Review: Screening for Substance Abuse in Women’s Health and Midwifery

This report, originally published in the Journal of Midwifery & Women’s Health, addresses the critical public health issue of substance abuse in women, with a focus on screening and early intervention. The article emphasizes the increased risks associated with substance abuse, including untreated mental health issues, intimate partner violence, and adverse pregnancy outcomes. It reviews the challenges in interpreting prevalence data and the arguments for using validated screening tools in both primary women's health care and during pregnancy. The article discusses the integration of drug and alcohol screening into clinical practice, highlighting the importance of early identification, intervention, and referral for treatment. It covers various screening tools available to healthcare providers and addresses the challenges that arise when women screen positive for substance abuse. The report underscores the need for comprehensive screening programs to improve women's health outcomes and reduce the negative impacts of substance abuse on individuals, families, and communities. The article also touches upon the importance of recognizing the need for sex-specific services and the integration of screening, intervention, and referral for treatment for women in primary care and perinatal settings.

Journal of Midwifery & Women’s Health www.jmwh.org
Original Review
CEUScreening for Substance Abuse in Women’s Health:
A Public Health Imperative
Daisy J. Goodman, CNM, WHNP-BC, DNP,Kristina B. Wolff, PhD, MPA
Alcohol and drug use is a significant public health problem with particular implications for the health and safety of women. Women
these substances are more likely to have untreated depression and anxiety and are at higher risk for intimate partner violence,homelessness,
incarceration, infectious disease, and unplanned pregnancy. Substance abuse during pregnancy places both mother and fetus at r
perinatal outcomes. Data regarding the prevalence of substance abuse in women are conflicting and difficult to interpret. On the c
strong arguments exist against routine urine drug testing and in favor of the use of validated instruments to screen women for dru
use both in primary women’s health care and during pregnancy.A number of sex-specific screening tools are available for clinicians, some of
which have also been validated for use during pregnancy. Given the risks associated with untreated substance abuse and depend
the integration of drug and alcohol screening into daily clinical practice is imperative. This article reviews screening tools available
in both the prenatal and primary women’s health care settings and addresses some of the challenges raised when women screen
and alcohol abuse.
J Midwifery Womens Health 2013;58:278–287c2013 by the American College of Nurse-Midwives.
Keywords:perinatal substance abuse, substance abuse screening, drug and alcohol abuse, women’s
INTRODUCTION
The use of alcohol, tobacco, and illicit drugs has been called
the nation’s leading health problem.1 Alcoholabuse alone
is estimated to cause 100,000 deaths per year in the United
States,with enormousindividual,social,and economic
costs.1 In the past decade, the prevalence of alcohol and drug
use among women and the need for sex-specific services has
become the focus of increased attention both in public policy
and research.2, 3The NationalInstitute on Drug Abuse has
identified the importance of sex in the course and treatment
of substance abuse and the particular risk for morbidity and
mortality experienced by women with untreated substance
use disorders.4 Women’s health care providers therefore face
a dualchallenge:identifying women who are in need of
treatment for alcohol and drug dependence and identifying
sex-appropriate, accessible services through which this treat-
ment can be provided. This article addresses the integration
of screening for drug and alcohol use,intervention,and re-
ferral for treatment for women in primary care and perinatal
settings.The topic of tobacco dependence is not addressed,
as it has been thoroughly reviewed elsewhere.5
Women who abuse alcoholor drugs are more likely to
have untreated psychiatric disease than women who do not
abuse alcohol or drugs and to experience intimate partner vi-
olence, incarceration, and homelessness.6–8Among women of
childbearing age,substance abuse is associated with higher
rates of sexually transmitted infections and unplanned preg-
nancy.The vast majority of HIV infection in women in the
United States can be traced to intravenous use of drugs or het-
erosexual contact with an intravenous drug user.2
Address correspondence to Daisy Goodman,CNM, WHNP-BC, DNP,
566 HanoverCenterRd., Hanover,NH 03755.E-mail:daisyjgood-
[e-mail]
Prenatal substance abuse is associated with increased r
of morbidity and mortality for the mother,fetus,and new-
born. Adverse pregnancy outcomes associated with illicit d
use include thromboembolic events;infectious disease,in-
cluding pericarditis, perinatal transmission of HIV and hep-
atitis, and exposure to multidrug-resistant organisms; pret
birth;placentalabruption;intrauterine growth restriction;
and intrauterine death.9–12Fetal alcohol exposure is the lead-
ing cause ofpreventable mentalretardation in the United
States and is associated with behavioral, developmental, a
physiologic deficits.9–11Emerging research also suggests there
