anyone, as it would bring shame on the family. Her mother hadbeen seriously depressed when she was a child.
She did well at school and started work in a local estate agent’s office when she leftschool. She began to see Mr Y, who was the brother of one of her school friends. Mr Y was a heroin user and eventually she started smoking cigarettes that he gave her.
She thought these were cannabis. After a few months, she noticed that she felt veryunwell if she did not smoke and Mr Y told her that the cigarettes had heroin in them.
She started rowing with her family and left home to live with Mr Y in a squat. Their drughabits were funded by Mr Y’s shoplifting.
When she was 19 she found she was 28 weeks pregnant. She presented to a local GP,who prescribed her methadone and referred her for antenatal care. Social services wereinvolved. She had very little antenatal care and avoided the appointments with the socialworker, who she only met once. She continued to use heroin on top of her prescription.
She went into labour at 36 weeks and had a baby boy. For a few weeks she went back,with her baby, to live with her parents (with the support of social services) and stoppedusing heroin but the rows with her mother were so bad she eventually left the baby withher mother and went to live with Mr Y in a big city.
Drugs of dependence: the role of medical professionals For the next three years she lived in a series of squats with Mr Y and continued to usedrugs. Ms B’s son lived at home with her mother. She occasionally slept with men to getdrugs. Mr Y started drinking alcohol and started hitting her when they argued.
She came into treatment when Mr Y was arrested for aggravated burglary and went toprison. He was sentenced to four years.
Ms B was engaged in treatment by the city’s drug services. She registered with a GP. She was prescribed buprenorphine and managed in an antenatal liaison clinic, where shereceived antenatal care and drug treatment. Social services were involved from thebeginning and found her a place in a local women’s hostel.
Ms B was able to stop using heroin and begin to think about some of the problems she had with her abusive relationship and her history of sexual abuse. Her second baby, a little girl, was born at full term and was immediately subject to child protectionproceedings and taken into foster care but Ms B had regular contact with the baby. She subsequently went, with the baby, to a mother and baby rehabilitation centre whereher parenting could be assessed and she could reduce her buprenorphine. Ms B was clearshe wanted to stop using all drugs, keep her daughter and re-establish a relationshipwith her son and her family.
Case study details provided by Dr Emily Finch, a consultant addiction psychiatrist.
Drugs of dependence: the role of medical professionals For opiate use in pregnancy, the focus is on stability. It is safest to prescribe opiate
substitution (see Chapter 8) ‘at a dose that stops or minimises illicit use’.62
Detoxification may be considered, if requested, during the second trimester, as long
as this does not precipitate a relapse in illicit drug use; but it should be avoided
during the first and third trimester because of the risk to the fetus.63,64
Buprenorphine is not licensed for use with pregnant women, but research suggestsno adverse effects on the pregnancy or neonatal outcomes.65,66 The UK guidelines on the clinical management of drug misuse and dependence63 advise that if apregnant woman is stable on buprenorphine and informed of the risks, it isreasonable to leave her on a prescribed dose of buprenorphine, rather than riskinducing withdrawal in the fetus or destabilising the patient’s treatment bytransferring to methadone, unless otherwise needed. The treatment focus again is on stability and maintaining engagement.
In all pregnant women using or prescribed opioid drugs, particular consideration willalso need to be given to their birthing plan, including pain management and the riskof fetal distress at birth.64,65 As in the case of the non-pregnant woman, there is currently no substitutiontreatment for cocaine. In view of the potential harms to the fetus and to themother’s health, the pregnant woman should be given support to stop using cocaineduring pregnancy. A non-judgemental, sensitive approach, with clear and effectivemultidisciplinary communication and team working are again essential, addressingthe full spectrum of psychosocial and physical health needs. Psychological therapies,including family therapy where possible, may be offered.63 Relapse prevention CBTshould be offered, and marked efforts made to ensure continued engagement of the patient.
Drugs of dependence: the role of medical professionals Summary
• Consistent evidence shows that doctors in primary and secondary care and in
mental health settings frequently do not address alcohol and drug use.
• Caution should be exercised in prescribing drugs with potential for dependence, particularly for patients who are at high risk for dependence or diversion.
• Management of medical emergencies related to acute symptoms of withdrawal should be followed by longer-term medical management and support to reducedependence.
• It is also important to address strategies for relapse prevention after detoxification.
• The use of naloxone for relapse prevention after opioid detoxification is of • Psychosocial interventions that help users to identify high-risk situations and use coping strategies have been shown to be helpful in managing cannabis dependence.
• In US studies, contingency management in the form of voucher-based reinforcement has been found to significantly improve outcomes for all substance use disorders apart from alcohol. Couples-based therapy and support groups are also of value.
• Brief therapist interventions and motivational interviewing have been shown to reduce drug use among young people. Opportunistic interventions in patientsattending for HIV testing has also been shown to increase the likelihood ofabstinence and reduce arrest rates.
• Illicit drug use in pregnancy needs particular care with medical management, to avoid harm to both the mother and her baby.
Drugs of dependence: the role of medical professionals Drugs of dependence: the role of medical professionals

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