What is Substance Use in Pregnancy?
Drug and alcohol use during pregnancy is a major health concern in the United States and around the world. In the US, 40% of people who have used drugs in their lifetime and 26% who used both alcohol and drugs in the past year are women. The highest risk of developing a substance use disorder occurs during a woman’s childbearing years, and using substances while pregnant is common. The substances most often used during pregnancy are tobacco, alcohol, and marijuana, but cocaine and opioids are also used. Substance use during pregnancy can cause numerous negative effects for both the mother and the unborn child.
It’s recommended that all pregnant women be tested for substance use so that effective help can be given if needed. However, pregnant women who use substances often feel judged and face obstacles to receiving the treatment that’s based on scientific evidence. It’s also important to consider legal and social issues and how a team of medical professionals can work together to improve health outcomes for pregnant women who use substances, and for their children.
What Causes Substance Use in Pregnancy?
Most women who consume substances like alcohol, tobacco, or drugs tend to lessen their usage while they’re pregnant. Generally, women don’t start taking any substances that could be harmful once they realize they’re pregnant. Those women who manage to quit on their own usually do—that’s the key difference between just using substances and having a substance use disorder (SUD).
The causes of SUD are many and complex, and this holds true for pregnant women as well. A number of factors, like genes, environment, mental state, biology, and socio-economic status, can make a person more likely to develop SUD. Legal substances like tobacco and alcohol are often seen as safe because they’re easy to get and are legal.
Prescription opioids, painkillers prescribed after childbirth, can also lead to opioid use disorder (OUD). They do this by introducing women to drugs that can be addictive and leaving extra pills that can be misused or given to others.
Other prescription drugs like amphetamines and barbiturates can also lead to dependency. Illegal drugs like heroin can be easy for those with SUD to get their hands on. Other influences like poor diet, sharing needles, not having safe housing, poverty, less education, and violence from a partner are all associated with being diagnosed with SUD. Surveys of patients have shown higher levels of alcohol and drug use in urban areas and communities with a high number of adolescents, young adults, and immigrants.
Risk Factors and Frequency for Substance Use in Pregnancy
Between 2005 and 2014, statistics reveal that some pregnant women use substances that could be harmful. Of these pregnant women, 11.5% of adolescents and 8.7% of adults admitted to drinking alcohol, while 23% of adolescents and 14.9% of adults confessed to using tobacco. A national survey in the U.S. found that 5.9% of pregnant women confessed to using illegal drugs, 8.5% to drinking alcohol, and 15.9% smoked cigarettes during their pregnancy. Similar situations have been seen in Europe and Australia.
- A study showed that about 2.5% of all pregnant women and 20% of those with U.S. Medicaid insurance were prescribed at least one opioid during their pregnancy.
- Most pregnancies in mothers with opioid use disorder (OUD) are not planned.
- It’s very common for pregnant women to use multiple substances at the same time, just like non-pregnant individuals.
- There’s a clear decrease in the use of cigarettes, alcohol, marijuana, and cocaine during pregnancy, with most women stopping or reducing their use.
Substance use disorder (SUD) rarely happens alone. It’s often aligned with an increased risk of mental health conditions like major depression, bipolar disorder, posttraumatic stress disorder, and panic disorder. Pregnant women with SUD are also at a higher risk of catching serious infectious diseases like HIV, hepatitis B and C, tuberculosis, and sexually transmitted infections. This is due to risky behaviors like having multiple sexual partners, sharing drug equipment, homelessness, and a heightened rate of imprisonment.
Signs and Symptoms of Substance Use in Pregnancy
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has a combined criteria for diagnosing Substance Use Disorders (SUD). If two or more of the following signs are seen in the last 12 months, it could indicate SUD:
- Risky substance use
- Social or relationship problems due to usage
- Ignoring responsibilities
- Experiencing withdrawal symptoms
- Building tolerance to the substance
- Using more or for a longer time than planned
- Failed attempts to stop using
- Physical or mental health problems linked to use
- Intense craving for the substance
- Choosing the substance over other important activities
To confirm the SUD diagnosis, a detailed medical history and physical examination are first required. Some individuals, like pregnant women, might fear revealing their substance use due to potential social consequences. If no substance use is reported, other health history indicators might hint at SUD. These could include recurring infections, HIV, hepatitis C, a history of abuse, and mental health disorders. Delayed prenatal care in pregnant women might indicate fears about revealing substance use.