is an association between marijuana exposure, both prena
and through breast milk,and decreased fetal growth,devel-
opmental delay, decrease in executive functioning, and mo
disorders in children.13–16A neonatal withdrawal syndrome
leading to prolonged hospitalization occurs in the majority
infants prenatally exposed to opiates and benzodiazepines9, 17
Postnatalsubstance abuse is strongly associated with child
abuse and neglect.18, 19
PREVALENCE OF SUBSTANCE ABUSE IN WOMEN
It is important to distinguish the use of substances (either
or illicit) from substance abuse and to distinguish both from
substance dependence. Substance abuse is defined in the
agnostic and StatisticalManualof MentalDisorders,4th
edition, as a “maladaptive pattern of substance use leadin
clinically significant impairment or distress”20 despite social
or personal problems associated with use. Substance depe
dence involves the development of at least 3 of the followi
additional criteria: 1) loss of control over the amount or du
tion of use; 2) unsuccessful attempts to control use; 3) cha
in usual activities as a result of use; 4) continued use desp
278 1526-9523/09/$36.00 doi:10.1111/jmwh.12035 c2013 by the American College of Nurse-Midwives

✦ Over the past decade, the need for sex-specific substance abuse treatment has been recognized by both cli
health policy makers.
✦ Screening for drug and alcohol abuse is associated with reduction in use; savings in general health care cos
in emergency room visits, hospitalizations, arrests, and motor vehicle accidents.
✦ Substance abuse screening should be integrated into primary health care, beginning in adolescence, and be
routine obstetric care.
✦ Midwives should oppose legislation that criminalizes women using alcohol or drugs during pregnancy and pr
cies that increase access to treatment.
knowledge thatphysicalor psychologicalharm willresult;
5) developmentof tolerance,necessitating larger amounts
of the substance;and 6) the developmentof withdrawal
symptoms when abstaining.20 Physiologic dependence re-
quires the presence of either tolerance or withdrawal symp-
tomswhen abstaining.Certain substancesare associated
with a rapid induction of physiologic dependence (eg,opi-
ates,methamphetamine),others with a more insidious on-
set (alcohol) or no evidence of physiologic dependence (eg,
marijuana).
An accurate assessment of the prevalence of alcohol and
illicit drug use among women in the United States is diffi-
cult to determine.Available data are largely based on self-
reporting using a variety ofretrospective methods.4, 21Ac-
cording to the Centers for Disease Controland Prevention
(CDC), 17.5% of women aged 18 years and older smoke to-
bacco and 61% drink alcohol.22, 23Heavy drinking is defined
by the CDC as more than one drink per day for women and
more than 2 for men, or episodic drinking of 4 or more drinks
in 2 hours for women.24 An estimated 5.9% of women older
than 18 years meet the diagnostic criteria for abuse and/or de-
pendence on alcohol and illicit drugs.2, 25
Between 2007 and
2009,11.4% of women aged 18 and older reported using an
illicit substance.26 These numbers are likely an underestima-
tion of the actual prevalence, as women may be more reluctant
to report concurrent use of illegal drugs than to report alcohol
and tobacco use and because of recall bias.
The overallnumber ofemergency room visits related
to the misuse ofalcoholor drugsremained stable from
2004 to 2009.However,significant increases have occurred
in the nonmedicaluse of prescription opiates,especially by
women.27 Although women make up just over one-third of
the totalnumber ofemergency room visits for substance-
related problems, more than half of visits related to abuse of
narcotic pain relievers were made by women. This number in-
creased significantly over the period from 2004 to 200821, 27
and is particularly troubling because of the chronic,relaps-
ing nature of opioid dependence and its implications during
pregnancy.10, 28, 29
The overallprevalence of substance use among women
is similar among different culturaland racialgroups in the
United States and is equally distributed among rural, subur-
ban,and urban areas.Regional and demographic variations
do exist in the type of substances.21, 23, 30For example, women
who are employed full-time are more likely to meet criteria for
needing treatment for alcohol dependence,whereas women
who are unemployed are more likely to need treatment for
illicit substance use.Rates of substance use do generally de-
crease with age.31
Prevalence of Drug and Alcohol Use During
Pregnancy
Determining prevalence rates for alcohol and drug use duri
pregnancy is complicated by inconsistent screening of preg
nant women and by the stigma associated with prenatal us
of alcohol,tobacco,and drugs,which makes it difficult for
women to be forthcoming.18According to data gathered in the
2009 National Survey on Drug Use and Health, approximat
11% of pregnant women reported they had used alcohol, to
bacco,or illicit substances during pregnancy.21, 22The CDC
estimates that 7.6% of women in the United States continu
to use alcohol during pregnancy.23Prenatal drug use is higher
among younger women, with 15.8% of pregnant women be
tween the ages of 15 and 17 years reporting illicit drug use19
Because alcohol is a known teratogen and exposure to illici
drugs is also associated with adverse perinatal outcomes, t
distinction between substance use and abuse is clinically le
relevant during pregnancy.
