Substance use is common in women of childbearing age. Prior to pregnancy, approximately 55 percent of women drink alcoholic beverages, 23 percent smoke cigarettes, and 10 percent use either illicit drugs or prescription drugs without a prescription [1]. Although most women are able to quit or cut back harmful substances during pregnancy, many are unwilling or unable to stop. National survey data indicate that during pregnancy, 10 percent of women drink alcohol (4 percent binge, i.e. have 5 or more alcoholic drinks on the same occasion on at least 1 day in the past 30 days), 15 percent smoke cigarettes [1], and 5 percent use an illicit substance. This makes substance use as more common than many conditions routinely screened for and assessed during prenatal care (PNC), such as cystic fibrosis, gestational diabetes, anemia, postpartum depression, or preeclampsia. Moreover, substance use during pregnancy is both costly and harmful. Substance use during pregnancy is associated with poor pregnancy outcomes, including preterm birth, low-birth weight, birth defects, developmental delays, and miscarriage [2]. Long-term effects on the mother and infant include medical, legal, familial and social problems, some of which are lifelong and costly [3, 4].
The perinatal provider, therefore, has an important medical and ethical role in screening for substance use, counseling women on the importance of avoiding harmful substances, supporting their behavioral change, and referring women with addiction to specialized treatment when needed [5, 6]. This process, known as SBIRT (screening, brief intervention, and referral to treatment), represents a public health approach to the delivery of early intervention and treatment services for persons with substance use disorders (SUDs) [7] (Figure 2.1). Its use in emergency, general primary care, and obstetric settings for alcohol and tobacco has been recommended by the U.S. Preventive Services Task Force [8, 9] as well as by professional societies such as the American College of Obstetricians and Gynecologists (ACOG) [10].
| Component | Goal | Approach |
|---|---|---|
| Screening | To assess substance use and its severity | Patient-/computer-administered instrument or direct provider questions (see Figure 2.2) |
| Brief intervention | To increase intrinsic motivation to affect behavioral change (i.e. reduce or abstain from use) | 1–5 patient-centered counseling sessions lasting less than 15 minutes using principles of motivational interviewing (see Figure 2.5) |
| Referral to treatment | To provide those identified as needing more treatment access to specialty care | Warm handoff to specialized treatment (e.g. provider to provider phone call), which requires practitioner familiarity with community resources and systems of care |
Figure 2.1 Components of screening, brief intervention, referral to treatment (SBIRT)
Unfortunately, a number of barriers have limited SBIRT’s public health impact, particularly during pregnancy. First, although universal screening for substance use is recommended during pregnancy [11], many women are not screened [12] or not screened with evidence-based screening tools [13]. Providers often feel overwhelmed by the number of disease states for which they are expected to screen and/or feel inadequately trained to screen for substance use [14]. Clinicians may also question the clinical utility of screening and the likelihood that women will reduce substance use or attain abstinence; conversely, they may be under the impression that they do not have patients who use substances in their practices or may not want to “play police” due to mandatory reporting requirements in some states [15]. In addition, providers may feel at a loss of what to do if they encounter a patient with a SUD or unsure how to help the patient if unaware of community resources for treatment. Finally, inadequate reimbursement for evaluation and management services is a disincentive to provide preventative care even in the case of pregnant women [16].
Second, failure to disclose substance use (or incomplete disclosure) is also common, and further complicates efforts to identify at-risk women [17–21]. Pregnant women also have reasons to withhold information about their use of substances in pregnancy. Some states have mandatory reporting requirements with the possibility of incarceration in a minority of states. This may not only create a disincentive for disclosure, but possibly for treatment-seeking itself [22]. Women may also be concerned about prejudicial treatment and stigma from their physicians who should be their advocates, while pregnant youth may fear disclosure to family members and the possible consequences of such disclosure.
