Screening for substance use in pregnancy: a practical approach for the primary care physician

Implementation of a Universal Screening Process for Substance Use in Pregnancy

OBJECTIVE

To implement a standardized universal substance use screening process in an outpatient prenatal clinic at an urban tertiary care hospital.

METHODS

Using a quality-improvement framework that involved process modeling, stakeholder analyses, and plan-do-study-act cycles, we implemented universal substance use screening for prenatal patients using a modified 5Ps screening tool (Parents, Peers, Partner, Past, Present). Implementation included an operational workflow based on the SBIRT (Screening, Brief Intervention, Referral to Treatment) model. The primary outcome measure was percentage of patients who were screened for substance use, with a goal of 90% screened. Secondary outcome measures were percentage who screened positive and percentage of the time a positive screen resulted in documentation of a brief intervention by a health care practitioner.

RESULTS

Over a 19-month implementation period, 733 patient encounters were sampled. A substance use screen was completed in 618 (84%). We exceeded our goal of screening 90% of eligible patients for the final 6 months of data collection. Of the 618 completed screens, 124 (20%) screened positive. Health care practitioner documentation of brief interventions for patients with a positive screen reached 80% in the final phase of implementation, but then declined to 50% by the completion of the study period.

CONCLUSION

A sustainable and generalizable process to carry out substance use screening within a large prenatal practice is feasible, and assisted with identification of patients not known to be at risk. Further efforts are needed to evaluate how to sustain health care practitioner documentation of intervention in response to positive screens.

Prenatal Practice Staff Perceptions of Three Substance Use Screening Tools for Pregnant Women

OBJECTIVE

There is a need to identify an acceptable and comprehensive substance use screening tool for pregnant women in the United States. This qualitative study sought to better understand prenatal practice staff perceptions of three existing substance use screening tools for use among pregnant women in an outpatient practice setting.

METHODS

Eight focus groups with 40 total participants were conducted with clinical and administrative staff of 2 diverse Maryland prenatal practices to determine the acceptability and usability of 3 substance use screening tools (4P's Plus, NIDA-Modified Alcohol, Smoking and Substance Involvement Screening Test, and the Substance Use Risk Profile-Pregnancy scale). The focus groups were digitally recorded, transcribed, coded, and analyzed using thematic analysis.

RESULTS

Participant perceptions of screening tools were dependent upon screening tool length, tone, comprehensiveness, subjectivity, time frame of questions, and scoring and clinician instructions. Most participants preferred the 4P's Plus screening tool because it is brief, comprehensive, easy for the patient to understand, and excludes judgmental language and subjective questions.

CONCLUSIONS

These results provide valuable insight into the specific needs and preferences of prenatal practice staff as it relates to prenatal substance use screening and provides evidence that the 4P's Plus may be a preferred screening tool for standardized use in prenatal care.

Prevalence of Illicit Drug Use During Pregnancy: A Global Perspective

The World Drug Report 2019 presented an alarming figure to the world: more than 5% of the world's population has been using some type of illicit drug, and that number is growing every year. While its use increases, its abuse during pregnancy has become a global public health problem, resulting in medical and social challenges related to maternal and child health. In this context, the objective of this review was to determine the prevalence of illicit drug use during gestation across the globe, alongside with a critical review of the evaluated studies. Research was performed by simultaneously searching terms ("pregnant woman OR pregnant" OR "gestation" OR "pregnancy" AND "illicit drugs" OR "street drugs") in the databases of the Scientific Electronic Library Online, PubMed, and Web of Science. Comparisons between studies were performed in software Statistica 10.0. The data presented worrying results in relation to the variation in prevalence of illicit drug use during pregnancy, when comparing studies based on interviews or questionnaires (self-reported) (1.65%) and studies based on toxicological analysis (12.28%). In addition, we emphasize the high prevalence (5.16%) of illicit drug use among adolescent pregnant women and the low number of studies on this population. This study reveals worrying data about pregnant drug-user population, mainly the underestimation of prevalence in studies that use only questionnaires or similar methods in comparison to studies that use toxicological analysis of biological matrices. This scenario reveals necessity for health systems in different countries to establish specific public health policies for this population.

Use and Misuse of Opioid Pain Medications by Pregnant and Nonpregnant Women

BACKGROUND

The use and misuse of opioid pain medication is a public health problem that has extended to pregnant women. Assessing both the use and misuse of opioid pain medication had been limited.

AIMS

The aim of the present study was to disseminate data from a national sample of pregnant and nonpregnant women, tracking the rate and predictors of opioid use and misuse.

