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Koenigs KJ, Chou JH, Cohen S, Nolan M, Liu G, Terplan M, Cummings BM, Nielsen T, Smith NA, Distefano J, Bernstein SN, Schiff DM. Informed consent is poorly documented when obtaining toxicology testing at delivery in a Massachusetts cohort. Am J Obstet Gynecol MFM 2022; 4:100621. [PMID: 35354087 DOI: 10.1016/j.ajogmf.2022.100621] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/09/2022] [Accepted: 03/23/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Positive toxicology testing at delivery can have enormous consequences for birthing persons and their families, including charges of child abuse or neglect and potential loss of custody for the birthing parent. Therefore state and national guidelines stipulate that, clinicians must obtain consent before toxicology testing at delivery. OBJECTIVE This study aimed (1) to determine clinician documentation of patient consent for peripartum toxicology testing and (2) to characterize the extent to which patient and hospital characteristics were associated with documented consent. STUDY DESIGN This was a retrospective cohort of individuals who underwent toxicology testing within 96 hours of delivery between April 2016 and April 2020 at 5 affiliated hospitals across Massachusetts. Medical records were reviewed for documentation of clinician intent to obtain maternal toxicology, testing indication, verbal consent to testing, and child protective services involvement. Hierarchical multivariable logistic regression was used to examine the association between patient and hospital characteristics and documentation of verbal consent. RESULTS Among 60,718 deliveries, 1562 maternal toxicology tests were obtained. Verbal consent for testing was documented in 466 cases (29.8%). Documented consent was lacking across most demographic groups. Consent was no more likely to be documented when a report was filed with child protective services and less likely in cases where the birthing parent lost custody before discharge (P=.003). In our multivariable model, consent was least likely to be documented when a maternal complication (abruption, hypertension, preterm labor, preterm premature rupture of membranes, or intrauterine fetal demise) was the indication for testing (adjusted odds ratio, 0.46; 95% confidence interval, 0.28-0.76). Verbal consent was twice as likely to be documented in delivery hospitals with established consent policies (adjusted odds ratio, 2.10; 95% confidence interval, 1.01-4.37). CONCLUSION Consent for toxicology testing at delivery seemed to be infrequently obtained on the basis of clinician documentation. Provider education and hospital policies for obtaining informed consent are needed to protect the rights of birthing individuals.
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Affiliation(s)
- Kathleen J Koenigs
- Brigham and Women's Hospital/Massachusetts General Hospital Integrated Residency Program in Obstetrics and Gynecology, Boston, MA (Dr Koenigs)
| | - Joseph H Chou
- Division of Newborn Medicine, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA (Drs Chou, Cohen, Cummings, and Schiff)
| | - Samuel Cohen
- Division of Newborn Medicine, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA (Drs Chou, Cohen, Cummings, and Schiff)
| | - Moira Nolan
- Massachusetts General Hospital, Boston, MA (Ms Nolan)
| | - Gina Liu
- Harvard Medical School, Boston, MA (Ms Liu)
| | | | - Brian M Cummings
- Division of Newborn Medicine, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA (Drs Chou, Cohen, Cummings, and Schiff)
| | - Timothy Nielsen
- Faculty of Medicine and Health, Children's Hospital Westmead Clinical School, University of Sydney, Sydney, Australia (Mr Nielsen)
| | - Nicole A Smith
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Boston, MA (Dr Smith)
| | - Joseph Distefano
- Boston University School of Public Health, Boston, MA (Mr Distefano)
| | - Sarah N Bernstein
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Dr Bernstein)
| | - Davida M Schiff
- Division of Newborn Medicine, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA (Drs Chou, Cohen, Cummings, and Schiff).
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Cook JL, Green CR, de la Ronde S, Dell CA, Graves L, Morgan L, Ordean A, Ruiter J, Steeves M, Wong S. Screening and Management of Substance Use in Pregnancy: A Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 39:897-905. [PMID: 28935055 DOI: 10.1016/j.jogc.2017.07.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 07/19/2017] [Accepted: 07/19/2017] [Indexed: 11/28/2022]
Abstract
Substance use during pregnancy has important implications for health care providers, policy makers, and can negatively impact a woman's health and the health of her children. Understanding trends, patterns of use and outcomes are critical to prevention campaigns, building awareness, and providing effective care. This review will discuss the current therapeutic approaches and recommendations for screening and patient management for substance use in pregnancy and during the postpartum period, and it is geared towards any care providers who care for patients or those who may care for patients who may be at risk for substance use during pregnancy.