Estimates of drug and alcohol use in pregnancy are high
when data are gathered using validated screening method
the time of entry to care rather than retrospectively. In 200
Chasnoff et al32 reported results from use of the 4P’s Plus to
screen pregnant women (N = 4865) in 4 culturally and ge-
ographically diverse communities in the United States. Afte
screening and follow-up assessment, 21% reported using a
hol in the month prior to becoming pregnant, and 11% con
tinued to do so during pregnancy.32The combined rate of al-
cohol and/or illicit drug use after diagnosis of pregnancy wa
15% and had decreased from 29% during the month prior
to pregnancy.These self-reported rates of substance use are
significantly higher than those identified through the 2010
National Survey on Drug Use and Health.21
Although alcoholand marijuana use decreases signif-
icantly during pregnancy,they also rebound quickly after
birth. At 3 months postpartum, women report consumption
has returned to approximately halfof prepregnancy levels.
At 18 months, alcohol and tobacco use approaches the sam
levels as prior to pregnancy,although binge drinking and
marijuana use remain significantly lower than prepregnanc
consumption.10, 28, 33
Journal of Midwifery & Women’s Healthr www.jmwh.org 279

SCREENING FOR SUBSTANCE ABUSE
In 2001, the Institute of Medicine called on clinicians to imple-
ment universal screening for health risk behaviors, including
substance abuse,with appropriate follow-up and referral.34
Given the prevalence of alcohol and drug use among women
in the United States, screening for substance use and depen-
dence should be an essentialcomponentof health assess-
ment during primary, gynecologic, and obstetric care.10, 34, 35
Screening should be integrated into routine health care be-
ginning in adolescence,with the goalof early intervention
and referral for treatment prior to the development of serious
morbidity.3 Addressing problem substance use prior to con-
ception is critical to the effort to decrease perinatal complica-
tions and to facilitate recovery prior to parenting.18, 19
Historically,identification ofsubstance abuse and de-
pendence has occurred primarily during medical encounters
related to heavy use of either alcohol or drugs (ie, emergency
department visits) or when an astute clinician has noted phys-
iologic, psychiatric, or social red flags suggesting the presence
of substance abuse. This approach is haphazard, as indicators
are easily missed, may be absent, or hidden under other dis-
ease manifestations.It is also potentially discriminatory be-
cause of provider bias.30, 36
Recognizing the need for a systematic approach to alcohol
and drug screening, the Substance Abuse and Mental Health
Services Administration developed a protocol titled Screen-
ing,Brief Intervention,and Referral for Treatment (SBIRT).
The SBIRT process has been widely accepted in primary care
practice nationally and is associated with savings in general
health care costs and decreases in emergency room visits, hos-
pitalizations,arrests,and motor vehicle accidents.3, 34How-
ever, the integration of substance abuse screening and treat-
ment protocols into women’s health and obstetric care has
been limited despite these recommendations.9, 10, 35, 39, 40
Variations in Practice
Despite the significance of substance abuse in women’s lives,
mosthealth care providers receive little training regarding
the issue.Wide variation in practice exists with regard to
screening women for alcohol and drug use, probably because
of a combination oflack ofeducation aboutthe nature of
addiction,lack oftraining in intervention techniques,and
negative attitudes about addiction.36, 41–44
Lack of confidence
regarding follow-up on positive screens is cited as an impor-
tant factor preventing primary care providers from screening
for alcohol and drug use.41 A recent study by Marshall et al
found that when training in screening and intervention tech-
niques was incorporated into medical resident education, res-
idents’ confidence in their ability to screen for substance abuse
significantly increased.41
Negative attitudes toward women struggling with alco-
hol and drug dependence may also contribute to avoidance
by providers.Despite an unequivocalposition statement to
the contrary from the American College of Obstetricians and
Gynecologists,45criminalization of perinatal substance abuse
is not always perceived negatively by physicians. A study pub-
lished in 2002 found that 45% of physicians favored statutes
thatdefined substance abuse during pregnancy as a form
of “child abuse.”43 Midwifery attitudes toward criminaliza-
tion have not been adequately studied.In general,obstetric
providers more consistently screen for and counselwomen
about tobacco use than for alcohol or drugs.