Third, SBIRT research and practice has traditionally focused on the more commonly used substances such as alcohol and tobacco, with relatively less focus on illicit drugs [23]. This gap has become particularly apparent and troubling as rates of prescription drug misuse in pregnancy have risen steadily in recent years, leading to almost fivefold increases in the incidence of Neonatal Abstinence Syndrome (NAS) between 2000 and 2012 [24]. Recent literature has shown utility for SBIRT for illicit drug use during pregnancy [25].
Screening
Screening for substance use should be universal, as SUDs occur in every socioeconomic class, racial and ethnic group. Moreover, screening based on “risk factors” such as late entry to PNC or prior poor birth outcome potentially leads to missed cases and can exacerbate stigma and stereotype [11]. Universal screening is recommended by many professional organizations, including ACOG [5], the AAP [26], the American Medical Association (AMA) [27], and the CDC [6]. Screening should be done at the first prenatal visit, and repeated at least every trimester for individuals who screen positive for past use. In addition, screening for tobacco use, at risk drinking, illicit drug use, and prescription drug misuse should occur on an annual basis as a part of routine well-woman care. Women should be asked at medical exams if they are planning to get pregnant in the next year, so that adequate contraception and preconception care can be provided.
Screening Summary:
Screening for substance use should be done on all pregnant women at the first prenatal visit and subsequently throughout pregnancy on those women at higher risk;
Screening can be done either by using a validated instrument with follow-up by the provider or by asking standardized questions during the interview;
Screening should be nonjudgmental and questions should be open-ended;
Urine toxicology testing should not be used in place of substance use screening questions.
Most of the studies looking at screening have focused on using instruments, such as TWEAK, TACE, 4P’s, or Audit C. These instruments have the advantage of being validated and most are fairly sensitive. Also, preliminary screening can be done by anyone in the practice, with follow-up by the provider (Figure 2.2).
| Instrument | Substance | Validated in pregnancy | Subjects identified |
|---|---|---|---|
CAGE (1)
| Alcohol | No | At risk drinking |
T-ACE (2)
| Alcohol | Yes | At risk drinking |
TWEAK (3)
| Alcohol | Yes | At risk drinking |
4Ps(4)
| Any substance | Yes | Any affirmative is considered a positive screen |
| Substance Use Profile-Pregnancy (5) | Alcohol Illicit drugs | Yes | Any drinking or illicit drugs |
| AUDIT-C | Alcohol | Yes | Any drinking |
* Modifications of the 4Ps screener are available, e.g. the 5Ps (adding smoking) and the 4P’s Plus© [3] which is copyrighted and requires a yearly fee to use.
1. Ewing J. A. Detecting alcoholism. The CAGE questionnaire. JAMA. 1984;252(14):1905–7.
2. Sokol R. J., Martier S. S., Ager J. W. The T-ACE questions: practical prenatal detection of risk-drinking. American Journal of Obstetrics and Gynecology. 1989;160(4):863–8; discussion 8–70.
3. Russell M. New assessment tools for risk drinking during pregnancy: T-ACE, TWEAK and others. Alcohol Health & Research World. 1994;18:55–61.
4. Ewing H. A Practical Guide to Intervention in Health and Social Services, with Pregnant and Postpartum Addicts and Alcoholics. Martinez, CA: The Born Free Project, Contra Costa County Department of Health Services, 1990.
5. Yonkers K. A., Gotman N., Kershaw T., Forray A., Howell H. B., Rounsaville B. J. Screening for prenatal substance use: development of the Substance Use Risk Profile-Pregnancy scale. Obstetrics and Gynecology. 2010;116(4):827–33.
Figure 2.2 Examples of screening instruments
Barriers to implementing instrument-based screening include patient discomfort and lack of literacy, staff resistance due to time pressures, and organizational issues such as lack of administrative support [28]. Integration into practice flow can be eased by incorporation into electronic medical record systems (EMR) or by using a computer-based approach, which may diffuse the discomfort women feel in disclosing a behavior about which they are embarrassed, but this has not been compared to clinician administered screening in pregnant women [29]. All positive screens require follow-up by the provider.
