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Substance Use Disorder and Pregnancy (FL INITIAL Autonomous Practice- Pharmacology)

1 Contact Hour including 1 Pharmacology Hour
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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN)
This course will be updated or discontinued on or before Friday, August 28, 2026

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.

Outcomes

≥ 92% of participants will know how to identify and care for pregnant women with substance use disorder.

Objectives

After completing this continuing education course, the participant will be able to:

  1. Define the terms related to substance use disorder.
  2. Determine the screening methods that are used to help identify substance use disorder in pregnant women.
  3. List the factors that may indicate possible substance use disorder in women who are pregnant.
  4. Identify the possible complications of substance use disorder to the mother and fetus.
  5. Describe the treatment for pregnant women with substance use disorder.
  6. Examine the appropriate nursing care for the women with substance use disorder during pregnancy.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
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Substance Use Disorder and Pregnancy (FL INITIAL Autonomous Practice- Pharmacology)
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Author:    Kelly LaMonica (DNP(c), MSN, RNC-OB, EFM)

Background

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.

Definitions

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).

Drug Screening in Pregnancy

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.

4P’s

The 4P's Screen is a screening tool that asks questions about substance use. If there is any positive finding, it should trigger further assessment. This tool was developed by Hope Ewing and is available for use by medical and non-medical providers in the public domain (Virginia Department of Behavioral Health and Developmental Services [DBHDS], n.d.). The 4 “P’s” are:

  1. Parents
  2. Partners
  3. Past
  4. Pregnancy

The 4P’s help to remember the four questions that are asked in the 4P’s Screen. These questions include (DBHDS, n.d.):

  1. Parents: Did any of your parents have problems with alcohol or other drug use?
  2. Partner: Does your partner/significant other have a problem with alcohol or drug use?
  3. Past: In the past, have you had difficulties in your life because of alcohol or other drugs, including prescription medications?
  4. Present: In the past month, have you consumed any alcohol or used other drugs?

The 4P's Plus © Screen is a revised version of the 4P’s tool. It includes additional questions that focus on domestic violence as well as mental health issues (NTI Upstream, 2024). This is a validated and copyrighted screening tool that requires fees and permissions for use.

This 4P’s tool has also been modified again as the 5P’s tool. The 5P’s tool is actually a six-question tool that asks additional questions about peers and smoking habits (DBHDS, n.d.; Chang & Rosenthal, 2023).

CRAFFT

The CRAFFT substance abuse screen for adolescents and young adults is free with open access and available for anyone to use (CRAFFT, 2018). The types of topics it asks about include (CRAFFT, 2018; Chang & Rosenthal, 2023):

  • C: Have you been in a CAR driven by someone (even yourself) who had been using drugs or alcohol?
  • R: Do you use drugs or alcohol to RELAX or feel better?
  • A: Do you use drugs or alcohol while you are ALONE?
  • F: Do you ever FORGET things you have done while using drugs or alcohol?
  • F: Do your FAMILY/FRIENDS tell you that you should cut down your drinking/drug use?
  • T: Have you gotten into TROUBLE while using drugs or alcohol?

NIDA Quick Screen

Although originally validated for the purpose of assessing drug abuse in the primary care setting with a high specificity and sensitivity, the National Institute on Drug Abuse (NIDA) Quick Screen may also screen pregnant women (National Institute of Drug Abuse [NIDA], 2020; Chang & Rosenthal, 2023). The NIDA Quick Screen asks the patient to choose either “never”, “once or twice”, “monthly”, “weekly”, or “daily or almost daily” for their use over the past year of the following (NIDA, 2016; Chang & Rosenthal, 2023):

  • 4 or more drinks per day
  • Tobacco products
  • Prescription drugs for non-medical reasons
  • Illegal drugs

SURP-P

The Substance Use Risk Profile–Pregnancy (SURP-P) is another screening tool that can be used for pregnant women (Chang & Rosenthal, 2023). This tool assesses the amount of alcohol that an expectant mother consumed in the month prior to pregnancy (Chang & Rosenthal, 2023). It asks questions like (Chang & Rosenthal, 2023):

  • Have you smoked marijuana?
  • How many beers, how much wine, or how much liquor have you consumed in the last month?
  • Have you ever felt that you needed to cut down on your drug or alcohol use?