A standard, comprehensive obstetric history generally i
cludes a few direct questions regarding prenatal alcohol,to-
bacco, and drug use, which may be asked by nurses or non
licensed personnel at the first prenatal interview. An analy
of 51 patient encounters with obstetric residents,midwives,
and nurse practitioners found that although clinicians pro-
vided information, advice, support, and referral for smokin
cessation,they failed to take a systematic approach to other
substance use.In this study,clinicians limited their discus-
sions about alcohol and drug use to statements of harmful
ness,questions about last use,and referralto genetics (de-
spite lack ofevidence supporting teratogenicity other than
for alcohol).11 Another review offollow-up after positive
screening for tobacco,alcohol,and drug use confirmed that
providers are more likely to intervene when pregnant wom
use tobacco than when they use alcoholor drugs.When
women screened positive, 32% of scripted follow-up quest
about smoking were not completed by providers, but 39%
questions regarding alcohol use and 93% of follow-up ques
tions about illegal drug use were not completed.40
Lack of follow-up on the part of providers during preg-
nancy is particularly troubling because women with sub-
stance use problems are more likely to participate in healt
care while they are pregnant than when they are not and a
more receptive/motivated to changing health behaviors du
ing pregnancy.46 Recognizing that most obstetric providers
lack training in how to address perinatal substance abuse,
American Society for Addiction Medicine calls for enhanced
professional education in the identification, intervention, re
ferral, and treatment of pregnant, substance-using women28
Clinicians should routinely discuss substance use with ever
woman,whether she is receiving preventive,preconception,
prenatal,or postpartum care.A consistent approach allows
providers to hone their assessment skills and eliminates th
unethical practice of selective screening.
Integrating Screening into Clinical Practice
A number of instruments have been validated for screenin
women for problematic drug and alcohol use. The best too
one that a provider uses regularly and easily and has high
sitivity and a high negative predictive value. A good screen
ing tool should be able to identify intermittent abuse of sub
stances, as well as regular use.32In regard to alcohol, which is
legal and socially accepted for nonpregnant women, scree
should be able to differentiate between moderate and hea
use.Addressing intermittent or binge use of alcoholis par-
ticularly important during pregnancy, when the threshold f
potential harm is low.10
Screening for drug and alcohol abuse is designed to ide
tify the presence of a problematic level of substance use in
woman’s life. It is important to recognize that a positive sc
for drug and alcoholabuse is notsynonymous with sub-
stance dependence. Once a woman screens positive, the g
of the brief intervention phase of the SBIRT process is to g
280 Volume 58, No. 3, May/June 2013

feedback about the role played by alcohol and drugs in her life
and to help determine the best approach based on her needs.
Screening Tools for Substance Abuse
Screening tools that have been validated in primary care or
specialty settings are presented in Table 1.The Alcohol Use
Disorders Identification Test (AUDIT-C); Alcohol, Smoking,
and Substance Involvement Screening Test (ASSIST);Two-
Item Conjoint Screening Tool (TICS); CRAFFT; T-ACE; and
TWEAK (the latter 3 acronyms based on their respective
screening questions) are frequently used in the primary care
setting.These instruments range from simple to complex.
T-ACE and TWEAK are brief (4 and 5 questions, respectively)
screens for heavy alcoholuse but do not reliably detect in-
termittent binge drinking.32The TICS is a simple, 2-question
screen: “In the past year, have you ever drunk or used drugs
more than you meant to?” and “Have you felt you wanted to
cut down on your drinking or drug use in the past year?”47The
ASSIST, which screens for both alcohol and drug abuse, and
AUDIT-C, which screens for alcoholabuse only,have been
validated internationally by the World Health Organization.