To counteract some of the institutional barriers to instrument-based screening, some experts encourage simply asking three open-ended questions regarding use of tobacco, alcohol, and other drugs (The NIDA Quick Screen) [30]: In the past year how many times have you drunk more than four alcoholic drinks per day? Used tobacco? Taken illegal drugs or prescription drugs for nonmedical reasons? This screen needs to be validated in pregnancy. Women are also more likely to report lifetime use or use before pregnancy than they are to disclose use during pregnancy because of the risks and stigma involved. More important than the use of any specific screen is to be consistent and to ask the questions of everyone.
Regardless of which method is used and how the screening is delivered, it is essential that conversations around substance use be nonjudgmental. Prefacing screening with statements such as “I ask all my patients about substance use” can help normalize the enquiry and increase patient comfort with disclosure. The process of screening is only the first step in a conversation with the patient that may lead to treatment referral or provision of other treatment resources.
Urine drug testing is a common practice for many obstetricians and family practice physicians. It does have the advantage of detecting use in cases where the woman does not disclose her use and may help in diagnosing NAS. Toxicology testing is a useful adjunct for individuals in SUD treatment [31] and has utility at the time of delivery [6] in case of complications of pregnancy, where knowing the substance used informs management decisions. Toxicology testing of pregnant women also has a number of limitations and negative consequences and should therefore never be done without the woman’s knowledge or consent. For example, it greatly increases the risk of legal or child welfare involvement, particularly in states with mandated reporting requirements that include mention of drug use during pregnancy. This places physicians in a difficult ethical position, and raises the likelihood that women will fail to disclose potential health risks or avoid recommended medical care [22]. Further, the reporting of drug use during pregnancy to child welfare – made more likely or even mandated as a result of positive toxicology – is strongly biased against racial and ethnic minorities [11], even following concerted efforts to prevent such bias [32]. A positive toxicology test also shows evidence of use, but does not provide any information about the nature or extent of that use; similarly, a negative test does not rule out substance use, which is often sporadic [15]. Additionally, the consequences of false positive results can be devastating to the woman and her family.
Finally, the use of toxicological testing for illicit drugs encourages a focus on substances such as cocaine, opiates, and marijuana that is not justified by their prevalence or the risk that they pose. Other substances such as tobacco and alcohol pose as much or more risk [33] and are far more prevalent [1]; similarly, other risk factors such as inadequate PNC, depression, or violence exposure present significant unique risks that should be acknowledged – and that is not amenable to toxicology testing. If drug testing is used, a discussion of all substances and medications taken is mandatory as it will allow the clinician to order the correct test(s). Many substances including synthetic opioids, such as oxycodone, fentanyl, buprenorphine, and some benzodiazepines [34], are not routinely captured by standard urine tests, and, if suspected, must be ordered separately. In addition, regular urine drug screens do not pick up alcohol use, and tests for alcohol metabolites, such as ethyl glucuronide (ET-G) and ethyl sulfate (ET-S) are not routine, nor well studied in pregnant women. For these reasons, most specialty societies including ACOG, APA, and ASAM do not endorse using urine drug testing as a primary means to screen women for drug use during pregnancy.
Clinicians who do use urine drug testing should ensure that all positive drug tests are followed-up by confirmatory testing by mass spectrometry (MS). The health care provider should be aware of the potential for false-positive and false-negative results of urine toxicology for drug use, the typical urine drug metabolite detection times, and the legal and social consequences of a positive test result. It is incumbent on the health care provider, as part of the procedure in obtaining consent before testing, to provide information about the nature and purpose of the test to the patient and how the results will guide management [35]. Further discussion of urine drug screening will occur in Chapter 3.