WIDUS

The Wayne Indirect Drug Use Screener (WIDUS) is another available tool that questions substance use (Chang & Rosenthal, 2023). This tool asks six true/false questions regarding (Chang & Rosenthal, 2023):

  • Being married
  • Being bothered by pain of the teeth or mouth
  • Having smoked at least 100 cigarettes
  • If friends smoke cigarettes
  • If for at least two weeks straight, at some point, everything felt like an effort
  • Getting mad easily and feeling the need to blow off some steam

Note Regarding Screening From AWHONN

The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) supports universal screening for substance use disorder. AWHONN also opposes laws that result in incarceration or punitive legal actions against women with SUD in pregnancy. By screening, pregnant women can be identified early and get treatment to help improve outcomes (Association of Women’s Health, Obstetric and Neonatal Nurses [AWHONN], 2019).

The laws around SUD in pregnancy vary by state. Some states require testing, while others require reporting positive findings. Federal law (in all states) requires reporting of newborns that are affected by substance use withdrawal or fetal alcohol spectrum disorder (FASD) (AWHONN, 2019). Most states do not consider SUD as a criminal offense, but is considered in child welfare laws, which could include removal of custody (AWHONN, 2019). If a woman feels threatened by criminal laws, they may be less likely to get the prenatal care they need, which can lead to bad outcomes.

Risk Factors for Substance Use Disorder

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).

Complications

Maternal

Women using drugs can have various complications. Some of the complications can have come from the drug itself, such as an overdose or cardiac arrest. Marijuana and alcohol do not have negative maternal effects.

Cocaine and amphetamines, however, are associated with maternal hypertension and abruptio placenta (when the placenta prematurely detaches from the uterus), which can be deadly to both the woman and the fetus (Prince et al., 2023). There is a risk for postpartum hemorrhage due to abruptio placenta (Prince et al., 2023).

Fetal

Tobacco, alcohol, illicit drugs, and misuse of prescription drugs can all cause fetal complications. These complications can be severe and can even include death (NIDA, 2020).

The fetal complications are dependent on the type of SUD. Miscarriage and fetal death can occur. Infants born to women who drink during pregnancy can have fetal alcohol syndrome (FAS). There is no known safe amount of alcohol (Centers for Disease Control and Prevention [CDC], 2022). Fetal alcohol syndrome can cause congenital malformations and intellectual disability (Prince et al., 2023).

Tobacco and marijuana have been shown to increase the risk of stillbirth, as well as prematurity and low birth weight. Sudden unexplained death is associated with tobacco use (Prince et al., 2023).

Amphetamines are linked to higher rates of fetal demise and neonatal death, while cocaine use is linked to low birth weight, small for gestational age, and prematurity (Prince et al., 2023). Heroin can cause fetal growth restriction, preterm labor, and fetal death (ACOG, 2017).

Infants born to women taking opioids, barbiturates, and benzodiazepines can have neonatal abstinence syndrome (NAS). This group of withdrawal symptoms can affect the newborn and usually require treatment to wean the baby off of the substance they have been exposed to (NIDA, 2020). NAS symptoms are affected by various factors including (NIDA, 2020):

  • The type of opioid the infant was exposed to
  • How long and how often the substance was used for
  • How the mother’s body breaks down the drug
  • Whether the infant was born premature or full term

Neonatal Abstinence Syndrome (NAS) signs and symptoms include (Anbalagan et al., 2024; NIDA, 2020):

  • Blotchy skin/mottling
  • Diarrhea
  • Vomiting
  • Excessive high-pitched cry
  • Abnormal sucking reflex
  • Exaggerated Moro reflex
  • Fever
  • Hyperactive reflexes
  • Increased muscle tone
  • Poor feeding
  • Irritability
  • Seizures
  • Rapid breathing
  • Trouble sleeping
  • Stuffy nose
  • Sneezing
  • Sweating
  • Trembling/tremors at rest
  • Slow weight gain

Infants born with NAS should be assessed using a validated screening assessment, such as the Finnegan scale, to diagnose NAS. Infants are often treated with methadone or morphine to treat symptoms (ACOG, 2017). “Eat, Sleep, Console” is a newer approach to caring for infants with NAS. This is a program that includes the mother and family. They are encouraged to spend as much time as possible with the infant in a low stimulation environment. Nonpharmacologic interventions are used to help the infant eat, sleep, and be consoled. This requires staff and patient education but has been shown to decrease the amount of medications used and decrease the length of stay in the hospital (Grisham et al., 2019).

