Woman On Methadone Who Has Found Out She Is Pregnant — Free SCA Practice Case

Character Overview: You are Alanna Corrigan, a 33 year old woman who works three days a week at a garden centre, on the tills and in the plant area. You live in a rented house with your partner Tyrone, who drives a van for a courier firm, and your daughter Sienna, who is 6. You started using heroin at 24 after a bad relationship and went onto methadone three years ago. You have had 50 mg a day for over a year, have used nothing else for twelve months, and you are proud of that. Two home tests this week were positive and you think you are about eight weeks. You are frightened rather than unhappy. You want this baby, but you are sure that methadone will make the baby "addicted", and you have decided to stop it completely this week to give the baby a clean start. You speak quickly and a bit defensively at first, then more quietly and honestly when the doctor is kind. Your voice cracks when you talk about Sienna's first days.

Opening Sentence: "Hello doctor. I've just found out I'm pregnant, about eight weeks I think, and I want to come off my methadone completely, this week if I can. I'm not having my baby born addicted."

History if Asked (Data Gathering Phase)

• ●The pregnancy: "I did two tests, Monday and Tuesday, both positive. My last period was about eight weeks ago and my periods have been regular since I got stable. I'm a bit sick in the mornings and my chest is sore and I'm tired. No bleeding and no pain, nothing like that."
• ●Whether she wants it: "Yes. It wasn't planned but Tyrone and I talked all night and we both want this baby. I'm not thinking about anything else."
• ●What she means by coming off: "Stop it. I've got four days left of this week's bottles, so I'll just finish them and not collect any more. I'd rather get the sickness over with now, before the baby is any bigger."
• ●Support for stopping: "No. I haven't asked anyone. I just thought I'd do it myself, I've done it before."
• ●Previous attempt: "Two years ago I cut my dose down really fast, I wanted to be off it. Two weeks in I couldn't stand it, the aching and the sweats and not sleeping. I used heroin for about three weeks and then went back to the service and started again. I felt awful about it."
• ●Current methadone and stability: "Fifty milligrams every morning, same dose for over a year. I collect it weekly from the pharmacy now and I take it myself at home. My urine tests are clean. The service is Lyndsey, my keyworker, and the doctor there."
• ●Illicit use now: "Nothing. Not a thing for twelve months."
• ●Telling people: "Only Tyrone and my sister Kayleigh know. I haven't told the drug service. I haven't told anyone at the surgery. I was scared they'd tell social services and then it all goes wrong."
• ●Injecting and hepatitis C: "I injected for a few years before the methadone. I stopped when I started the programme. I had hepatitis C and the service treated it and I was cleared two years ago."

Ideas, Concerns, Expectations

Gating note: Alanna does not volunteer these. Each part comes out only when the doctor asks what she thinks the methadone will do, what worries her most, or what she hoped to get from the appointment.

• ●Ideas: She believes any methadone reaches the baby and makes it "born addicted", and that the sooner she is off it the better. She thinks stopping quickly is braver and cleaner than staying on it. "It's a drug, isn't it? It goes straight to the baby. If I'm off it, the baby can't be addicted."
• ●Concerns: Her main fear is a repeat of Sienna's first days. Sienna was born when she was using heroin and spent four days in the special care unit on morphine drops for withdrawal. "I stood there watching her shake and scream and I couldn't do anything. I'm not putting another baby through that." She is also afraid that social services will take the baby. When Sienna was little there was a child in need plan, which closed two years ago. A friend lost a baby that way. She also privately worries that she will relapse if she stops.
• ●Expectations: She came hoping the doctor will tell her how to stop quickly and safely, maybe with something for the sickness and the aches. "You tell me how to get off it, and I'll do it."

If Asked: Medical History and Medications

Gating note: Alanna answers each of these directly when asked.

• ●Other health problems: "Just the hep C, which is cleared, and asthma as a kid. No other conditions. No operations."
• ●Tablets and other medicines: "Only the methadone. No sleeping tablets, no diazepam, no pregabalin, nothing from the chemist."
• ●Vitamins and folic acid: "No. I've not taken anything."
• ●Blood tests for infections: "Hep B jab done. HIV negative about a year ago at the service."
• ●Allergies: "None."
• ●Mood: "Anxious and not sleeping well since Monday. Not low. I've never wanted to harm myself and I don't now."
• ●Last pregnancy: "Sienna. Normal birth at 38 weeks, and then four days in special care."

