Substance Use in Pregnancy:
Guidelines for Health Care Practitioners

The following links share a variety of resources for practitioners, ranging in topics from: guidelines, treatment and screening tools. Use the links below to jump to the section that most interests you.

Practitioners
Treatment Options
Screening Tools

Utilize the Controlled Substance Monitoring Database

For healthcare providers seeking to query a patient’s prescription history, registering to become a user on the CSMD website may be accomplished by navigating to www.TNCSMD.com and click on “Register” and provide all required information. The email address provided should be personal and confidential. Once approved, the new user will receive an email with their login credentials for the database.

Do not use naloxone to diagnose opioid dependence in pregnant women as opioid withdrawal may precipitate preterm labor or fetal distress.

Pseudoaddiction is a situation in which a patient’s legitimate chronic pain is undertreated with pain medication, leading the patient to act in a way that resembles addictive behavior. This condition usually arises when a clinician is reluctant to prescribe enough of a controlled drug to provide adequate symptom relief. It is important to carefully distinguish pseudoaddiction from true substance abuse.

Visit the CSMD website

Effects on Pregnancy and the Child

  • Chronic heroin abuse is associated with an increased risk of fetal growth restriction, abruption placentae, fetal death, preterm labor, and intrauterine passage of meconuim. These effects may be related to the repeated exposure of the fetus to opioid withdrawal and the effects of withdrawal on placental function and may also occur in other types of opioid abuse.

  • First-trimester use of codeine has been associated with congenital heart defects in three of four case-control studies. No association has been described between the use of other opioids during pregnancy and an increased rate of birth defects.

  • The lifestyle issues associated with illicit drug use put a pregnant woman at risk of engaging in activities such as prostitution, theft, or violence, to support herself and her addiction. The consequences of these activities pose a host of risks to the fetus.

  • Long-term data for children with in-utero narcotic exposure is limited, but studies have not found significant decreases in cognitive development with maternal opioid abuse.

  • Neonatal abstinence syndrome (NAS):

    Occurs when newborns of opioid-abusing mothers are withdrawn from narcotic exposure. NAS usually manifests within hours to weeks of birth, when the child is separated from opioids in the mother’s body.

    Symptoms of NAS include hyperactivity of the central and autonomic nervous systems, uncoordinated sucking reflexes leading to poor feeding, increased irritability, and high-pitched crying.

Treatment Options

Comprehensive prenatal care and monitoring, chemical dependency counseling, and other psychosocial services for women with opioid dependence should be a part of any treatment plan. It is important to give a woman all of her treatment options so she can make an educated and informed decision.

Note: There are no medications recommended for anything other than opioid use disorder for treatment at this time. A treatment provider needs to work collaboratively with the provider and mother to find the best treatment plan.

Methadone

  • The rationale for opioid-assisted therapy during pregnancy is to prevent complications of illicit opioid use and opioid withdrawal, encourage prenatal care and drug treatment, reduce criminal activity, and avoid risks to the patient of associating with a drug culture. Comprehensive opioid-assisted therapy that includes prenatal care has been shown to reduce the risk of obstetric complications.

  • Perinatal methadone dosages are managed by addiction treatment specialists within registered methadone treatment programs. A list of local treatment programs can be found at the federal Substance Abuse and Mental Health Services Administration.

  • The severity of NAS does not appear to differ based on the maternal dosage of methadone treatment.

Buprenorphine

  • Buprenorphine is the only opioid which may be legally prescribed for the treatment of opioid dependence in an office-based setting. Physicians wishing to prescribe this medication must undergo specific credentialing.

  • Advantages over methadone include a lower risk of overdose, fewer drug interactions, the ability to be treated on an outpatient basis without the need for daily visits to a methadone clinic, and evidence of less severe NAS.

  • Disadvantages to buprenorphine include reports of hepatic dysfunction, lack of long-term data on infant and child effects, a clinically important patient dropout rate due to dissatisfaction with the drug, a more difficult induction with the potential risk of precipitated withdrawal, and an increased risk of diversion.

  • The drug is available as a single agent or combined with naloxone, but the single agent is recommended during pregnancy. Although the single agent has a higher risk of abuse, it also has a reduced risk of exposing the fetus to naloxone which could lead to dangerous withdrawal symptoms.

