Implementing Substance Use Screening in Family Planning

Clinician responses to cannabis use during pregnancy and lactation: a systematic review and integrative mixed-methods research synthesis

BACKGROUND

Perinatal cannabis use is increasing, and clinician counselling is an important aspect of reducing the potential harm of cannabis use during pregnancy and lactation. To understand current counselling practices, we conducted a systematic review and integrative mixed-methods synthesis to determine "how do perinatal clinicians respond to pregnant and lactating patients who use cannabis?"

METHODS

We searched 6 databases up until 2021-05-31. Eligible studies described the attitudes, perceptions, or beliefs of perinatal clinician about cannabis use during pregnancy or lactation. Eligible clinicians were those whose practice particularly focusses on pregnant and postpartum patients. The search was not limited by study design, geography, or year. We used a convergent integrative analysis method to extract relevant findings for inductive analysis.

RESULTS

Thirteen studies were included; describing perspectives of 1,366 clinicians in 4 countries. We found no unified approach to screening and counselling. Clinicians often cited insufficient evidence around the effects of perinatal cannabis use and lacked confidence in counselling about use. At times, this meant clinicians did not address cannabis use with patients. Most counselled for cessation and there was little recognition of the varied reasons that patients might use cannabis, and an over-reliance on counselling focussed on the legal implications of use.

CONCLUSION

Current approaches to responding to cannabis use might result in inadequate counselling. Counselling may be improved through increased education and training, which would facilitate conversations to mitigate the potential harm of perinatal cannabis use while recognizing the benefits patients perceive.

Family Planning Providers' Assessment of Intimate Partner Violence and Substance Use

Background: Intimate partner violence (IPV) and substance use are intersecting health problems that adversely impact sexual and reproductive health outcomes for women seeking care at family planning (FP) clinics. We aimed to characterize whether and how FP clinic providers (1) assessed for IPV and substance use and (2) combined IPV and substance use assessments. Methods: Providers and patients (female, 18-29 years old, English speaking) at four FP clinics participating in a larger randomized controlled trial on provider communication skills were eligible. Providers received training on universal education, a research-informed IPV assessment approach. Visits were audio recorded, transcribed verbatim, and coded by two independent coders. We used inductive and deductive coding to assess providers' communication approaches and examined codes for patterns and categories. We then converted these approaches into variables to calculate frequencies among recorded visits. Results: Ninety-eight patient-provider encounters were analyzed. In almost all encounters (90/98), providers assessed for IPV. Many providers adopted best practice IPV assessment techniques, such as universal education (68/98) and normalizing/framing statements (45/98). Tobacco use screening was common (70/98), but alcohol (17/98) and other drug use screening (17/98) were rare. In only one encounter did a provider discuss IPV and substance use as intersecting health problems. Conclusion: This study provides insight on how FP clinicians, as key providers for millions of women in the United States, assess patients for IPV and substance use. Results show providers' willingness to adopt IPV universal education messaging and demonstrate room for improvement in substance use assessments and integrated discussions of IPV and substance use. Trial Registration Number: NCT01459458.

Health Care Providers' Perceived Barriers to Screening for Substance Use During Pregnancy

OBJECTIVE

To explore health care providers' perceived barriers to conducting standardized screening processes for substance use during pregnancy.

DESIGN

Descriptive survey.

SETTING/LOCAL PROBLEM

A health system in the northwestern United States where there was a lack of consistent substance use screening in prenatal clinics.

PARTICIPANTS

A convenience sample of 12 women's health care providers from two hospitals in the health system, including obstetricians/gynecologists, women's health nurse practitioners, women's health physician assistants, and certified nurse-midwives.

INTERVENTION/MEASUREMENTS

We created a 16-item questionnaire that identified potential barriers to screening, such as education/resources for providers, screening tools, referral processes, legal implications, patient relations, and infrastructure.

RESULTS

A majority (n = 8, 66.7%) of participants indicated they had received adequate training regarding substance use during pregnancy and felt comfortable asking pregnant women about their substance use. All (n = 12, 100%) providers indicated that women would feel safe disclosing their substance use but might feel offended if their provider asked them about it. Although most reported screening women for substance use, they did not use a consistent screening tool or process. Participants identified lack of time, legal concerns, and lack of access to resources for referrals as other barriers to screening.

CONCLUSION

Clinicians perceive barriers to screening for substance use during pregnancy, and they may be unaware of legal implications for patients related to perinatal substance use. Identifying barriers to universal screening may facilitate development of best practices related to counseling patients about substance use during pregnancy.