METHODS

In 2015 the National Survey on Drug Use and Health expanded the assessment of opioid pain reliever use and misuse. Here, a secondary analysis of 2 years of National Survey on Drug Use and Health expanded data assesses the use and misuse of opioids in pregnant and nonpregnant women ranging in age from 18 to 44 years (N = 46,229).

RESULTS

Opioid medication use was reported by 31.89% of pregnant women and 38.87% of nonpregnant women. Race and pregnancy status were associated with risk, with pregnancy being protective and White women having significantly higher risk.

CONCLUSIONS

The high rates of use and misuse of opioids in pregnant women underscores a critical need for screening for opioid use and misuse, particularly among White women. Pregnancy provides a unique window of opportunity to educate, screen, and provide treatment.

Prenatal Substance Use and Perceptions of Parent and Partner Use Using the 4P's Plus Screener

Background Prenatal substance use screening is recommended. The 4 P's Plus screener includes questions on perceived problematic substance use in parents and partner that are not considered in risk stratification. Objectives This research examined the: (1) prevalence of self-reported problematic parental and partner substance use and associations with biochemically-verified prenatal substance use; (2) utility of self-reported perceptions of parent/partner substance use as proxies for prenatal substance use; and (3) degree to which the sensitivity of the 4P's Plus can be augmented with consideration of parent/partner questions in risk stratification. Methods A convenience sample of 500 pregnant women was recruited between January 2017 and January 2018. Participants completed the 4P's Plus and provided urine for drug testing. Diagnostic utility of problematic parent/partner substance use questions was assessed, then compared to the 4P's Plus used as designed, and to the 4P's Plus used with these 2 questions included in risk stratification. Results Half (51%) of respondents reported either partner or parental problematic substance use. When partner or parent problematic substance use were considered as proxies for prenatal substance use, sensitivity was 65% and specificity was 55%. When used as intended, sensitivity was 94% and specificity was 29%. Including partner/parent questions increased sensitivity to 96% but lowered specificity (19%). Partner substance use and combined partner/parent use were associated with prenatal substance use [adjusted odds ratio (aOR): 2.0 (1.2, 2.4; p = 0.006); aOR = 1.6 (1.1, 2.5, p = 0.04)]. Conclusions for Practice Sensitivity of the 4P's Plus may improve with inclusion of self-reported problematic partner/parent substance use items in risk stratification.

Differences in successful treatment completion among pregnant and non-pregnant American women

The present study explores characteristics of successful substance abuse treatment completion of pregnant women through an analysis of retrospective outcomes data. Women without prior treatment admissions, aged 18-44, and not in methadone maintenance therapy were included (N = 678,782). Chi-square tests analyzed significant differences; logistic regression provided predictive probabilities; odds ratios (OR) and risk differences with 95 % confidence intervals represent the effect sizes and clinically meaningful differences. Pregnant women were less likely to successfully complete treatment than non-pregnant women (χ (2) = 321.33, df = 1, p < 0.0001), though the difference was not clinically meaningful (risk difference = 4.75, 95 % confidence interval (CI) = 4.23-5.26). Aside from criminal justice agencies, "other community agencies" refer the greatest percentage of pregnant women to treatment (risk difference = 6.37, 95 % CI = 5.89-6.84). Pregnant women successfully complete treatment more than non-pregnant women in only non-intensive outpatient settings (χ (2) = 10,182.48, df = 7, p < 0.0001). Further attention to referral source and treatment setting for pregnant women may improve successful treatment completion by targeting needs of pregnant women. Referring to non-intensive outpatient and residential hospital treatment settings may help to ameliorate prenatal substance abuse treatment contingent on the primary problem substance.

Least explored factors associated with prenatal smoking

Poor pregnancy and birth outcomes are major problems in the United States, and maternal smoking during pregnancy has been identified as one of the most preventable risk factors associated with these outcomes. This study examines less explored risk factors of smoking among underserved African American pregnant women. A cross-sectional survey was conducted at an outpatient obstetrics-gynecology clinic of an inner-city university hospital in Virginia from March 2009 through January 2011 in which pregnant women (N = 902) were interviewed at their first prenatal care visit. Survey questions included items related to women's sociodemographic characteristics as well as their pregnancy history; criminal history; receipt of social services; child protective services involvement; insurance status; and history of substance abuse, domestic violence, and depression. Multiple logistic regression was conducted to calculate odds ratios and 95 % confidence intervals depicting the relationship between these factors and smoking during pregnancy. The analysis reported that maternal age [OR = 1.08, 95 % CI = 1.05-1.12], less than high school education [OR = 4.30, 95 % CI = 2.27-8.14], unemployed [OR = 2.33, 95 % CI = 1.35-4.04], criminal history [OR = 1.66, 95 % CI = 1.05-2.63], receipt of social services [OR = 2.26, 95 % CI = 1.35-3.79] alcohol use [OR = 2.73, 95 % CI = 1.65-4.51] and illicit drug use [OR = 1.97, 95 % CI = 1.04-3.74] during pregnancy were statistically significant risk factors associated with smoking during pregnancy. In addition to the well known risk factors, public health professionals should be aware that criminal history and receipt of social services are important factors associated with smoking during pregnancy. Social service providers such as WIC and prisons and jails may offer a unique opportunity for education and cessation interventions during the preconception or interconception period.