The overarching purpose of screening for substance use is to stratify women into zones of risk given their pattern of use. The Expert Group on Perinatal Illicit Drug Abuse [36] developed the risk pyramid shown in Figure 2.3. The majority of women will fall into the low-risk zone (i.e. no past use of tobacco, alcohol, or other drugs, or low levels of substance use that stopped prior to or immediately following knowledge of pregnancy) and will need only brief advice/reinforcement. Moderate-risk women are those who have used high quantities of (any) substances in the past (including those who have been recently treated for SUDs), those who stopped during pregnancy, and those with sporadic, low-level use during pregnancy. Per the consensus of the group, these are the women who benefit most from brief intervention (BI). Only about 4–5 percent of women will fall into the high-risk zone of continued use of illicit drugs during pregnancy [1]. Women in the high-risk zone meet criteria for SUD. While these women can benefit from BI, most need referral to specialized addiction treatment. Figure 2.4 illustrates the flow of SBIRT in clinical practice.
Figure 2.3 Risk pyramid for substance use in pregnancy
SUD = substance use disorders
Figure 2.4 Flow chart of SBIRT in practice
Brief Intervention
Women who did not use substances prior to pregnancy or those who used at low-levels in the past and report cessation of all substance use (often due to pregnancy) are considered to be in the low-risk group. For this group, brief advice can be given. The simplest form of such intervention is reinforcement to remain abstinent (e.g. “That’s great you do not use drugs or alcohol, as drug use has been shown to cause many complications in pregnancy and problems with your baby, and there is no safe amount of alcohol use in pregnancy” [37]). Providing written handouts to all women can reach women who are afraid to disclose use, but may be at risk and need treatment.
Individuals who screen positive for any substance use in pregnancy and fall into the moderate-risk group should receive a BI. This type of intervention is a patient-centered form of counseling using the principles of motivational interviewing (MI) to effect behavioral change. Motivational interviewing was first described by Miller in 1991 [38] and has been adapted to various interventions in health care settings [39]. The purpose of MI is not to “cure the patient,” but to instill in her a desire to change by pointing out discrepancies between her current behavior and her future goals. This is facilitated in pregnancy because the overwhelming majority of women desire a healthy pregnancy and healthy baby. Principles of MI include using an empathetic counseling style, asking open-ended questions, developing rapport and trust, expressing empathy, and rolling with resistance. MI must be nonjudgmental and works best if the patient adopts the motivation and develops a plan to change her behavior [38].
For the provider, the three tasks of an effective BI are to: (1) provide feedback of personal responsibility (e.g. “As your doctor, I recommend you stop using cocaine for your health and the health of your baby, but it’s your decision on what you want to do.”); (2) listen and understand a patient’s motivation for using one or more substances (e.g. “I hear that you use drugs to deal with the stress of your life at home”); and (3) explore other options to address patient’s motivation for substance use (e.g. “Are there other ways you deal with stress in a more healthy way?”). Yet, the provider’s objective is not to warn the patient as strong warning statements are often met with resistance from the patient. For example, stating: “Your baby could have a birth defect if you continue to drink alcohol” can be countered with: “I drank in my last pregnancy and that baby is fine.” Resistance is a sign that the provider has pushed too hard. “Rolling with resistance” is a technique to redirect the conversation to a less threatening area. For example: “I’m not saying that your baby will definitely have a birth defect, but as your doctor, I’m concerned that your baby may be affected by your drinking. Babies who are exposed to alcohol in the womb can have lifelong medical and psychological problems.”
Being judgmental, finger waiving, shaming, and/or using sarcasm are not effective ways of motivating people to implement behavioral changes. Finding a “hook” or reason for which the patient would like to change their harmful behavior is more effective (e.g. “How would your life be better if you didn’t use opioids?”). One technique used often to discover this “hook” is to ask open-ended questions (e.g. “What do you like about …?” or “What don’t you like about …?”) followed by summary statements (e.g. “I hear that you smoke cigarettes to calm you down, but you don’t like how much they cost and how they make you smell [i.e. reflecting the patient’s own words], and you’re worried about the effects they could have your baby. It sounds like having a healthy baby is very important to you.”) Examples of language that can be used in a brief intervention are illustrated in Figure 2.5.
| Raise subject |
|
| Provide feedback |
|
| Enhance motivation |
|
| Negotiate plan |
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