Barriers and Challenges to Making Referrals for Treatment and Services for Opioid Misuse in Family Planning Settings

Background: In this opioid overdose epidemic, women are an overlooked group seeing increasing rates of overdose death. Implementation challenges have prevented evidence-based interventions from effectively reaching women who misuse opioids, with gaps in access to effective treatment and services. Family planning clinics could serve as important points of contact for referral to needed treatments and services. The study explores how family planning staff knowledge and attitudes related to opioid misuse serve as potential barriers and challenges in making referrals for evidence-based services and treatments. Methods: In 2018, we conducted a national online survey of family planning staff, assessing knowledge and attitudes of treatments and services for opioid misuse. Results: A total of 691 family planning staff completed the survey. Most respondents agreed that opioid misuse was a major problem in their community (86.0%) and identified challenges in responding to it, including a lack of treatment access (70.3%), the absence of in-house behavioral health staff (67.2%), and unfamiliarity with local treatment providers (54.1%). Respondents reported low levels of acceptability for syringe services programs (46.0%), medications such as methadone and buprenorphine (55.4%), and naloxone to reverse opioid overdose (60.1%). Controlling for other factors, race/ethnicity, urbanicity, workplace role, and substance use training were associated with differences in acceptability. Conclusions: Family planning settings could play a critical role in connecting women who misuse opioids to treatment and services. Strategies are needed to increase the acceptability of evidence-based interventions and the feasibility of having family planning staff play a linkage role.

Perceived Risk of Weekly Cannabis Use, Past 30-Day Cannabis Use, and Frequency of Cannabis Use Among Pregnant Women in the United States

BACKGROUND

While accumulated evidence has shown that the prevalence of cannabis use among pregnant women in the US has increased in recent years, little is known about the specific subpopulations affected. The aim of this study was to estimate the prevalence and correlates of the perceived risk of weekly cannabis use, past 30-day cannabis use, and frequency of past 30-day cannabis use among US pregnant women.

METHODS

We analyzed data from 2,247 pregnant women 14 to 44 years of age surveyed in the 2015 to 2017 cross-sectional National Survey on Drug Use and Health. Analyses account for the sampling design. Primary outcomes included perceived risk of weekly cannabis use, past 30-day cannabis use, and frequency of cannabis use. We conducted multivariable logistic and negative binomial regression models to assess the associations between the primary outcomes and multiple correlates.

RESULTS

Among US pregnant women, 21.6% (95% CI=19.4, 23.8) did not perceive any risk associated with weekly cannabis use, 5.3% (95% CI=4.2, 6.5) used cannabis in the past 30 days, and among past-month users, the average number of days of use was 15.6 (95% CI=13.5, 17.7). Pregnant women living below the poverty line were both more likely to perceive no risk of weekly cannabis use (aOR=1.8; 95% CI=1.3, 2.5) and use cannabis more often in the past 30 days (aOR=2.9; 95% CI=1.5, 5.7) than pregnant women within an income bracket of more than two times the federal poverty threshold. Age, race, trimester of pregnancy, co-use of tobacco and/or alcohol were also associated with these outcomes.

CONCLUSION

Younger age, living in poverty, early trimester of pregnancy, and co-use of tobacco and/or alcohol increased the odds of cannabis use among pregnant women. As cannabis legalization spreads and cannabis use is increasingly perceived as safe, there is a growing need for research to determine the reasons why women in the identified at-risk subgroups are using cannabis during pregnancy.

Family Planning Practices in Appalachia: Focus Group Perspectives on Service Needs in the Context of Regional Substance Abuse

Reproductive health disparities in the Appalachian region may be driven by barriers to healthcare access. However, the barriers specific to accessing family planning services in Appalachia have not yet been identified from the perspectives of Appalachian community members. Moreover, it is unclear how community members might perceive elevated levels of opioid use in the region to impact family planning practices. To fill this gap in knowledge, the current qualitative study explored community perspectives about family planning in Appalachia in the context of the opioid epidemic for the purpose of developing a survey instrument based on these responses. We conducted three video call focus group interviews with community stakeholders, those who live, work and are invested in Appalachia (N = 16), and analyzed the responses using Levesque, Harris, and Russell's (2013) five pillars of healthcare access as a framework to categorize family planning practices and perceptions of service needs in the context of regional substance abuse: (1) approachability, (2) acceptability, (3) availability and accommodation, (4) affordability, and (5) appropriateness. Subthemes within each of these five categories were also identified. Our findings highlight stakeholder concerns around a lack of knowledge about and access to family planning services in Appalachia. Community members also expressed concern around the lack of availability of substance use treatment services, which may negatively impact family planning use and access in the region.

Family Planning Practices in Appalachia: Focus Group Perspectives on Service Needs in the Context of Regional Substance Abuse

Reproductive health disparities in the Appalachian region may be driven by barriers to healthcare access. However, the barriers specific to accessing family planning services in Appalachia have not yet been identified from the perspectives of Appalachian community members. Moreover, it is unclear how community members might perceive elevated levels of opioid use in the region to impact family planning practices. To fill this gap in knowledge, the current qualitative study explored community perspectives about family planning in Appalachia in the context of the opioid epidemic for the purpose of developing a survey instrument based on these responses. We conducted three video call focus group interviews with community stakeholders, those who live, work and are invested in Appalachia (N = 16), and analyzed the responses using Levesque, Harris, and Russell’s (2013) five pillars of healthcare access as a framework to categorize family planning practices and perceptions of service needs in the context of regional substance abuse: (1) approachability, (2) acceptability, (3) availability and accommodation, (4) affordability, and (5) appropriateness. Subthemes within each of these five categories were also identified. Our findings highlight stakeholder concerns around a lack of knowledge about and access to family planning services in Appalachia. Community members also expressed concern around the lack of availability of substance use treatment services, which may negatively impact family planning use and access in the region.