Alcohol consumption in pregnancy: results from the general practice setting

BACKGROUND

There is no established safe level of alcohol consumption in pregnancy. Studies from Ireland have consistently shown lower abstention and higher binge drinking rates in pregnancy than other countries, indicating a high potential for foetal alcohol-related disorders. There has been little research on alcohol in pregnancy in primary care.

AIMS

To determine the prevalence of alcohol consumption amongst pregnant women attending their GP for antenatal care, and to compare this to use in the year prior to conception.

METHODS

Prospective cross-sectional study was carried out in fifteen teaching practices in the greater Dublin area. Women were recruited at their antenatal visits. Data were gathered by self-completed questionnaire in the practice, or researcher-administered telephone questionnaire. The questionnaire was based on the AUDIT, a WHO-validated data collection instrument designed for use in primary care.

RESULTS

Two hundred and forty valid questionnaires were returned (80 % recruitment rate). Alcohol intake and binge drinking levels were much lower during pregnancy compared to the year prior to pregnancy (p < 0.001). There was a marked reduction in the prevalence of alcohol use in pregnancy compared to previous research. Over 97 % drink no more than once a week, including almost two-thirds of women who abstain totally from alcohol in pregnancy. Non-pregnant Irish women drink alcohol more frequently, and with higher rates of binge drinking, than women of other nationalities.

CONCLUSIONS

Primary care is a suitable setting to research alcohol use in pregnancy. Alcohol use in pregnancy in Ireland has decreased markedly compared to previous research from this jurisdiction.

The Relationship Between Postpartum Depression, Domestic Violence, Childhood Violence, and Substance Use

The objective of this study was to determine the contribution of interpersonal violence and substance use to the prediction of postpartum depressive symptomatology. A community-based sample of 634 women in British Columbia, Canada was screened for interpersonal violence and substance use using the Antenatal Psychosocial Health Assessment (ALPHA) form. Of these women, 497 (78%) subsequently completed questionnaires at 8 weeks postpartum to assess for depressive symptomatology using the Edinburgh Postnatal Depression Scale (EPDS). A predictive model for postpartum depressive symptomatology (EPDS > 9) was developed using regression analysis. Findings suggest that women who experience past or current interpersonal violence or personal or partner substance use problems should be considered for targeted screening for postpartum depression (PPD).

Screening for use of alcohol, tobacco and cannabis in pregnancy using self-report tools

The World Health Organization has identified substance use in the top 20 risk factors for ill health. Risks in pregnancy are compounded, with risk to the woman's health, to pregnancy progression and on both the foetus and the newborn. Intrauterine exposure can result in negative influences on offspring development, sometimes into adulthood. With effectively two patients, there is a clear need for antenatal screening. Biomarker reliability is limited and research efforts have been directed to self-report tools, often attempting to address potential lack of veracity if women feel guilty about substance use and worried about possible stigmatization. Tools, which assume the behaviour, are likely to elicit more honest responses; querying pre-pregnancy use would likely have the same effect. Although veracity is heightened if substance use questions are embedded within health and social functioning questionnaires, such tools may be too lengthy clinically. It has been proposed that screening only for alcohol and tobacco, with focus on the month pre-pregnancy, could enable identification of all other substances. Alternatively, the Revised Fagerstrom Questionnaire could be used initially, tobacco being highly indicative of substance use generally. The ASSIST V.3.0 is readily administered and covers all substances, although the pregnancy 'risk level' cut-off for tobacco is not established. Alcohol tools - the 4Ps, TLFB and 'drug' CAGE (with E: query of use to avoid withdrawal) - have been studied with other substances and could be used. General psychosocial distress and mental ill-health often co-exist with substance use and identification of substance use needs to become legitimate practice for obstetric clinicians.

Neonatal drug withdrawal

Maternal use of certain drugs during pregnancy can result in transient neonatal signs consistent with withdrawal or acute toxicity or cause sustained signs consistent with a lasting drug effect. In addition, hospitalized infants who are treated with opioids or benzodiazepines to provide analgesia or sedation may be at risk for manifesting signs of withdrawal. This statement updates information about the clinical presentation of infants exposed to intrauterine drugs and the therapeutic options for treatment of withdrawal and is expanded to include evidence-based approaches to the management of the hospitalized infant who requires weaning from analgesics or sedatives.