Training manuals for both the ASSIST and AUDIT are avail-
able to download.48
Fewer instruments have been validated for use during
pregnancy. CRAFFT, which was originally developed for use
in adolescents (aged 15-24 years), has recently been validated
for pregnant women in the same age range.31 The AUDIT-
C, T-ACE,and TWEAK are also valid for screening during
pregnancy.31, 40, 49–51The 4P’s Plus and the Substance Use Risk
Profile, Pregnancy Scale are screening tools developed specif-
ically for use with pregnant women.50, 51
Integrating a screening program into clinicalpractice
can present logistical challenges. Screening for substance use
should always occur with a woman alone, both to protect her
privacy and to prevent the potential repercussions of revealing
drug and alcohol use unknown to her partner or other fam-
ily members. Some instruments are designed to be adminis-
tered verbally by a health care provider;others can be self-
administered as long as a woman is able to read.Screening
questions can either be built into the electronic medical record
or completed on paper.
Introducing a screening protocolis a smoother process
if there is generalacceptance from everyone on staff.Pro-
viding training on how to screen for substance abuse and in
interventionaltechniques improves the chance that screen-
ing willbe done welland consistently.44 Practicalissues to
consider in choosing which instrument to use include ease
of administration, the amount of nursing and provider time
the screening and documentation process adds to each visit,
and whether a toolis proprietary and must be purchased.
Provider reimbursement for SBIRT services is available from
private insurers, Medicaid, and Medicare. Coding and reim-
bursement are dependent on payer type. Additional informa-
tion regarding coding and billing for screening is available
from the Web site of the Substance Abuse and Mental Health
Services Administration.3
BRIEF INTERVENTION
Substance abuse screening can identify a woman at risk for
but does not diagnose the presence of a substance use disorder.
Following a positive screen,a woman’s health care provider
must assess how significant a role alcohol, tobacco, and dr
play in a woman’s life and how she perceives that role. Cha
recommends exploring the context(s) in which a woman is
likely to use substances, that is, socially (with friends), in a
intimate setting (with partner),or when anxious or upset.31
When drug or alcohol abuse is identified, motivational inter
viewing techniques are useful to assess a woman’s percept
of her current substance use patterns,her confidence level,
and her willingness to initiate change.52
Motivationalinterviewing is a therapeutic approach in-
troduced in 1991 by Miller and Rolnick52, 53and is used in a
variety of settings. The approach was developed from cogn
tive behavioral therapy with the goal of “increasing the imp
tance of change from the client’s perspective.”53Motivational
interviewing techniques are designed to elicit changes in b
havior and have been widely validated for use in the conte
drug and alcohol abuse.52, 53The basis for this approach is the
understanding that change is a process that can be positive
influenced by positive input in a therapeutic context. For ex
ample,if a woman screens positive for substance abuse and
is unmotivated to reduce her use,motivational interviewing
techniques can help her perceive the negative impact of su
stances in her life, understand the discrepancy between co
tinuing to use and her personal goals and priorities, and en
hance her efficacy in making change.52, 53Web-based training
for providers in motivational interviewing techniques is ava
able on the Substance Abuse and Mental Health Services A
ministration Web site.
REFERRAL FOR TREATMENT
If a woman agrees to substance abuse treatment, referral c
be made either by a primary care or obstetric provider. If th
diagnosis of a substance use disorder is unclear or if a wom
is reluctant to seek treatment for substance abuse, she ma
cept referral to a psychiatric provider or counselor with dru
and alcohol certification for further assessment.Addressing
underlying mood or anxiety problems by referring a woman
to a psychiatric provider may facilitate treatment for both d
agnoses and may feel more acceptable to her.
When physiologic dependence is present, a woman may
need referral to an inpatient facility, a residential program,
intensive outpatient treatment.In the case of opioid depen-
dence, maintenance therapy either with buprenorphine (Su
oxone) or methadone (Dolphine) is recommended initially.
Women’s health care providers should know what types of
treatment are available in or near a woman’s home commu
nity, as well as cost, insurance coverage, and other hidden
riers to access such as transportation, lack of child care, an
clinic hours of operation. When case management is availa
women may be able to get assistance in these areas.
