Substance Use Disorder and Pregnancy

Almost 90% of women who have substance use disorder (SUD) are of childbearing age. Substance use and abuse can cause significant harm to the mother and the fetus. The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that 5.4% of pregnant women use illicit drugs, 8% drink alcohol, and 1 in 14 smoke cigarettes (Stotts, 2024). Nurses must know how to best care for these women and their babies.

It is important to define some terms.

Substance use is the sporadic consumption of alcohol or drugs with no adverse consequences from that use. Patients who use substances can quit on their own (Prince et al., 2023).

Substance use disorder (SUD) does not define frequency, but the user has experienced adverse consequences because of that use. It is also important to note that even though negative consequences have occurred as a result, this has not deterred the individual from continuing to use that substance (American Psychiatric Association [APA], 2020). In fact, SUD features uncontrolled use of a substance regardless of harmful outcomes (APA, 2020).

Physical dependence means that the woman's body has adapted to the substance and will have withdrawal symptoms if she continues using it and then tries to stop (American Psychiatric Association [APA], 2020).

Psychological dependence is a perceived sense of need for the substance by the user (American Psychiatric Association [APA], 2020). These patients have an intense focus on the substance. These patients have distorted thinking and can have abnormal behaviors as well as changes in personality due to changes in the structure of the brain (American Psychiatric Association [APA], 2020).

Screening for substance use is recommended during the initial prenatal visit and each trimester (Prince et al., 2023). Universal urine drug screening would find all women who have used illicit substances but is expensive to perform. It is likely that many patients would be missed if drug screening is only done when the provider suspects possible drug use and could also be quite biased (Prince et al., 2023).

Various validated screening tools can be used to determine if the woman abuses substances. These tools are easy to administer and do not cost anything, however, they can take time, especially if a patient has a positive screen and women may be offended by being asked these questions (Prince et al., 2023). A study by Ondersma et al. (2019) showed that none of the following screening tools had both high sensitivity and high specificity.

Nurses and providers must know the risk factors that may indicate that the woman has a history of drug use. There are biological and social factors that have been linked to a risk for SUD. Some of these include genetics, a young age when they began using substances, adverse childhood experiences (ACEs), and mental health issues. Social norms may contribute to SUD. Brain development affects self-regulation in the younger population. Stress in childhood could delay the development also. Within the environment, access to drugs and a poor social support system are risks for SUD.

Adverse social environments such as housing instability, unemployment, and the effects of racism or discrimination can all put a patient at risk for SUD (Volkow & Blanco, 2023).

In the prenatal setting, some factors that may alert you and possibly indicate SUD can include women who (Chang & Rosenthal, 2023):

• Have started prenatal care late or have missed appointments
• With sudden behavior changes
• With relationship problems
• With poor work or job performance
• With poor weight gain
• With high-risk sexual behaviors
• Have a history of a mental health disorder
• Have a family history of or partner with substance abuse

Women who have an unexplained obstetric history such as demise, miscarriages, etc., and women who do not have custody of their other children also may have a history of using (Chang & Rosenthal, 2023).

Urine drug testing may be considered for women with a history of drug use, a positive screen, and poor prenatal care. Women with abruptio placenta, preterm labor, and unexplained fetal demise may also need drug testing. However, all urine drug testing should be performed according to state laws. The woman should be informed of the test and any mandatory reporting requirements prior to running the test (American College of Obstetricians and Gynecologists [ACOG], 2017).

Women who use substances during pregnancy usually want help to provide the best care for their babies. It is essential to do what we can to help these women to get the assistance they require. For opiate dependence, methadone or buprenorphine are safe during pregnancy and are good treatment options for these women.

Methadone is dispensed daily by a registered opioid treatment program. The dosing may need to be adjusted during pregnancy. It is important that the patient has the appropriate dose to stop all withdrawal symptoms (ACOG, 2017).

Buprenorphine has fewer drug interactions, is harder to overdose with, and there is less need for dosage adjustment. Infants exposed to this appear to have less severe neonatal abstinence syndrome symptoms. Buprenorphine can be prescribed by any trained provider. There is a higher potential of misuse and diversion with buprenorphine and there have been rare cases of hepatic dysfunction (ACOG, 2017).

These medications can also lead to withdrawal signs and symptoms in the newborn but are generally considered safer for pregnancy than illicit drugs. Women on high doses of benzodiazepines and alcohol may need a detoxification program to help them stop using. Any psychiatric diagnoses should be addressed to help these women with substance use problems (Chang & Rosenthal, 2023). A comprehensive drug rehabilitation program can help to reduce the risk of miscarriage, congenital disabilities, preterm delivery, and neonatal abstinence syndrome (Stotts, 2024).

Women who use substances need to feel safe with their providers to be able to share openly. If not, they could just not return for further care. Nurses are trusted healthcare professionals who can create a positive impact as long as they are not judgmental when caring for these women.

AWHONN believes that all pregnant women with SUD should be treated with respectful, equitable, and nonjudgmental care. SUD is a disease, and nurses can help to prevent bias to these women. Treatment for drug use should be family-focused and non-stigmatizing (AWHONN, 2019).

It is important that pregnant women are told about the complications of SUD in pregnancy for the mother and the fetus, including a possible admission to the neonatal intensive care unit (NICU) after delivery (Prince et al., 2023). Nurses need to be aware of screening tools and their institution and state's policy for drug testing and reporting. Each state may have different laws regarding testing and reporting, which the nurse must follow. It is also imperative that a nurse caring for a woman with SUD is educated about safe-sex and the risks of needle sharing. These women should also be screened for violence at home (AWHONN, 2019).

Nurses should also make sure to advocate for women with SUD to receive adequate pain relief while in labor. This may include epidurals, non-narcotic analgesia, as well as all non-pharmacologic therapies, including, but not limited to, movement, water, massage, and any other interventions that the patient finds useful (ACOG, 2017). These patients are entitled to the same care as any other patient and may need more support.

During the postpartum period, women should be encouraged to spend time with their infant and to breastfeed, if appropriate (ACOG, 2017). There is a high risk of relapse for women with SUD. It is important that these women receive support and evaluation during this time. Therapists can help provide support, but these it is also important that these women have access to medical care, transportation, housing, food, and childcare. Support groups may also be beneficial (Prince et al., 2023). Women with SUD who had infants with withdrawal have a higher incidence of postpartum depression and anxiety and should be monitored for this as well (Ramsey et al., 2021).

Laura is a 22-year-old woman who presents to the OB clinic for her first prenatal visit. She thinks she is around 26 weeks pregnant. She is thin and looks malnourished. She says she did not have a car to get to prenatal visits sooner. Her obstetric history is questionable. She says she had 2 spontaneous miscarriages at approximately 7-8 weeks and one elective abortion back when she was 16. She also states that she has had multiple partners and does not know who the baby's father is.

What do you think about this patient? Do you think she is using any illicit substances? How will you find out?

Laura is young and appears to not be in ideal physical condition and she has not received prenatal care until this point. It is important to ask questions and use a screening tool. It is also important to question her gently and non-judgmentally. The goal is to get her help and have her return for care. You do not want to scare her away from getting treatment or prenatal care.

Laura should be screened for social determinants of health. It is important to provide her with realistic resources that she can utilize. The nurse should then provide this patient with resources that she may need including treatment centers, transportation, food, housing, and any other social support that is needed. This patient may have co-existing mental health issues or trauma. This is always important to consider. The nurse should also educate her about the complications of SUD in pregnancy for herself and her baby. This patient should also receive testing for sexually transmitted infections as well as fetal testing.

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