Gender differences in provider's use of a standardized screening tool for prenatal substance use

OBJECTIVES

Prenatal substance use contributes birth defects, prematurity, and infant mortality in the U.S. As such, it is critical that medical professionals receive appropriate education and actively engage in screening patients; however, a physician's gender may influence differences in screening practices. The purpose of this study is to examine male and female Ob/Gyn physician's beliefs and practices related to perinatal substance use screening and to identify the significant correlates of using a standardized screening tool.

METHODS

Data were collected from 131 Ob/Gyn physician's in Kentucky using a web-based survey. Chi-square and t-tests were used to distinguish differences between male (n=84) and female (n=47) providers. Binary logistic regression was also used to assess the independent correlates of the use of a standardized screening tool.

RESULTS

Female Ob/Gyn physician's were more likely to "believe in" the effectiveness of screening, to discuss sensitive topics with patients, and were motivated to screen as a part of comprehensive care or because screening could produce a behavioral change. Female providers were also more likely to use a screening tool in a multivariate model; however, being female was no longer significant after additional variables were included in the model. Specifically, younger Ob/Gyn physicians who frequently discussed mental health issues with female patients of childbearing age, and were motivated to screen because it is part of comprehensive care were significantly more likely to use a standardized substance use screening tool.

CONCLUSIONS

In summary, less than half of Ob/Gyn physicians were using a standardized screening tool and the majority of physicians were using the CAGE. This suggests additional training is needed to increase their use of substance use screening tools, especially those geared towards pregnant women.

Screening for prenatal substance use: development of the Substance Use Risk Profile-Pregnancy scale

OBJECTIVE

To report on the development of a questionnaire to screen for hazardous substance use in pregnant women and to compare the performance of the questionnaire with other drug and alcohol measures.

METHODS

Pregnant women were administered a modified TWEAK (Tolerance, Worried, Eye-openers, Amnesia, K[C] Cut Down) questionnaire, the 4Ps Plus questionnaire, items from the Addiction Severity Index, and two questions about domestic violence (N=2,684). The sample was divided into "training" (n=1,610) and "validation" (n=1,074) subsamples. We applied recursive partitioning class analysis to the responses from individuals in the training subsample that resulted in a three-item Substance Use Risk Profile-Pregnancy scale. We examined sensitivity, specificity, and the fit of logistic regression models in the validation subsample to compare the performance of the Substance Use Risk Profile-Pregnancy scale with the modified TWEAK and various scoring algorithms of the 4Ps.

RESULTS

The Substance Use Risk Profile-Pregnancy scale is comprised of three informative questions that can be scored for high- or low-risk populations. The Substance Use Risk Profile-Pregnancy scale algorithm for low-risk populations was mostly highly predictive of substance use in the validation subsample (Akaike's Information Criterion=579.75, Nagelkerke R=0.27) with high sensitivity (91%) and adequate specificity (67%). The high-risk algorithm had lower sensitivity (57%) but higher specificity (88%).

CONCLUSION

The Substance Use Risk Profile-Pregnancy scale is simple and flexible with good sensitivity and specificity. The Substance Use Risk Profile-Pregnancy scale can potentially detect a range of substances that may be abused. Clinicians need to further assess women with a positive screen to identify those who require treatment for alcohol or illicit substance use in pregnancy.

LEVEL OF EVIDENCE

III.

Identifying infants at risk for neonatal abstinence syndrome: a retrospective cohort comparison study of 3 screening approaches

OBJECTIVE

The main objective of this study was to analyze the consistency in using a standardized newborn toxicology screening protocol to identify infants at risk of developing neonatal abstinence syndrome (NAS).

DESIGN

A retrospective cohort comparison design was approved by the institutional review board at the regional hospital and used to gather data from the infants' medical records during the study period.

SETTING

The data were collected for a period of 1 year from a regional hospital serving 100,000 patients per annum.

PATIENTS/PARTICIPANTS

Data were based on expectant mothers who delivered between March 2006 and March 2007.

METHOD

Data of maternal self-reported substance use, and urine toxicology results and meconium results were obtained through retrospective chart review of infants exhibiting signs of NAS as noted by nurses on the Finnegan Scoring Tool.

RESULTS

In the absence of accurate prenatal screening, this study lends positively to support the use of toxicology screening protocols at birth to adequately assess and treat infants exposed to illicit substances. Toxicology screening in not intrusive and despite emotional discomfort experienced by mothers of the infants tested, the benefits of attaining accurate information regarding substance exposure is critical for the well-being of the infant.

CONCLUSION

The use of a toxicology screening protocol at birth appears beneficial in determining the need for identifying infants with NAS. Early detection of substance exposure in newborns leads to timely assessment for NAS and subsequent treatment to reduce symptoms in newborns.