The physical examination starts with checking vital signs. High blood pressure might imply stimulant use like cocaine or amphetamines. A nasal perforation might hint at cocaine use, while being underweight might be a sign of malnutrition due to substance use. Health professionals should observe the patient’s general appearance. For women, appearing dazed, agitated, or drowsy might indicate substance influence. Enlarged or shrunk pupils and needle marks could indicate opioid use. Other indicators might include bruising, strong smells of tobacco, alcohol, or marijuana, and poor dental health.
Testing for Substance Use in Pregnancy
Substance use during pregnancy can lead to serious health issues. Doctors often rely on medical history and physical exams to identify substance use disorders (SUD). However, many women might not openly share this information, making it crucial for doctors to use other ways to identify those at risk.
The American College of Obstetricians and Gynecologists (ACOG) advises that all pregnant women should be screened for substance use as part of their prenatal care as early as possible. This helps doctors treat any problems before they become serious. Typical screening involves simple and cost-effective methods that can quickly identify risk. While some people worry that screening could offend or upset women, the screening tools used are fairly straightforward and easy to use.
It’s important to note that screening alone cannot confirm SUD. It can sometimes indicate occasional substance use rather than an ongoing disorder. Once the screening results are available, doctors will discuss them with the patient and provide guidance about the potential risks of substance use during pregnancy, including risks to the baby. If SUD is confirmed, the doctors then provide information about possible treatments and resources in a non-judgmental way.
Screening for substance use is different from drug or alcohol testing. While screening is advised for all pregnant women, routine drug or alcohol testing is not. However, tests for biological markers of substance use can be useful in certain situations, such as when detailed information about multiple substances is needed. This kind of testing may require collecting samples like urine, hair, or meconium (the first stools of a newborn) to identify substance use.
It’s crucial to mention that under normal circumstances, a woman’s consent is needed before performing any drug testing during pregnancy. For those enrolled in treatment programs or in contact with the legal system, mandatory drug testing may apply. This kind of testing does not distinguish between sporadic and regular substance use, and it should be conducted based on medical criteria rather than demographic profiling. Ensuring the validity of samples is essential as sometimes patients may swap their own urine with others’ to produce a negative test result.
Treatment Options for Substance Use in Pregnancy
The best approach to managing pregnant women struggling with substance or drug misuse, known as ‘substance use disorder’ or SUD, starts with complete prenatal care. Following this, the focus is educating them around the potential harm of things like smoking, drinking, and drug use for both themselves and their unborn child. Encouraging them to stop or reduce use is crucial, done in a supportive, motivational way instead of judgmental. Anyone with SUD should receive immediate referral to appropriate experts for treatment covering both mental and physical health.
Treatment for all forms of SUD poses benefits, as it helps reduce the risk of falling back into substance misuse and improves pregnancy health. The ACOG advises that pregnant women who smoke or use nicotine and tobacco should stop. If this is achieved by 15 weeks into the pregnancy, it benefits the baby the most. While medications like varenicline, bupropion, and nicotine replacement can be considered if counselling doesn’t lead to quitting, it’s important to note that these treatments lack safety data for use in pregnancy or have not proven to lead to long-term smoking cessation.
Patients who misuse alcohol or benzodiazepines can be managed with detoxification, which involves reducing usage over time, but it’s essential to remember that the approved medicines for alcohol misuse (naltrexone, disulfiram, and acamprosate) carry some risk as there isn’t enough safety data around using them during pregnancy. Alcohol withdrawal syndrome is serious and potentially fatal, leading to seizures and delirium tremens, thus those experiencing withdrawal should receive inpatient detoxification.
For pregnant women with OUD, referred to as ‘opioid use disorder’, medication-assisted treatment is the standard care. While some may opt for medical supervision during withdrawal, current advice is treatment with methadone or buprenorphine. It’s noted that the likelihood of going back to using during pregnancy is higher for those who choose detoxification over medication-assisted treatment. Naltrexone, another approved OUD drug, doesn’t have enough data to recommend starting it during pregnancy. However, for pregnant women already on naltrexone with close medical supervision, the choice to continue it after discussing potential risks and benefits with her healthcare provider exists.
