Pregnant Women with SUDs Not Identified with Initial Screening

Women with appropriate opioid use such as those taking prescribed opioids via prescriptions will be more likely to be identified during the screening process than the woman who is misusing prescription medications or using illicit drugs. For those who do not report taking prescribed opioids, they should be identifiable using the state prescription monitoring programs (PMPs) [1]. All physicians should register for their state PMP programs [2]. Patients who may not be identified via a state PMP could include women who are being prescribed and filling their prescriptions out of state. Some patients may be using online pharmacies but this should be considered misuse unless the patient received the prescription from a regular caregiver.

Out-of-state prescriptions can be a particular problem in border areas. Some states have agreements with bordering states to share information across state lines in their prescription monitoring databases. Physicians should familiarize themselves with their own states’ PMP and whether information from neighboring states is included. A large number of states do share their PMP data and physicians should stay current on the availability of this information in their state and which states participate in PMP data sharing [3]. If a patient is using a prescribed opioid for pain as directed by a legitimate prescriber and does not disclose this information to her obstetrician, this could be considered a red flag for SUD, but also could be due to fear of reporting to child welfare. This should be addressed in a nonjudgmental manner, and confidentiality should be assured.

Women taking prescription opioid medications can be considered to have an opioid use disorder (OUD) if they take more than prescribed or use in an aberrant pattern. Additionally, any woman taking prescription opioid medication that was not prescribed for her should be considered to have an OUD or to be at high risk for an OUD. This includes women borrowing opioid medication from friends or family.

Unfortunately, there are some physicians and other prescribers who have overprescribed and who have contributed to the current epidemic of opioid use. The medical world is at a crossroads regarding the ongoing practice of long-term use of high dose opioid medication for chronic pain conditions [4]. If a woman has been chronically prescribed unusually high doses of an opioid, she will typically have a diagnosis to support that use, will become dependent on that dose, and both she and her physician may be very resistant to the suggestion that her use is inappropriate or that other modalities may be available. The fact that she has a physician supporting her use is extremely validating to that patient. It is inappropriate to suggest that this patient have her medication changed to methadone or buprenorphine without further assessment. Doing so labels her as having an OUD. Being treated as a patient with an OUD rather than a patient with chronic pain puts her in a different treatment milieu, which could be alternatively helpful or harmful. This will be a very difficult and frustrating situation for the obstetrical care team. Instead of labeling the patient with an OUD, using harm reduction principles and “meeting the patient where she’s at,” can continue the patient’s engagement in prenatal care and other treatment, which is imperative for the best pregnancy outcomes. It is important to individualize treatment to best meet the needs of that patient, in coordination with her other prescribers and consultation with addiction medicine specialists.

Risk Factors for SUD

Recognized signs and symptoms that represent a risk of SUD will generally fail to be all-inclusive and will also be nondiagnostic. When interviewing a patient at risk for SUD, there can be subtleties that suggest the patient may be avoiding disclosure. Patients with SUDs may minimize or rationalize their drug or alcohol use, they may exhibit behaviors that discourage further questioning such as anger or irritability, they might lie, and they might have personal denial of the consequences of their use.

Whether the 4Ps [5] are used as a screening tool or not, the last two questions of that tool are useful to keep in mind:

Family and partner history are not only risk factors, but are also a good way to initiate a conversation. Patients are often more comfortable discussing drug and alcohol use among others than in discussing their own use. This discussion can lead to better rapport if the information is discussed in an empathic and nonjudgmental style.

There are many psychosocial factors that may be considered risk factors for substance use. These include an unstable job or educational history as demonstrated by frequent job changes or interruptions in education. High-risk behaviors include multiple sexual partners, history of sexually transmitted diseases, multiple pregnancy terminations, and working in strip or nude clubs or erotic dance clubs. Relationship problems such as intimate partner violence, history of childhood physical or sexual abuse, current marital dysfunction, and other social behaviors such as isolation, loss of friendships, distance from family members, and lack of interest or participation in hobbies or recreational activities can all be risk factors or warning signs of drug or alcohol use. Patients with chronic pain syndromes may be at risk for substance use in order to self-medicate their symptoms [6].

Behaviors and activities leading to legal problems are red flags for drug and alcohol use. This includes prostitution, violent behavior, assaults, DWI history, child custody problems, theft, and the more obvious crimes such as drug possession or sale. Frequent accidents, injuries, and falls can be additional signposts.

A thorough psychiatric history should be taken and patients should be observed for symptoms of depression, anxiety, post-traumatic stress disorder, sleep disturbance, memory problems, difficulty concentrating, and suicidal ideation.

During pregnancy, women with SUDs may initiate prenatal care late or not at all, have frequent missed appointments, behave erratically, or show signs of sedation, euphoria, intoxication, or withdrawal. Poor weight gain and poor nutrition can accompany substance use. The obstetrical history may also suggest risk factors, such as placental abruption, premature birth, low gestational size, and neonatal withdrawal syndrome in the infant.

Physical Signs of Drug and Alcohol Use

If drug use is parenteral, a thorough examination of the skin may reveal needle marks, track marks, signs of acute or chronic inflammation, evidence of “skin popping” or intradermal injection, cellulitis, and abscesses [7]. Parenteral use also increased the risk of co-existing HIV, Hepatitis B and C, bacterial endocarditis, and osteomyelitis. Histamine release from opioids causes itching and scratching, which can cause excoriation.