Substance abuse among reproductive age women

Substance abuse poses significant health risks to reproductive age women in the United States and, for those who become pregnant, to their children. Substance abuse or dependence is defined as a maladaptive pattern of substance use marked by recurrent and significant negative consequences related to the repeated use of substances. Alcohol is the most prevalent substance consumed by childbearing-aged women, followed by tobacco and various illicit drugs. Substance use in the preconception period predicts continued but often limited substance use during the prenatal period. Providers must be aware of reproductive age women's unique physiologic, psychological, and social needs and the related legal and ethical ramifications surrounding substance abuse before referral to a community-based multidisciplinary team for often long-term treatment.

Illicit drug use among women with children in the United States: 2002-2003

PURPOSE

Given research that shows youth exposed to maternal addiction have increased rates of cognitive, socioemotional, and behavioral problems, we examined the prevalence and correlates of past year illicit drug abuse or dependence among women with children younger than 18 years of age in the home to identify maternal risk factors.

METHODS

Data were from the 2002 and 2003 National Survey on Drug Use and Health, a nationally representative sample of the U.S. civilian population. The current analysis utilized a subsample of women (N=19,300) who reported having children younger than 18 years in the home. Past year abuse or dependence on cocaine, heroin, marijuana, stimulants, and hallucinogens as well as nonmedical use of prescription medications were assessed.

RESULTS

The prevalence of illicit drug abuse or dependence was 1.9%. Mothers reporting drug abuse or dependence had increased odds of being unmarried, controlling for other demographics. They also were more likely to report stress, poorer health status, and meet the criteria for serious mental illness (SMI).

CONCLUSIONS

Prevention and intervention strategies should focus on developing and testing methods to screen for both risk factors associated with maternal drug abuse and actual substance abuse in primary and emergency care settings to reduce youth exposure and improve child developmental outcomes.

Alcohol use before and during pregnancy in western Washington, 1989-2004: implications for the prevention of fetal alcohol spectrum disorders

OBJECTIVE

We examined trends in rates of self-reported pregnancy alcohol use among women in western Washington.

STUDY DESIGN

Between 1989 and 2004, we conducted 3 studies in western Washington State on problems that are associated with maternal prenatal alcohol or drug abuse (n = 12,526). To determine study eligibility, we screened hospitalized postpartum women for alcohol and drug use in the month before and during pregnancy. We examined trends in alcohol use rates and identified characteristics that were associated with any drinking and binge drinking (> or = 5 drinks on any occasion).

RESULTS

We found a substantial decrease in pregnancy alcohol use between 1989 and 2004 (from 30-12%) across almost all demographic categories. Binge drinking in the month before pregnancy increased significantly among all race categories, except Native American.

CONCLUSION

Increased prepregnancy binge drinking rates may estimate alcohol use during very early gestation and warrant clinical attention because of the potential for fetal alcohol spectrum disorders.

Cueing prenatal providers effects on discussions of intimate partner violence

BACKGROUND

Intimate partner violence (IPV) during pregnancy poses a significant health risk to the mother and developing fetus. Practice guidelines recommend that prenatal providers screen for and counsel their patients about IPV, yet many physicians express reluctance or discomfort regarding such discussions. The Health in Pregnancy (HIP) computer program was designed to improve prenatal providers' counseling about behavioral risks.

METHODS

English-speaking women 18 years or older, less than 26-weeks pregnant, and receiving prenatal care at one of the five participating clinics in the San Francisco area, were randomized in parallel groups in a controlled trial (June 2006-present; data analyzed June 2007). Participants reporting one or more risks were randomized to intervention or control in stratified blocks. Providers received summary "cueing sheets" alerting them to their patient's risk(s) and suggesting counseling statements.

RESULTS

Thirteen percent (37/286) of the sample reported current IPV. Provider cueing resulted in 85% of the IPV-intervention group reporting discussions with their provider, compared to 23.5% of the control group (p<0.001).

CONCLUSIONS

IPV discussions were influenced strongly by cueing providers. Provider cueing is an effective and appropriate adjunct to routine risk counseling in prenatal care.

Maternal and fetal effects from substance use

This article discusses a variety of issues related to pregnancies complicated by substance use. Drug use is most prevalent in the reproductive age population. Even though a reduction in substance use may occur during pregnancy, some women may not alter their drug use patterns until pregnancy is diagnosed. For these reasons, a large number of fetuses are exposed to illicit substances in utero. Care of substance-using pregnant women is complex, difficult, and often demanding. Providers must be aware of their unique psychologic and social needs, and the related legal and ethical ramifications surrounding pregnancy.