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Affiliation(s)
- Jocelynn L Cook
- The Society for Obstetricians and Gynaecologists of Canada and the Department of Obstetrics and Gynaecology, University of Ottawa, Ottawa, ON.
| | - Courtney R Green
- The Society of Obstetricians and Gynaecologists of Canada, Ottawa, ON
| | | | | | - Lisa Graves
- Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI
| | | | - Alice Ordean
- Department of Family and Community Medicine, University of Toronto and St. Joseph's Health Centre, Toronto, ON
| | | | - Megan Steeves
- School of Public Health, University of Saskatchewan, Saskatoon, SK
| | - Suzanne Wong
- Department of Obstetrics and Gynecology and Department of Family and Community Medicine, University of Toronto, Toronto, ON
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3
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Racine E, Bell E, Zizzo N, Green C. Public Discourse on the Biology of Alcohol Addiction: Implications for Stigma, Self-Control, Essentialism, and Coercive Policies in Pregnancy. NEUROETHICS-NETH 2015. [DOI: 10.1007/s12152-014-9228-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ross EJ, Graham DL, Money KM, Stanwood GD. Developmental consequences of fetal exposure to drugs: what we know and what we still must learn. Neuropsychopharmacology 2015; 40:61-87. [PMID: 24938210 PMCID: PMC4262892 DOI: 10.1038/npp.2014.147] [Citation(s) in RCA: 253] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 05/29/2014] [Accepted: 06/02/2014] [Indexed: 01/13/2023]
Abstract
Most drugs of abuse easily cross the placenta and can affect fetal brain development. In utero exposures to drugs thus can have long-lasting implications for brain structure and function. These effects on the developing nervous system, before homeostatic regulatory mechanisms are properly calibrated, often differ from their effects on mature systems. In this review, we describe current knowledge on how alcohol, nicotine, cocaine, amphetamine, Ecstasy, and opiates (among other drugs) produce alterations in neurodevelopmental trajectory. We focus both on animal models and available clinical and imaging data from cross-sectional and longitudinal human studies. Early studies of fetal exposures focused on classic teratological methods that are insufficient for revealing more subtle effects that are nevertheless very behaviorally relevant. Modern mechanistic approaches have informed us greatly as to how to potentially ameliorate the induced deficits in brain formation and function, but conclude that better delineation of sensitive periods, dose-response relationships, and long-term longitudinal studies assessing future risk of offspring to exhibit learning disabilities, mental health disorders, and limited neural adaptations are crucial to limit the societal impact of these exposures.
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Affiliation(s)
- Emily J Ross
- Chemical & Physical Biology Program, Vanderbilt University, Nashville, TN, USA
| | - Devon L Graham
- Department of Pharmacology, Vanderbilt University, Nashville, TN, USA
| | - Kelli M Money
- Neuroscience Graduate Program, Vanderbilt University, Nashville, TN, USA
| | - Gregg D Stanwood
- Department of Pharmacology, Vanderbilt University, Nashville, TN, USA
- The Vanderbilt Kennedy Center for Research on Human Development, Vanderbilt University, Nashville, TN, USA
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5
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Bhuvaneswar CG, Chang G, Epstein LA, Stern TA. Cocaine and opioid use during pregnancy: prevalence and management. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2011; 10:59-65. [PMID: 18311423 DOI: 10.4088/pcc.v10n0110] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Thompson BL, Levitt P, Stanwood GD. Prenatal exposure to drugs: effects on brain development and implications for policy and education. Nat Rev Neurosci 2009; 10:303-12. [PMID: 19277053 PMCID: PMC2777887 DOI: 10.1038/nrn2598] [Citation(s) in RCA: 239] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The effects of prenatal exposure to drugs on brain development are complex and are modulated by the timing, dose and route of drug exposure. It is difficult to assess these effects in clinical cohorts as these are beset with problems such as multiple exposures and difficulties in documenting use patterns. This can lead to misinterpretation of research findings by the general public, the media and policy makers, who may mistakenly assume that the legal status of a drug correlates with its biological impact on fetal brain development and long-term clinical outcomes. It is important to close the gap between what science tells us about the impact of prenatal drug exposure on the fetus and the mother and what we do programmatically with regard to at-risk populations.
