This course will look at the risk factors and screening tools used to identify women who are at greater risk of abusing drugs. Participants will become familiar with complications that can occur to the woman and infant who abuse drugs and how to care for each of these patients.
After completing this continuing education course, the participant will be able to:
In 2016, over 6% of women interviewed stated that they had used illicit substances in the past month. Substance use and abuse can cause significant harm to the mother and to the fetus. Every year nearly 2 million babies in America are exposed to tobacco, alcohol, and illicit drugs in utero.1 Nurses must know how to care for these women and 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. Abuse does not define frequency, but the user has experienced adverse consequences because of that use. Physical dependence means that the woman’s body has adapted to the substance and will have withdrawal symptoms if she does not continue to use it. Psychological dependence is a perceived sense of need for the substance by the user. Addiction is a primary, chronic disease of brain reward, motivation, and memory.2
Screening for substance abuse is recommended during the initial prenatal visit and again during each trimester. The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) opposes laws that result in incarceration or punitive legal actions against women because of a substance use disorder (SUD) in pregnancy and the postpartum period.3 Universal urine drug screening would find all women who have used illicit substances but is expensive to perform. There are various validated screening tools that can be used to determine if the woman abuses substances. The 4P’s Plus Screen is a screening tool that asks questions about substance use, and any positive finding should trigger further assessment. This is a copyrighted screening tool. The CRAFFT substance abuse screen for adolescents and young adults is available for anyone to use. The National Institute on Drug Abuse (NIDA) quick screen may also be used to screen women. There are other tools also available.4
It is important that nurses and providers know risk factors that may indicate that the woman has a history of drug use. Young, unmarried women with a low education level are at a higher risk of using. Women who have started prenatal care late or have missed appointments may be using. Women with a sudden change in behavior, relationship problems, poor work or job performance, and poor weight gain may be at risk. Women with high-risk sexual behaviors, have a history of a mental health disorder or have a family history of or partner with substance abuse are at risk. 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.4
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.5
Women using drugs can have various complications. Some of the complications that they can have come from the drug itself, such as an overdose or cardiac arrest. These women can also experience an abruptio placenta, which can be deadly to the woman and fetus. Miscarriage, intra-amniotic infection, preeclampsia, septic thrombophlebitis, and postpartum hemorrhage are also complications that can affect the woman.4
Miscarriage and fetal death can occur. Fetal growth restriction, low-birth weight, and preterm delivery are both complications that can affect the fetus. Infants born to women who drink during pregnancy can have fetal alcohol syndrome. Infants born to women who are abusing substances can have neonatal abstinence syndrome (NAS). This is a group of withdrawal symptoms that can affect the newborn and usually require treatment to wean the baby off of the drugs.6 NAS symptoms are affected by a variety of factors, including the type of opioid the infant was exposed to, the point in gestation when the mother used the opioid, genetic factors, and exposure to multiple substances.7
Women who are using substances during pregnancy usually want help to provide the best care for their babies. It is important to help these women to get assistance. For opiate dependence, methadone or buprenorphine are safe during pregnancy and are treatment options for these women. These medications can also cause withdrawal in the newborn, but are generally considered safer for use in pregnancy than the illicit drug. 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 their substance abuse problem.4 A comprehensive drug rehab program reduces the risk of miscarriage, preterm delivery, birth defects, and neonatal abstinence syndrome.1
Women with substance abuse need to feel safe with their providers or they won’t return. Nurses are trusted healthcare professionals that can have a positive impact as long as they are not judgmental when caring for these women. Treatment for drug abuse should be family focused and non-stigmatizing.3 It is important for nurses 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.
LS 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 any sooner. Her obstetric history is questionable. She says she had 2 spontaneous miscarriages at approximately 7-8 weeks and one elective abortion when she was 16. She also states that she has had multiple partners and does not know who the father of the baby is.
What do you think about this patient? Do you think she is using any illicit substances? How will you find out?