Reimbursement for substance abuse treatment varies b
insurer. The type of services and duration of treatment cov
ered for Medicaid recipients also vary from state to state.54
In addition to the barriers described above, substance abus
treatmentis often notavailable,especially in ruralareas,
or there may be a long waiting listfor enrollment.When
this is the case,the burden of intervening to help a woman
decrease her substance use falls on her primary provider,
Journal of Midwifery & Women’s Healthr www.jmwh.org 281

Table 1.Screening Tools
Description/Time it
Takes to Training
Tool Complete Sensitivity Screens for Validation Available Cost
ASSIST48 8 Initial questions
with follow
up/lengthy
54%-97% SensitiveSpecific drugs
of abuse,
EtOH and
tobacco
Cross-nationally/
WHO screening
tool.
No Free
Discriminates
between casual
use/abuse/
dependence
50%-96% Specific Not for prenatal
patients
AUDIT-C40, 49 3 Questions/
approximately
1-2 min
67%-95% Sensitive
85% Specificity
Positive predictive
value 92%-100%
EtOH use For prenatal patients
Sensitivity varies
widely in
different studies
No Free
CRAFFT31 Validated for use for
patients aged
15-24
76% Sensitivity
94% Specificity
EtOH and
drug use
Recently for
prenatal patients
No Free
6 Questions/
approximately
2-3 min
4P’s Plus32, 50 5 Questions with
follow-up if
positive; 2-5 min
87% Sensitivity
76% Specificity
All substances For prenatal patients Yes Requires
permission
for usea
Substance Use
Risk Profile
Pregnancy
Scale51
3 Questions/
approximately
2 min
91% Sensitivity
67% Specific
EtOH and
THC
Recently developed
Specifically for
prenatal patients
No Free
T-ACE49 4 Questions/
approximately
1-2 min
69%-88% Sensitivity
1%-89% Specificity
EtOH only —
for heavy
use
For prenatal patients No Free
TICS42, 47 2 Questions/⬍1 min80% Sensitivity
80% Specificity
Negative predictive
value 92.7%
EtOH and
drug use
Easy to implement
in primary care
setting
No Free
TWEAK49 5 Questions/
approximately
1-2 min
71%-91% Sensitivity
73%-83% Specificity
ETOH only —
effective for
heavy use
For prenatal patients No Free
Abbreviations: ASSIST, Alcohol, Smoking, and Substance Involvement Screening Test; AUDIT-C, Alcohol Use Disorders Identification Test; CRAFFT, T-ACE
acronyms based on their respective screening questions; EtOH, ethanol; TICS, Two-Item Conjoint Screening Tool; WHO, World Health Organization.
aCost is prorated. Can be customized and includes training.
regardlessof his or her training in thisarea.Collabora-
tion with family practice, internal medicine, and psychiatric
services is the best interim approach in this circumstance.
Women’s health care providers can work within health care
organizations, with public health officials, and with legislators
to encourage funding for increased availability of substance
abuse treatment services.Population-specific data collected
through the SBIRT process can play an importantrole in
developing a community needs assessment and helping an
organization access funding.
Special Concerns for Pregnant Women
When a pregnant woman is physically dependent on drugs
or alcohol,admission for medically assisted detoxification
and/or stabilization should be strongly considered. If she h
282 Volume 58, No. 3, May/June 2013

opioid dependence, the current standard of care includes tran-
sition to opioid maintenance therapy using methadone, with
buprenorphine as a second option.9, 29
Physicaldependence
on alcohol or benzodiazepines should be managed by addic-
tion or internalmedicine specialists.Referralto the emer-
gency department is recommended if a pregnant woman is
in acute withdrawal from alcohol or drugs and unable to ac-
cess immediate treatment. Obstetric providers should not at-
tempt to prevent withdrawal by prescribing opioids or to treat
a woman who is withdrawing from drugs in the outpatient set-
ting without consultation with addiction medicine. If admis-
sion is not medically indicated, a provider can explore other
strategies, including individual counseling, an intensive out-
patient program, an appropriate 12-step program, referral to a
licensed alcohol and drug counselor, or other outpatient treat-
ment options that are locally available.
