19.12 Maternal Substance Use During Pregnancy

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), substance use disorder (SUD) is a problematic pattern of substance use leading to clinically significant impairment. Substances include alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, anxiolytics, stimulants (amphetamines, cocaine, and other stimulants), tobacco, or other substances like nitrous oxide. All these substances taken in excess have a common effect of directly activating the brain reward system and producing such an intense activation of the reward system that normal life activities may be neglected.^[1] Use and misuse of substances by рrеgոaոt women can lead to maternal and fetal morbidity and mortality, including fetal alcohol spectrum disorder and neonatal abstinence syndrome.

The ACOG recommends universal screening for substance use disorders in all pregnant clients with a validated tool. However, nurses and health care providers are also aware there are many reasons why a client may not self-disclose the use of substances, such as denial, legal concerns, lack of understanding of treatment options, lack of hope for effective treatment, and stigma.^[2]

Examples of sensitive and specific screening tools include the 4 P’s tool, and the Substance Use Risk Profile-Pregnancy (SURP). The 4 P’s tool is copyrighted and requires purchase for use. The SURP includes the following questions^[3]:

• Have you ever used marijuana?
• How many alcoholic drinks have you consumed in the month before knowing you were pregnant?
• Do you feel the need to cut down on your alcohol or drug use?

Scoring of the SURP involves classifying the number of alcoholic drinks consumed in the month before pregnancy as either “none” compared with “any,” and then counting the total number of other affirmative items. Negative responses for all items are considered low-risk, one affirmative response is considered moderate risk, and two or three affirmative responses are considered high-risk for substance use (not just alcohol and marijuana). Moderate- and high-risk classifications are considered a positive screen that requires follow-up assessment and intervention.^[4]

If a client screens positive for substance use, a brief intervention is implemented to increase insight and awareness regarding their substance use, as well as to promote motivation toward behavioral change. A brief intervention is part of the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model used as a process for helping clients decide what to do next and to help the client initiate treatment.^[5]

There is no expert consensus regarding laboratory testing for alcohol and drug use during pregnancy. Positive tests for illicit ԁrսgѕ can have legal and economic implications, so written informed consent is required prior to testing. Clinicians must be aware of their state’s requirements for testing and reporting drug test results and understand their laboratory’s false-positive rates for many substances. A positive initial test should be followed by a confirmatory test to exclude false-positive results.^[6]

Nurses teach clients about maternal and fetal morbidity associated with substance use and attempt to identify clients who are currently using substances during pregnancy for further interventions. Other conditions, such as mental health disorders and intimate partner violence, occur in individuals with substance use disorders. The interrelationships between these issues and substance misuse must be addressed when providing prenatal care. Nursing interventions include notifying the health care provider of positive screening results and facilitating referrals to counselors and other local resources to promote abstinence from substances and recovery.^[7]