Validation of the 4P's Plus screen for substance use in pregnancy validation of the 4P's Plus

OBJECTIVE

The purpose of this study is to validate the 4P's Plus screen for substance use in pregnancy.

STUDY DESIGN

A total of 228 pregnant women enrolled in prenatal care underwent screening with the 4P's Plus and received a follow-up clinical assessment for substance use. Statistical analyses regarding reliability, sensitivity, specificity, and positive and negative predictive validity of the 4Ps Plus were conducted.

RESULT

The overall reliability for the five-item measure was 0.62. Seventy-four (32.5%) of the women had a positive screen. Sensitivity and specificity were very good, at 87 and 76%, respectively. Positive predictive validity was low (36%), but negative predictive validity was quite high (97%). Of the 31 women who had a positive clinical assessment, 45% were using less than 1 day per week.

CONCLUSION

The 4P's Plus reliably and effectively screens pregnant women for risk of substance use, including those women typically missed by other perinatal screening methodologies.

Mental health during pregnancy: a study comparing Asian, Caucasian and Native Hawaiian women

OBJECTIVE

This study examines perinatal mental health issues, ethnic differences, and comorbidity among pregnant women in Hawaii.

METHODS

Eighty-four participants were recruited from women, ages 18-35, seeking prenatal care on Oahu. They were interviewed at their initial prenatal visit about substance use, depression, and anxiety.

RESULTS

Sixty-one percent of women screened positive for at least one mental health issue. Thirteen percent of all pregnant women reported drinking during pregnancy with 5% reporting problem drinking, 15% reported smoking cigarettes on a regular basis, 5% of pregnant women had probable depression, and 13% of pregnant women had probable anxiety. Significant ethnic differences were found in cigarette smoking, with the highest rate among Native Hawaiian women (35%). Native Hawaiian women were also more likely to binge drink.

CONCLUSION

Given the high rates of potential mental health issues in our sample, our findings highlight the importance of screening and treatment for mental health issues early in pregnancy in Hawaii.

Do Canadian prenatal records support evidence-based practices to reduce maternal smoking?

OBJECTIVES

Maternal smoking remains the most important modifiable risk factor for adverse perinatal outcomes. Integrating evidence-based screening questions and intervention guides for maternal smoking into standardized prenatal records may improve the identification and treatment of pregnant smokers. This study sought to identify and compare how prenatal records across Canadian provinces and territories currently address the issue of maternal tobacco use.

METHODS

Content analysis of prenatal record forms from 11 provinces and territories was used to identify assessment questions and intervention prompts related to maternal smoking or exposure to environmental tobacco smoke. Findings were evaluated in light of current best-practice recommendations for maternal smoking cessation and prevention of relapse.

RESULTS

The content of prenatal records related to maternal smoking varies widely among Canadian provinces and territories. Most of the prenatal records surveyed lacked prompts to support key practices for the effective screening and treatment of maternal tobacco dependence, such as providing multiple response options to determine whether the pregnant woman or her partner smokes, monitoring maternal smoking patterns throughout the course of pregnancy, and referring pregnant smokers to specialized resources for smoking cessation.

CONCLUSION

Simple changes to Canadian prenatal record forms may lead to improved population-wide screening and counselling of pregnant smokers.

Seizing the 9-month moment: addressing behavioral risks in prenatal patients

OBJECTIVE

Our qualitative study explored prenatal care providers' methods for identifying and counseling pregnant women to reduce or stop smoking, alcohol use, illicit drug use, and the risk of domestic violence.

METHODS

We conducted six focus groups (five with OB/Gyn physicians, one with nurse practitioners and certified nurse midwives), total N=49, using open-ended questions. Investigators analyzed transcripts to identify and describe themes.

RESULTS

Three major themes emerged: (1) specific risk-prevention tactics or strategies exist that are useful during pregnancy; (2) some providers address patients' isolation or depression; and (3) providers can adopt a policy of "just chipping away" at risks. Specific tactics included normalizing risk prevention, using specific assessment techniques and counseling strategies, employing a patient-centered style of smoking reduction, and involving the family.

CONCLUSIONS

Providers generally agreed that addressing behavioral risks in pregnant patients is challenging. Patient-centered techniques and awareness of patients' social contexts help patients disclose and discuss risks.

PRACTICE IMPLICATIONS

Brief but routine assessment and risk reduction messages require little time of the provider, but can make a big difference to the patient, who may make changes later.

The 4P's Plus screen for substance use in pregnancy: clinical application and outcomes

OBJECTIVE

Determine the prevalence of substance use among pregnant women in five diverse communities utilizing the 4P's Plus screen for alcohol, tobacco, and other drug use.