Medically-Supervised Withdrawal

  • Not recommended because of its association with high relapse rates.

  • If this is to be undertaken, however, supervised withdrawal should ideally occur during the second trimester and with the aid of a perinatal addiction specialist. If the only alternative to medically-supervised withdrawal is continued illicit drug use, the withdrawal should take place as soon as possible no matter the trimester.

  • Breastfeeding should be encouraged in both methadone and buprenorphine patients as minimal levels of these drugs are found in breast milk.

Screening Tools for Substance Use

If you think your loved one has a problem, ask them to answer the following questions. This screening tool is called the “CAGE Model” and can often lead to an individual understanding they have a problem with drugs or alcohol. If they answer yes to two or more questions, consultation with a medical professional is necessary.

Note: There are no medications recommended for anything other than opioid use disorder for treatment at this time. A treatment provider needs to work collaboratively with the provider and mother to find the best treatment plan.

C   Have you ever felt you ought to cut down on your drinking or drug use?
A   Have people annoyed you by criticizing your drinking or drug use?
G   Have you ever felt bad or guilty about your drinking or drug use?
E   Eye-opener: Have you ever had a drink or drug first thing in the morning to steady your nerves or get rid of a hangover?

The CAGE can identify alcohol problems over the lifetime. Two positive responses are considered a positive test and indicate further assessment is warranted. If you answered yes to two questions or more, call the Tennessee Redline at 1-800-889-9789.

National Institute on Alcohol Abuse and Alcoholism

  • A urine drug screen is the single most useful test to determine if someone is abusing controlled substances.
  • Before pregnancy and in early pregnancy, all women should be routinely asked about their use of alcohol and drugs, including prescription drugs. The patient should be informed that such questions are asked of all pregnant women to ensure they receive appropriate care and that all information will be kept confidential. Maintaining a caring and nonjudgmental approach will yield the most inclusive disclosure.

Signs and symptoms suggestive of a substance abuse disorder:

  • Seeking initial prenatal care late in pregnancy
  • Poor adherence to appointments
  • Poor weight gain
  • Sedation, intoxication, or withdrawal symptoms
  • Erratic behavior
  • Multiple requests for early refills of a prescribed controlled substance
  • Pressuring behaviors in the office, such as pleading for another prescription, excessively complimenting the prescribing practitioner, or threatening harm to self or others.

The 5Ps was adapted by the Massachusetts Institute for Health and Recovery in 1999 from Dr. Hope Ewing’s 4Ps (1990). The 5Ps is an effective tool of engagement for use with pregnant women who may use alcohol or drugs. The screening tool poses questions related to substance use by women’s parents, her peers, her partner, during her pregnancy and in her past. The non-confrontational questions elicit genuine responses that can be useful in evaluating the need for a more complete assessment and possible treatment for substance abuse. It is important to advise your patient that the responses she provides are confidential. A single “YES” to any of these questions suggests further assessment.

5P’s

  • Parents: Did any of your parents have a problem with alcohol or drug use?
  • Peers: Do any of your friends have a problem with alcohol or other drug use?
  • Partner: Does your partner have a problem with alcohol or drug use?
  • Past: In the past, have you had difficulties in your life because of alcohol or other drugs, including prescription medications?
  • Present: In the past month, have you drunk any alcohol or used other drugs?

Adverse childhood experiences, or ACEs, are potentially traumatic events that occur in childhood (0-17 years). For example:

  • experiencing violence, abuse, or neglect
  • witnessing violence in the home or community
  • having a family member attempt or die by suicide

Also included are aspects of the child’s environment that can undermine their sense of safety, stability, and bonding such as growing up in a household with:

  • substance misuse
  • mental health problems
  • instability due to parental separation or household members being in jail or prison

ACEs are linked to chronic health problems, mental illness, and substance misuse in adulthood. ACEs can also negatively impact education and job opportunities. However, ACEs can be prevented. If you are interested in having an Metro Drug Coalition staff member come to your school or business to educate your team on ACES, please email one of the contacts below.  To learn more about ACEs you can: visit their website here, email Mira Gaylon at mgalyon@metrodrug.org, or watch the video below.