Screening For Drug Use in Pregnancy
In the United States (U.S) opioid addiction in pregnancy has skyrocketed ("Committee Opinion NO. 711 Summary," 2017) ("Committee Opinion NO. 711 Summary," 2017). Perinatal opiate use is associated with various co-morbidities including fetotoxicity, and neonatal abstinence syndrome (NAS), which is a cluster of symptoms the newborn develops after being exposed to opioids in utero. Complications such as respiratory distress, feeding difficulties, low birth weight, and prematurity are more common among newborns with NAS compared to all other newborns (Pennsylvania Health Care Cost Containment Council, 2019). Opioid use disorder (OUD) in pregnancy is an increasingly significant problem in rural communities where access to treatment facilities is limited.
The quality of the screening of pregnant people for substance use needs to be evaluated. Although the approach of Screening Brief Intervention, and Referral to Treatment (SBIRT) is proactive to identify drug and alcohol use, the required training and time commitment produces 9 barriers to implementation (Martino et al., 2018). Furthermore, the lack of understanding of SBIRT, absence of an organized process for screening, discomfort in discussing the topic, and time constraints prevent health care providers from routine screening, intervention, and referral of patients with drug use (Gance‐Cleveland et al., 2019). Work volume and short prenatal visits with limited time for healthcare providers to assess and counsel their patients complicate the ability of clinicians to address pregnancy risk and neonatal outcomes (Gance‐Cleveland et al., 2019).
Screening, brief intervention, and referral to treatment (SBIRT) is a comprehensive, public health model designed to provide universal screening, secondary prevention, early intervention, and timely referral (Substance Abuse and Mental Health Services Administration [SAMHSA], 2019. SAMHSA (2019) supports the research-based, comprehensive behavioral health SBIRT model that reflects six characteristics. The benefits of the model include the interaction with the individual is brief, the screening is universal and does not discriminate due to demographic characteristics, the brief intervention is initiated as the multidisciplinary team is activated, the referral to treatment occurs and the individuals are provided referrals to medication assisted treatments and outpatient treatment centers. Universal screening of all pregnant persons on their first prenatal visit is essential to identify OUD early in the pregnancy. The pregnant persons are then followed and evaluated at each subsequent prenatal visit. SBIRT is comprehensive with strong research and substantial experiential evidence supporting the model (SAMHSA, 2019).
Several screening instruments for alcohol and other drug use have been validated for use during pregnancy but, not specifically for prenatal or antenatal screening (Pennsylvania Department of Health, 2019). For example, evidence-based tools for use with pregnant people (Pennsylvania Department of Health, 2019) are ASSIST V3.0 (Alcohol, Smoking and Substance Involvement Screening Test) and CAGE-AID (Cut Down, Annoyed, Guilty, Eye Opener Adapted to Include Drugs), which are targeted to the general population, as well as CRAFFT (Car, Relax, Alone, Forget, Family or Friends, Trouble), which is targeted towards teens. Specifically, the Institute for Health and Recovery’s Integrated 5 P’s Screening Tool, a free version of the 4 P’s Plus©, was designed to be a quick, easy, and non-threatening means to identify a pregnant person’s risk and current substance uses (Pennsylvania Department of Health, 2019). The inclusion of tobacco use and interpersonal violence as additional risk factors are frequently intertwined with substance use factors, are a part of the 5 P’s Screening Tool and the 4P’s Plus© to be used throughout the prenatal period. Both the 5 P’s Screening Tool and the 4 P’s Plus© require little training and can be administered by a wide range of individuals who are trained in the use and administration of the selected tool (SAMSHA, 2019). See attached 5 P’s Screening Tool below.
Committee opinion no. 711 summary. (2017). Obstetrics & Gynecology, 130(2), 488–489. https://doi.org/10.1097/aog.0000000000002229
Gance‐Cleveland, B., Leiferman, J., Aldrich, H., Nodine, P., Anderson, J., Nacht, A., Martin, J., Carrington, S., & Ozkaynak, M. (2019). Using the technology acceptance model to develop startsmart : Mhealth for screening, brief intervention, and referral for risk and protective factors in pregnancy. Journal of Midwifery & Women's Health, 64(5), 630– 640. https://doi.org/10.1111/jmwh.13009
Martino, S., Ondersma, S. J., Forray, A., Olmstead, T. A., Gilstad-Hayden, K., Howell, H. B., Kershaw, T., & Yonkers, K. A. (2018). A randomized controlled trial of screening and brief interventions for substance misuse in reproductive health. American Journal of Obstetrics and Gynecology, 218(3), 322.e1–322.e12. https://doi.org/10.1016/j.ajog.2017.12.005
Pennsylvania Department of Health. (2019). Pennsylvania plan of safe care guidelines. https://doi.org/www.keepkidssafe.pa.gov
Pennsylvania Health Care Cost Containment Council. (2019). Maternal hospital stays involving substance use and opioids (PCH4 Research Brief).
Substance Abuse and Mental Health Services Administration. (2019). Systems level implementation of screening, brief intervention, and referral to treatment (TAP 33) [Technical Assistance Publication Series]. https://doi.org/www.samhsa.gov“