STUDY DESIGN

Pregnant women enrolled in prenatal care clinics in five communities were screened for substance use with the 4P's Plus. Those women with a positive screen underwent an assessment for substance use through a follow-up structured clinical interview conducted at the same prenatal visit.

RESULTS

Among 7818 women in five communities, 2555 (32.7%) had a positive screen for substance use in pregnancy. Four of the communities conducted a follow-up assessment on all women with a positive screen (n = 1548). Among these women, 717 (15% of the total population) had continued use after learning of the pregnancy. Overall, 21% of the pregnant women used alcohol prior to recognition of the pregnancy, and 11% continued use after knowledge of the pregnancy. Among the 512 women who continued to use alcohol, 2% were drinking daily, 7% were drinking 3 to 6 days per week, 27% were drinking 1 to 2 days per week, and 63% were drinking less than 1 day per week. The rates of marijuana use and other illicit drug use among the women were 7 and 2%, respectively, prior to knowledge of pregnancy and dropped to 3 and 1% after learning of the pregnancy.

CONCLUSION

The 4P's Plus identifies not only those pregnant women whose drinking or drug use is at a high enough level to impair daily functioning, but provides an opportunity for early intervention for the much larger group of women whose pregnancies are at risk from relatively small amounts of substance use.

Identification and Management of Neonatal Abstinence Syndrome

The nursing care of infants experiencing withdrawal from drug abuse through passive exposure is often challenging. These infants are at higher risk for many medical complications in addition to withdrawal itself. Often, infusion nurses play an important role in caring for an infant with drug withdrawal by providing infusion therapy for the infant's compromised medical condition, poor oral intake, and withdrawal symptoms. This article focuses on drug abuse during pregnancy, the withdrawal symptoms it may cause in the infant, ways to recognize an infant experiencing neonatal abstinence syndrome, and available scoring tools and treatment options.

Improving screening for alcohol use during pregnancy: the Massachusetts ASAP program

OBJECTIVE

To motivate prenatal care staff in public and private settings to universally screen for risk of alcohol and drug use and to conduct a brief intervention with follow-up referral when appropriate during a routine office visit.

METHODS

The ASAP Project methods were engagement of site staff; staff training; self-administered questionnaires embedded with a relational and broad catch screening tool; a brief intervention protocol; unique clinical decision tree/protocols for each site; identification of treatment and referral resources; and ongoing technical assistance and consultation. Sites were located in four regions of the state and included four community health centers, a network of multi-specialty private practices and a teaching hospital.

RESULTS

Across 16 sites, 118 prenatal staff were trained on use of the screening tool and 175 staff on the brief intervention. The ASAP Project resulted in 95% of pregnant women being screened for alcohol use and 77% of those screening positive for at least one risk factor receiving a brief intervention during a routine office visit.

CONCLUSIONS

Screening and brief interventions for alcohol use can be delivered effectively within a routine prenatal care visit by prenatal staff by utilizing and building on existing office systems with practice staff, screening for any use not only at risk use, providing training with skills building sessions and information delivered by physicians, offering easy-to-access community treatment resources, and providing ongoing technical assistance.

Medical illness and comorbidities in drug users: implications for addiction pharmacotherapy treatment

Providing effective medical care to those with substance use disorders can be a challenge to clinicians. In this article, we briefly summarize issues that occur frequently in the medical treatment of substance users. The focus of this article is twofold. The first is to briefly summarize common co-occurring medical illnesses in those manifesting substance use disorders with an emphasis on issues related to providing effective treatment for these diseases in this population. Using specific examples of frequently occurring comorbid medical illness in substance users, including infectious diseases (hepatitis C and HIV disease), sexually transmitted diseases, and pregnancy as examples, the complexities of medical care for this population is demonstrated. Second, this article addresses some of the difficulties encountered in pharmacotherapy aimed specifically at treatment of substance use disorders. For example, difficulties in managing concomitant opiate therapy in those requiring medications for medical illness that may have strong and adverse interactions with opiates are addressed. Adverse events reported for some substance use disorder pharmacotherapies are also highlighted. We conclude with a brief review of models of care that have been effective in addressing the needs of this challenging population that can provide additional means for enhancing the clinical care of substance users.

Pharmacotherapy for pregnant women with addictions

OBJECTIVE

Dependence on alcohol, nicotine, or illicit drugs during pregnancy continues to be a problem of major medical, social, and fetal consequences. The purpose of this systematic review was to summarize current experience that pertains to pharmacotherapy for pregnant women with specific chemical addictions.

STUDY DESIGN

Studies were identified through Medline and HealthSTAR (1979-2003) that linked specific pharmacotherapy with pregnancy. This article reviews the English language literature for clinical studies that link the 2 conditions. In addition, reference lists of all articles that were obtained were evaluated for other potential citations.