Treatment

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).

Nursing Care

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).

Case Study

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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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.

References

  • American College of Obstetricians and Gynecologists. (ACOG). (2017). Committee Opinion No. 711: Opioid use and opioid use disorder in pregnancy. Obstetrics and Gynecology, 130(2), e81–e94. Visit Source.
  • American Psychiatric Association. (APA). (2020). What is a substance use disorder? American Psychiatric Association (APA). Retrieved January 19, 2024. Visit Source.
  • Anbalagan, S., Falkowitz, D.M., & Mendez, M.D. (2024). Neonatal abstinence syndrome. In StatPearls. StatPearls Publishing. Visit Source.
  • Association of Women’s Health, Obstetric and Neonatal Nurses. (AWHONN). (2019). Optimizing outcomes for women with substance use disorders in pregnancy and the postpartum period. Journal of Obstetric, Gynecologic, and Neonatal Nursing: JOGNN, 48(5), 583–585. Visit Source.
  • Centers for Disease Control and Prevention. (CDC). (2022). Substance use during pregnancy. Reproductive Health. Retrieved January 19, 2024. Visit Source.
  • Chang, G. & Rosenthal, E. (2023). Substance use by pregnant women. UpToDate. Retrieved January 19, 2024. Visit Source.
  • CRAFFT. (2018). Get the CRAFFT. CRAFFT. Visit Source.
  • Grisham, L. M., Stephen, M. M., Coykendall, M. R., Kane, M. F., Maurer, J. A., & Bader, M. Y. (2019). Eat, sleep, console approach: A family-centered model for the treatment of neonatal abstinence syndrome. Advances in Neonatal Care: Official Journal of the National Association of Neonatal Nurses, 19(2), 138–144. Visit Source.
  • National Institute of Drug Abuse. (NIDA). (2020). Substance use while pregnant and breastfeeding. National Institute of Drug Abuse (NIDA). Retrieved January 19, 2024. Visit Source.
  • National Institute of Drug Abuse. (NIDA). (2016). The NIDA Quick Screen. Visit Source.
  • NTI Upstream. (2024). The 4P’s plus © screening instrument. NTI Upstream. Visit Source.
  • Ondersma, S. J., Chang, G., Blake-Lamb, T., Gilstad-Hayden, K., Orav, J., Beatty, J. R., Goyert, G. L., & Yonkers, K. A. (2019). Accuracy of five self-report screening instruments for substance use in pregnancy. Addiction, 114(9), 1683–1693. Visit Source.
  • Prince, M. K., Daley, S. F., & Ayers, D. (2023). Substance use in pregnancy. In StatPearls. StatPearls Publishing. Visit Source.
  • Ramsey, K. S., Cunningham, C. O., Stancliff, S., Stevens, L. C., Hoffmann, C. J., Gonzalez, C. J., & Substance Use Guidelines Committee. (2021). Substance use disorder treatment in pregnant adults. Johns Hopkins University. Visit Source.
  • Stotts, I. (2024). Drug use during pregnancy: Two lives at risk. Addiction Resource. Retrieved January 19, 2024. Visit Source.
  • Virginia Department of Behavioral Health and Developmental Services. (DBHDS). (n.d.). Perinatal screening instruments. Virginia Department of Behavioral Health and Developmental Services (DBHDS). Visit Source.
  • Volkow, N. D., & Blanco, C. (2023). Substance use disorders: A comprehensive update of classification, epidemiology, neurobiology, clinical aspects, treatment and prevention. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 22(2), 203–229. Visit Source.