Pregnant women should be given priority for enrollment
in substance abuse treatment and ideally should be seen by a
treatment provider within 48 hours after requesting care. If at
all possible, a woman should leave her obstetric provider’s of-
fice with an initial appointment made.Unfortunately,many
treatment programs do not accept pregnant clients. Accord-
ing to the Guttmacher Institute, 18 states in the United States
have substance abuse treatment programs targeted to preg-
nant women, and only 4 states protect pregnant women from
discrimination in publicly funded treatment programs.42
When a pregnant woman does not wish to accept treat-
ment for substance abuse, she should be offered relevant, writ-
ten information about the risks of exposure to substances dur-
ing pregnancy.A follow-up prenatalvisit should be sched-
uled within a short interval to maintain contact and build re-
lationships. In the authors’ experience, many women change
their minds about seeking treatment and will reopen the con-
versation ifcommunication lines remain open.Continuity
of care with a provider who is able to demonstrate empathy
should be provided. Coexisting psychiatric conditions and so-
cialfactors that may prevent her from accessing treatment
should also be addressed. Communication and coordination
between a woman’s obstetric, psychiatric, and addiction treat-
ment providers are essential to providing good care. Because
of federal laws protecting the privacy of those in alcohol and
drug treatment, a woman must give written permission specif-
ically for release ofinformation regarding substance abuse
treatment.
Should Pregnant Women Undergo Urine Drug
Testing?
Some practices in the United States routinely perform urine
drug testing for pregnantpatients atentry to care.How-
ever,there is little evidence that this is beneficial.10, 45Rou-
tine urine drug testing adds significant cost to prenatal care.
Most urine drug tests performed in the hospital or clinic set-
ting require confirmation by more expensive assays before
they can be considered accurate. The accuracy of urine drug
tests can also be confounded by a variety of techniques de-
scribed on the Web and widely used by patients.Standard
urine drug tests also lack the ability to detect intermittent use,
may not include drugs commonly used in a particular com-
munity, and do not routinely test for alcohol, the most com-
monly abused substance next to tobacco. Urine toxicology
be usefulto confirm recent use when a woman has a posi-
tive screen for substance abuse or to monitor progress dur
treatment.
Mandatory urine drug testing may also deter women fro
seeking prenatalcare,especially in states in which report-
ing of drug abuse during pregnancy is mandated.9, 10, 45, 52, 54
Because of its potential legal implications,drug testing dur-
ing pregnancy should be undertaken cautiously and always
with a woman’s informed consent, except in the case of me
icalemergency.In fact,self-report of drug and alcoholuse
during pregnancy yields more than urine drug testing. Cha
noff et al32 examined the results of urine drug testing com-
pared with self-reported use by the same women screened
using the 4P’s Plus.Women who screened positive reported
significantly more drug and alcoholuse than was actually
detected in the urine samples from the same group32 be-
cause they reported intermittentuse.Had providers relied
only on urine testresults,the majority ofsubstance use
among the pregnant women in this study would have been
unrecognized.
Over the past 30 years, a legal and policy debate has ra
regarding the role of individual states in detecting, punishin
or treating substance abuse during pregnancy.36, 42, 52, 54–56
In
the mid-1980s,shortly after policy makers began to address
the issue of perinatal substance use in the United States, m
states adopted a punitive approach,ostensibly to protect fe-
tal health and development. Some of these interventions h
included mandatory drug testing,reduction or elimination
of public assistance benefits,incarceration,and the removal
of children from their mothers.36, 45, 52, 54, 56
In some instances,
such efforts to curb women’s behavior have been determin
to be unconstitutional.36, 42
Table 2 lists the current state policies that apply to preg
nant women who have a positive screen for substance abu
Fifteen states consider substance abuse during pregnancy
be a form of child abuse, as defined by child-welfare statut
and 3 states consider it grounds for civilcommitment (in-
carceration).Fourteen states require health care profession-
als to reportprenataldrug abuse ifdetected,and 4 states
require drug testing if exposure is suspected.42 State guide-
lines in Washington and Vermont recommend screening all
pregnant women using a validated instrument such as thos
discussed above, but this is not required by law.57, 58It is im-
perative that providers know the regulatory environment o
the state in which they practice and the legalimplications
for a woman who screens positive for substance abuse dur
pregnancy.