RESULTS

Pregnant women are excluded systematically from almost all drug trials. Most knowledge about the fetal effects from maternal substance and medication use comes from animal data and from case reports and small clinical series. With the exception of methadone and nicotine replacement, clinical experience with antiaddictive medications in pregnant women is either very limited (alcohol, stimulants) or nonexistent (cannabis, hallucinogens).

CONCLUSION

Antiaddiction medications are important in the treatment of pregnant women with opioid and nicotine dependence and are of growing importance in the treatment of alcohol and stimulant dependence. Future directions will be toward increasing knowledge about current drug therapy and in developing new antiaddiction medications.

Patients' characteristics and providers' attitudes: predictors of screening pregnant women for illicit substance use

OBJECTIVE

This study's aim was to determine how patients' and providers' characteristics affect hospital providers' decisions to screen pregnant and postpartum women for illicit substances.

METHODS

A retrospective design was used. Participants included all low-income women (N = 1,100) who delivered at an urban teaching hospital over a 12-month period and the providers (N = 40) who provided prenatal and delivery care for these women. The medical records of the women were abstracted to obtain demographic, medical, social, and substance use information. Providers were interviewed to obtain data on their attitudes. The outcome was a dichotomous indication of whether patients were screened for illicit substances.

RESULTS

Multivariate logistic regression analyses found that women who were single (OR = 7.1), Black (OR = 1.9), received prenatal care at the prenatal clinic (OR 5.6), saw fewer providers (1.1), or had a placental abruption (OR 15.8), preterm labor (OR = 3.0), inadequate prenatal care (OR = 4.9), a history of involvement with Child Protective Services (OR = 3.9), a high social/Mental Health Risk Factor Score (OR = 1.4), a past or present history of illicit drug use (OR = 6.7), or a present history of tobacco use (OR = 1.7) were more likely to be screened than women without these characteristics. Women whose providers scored medium (OR = 2.5) or high (OR = 2.5) on the Professionalism Scale were more likely to be screened than women whose providers scored low on this scale.

CONCLUSIONS

Providers' decisions to screen pregnant women for illicit substance use are influenced by both patients' characteristics and providers' personal attitudes. Hospital protocols might help reduce the potentially biased impact of attitudes on screening decisions.

Substance use disorders in women: special considerations during pregnancy

Care of substance-using pregnant women is complex, difficult, and often demanding. Women's care providers must be aware of these women's unique psychologic and social needs and the related legal and ethical ramifications surrounding pregnancy. In addition, relating specific substances to perinatal outcome is difficult, because concurrent use of multiple substances is frequent and many pregnant abusers are members of economically disadvantaged segments of society in which unfavorable perinatal outcomes are more common. It is also difficult to follow up outcomes in such pregnancies prospectively and to analyze research data. This article discusses various issues related to pregnancies complicated by substance use, including perinatal pharmacology and teratogenic risks, identification of substance abuse, treatment approaches, and comprehensive perinatal management.

Prenatal care reduces the impact of illicit drug use on perinatal outcomes

OBJECTIVE

To estimate the extent that prenatal care (PNC) retains its protective influence against prematurity, low birth weight (LBW), and small for gestational age (SGA) status in infants exposed to illicit drug use (IDU) in pregnancy.

STUDY DESIGN

This was a prospective cohort analysis including 6673 women residents of the District of Columbia (Washington, DC, USA) delivering at four city hospitals. Women were screened in the immediate postpartum period. Levels of PNC were established according to American College of Obstetrics and Gynecology guidelines and the Kotelchuck index. PNC and IDU were compared between subgroups. Adjusted relative risks for prematurity, LBW and SGA, controlling for maternal and gestational ages, were calculated in different groups according to IDU and level of PNC.

RESULTS

IDU was identified in 13% of mothers screened. PNC was classified as none (6%), inadequate (10%), intermediate (20%), and adequate (64%). The highest risk for prematurity, LBW, or SGA occurred in infants born to mothers with no PNC and positive IDU in pregnancy (prematurity OR=12.05, 95% CI: 8.99 to 16.16; LBW OR=14.76, 95% CI: 11.03 to 19.75; SGA OR=9.20, 95% CI: 5.32 to 15.92). As PNC levels increased, significant reductions in risk for prematurity and LBW (not for SGA) in IDU-exposed infants were observed. Risk for SGA in IDU-exposed infants reduced significantly when PNC was introduced.

CONCLUSIONS

In infants exposed to IDU, a reduction in risk for prematurity, LBW, and SGA, was consistently demonstrated with improved levels of PNC. In high-risk populations, health care should seek to reach mothers early, especially those identified at risk for IDU, and deliver PNC to them effectively.