Medication-assisted treatment can help suppress cravings and withdrawal symptoms, making those in treatment less likely to use illicit substances. Pregnant women who follow this form of treatment often stick to prenatal care more and experience fewer complications associated with injecting drug use, such as overdose and infection. However, access to this form of treatment can be challenging, particularly for pregnant women not covered by health insurance, those in rural areas, and non-English speakers.
Deciding between buprenorphine or methadone treatment depends on several factors like the availability of treatment programs and the patient’s preferences. Methadone treatment requires daily, supervised medication appointments, while buprenorphine can be taken at home with regular doctors visits.
The Mainstreaming Addiction Treatment (MAT) Act updated federal guidelines to allow all healthcare providers to prescribe buprenorphine for OUD, aiming to reduce stigma and incorporate substance use disorder treatment across all healthcare settings. Since December 2022, the MAT Act has removed the need for a DATA-Waiver (X-Waiver) program, which means that all DEA-registered practitioners can now prescribe buprenorphine for OUD in their practice if state law allows it. This changed the limit of patients a practitioner can treat, and no longer requires patient or prescription tracking.
Neonatal opioid withdrawal syndrome (NOWS), previously termed neonatal abstinence syndrome (NAS), is a manageable condition anticipated in newborns whose mothers used opioids while pregnant. Studies suggest that newborns exposed to prenatal buprenorphine may need less medication and have shorter hospital stays than those exposed to methadone.
Women opting for medication-assisted treatment at the beginning or early parts of their pregnancy are more likely to care for their prenatal health and deliver healthier babies. This type of treatment should be made readily available for all pregnant women identified with OUD to improve outcomes for both mother and baby.
On breastfeeding, it is generally beneficial for mothers to breastfeed and stay in the same room with their newborns. However, it’s not advisable if the mother consumes illicit substances, including marijuana, because traces can be found in the breast milk. For women with hepatitis C, breastfeeding is generally okay, unless they have cracked or bleeding nipples. For those with HIV, breastfeeding is generally not advised. In some situations such as intimate partner violence, where the mother may feel discomfort while breastfeeding, formula feeding should be seen as a respected alternative opportunity to nourish her baby.
What else can Substance Use in Pregnancy be?
The process of diagnosing a medical condition is usually done by assessing the symptoms and considering other related conditions. In cases where pregnant women may be using certain substances, doctors need to work out whether the usage is occasional or prescribed, or whether there could be a Substance Use Disorder (SUD).
If a woman is diagnosed with SUD, it’s important for her to be checked for use of one or multiple substances, as the effects and treatments can vary depending on the substances involved. Doctors also need to look for related health issues that SUD patients frequently experience, such as sexually transmitted infections like HIV and mental health disorders. It can sometimes be challenging to diagnose these mental health conditions because their symptoms often overlap with those of SUD.
People with SUD often have issues with poor nutrition and dental hygiene. Doctors who carefully listen to their patients, conduct thorough physical examinations, and use reliable medical tools for screening are more likely to identify if a patient has SUD early on, and start the right treatment.
Pregnant women with SUD need to be checked for additional conditions that could negatively affect the pregnancy if not quickly diagnosed and managed. Knowing to look out for SUD can lead to earlier treatment and better health outcomes for both the mother and her baby.
What to expect with Substance Use in Pregnancy
Abstaining and undergoing medication-assisted treatment can lead to better outcomes for pregnant women and their children. Pregnancy often inspires women to decrease or refrain from using substances such as tobacco, alcohol, marijuana, and cocaine, particularly by the second trimester. Pregnant women with Opioid Use Disorder (OUD) who are enrolled in holistic programs, which include medication-assisted treatment, behavioral counseling, and psychosocial support, generally maintain sobriety up until the baby is born.
However, it’s common for women to relapse after delivery, especially with substances like tobacco, marijuana, and alcohol — the relapse rates can even reach 80% during the first year after childbirth. This is mainly due to the added stress that comes from caring for a new baby, hormonal changes, and lack of sleep, which can make recovery more difficult. There is also a risk of unintentional overdoses after childbirth, which can contribute to maternal mortality. Therefore, it’s crucial for these women to receive regular monitoring and support during the first year after birth.
