In this issue of the American Journal of Obstetrics and Gynecology , we are introduced to “The role of screening, brief intervention, and referral to treatment (SBIRT) in the perinatal period: A Special Report on the Expert Panel of Perinatal and Illicit Drug Use.” While SBIRT is a well-known acronym in the practice of addiction medicine, it has not yet made its way to the myriad acronyms that we embrace in obstetrics and gynecology. This panel of experts convened in September 2012 to address key issues related to drug use during pregnancy in the United States. In spite of the gap in time between the panel and this publication, the message remains timely and calls for action. Substance abuse in pregnancy, the panel argues, is often ignored or managed poorly, and screening for substance abuse using SBIRT in pregnancy should be universal.

Any person currently caring for obstetric patients has been faced with the opiate epidemic. While the babies affected by neonatal abstinence syndrome first brought this problem to the forefront, the prevalence of opioid use among women of childbearing age has concomitantly reached epic proportions. The genesis of this epidemic has been multifactorial: overprescription of narcotics, pain control being considered a vital sign that is linked to patient satisfaction, and a highly evolved/elusive system of drug trafficking that we have not encountered before. As prescription narcotics have become highly regulated and less accessible, heroin has reemerged as a readily accessible and highly addictive alternative. In spite of the disease burden substance abuse and opiate use disorder represents, we are unable to really quantify it in pregnancy, because we are not organized in our attempts to identify the disease.

In current practice, we hesitate to screen for substance abuse for many reasons. Specialists in obstetrics and gynecology discuss sensitive topics daily. Hence, the sensitive nature of the topic is unlikely to be the main barrier to discussion. Barriers that our authors identify include the need to identify the optimal screening tool for pregnancy, time and resources to effectively screen, the impact of reporting requirements upon the doctor/patient relationships, and the overall lack of treatment options that exist for referral should screening identify a problem. These barriers, coupled with a lack of training that obstetrician-gynecologists receive in identifying and managing substance abuse, make implementing SBIRT a difficult, but not insurmountable, task. A tool such as SBIRT may allow universal screening to become routine and of little burden to providers.

Obstetrician-gynecologists are often encouraged by outside influences to pursue universal urine drug screening (UDS) as a screening tool for substance abuse in pregnancy, but this is likely not the answer. What sounds like a simple and efficient idea in theory is plagued by its own set of limitations. Among them: a positive toxicology test shows evidence of current use, but not the extent of use or chronicity, and a negative drug screen does not necessarily rule out substance misuse. Although there are times when UDS is helpful in patient management, the overall negative consequences (ie, fear of involvement of the legal and child welfare systems may actually limit women from seeking prenatal care) of universal UDS as a screening tool outweigh the benefits. If we truly wish to do best by our patients, we must engage them in these conversations prompted by SBIRT and use UDS only: (1) with patient consent; and (2) as an adjunct to our conversations. There is no shortcut, and we must ensure that these conversations occur in compassionate, nonjudgmental ways.

The authors have supplied us with an excellent tutorial on SBIRT, both in theory and in practice. Readers will benefit both from an in-depth review of the rationale behind SBIRT and risk stratification, as well as samples of doctor/patient discourse that may enhance our interactions. The article reminds us that when screening identifies a low-risk woman, the brief intervention provides positive reinforcement of a woman’s decision to remain drug-free. Moderate-risk women may benefit most from a brief intervention that involves motivational interviewing to effect behavioral change, if needed. High-risk women, expected to be 4-5% of the general population, will be identified with ongoing use in pregnancy and require referral to treatment. The need for referral in high-risk women underscores the importance of familiarizing oneself with available treatment options in our communities, even if those options are perceived to be scarce.

As a physician who has worked with women having opiate use disorder specifically for the last 8 years, I hope that this report inspires us to embrace screening for substance abuse in pregnancy the same way we screen for much less prevalent disease states. SBIRT is predicated on being brief to increase the feasibility of implementation, and further, this practice is reimbursable. Current Procedural Terminology codes exist for SBIRT or E/M time-based billing may be employed, and RVUs are associated with this pursuit.

I encourage you to find a screening tool that works in your practice, and use it with regularity. Options validated in pregnancy include the 4Ps. Options we might borrow from primary care may include the single-question screen: How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons? The experts in this article also suggest the sensitivity of the National Institute on Drug Abuse quick screen : 3 open-ended questions regarding use of tobacco, alcohol, and other drugs: In the past year how many times have you drunk >4 alcoholic drinks per day? Used tobacco? Taken illegal drugs or prescription drugs for nonmedical reasons? As the optimal tool for screening in pregnancy has not been identified, at this time, the perfect tool is the one that you will reliably use.

Only good can come from attention to employing SBIRT during the perinatal period: as we incorporate SBIRT universally, we will only become better at it. The more confident we feel asking questions and providing referrals, the less stigma we will see associated with this disease state. As stigma decreases, patient-perceived barriers to seeking treatment may decrease, and we have the potential to see improved outcomes for a population that may not have previously embraced prenatal care. For those concerned that screening will identify more people than we have adequate resources to treat, I would argue that the only way we can demand more resources is to fully characterize the problem so our demands carry appropriate weight. Without data, our requests will fall upon deaf ears.

Thank you to the authors for submitting their special report and call to action. In my experience in the area of substance abuse and pregnancy, there are a lot of interested parties calling for someone to do something. This expert opinion calls on all of us to be those “someones.” SBIRT may appear to be an additional, onerous burden, but in today’s world, it is all in a day’s work. SBIRT is now in our tool belt… so, let’s get to work.