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Affiliation(s)
- Barbara L Thompson
- Department of Pharmacology, Vanderbilt Kennedy Center for Research on Human Development, Vanderbilt University, Nashville, TN 37232, USA
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7
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Alcohol and Drug Screening of Newborns: Would Women Consent? JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2009; 31:331-339. [DOI: 10.1016/s1701-2163(16)34150-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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8
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Oral R. Perinatal illicit drug use and fetal exposure: consequences and management with a public health approach. Drug Test Anal 2009; 1:59-64. [PMID: 20355177 DOI: 10.1002/dta.21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Resmiye Oral
- Department of Pediatrics, Carver College of Medicine, University of Iowa, USA.
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9
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Oral R, Strang T. Neonatal illicit drug screening practices in Iowa: the impact of utilization of a structured screening protocol. J Perinatol 2006; 26:660-6. [PMID: 17036035 DOI: 10.1038/sj.jp.7211601] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The purpose of the study was to determine the neonatal illicit drug screening practices of Iowa birthing hospitals. STUDY DESIGN Cross-sectional survey design was implemented. The impact of structured screening protocols on the numbers of neonates screened and positive testing in 2004 was reviewed. RESULTS Of 81 birthing hospitals, 53 (65%) participated in the study. Screening and positive test rates were higher in hospitals utilizing a structured screening protocol compared to those not utilizing one (10.9 versus 2.1% and 0.9 versus 0.2%, respectively, P < 0.0001). Hospitals with higher population, numbers of outpatients, inpatients, deliveries, and availability of drug abuse treatment services utilized a structured screening protocol more often. CONCLUSION Utilization of a structured screening protocol increases the number of neonates screened for illicit drugs and positive testing rate regardless of urbanization. Regional standardization of structured screening protocols may improve the recognition of perinatal illicit drug exposure and provision of treatment services.
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Affiliation(s)
- R Oral
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA.
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de Mendoza Asensi D, Rodríguez Jornet A, Carvajal Díaz A, Andreu Navarro F, Sala Rodó M, Cervantes García M. Insuficiencia renal aguda por consumo de cocaína. Rev Clin Esp 2004. [DOI: 10.1016/s0014-2565(04)71436-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Roberts LW, Dunn LB. Ethical considerations in caring for women with substance use disorders. Obstet Gynecol Clin North Am 2003; 30:559-82. [PMID: 14664327 DOI: 10.1016/s0889-8545(03)00071-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
People living with addiction endure many hardships, and this may be especially true for women who face distinct clinical and significant psychologic and socioeconomic repercussions of addictive disorders and their companion stresses. Clinicians who work with women with addictions are confronted by many challenges, particularly in the care of pregnant and parenting women. The dilemmas faced by patients with addictions and their providers often arise directly from tensions among core ethical principles, from inconsistencies in the way these principles are applied, and from the pervasive effects of stigma. Although difficult issues are to be expected in the arena of substance abuse treatment, consideration of principles of voluntarism, beneficence, respect for persons and justice, confidentiality and truth-telling, and informed consent are invaluable in shaping clinical ethical decision making. Furthermore, proactive steps can be taken to enhance the ethical caliber of care. These steps involve policy-level and systemic actions, such as the development and expansion of programs serving women's unique needs, empiric research into the most effective treatments for women with various disorders, and reexamination of legal and societal stances toward pregnant and parenting women who have addictions. In addition, local and individual steps are needed, including addressing gaps or inherent biases in programs, training counselors and clinicians in effective strategies or counseling styles, and developing awareness of one's own attitudes when dealing with difficult patients and challenging disorders. Such efforts will help ensure that women who have addictions will be cared for in a manner that is respectful, beneficent, compassionate, honest, and just.