Comorbid Conditions Complicating Substance Use
Disorders
Substance use disorders in women are highly correlated wi
untreated psychiatric disease,childhood abuse and neglect,
and past or current domestic violence.2, 6, 7, 45Posttraumatic
stress, depression, and anxiety are frequent comorbid cond
tions.Women for whom dual diagnosis is suspected need a
comprehensive treatment plan.4, 5, 46Treatment for substance
use disorders is significantly complicated by the presence o
mood and anxiety disorders,and treatment for mood and
Journal of Midwifery & Women’s Healthr www.jmwh.org 283

Table 2.Substance Use During Pregnancy: State Responses (as of November 2012)
Substance Abuse During
Pregnancy Is Considered Under
Child Abuse Statutes
When Abuse Is Suspected State
Requires Health Care
Professionals to History of Prosecution, , –
Grounds for
Civil Report Test
State Child Abuse Commitment (Postnatal) (Postnatal) Prenatal Postnatal
Alaska X
Arizona X X
Arkansas X
California X
Colorado X
Florida X X X
Georgia X
Illinois X X X
Indiana X X
Iowa X X X
Kentucky X X
Louisiana X X
Massachusetts X X
Michigan X X
Minnesota X X X X
Montana X
Nebraska X
Nevada X X
New Jersey X
New York X
North Carolina X
North Dakota X X
Ohio X
Oklahoma X X X
Pennsylvania X
Rhode Island X X
South Carolina X X X
South Dakota X X
Texas X X
Utah X
Virginia X X X
Wyoming X
Wisconsin X X X
Washington, DC X
Total 16 3 14 4 6 19
Portions adapted from Guttmacher Institute.52
anxiety disorders is similarly affected by substance abuse.
Women’s health care providers should screen for both in-
timate partner violence and common psychiatric problems
concurrently with drug and alcohol screening and refer appro-
priately when a psychiatric condition is suspected or a woman
needs domestic violence services.
CONCLUSION
Screening for substance use and dependence is an essenti
component of women’s health care. Addressing the proble
with women ofchildbearing age early and consistently re-
duces lifelong morbidity and mortality for women, and pro
vides an opportunity to prevent or at least reduce exposur
284 Volume 58, No. 3, May/June 2013

during pregnancy.Linking substance abuse screening and
treatment to obstetric care improves perinatal outcomes and
results in significant cost savings.47, 48
Unfortunately, obstetric
providers, including midwives, have failed to consistently or
effectively adopt screening protocols. Given the serious risks
associated with substance abuse in women,it is imperative
that midwives engage with women to reduce substance use
and promote healing.
In states in which drug testing and reporting of women
suspected of prenatal substance use are required by law,the
decision to screen women for substance use during preg-
nancy has significant ethical implications. Policies that punish
pregnant women with substance use disorders have not been
shown to be efficacious.9 Comprehensive programs that ad-
dress the underlying reasons why women abuse alcohol and
drugs are supported by both obstetric and addiction medicine
specialties.9, 28
The American College of Nurse-Midwives calls
for
. . .a health care system where women with addictions in
pregnancy are treated with compassion,not punishment.
This care should occur within a multidisciplinary environ-
ment that provides holistic care for the pregnant woman in
the context of her social environment and where consider-
ation of the health risks is paramount.59
Women’s health care providers can choose from a number
of tools for screening women for alcohol and drug use during
primary care and pregnancy. The best tool is one that will be
used consistently and that serves to open a door for commu-
nicating about a difficult issue,rather than closing one.Ul-
timately,the goal of screening for substance abuse is not to
identify and punish women but to start the conversation about
healing the problems caused by substance abuse and depen-
dence in the lives of the women we care for, their families, and
our communities.
AUTHORS
Daisy Goodman, CNM, WHNP-BC, DNP, is a member of a
statewide working group in Maine developing guidelines for
managing substance-exposed pregnancies.She is a fellow in
the VA Quality Scholars program and is currently pursuing
her Masters of Public Health degree at The Dartmouth Insti-
tute for Health Care Policy and Clinical Practice.
Kristina Wolff,PhD,MPA, is a sociologist,researcher,and
consultant. Her newest research concerns women with Post-
Traumatic Stress Disorder and Military Sexual Trauma.She
is currently pursuing her Masters of Public Health degree at
The Dartmouth Institute for Health Care Policy and Clinical
Practice.
CONFLICT OF INTEREST
The authors have no conflict of interest to disclose.
ACKNOWLEDGMENTS
This material is based in part on support from the VA Office of
Academic Affiliations and with resources and the use of facil-
ities at the White River Junction VA Medical Center,White
River Junction,VT. We gratefully acknowledge the support
of Molly Chaplin, RN and the staff and providers at Franklin
Health Women’s Care, Farmington, Maine.
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