Possible Complications When Diagnosed with Substance Use in Pregnancy
Using tobacco during pregnancy can lead to various negative outcomes including stillbirth, fetal growth reduction, low birth weight, preterm birth, and unexplained infant death. Furthermore, it has been linked with attention deficit/hyperactivity disorder (ADHD) in childhood, although the exact connection has not been confirmed.
Drinking alcohol while pregnant can cause fetal alcohol syndrome (FAS) and birth defects. Even though alcohol is legal and perceived as safe by some, no amount is considered safe during pregnancy. According to data from the Centers for Disease Control, 13.5% of pregnant women have consumed alcohol in the past month. It’s important to remember that alcohol can cause birth defects, and FAS is the biggest cause of preventable intellectual disability in the US.
Marijuana, while illegal federally in the US but legal in some states, is also a concern during pregnancy. While studies are not sufficient, there is evidence linking it with stillbirth, low birth weight, and premature birth. It is also feared that marijuana use during pregnancy may lead to poorer cognitive outcomes in children when they’re of school age. Despite some research implying otherwise, other reports suggest that marijuana exposure in utero can result in several adverse outcomes in newborns, such as low birth weight, small size for gestation age, prematurity, low Apgar score at 1 minute, and smaller average head circumference. As such, organizations like ACOG and the AAP advise against its use during pregnancy.
Cocaine usage during pregnancy is associated with maternal hypertension and placental abruption, and can lead to potential complications in newborns including low birth weight, small size for gestational age, and preterm birth. It has also been linked with slowed growth in all parameters, particularly in late gestation.
- Amphetamines can increase health risks for both mother and fetus, such as maternal hypertension, preeclampsia, placental abruption, fetal death, and neonatal death.
- Opioids, whether illegal or prescribed, can result in Neonatal Opioid Withdrawal Syndrome (NOWS), affecting the newborn’s central nervous, autonomic, respiratory, and gastrointestinal systems, and may lead to extended hospital stays. Symptoms include irritability, poor feeding, unstable temperature, and difficulty sleeping. Furthermore, prenatal opioid use also escalates the risk of low birth weight and babies born small for their gestational age.
Legally, substance use during pregnancy can also result in various issues. In eighteen states in the US, substance use is classified as child abuse, and in three states it’s considered grounds for detention. Therefore, many women avoid prenatal care or don’t notify their doctors about their substance use. Some states require all illegal or prescribed substance use to be reported to child protective services. Medical providers must be aware of their local testing and reporting requirements and share this information with their expecting patients, all while advocating for complete and comprehensive care. Criminalizing substance use doesn’t contribute to improved clinical outcomes for the mothers or their children.
Preventing Substance Use in Pregnancy
Teaching pregnant women about the potential health risks of substance use for both themselves and their newborns is absolutely critical. This includes not only traditional prenatal and postnatal care, but also behavioral counseling and social support, which have been shown to improve health outcomes. It’s important for women of childbearing age to understand the risks of using substances like alcohol, tobacco, and marijuana during pregnancy, especially since many pregnancies aren’t planned. For women struggling with opioid use disorder (OUD), beginning treatment with medications before they become pregnant is a recommended public health strategy.
For women whose newborns may be at risk for Neonatal Opioid Withdrawal Syndrome (NOWS), it’s helpful for them to know what to expect after giving birth. Medical professionals can advise them about the symptoms of newborn withdrawal, how to comfort an infant experiencing these symptoms, options for medication and the importance of close monitoring. Special tours are often available on maternity wards to help mothers with OUD better prepare for the birth of their baby.
Support for women with Substance Use Disorders (SUD) doesn’t end after giving birth. There’s a high risk that women with SUD could relapse and begin using substances again, so it’s crucial to educate them about these risks. Regular screenings and careful monitoring are particularly important in the first year after giving birth. Ongoing medication-assisted treatment and consultations with experts in substance use and behavioral therapy can help ensure the best possible health outcomes.
In a broader sense, patient education also involves providing information and access to resources for transportation, safe housing, securing food, childcare, and birth control options. Counseling that takes into account past trauma and support groups with individuals who are also in recovery can increase the likelihood of staying sober after giving birth.
