Substance Use Disorder and Pregnancy
Alcohol and other substance use during pregnancy can lead to serious long-lasting consequences for women and infants including miscarriage, stillbirth, fetal alcohol spectrum disorders (FASD), and neonatal abstinence syndrome (NAS). While the risks of substance use during pregnancy are often known among providers, few women of childbearing age receive substance use screening. Only 17 of pregnant women have talked to their doctors about alcohol use, yet nine percent report using alcohol and three percent report binge drinking (more than three drinks at one setting). Additionally, six percent of pregnant women ages 15 to 44 and 18% of pregnant women ages 15 to 17 reported using illicit drugs during pregnancy. Identifying risk of substance use before and during pregnancy is a critical first step to preventing use and reducing harm through treatment and services.
Evidence-based models, such as Alcohol Screening and Brief Intervention (SBI) and Screening, Brief Intervention and Referral to Treatment (SBIRT) are available, but are underutilized by healthcare providers for a variety of reasons. One major barrier is a lack of provider comfort in responding to positive screenings; however, having the right training and tools can help providers overcome this challenge and lead to positive health outcomes among patients. For example, conducting Alcohol SBI in primary care settings resulted in reduced weekly alcohol consumption and long-term adherence to recommended drinking limits. The major components of SBIRT, Screening, Brief Intervention, and Referral to Treatment, have been applied to and adapted for women of childbearing age and pregnant women.
Universal screening is recommended by numerous professional organizations including the Centers for Disease Control and Prevention (CDC) and the American Medical Association. Providers can choose from a number of substance use screening tools validated for use during pregnancy that meet their clinics’ needs. Screening tools validated for use during pregnancy include:
- T-ACE (Takes, Annoyed, Cut down, Eye opener)
- TWEAK (Tolerance, Worry, Eye opener, Amnesia, Cut down)
- 4 Ps (Past, Present, Parents, Partner)
There are four components of brief intervention: raise subject, provide feedback, enhance motivation, and negotiate plan. These four components can be modified to better meet the needs of women of childbearing age and pregnant women. Wright and others recommend the following modifications (2016):
- “Thank you for answering my questions–is it ok with you if we talk about your answers?”
- “Can you tell me more about your past/current drinking or drug use? What does a typical week look like?”
- “Sometimes patients who give similar answers are continuing to use drugs or alcohol during their pregnancy.”
- “I recommend all my pregnant patients not to use any alcohol or drugs, because of risk to you and to your baby.”
- “What do you like and what are you concerned about when it comes to your substance use?”
- “On a scale of 0–10, how ready are you to avoid drinking/using altogether? Why that number and not a ____ (lower number)?”
- Summarize conversation. Then: “What steps do you think you can take to reach your goal of having a healthy pregnancy and baby?”
- “Can we schedule a date to check in about this next time?”
Referral to Treatment
Providers conducting screening will need to determine risk among patients in order to appropriately provide brief services and make referrals to treatment. Patients who are identified as high risk should be referred to specialized substance use disorder providers. Patients who have moderate risk could receive a lower-level of services that might include brief intervention, motivational interviewing and frequent follow up visits. Individuals who are low risk could receive educational materials and brief advice. Prior to engaging in screening, providers should determine criteria for determining risk and establish the appropriate resources, linkages to care, and referrals to connect patients to effective services. For most providers, the majority of patients screened will have low or moderate risk requiring education and brief intervention services.
In order to ease practitioner adoption, there are a growing number of trainings, resources, and tools available for providers to effectively implement Alcohol SBI and SBIRT to reduce risks due to substance use during pregnancy.
The SAMHSA-HRSA Center for Integrated Health Solutions recommends the following tools and resources to help providers implement substance use screening for pregnant women and women of childbearing age:
The Role of Screening, Brief Intervention and Referral to Treatment in the Perinatal Period
SAMHSA Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and their Infants
Northern New England Perinatal Quality Improvement Network A Toolkit for the Perinatal Care of Women with Opioid Use Disorders
- The CDC CHOICES Intervention