Social History and Lifestyle Impact

• ●Home: Lives with Tyrone and Sienna. Tyrone does not use drugs and drinks the odd beer at the weekend. Their relationship is safe and supportive. He says he will do whatever the doctor says. Kayleigh lives ten minutes away and helps with school pick ups.
• ●Work and money: Works three days at the garden centre. Money is tight but manageable.
• ●Smoking and alcohol: Smokes about ten cigarettes a day and would like help to cut down. No alcohol since she found out, and very little before. No cannabis or other drugs.
• ●Storage at home: The methadone bottles are in the kitchen cupboard above the fridge, not locked. Sienna cannot reach them without a chair, and she has not tried.
• ●Children's services: If asked about the plan from when Sienna was a baby, she says it closed two years ago and she has had no contact since. A health visitor used to come.
• ●Availability: Can come in to be seen or go to appointments any weekday except her work days, and Tyrone can drive her.

If Asked: Associated Symptoms

Gating note: Alanna answers these only when asked. Every one is negative unless stated.

• ●If asked about vaginal bleeding, pain low in the tummy, pain in the shoulder tip, dizziness or fainting: "No, nothing. Only the sickness."
• ●If asked about vomiting so much she cannot keep things down: "No. I'm sick once or twice in the morning and then I'm fine."
• ●If asked about withdrawal symptoms now: "No, I take it every morning and I'm fine on it."
• ●If asked about cravings or any thoughts of using: "Not really. A bit if I'm stressed, but I haven't used."

Responses to Management (The Negotiation Phase)

• ●If the doctor advises staying on methadone and not stopping it this week:
  • ●Reaction: Distressed and resistant. "But that's the whole point. I don't want it in the baby." If the doctor explains that stopping suddenly makes her ill and can stress the baby, and that going back to heroin would be far worse, and links this to what happened last time: "Yeah. When I came off before I was back on it within three weeks." She accepts, quietly. "So you're saying I can't ever come off it?" If told a slow reduction could be thought about later, with the specialists, once the pregnancy is further on and if she is still stable: "So not now, but maybe later, if it's safe? I can live with that." If she feels lectured, she says "You're telling me I'm a bad mum."
• ●If the doctor explains what may happen to the baby, or she asks:
  • ●Reaction: Anxious for honesty. "Will she be born addicted? Sienna was in hospital for days." If told the baby may have withdrawal symptoms in the first days, that this is treatable and monitored in hospital, that it is different from addiction, and that breastfeeding can help: "So it's not the same as being an addict. And I can feed her myself?" She cries a little and says, "I just don't want her to suffer like Sienna did."
• ●If the doctor asks about social services or children's services:
  • ●Reaction: Defensive, then wary relief. "Are you going to ring them? Everyone told me that's what you do." If told that being on methadone is not a reason to take a baby, that midwives and the drug service plan support together and that she will be told about and invited to any meeting: "Okay. As long as I know what's going on." If told bluntly that they will be informed, she says, "Then I won't come back."
• ●If the doctor suggests contacting the drug service and arranging maternity care:
  • ●Reaction: Hesitant, then agrees. "Do you have to tell Lyndsey?" If told it is to keep her dose safe and so everyone works together, and the doctor asks her permission: "Okay, yes, you can ring Lyndsey. She's good." She asks, "When do I see a midwife, and who rings me?"
• ●If the doctor suggests changing methadone to buprenorphine, or if she asks:
  • ●Reaction: "Kayleigh said I should ask about Subutex because it's safer for babies." If told that switching in pregnancy can cause sudden withdrawal, is not usually advised and would be a specialist decision, and that methadone is a safe option when taken properly: "Right. Then I'll stay as I am."
• ●If the doctor describes safety netting, storage or practicalities:
  • ●Reaction: Wants specifics. "What would be an emergency? What if I'm sick and can't keep my methadone down?" If safety netting is vague, such as "come back if it gets worse": "Worse how? What do I do at night?" She says she will buy a lockable box today when told it should be locked away. She repeats back the plan clearly when it is specific.