Opioid use causes meiosis, and withdrawal causes mydriasis. Excessive opioid use causes sedation, nodding off, and respiratory depression but mild intoxication will induce euphoria, talkativeness (soap boxing) [8], increased sociability, and stimulation with associated increased activity. These periods of good mood and activity may be difficult for a clinician to recognize as an opioid effect. Opioid withdrawal symptoms also include anxiety, restlessness, irritability, yawning, rhinorrhea, lacrimation, nausea, vomiting, sweating, chills, and gooseflesh (piloerection).

Opioid users will often use other drugs (polysubstance use) and this will confound the clinical picture. Signs and symptoms of other drug or alcohol use include alcohol on the breath, ascites, an enlarged liver, nasal ulcers or a perforated septum, poor dental health, obesity or cachexia, abnormal gait, tremor, slurred speech, change in pupil size, blackouts, accidental overdoses, other liver or gastrointestinal problems, conjunctival injection (bloodshot eyes), hyperphagia or anorexia, elevated blood pressure, tachycardia, chest pain, transient ischemic attacks, restlessness, sweating, and tremor – from withdrawal or stimulant intoxication [6].

Clinical Assessment of SUDs during Pregnancy

All pregnant women with an identified SUD should have a comprehensive medical history and physical examination including laboratory testing and a through psychosocial assessment. All elements of routine prenatal care should be provided. Consultation, communication, and coordination with an addiction specialist is recommended as the care of these patients can require multiple additional visits, phone calls, follow-up, and laboratory testing that may be beyond the capability and expertise of many obstetrical practices.

Mental health disorders, which often co-exist with SUDs, should be referred for appropriate psychiatric evaluation and treatment. It is best to find specialized psychiatric providers experienced in the care of pregnant women in order to maximize the use of nonpharmacologic treatments and to avoid or minimize the use of psychoactive medications such as benzodiazepines. Significant psychiatric conditions will require medication treatment. These conditions will be addressed in Chapter 4.

Monitoring abstinence from drugs and alcohol is best done through a combination of open patient communication as well as observation of signs and symptoms and behavioral patterns. Toxicology testing can be a useful adjunct in treatment settings, but should only be done with the written consent of the pregnant patient for the reasons discussed in Chapter 2. Drug testing will be discussed in detail later in this chapter.

Monitoring Pregnant Patients on Opioid Agonist Treatment (OAT)

Treatment of pregnant women with OUDs with opioid agonist medication throughout the pregnancy is the gold standard of care. A small percentage of women who have been either prescribed opioid pain medication or who have a mild OUD and are highly motivated may be candidates for medically supervised withdrawal (MSW) under the care of an addiction medicine specialist. MSW undertaken by the obstetrician should be done as part of a comprehensive substance use program and caution should be taken that all laws regarding opioid treatment are followed. Long-term intensive behavioral treatment is needed for successful outcomes with MSW during pregnancy, otherwise rates of relapse to harmful substance use with often deadly consequences is all too common [9].

The two opioid agonists currently approved for treatment of OUDs in the United States are buprenorphine and methadone. Treatment with these medications is usually referred to as Medication Assisted Treatment (MAT) or Opioid Agonist Treatment (OAT). Details of MAT/OAT will be addressed in Chapter 10.

Assessment of pregnant women receiving MAT requires communication with the MAT prescribers, with signed CFR 42 part B compliant release forms. Participation by a woman in an MAT program does not necessarily mean she is abstinent from illicit opioid use or other drug or alcohol use. Therefore, it is necessary to periodically review the woman’s success or address her struggles in treatment with the addiction treatment team.

Physicians and clinicians working in MAT programs are identified as addiction treatment providers and, as such, can only communicate with others, including other health care providers and obstetrical care providers, after the patient has signed a specialized consent form that complies with the law, specifically CFR 42 part B. Addiction providers will have CFR 42 part B compliant release forms. All pregnant patients known to be receiving these medications should be asked to sign a CFR 42 part B compliant release form allowing communication between the obstetrical team and the MAT team.

Not all pregnant women who are receiving MAT will be willing to sign a release form. This may be due to fear of child custody issues or other concerns. It is possible that a pregnant woman may never reveal her MAT with her obstetrical team. This is particularly true for women receiving methadone, which is always dispensed from a specialized federally licensed Opioid Treatment Program (OTP) in the United States. Although the methadone is prescribed, it is not dispensed by a pharmacy and, therefore, the methadone will not appear on a state PMP, or Prescription Monitoring Program, review. With appropriate and persistent counseling done by the OTP about the importance of disclosure of the treatment in order to provide the best care of her and her infant, hopefully most women will provide consent.

Pregnant women being prescribed buprenorphine for an OUD may be treated in an OTP, in a practice or clinic specializing in buprenorphine treatment, or in a private medical practice office. A CFR 42 part B compliant release form is also required in order to communicate with buprenorphine prescribers.

Obstetricians should contact the MAT prescribers if there are concerns of excessive medication effect or other signs and symptoms of drug use. Patients who are using additional drugs or medication may do so after they have seen their MAT prescriber and the MAT prescriber may not be aware of these signs or symptoms. There are many sedating medications now being misused by patients in order to augment the effects of their treatment medications. These drugs may not show up on a drug test because they are not all uniformly recognized as drugs of abuse. Common medications used in this fashion are clonidine [10], gabapentin, promethazine [11], and muscle relaxants, in addition to the commonly abused medications such as benzodiazepines, sleeping medications, and barbiturates.