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Affiliation(s)
- Laura Weiss Roberts
- Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
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12
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Warner EA, Walker RM, Friedmann PD. Should informed consent be required for laboratory testing for drugs of abuse in medical settings? Am J Med 2003; 115:54-8. [PMID: 12867235 DOI: 10.1016/s0002-9343(03)00236-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Laboratory testing for drugs of abuse is often conducted in medical settings, with little consideration of the technical limitations and the potential for legal and social harm to the patient. We consider several technical problems associated with such testing, including the lack of chain-of-custody procedures, the possibility of false-positive results with screening immunoassays, and the infrequency of confirmatory testing. Important ethical issues arise because of the sensitive nature of drug test results, the ramifications of false-positive results, the limitations of confidentiality protection, and the practice of testing without the patient's knowledge. Taken together, these technical and ethical concerns suggest that drug testing policies in medical settings should specify which conditions require explicit informed consent, as well as create procedures for protecting this sensitive information.
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Affiliation(s)
- Elizabeth A Warner
- Department of Internal Medicine, Division of General Internal Medicine, University of South Florida, Tampa, Florida 33612, USA.
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13
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Di Bari M, Marchionni N, Pahor M. Beta-blockers after acute myocardial infarction in elderly patients with diabetes mellitus: time to reassess. Drugs Aging 2003; 20:13-22. [PMID: 12513113 DOI: 10.2165/00002512-200320010-00002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Beta-blockers effectively reduce mortality and recurrent cardiovascular events in patients surviving myocardial infarction. However, these agents are underused in clinical practice, especially in older patients with diabetes mellitus. The current literature shows that beta-blockers are at least as effective in older diabetic patients as in other patients, without major safety concerns for their possible adverse effects. The use of these agents in clinical practice should therefore be encouraged, in order to reduce the burden of cardiovascular mortality and morbidity in older diabetic patients post-infarction.
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Affiliation(s)
- Mauro Di Bari
- Department of Internal Medicine, Sticht Center on Aging, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina, USA.
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Bornstein BH. Pregnancy, drug testing, and the fourth amendment: legal and behavioral implications. JOURNAL OF FAMILY PSYCHOLOGY : JFP : JOURNAL OF THE DIVISION OF FAMILY PSYCHOLOGY OF THE AMERICAN PSYCHOLOGICAL ASSOCIATION (DIVISION 43) 2003; 17:220-228. [PMID: 12828018 DOI: 10.1037/0893-3200.17.2.220] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
In its efforts to protect the health of unborn children, the government is increasingly attempting to regulate pregnant women's conduct. As with other policies affecting pregnant women's autonomy, these policies have constitutional overtones. In Ferguson v. City of Charleston (2001), the Supreme Court struck down a South Carolina hospital's policy of testing pregnant women for cocaine and turning positive results over to law enforcement for prosecution. This article discusses the basis of the decision and its legal and behavioral implications. Although the decision came down on the side of pregnant women's rights, it left unresolved the issue of whether a similar policy could be constructed that would pass constitutional muster. The article concludes with a consideration of the likely effects of, and alternatives to, such a policy.
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Affiliation(s)
- Brian H Bornstein
- Department of Psychology, University of Nebraska, 238 Burnett Hall, Lincoln, Nebraska 68588-0308, USA.
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Lazzarini Z, Bray S, Burris S. Evaluating the impact of criminal laws on HIV risk behavior. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2002; 30:239-253. [PMID: 12066601 DOI: 10.1111/j.1748-720x.2002.tb00390.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Criminal law is one of the regulatory tools being used in the United States to influence risk behavior by people who have HIV/AIDS. Several different types of laws have been or could be used in this way These include:HIV-specific exposure and transmission laws — i.e., laws that explicitly mention and exclusively apply to conduct by people with HIV;public health statutes prohibiting conduct that would expose others to communicable diseases and/or sexually transmitted diseases (STDs); andgeneral criminal laws governing attempted murder and assault.
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