NNEPQIN Guideline for Screening for Use of Alcohol, Tobacco and Drugs of Abuse in Pregnancy. March 2014

The following guidelines are intended only as a general educational resource for hospitals and clinicians, and are not intended to reflect or establish a standard of care or to replace individual clinician judgment and medical decision making for specific healthcare environments and patient situations. NNEPQIN Guideline for Screening for Use of Alcohol, Tobacco and Drugs of Abuse in Pregnancy March 2014 Approximately 12% of pregnant women report the use of alcohol within the last month. Four percent of pregnant women report the use of illicit drugs. 16.5% report continuing smoking tobacco while pregnant. The rate of illicit drug use is higher in women age 15-19 (1). The continued use of alcohol is more prevalent in women that are over age 35, of white race, college educated, married and obtaining care from a private physician (2). Obstetrical care providers have a professional obligation to screen all patients for substance abuse in pregnancy (3). Identification of substance abuse can lead to appropriate referral and treatment for the mother, while possibly mitigating risk for the fetus. Several screening methods and tools have been proposed and validated, but the routine use of these has in some cases been difficult to incorporate into practice. Communication with patients about drug and alcohol use is often difficult and requires additional skill and time. There can be confusion about legal reporting obligations. Often, treatment options are not clear or obtainable. Unit Structure Each hospital should develop policy and procedure guidelines that employ universal screening for at-risk drug and alcohol use, as well as continued tobacco use in pregnancy. These guidelines should include a description of screening methods, methods of notification of members of the care team, as well as legal authorities when necessary, and resources for ancillary support, education and treatment. Hospital screening programs should be coordinated with outpatient screening during the antenatal period. An important aspect of screening and counseling is that is performed in a non-judgmental, nonpunitive manner. Substance abuse and dependence are medical conditions, not moral problems. Using respectful communication that engages the patient in ongoing care and screening with informed consent are techniques that nurture the therapeutic relationship between provider and patient. 1

Definitions At-Risk Behaviors: Behaviors or circumstances that indicate a substantially higher likelihood of the use of alcohol, tobacco, or illicit substances, as identified by screening. Substance Use Disorder: A recurring pattern of alcohol or other drug use which substantially impairs a person s functioning in one or more important life areas such as familial, employment, psychological, legal, social, or physical. Any use by youth is considered a use disorder. (4) Substance Dependence: A primary chronic disease leading to clinically significant impairment or distress, including physical and psychological dependence as evidenced by tolerance, withdrawal, and unsuccessful attempts to cut down or control use (4). Role of the Obstetrical Care Provider The role of the obstetrical care provider in the process of evaluation of patients for substance abuse has been suggested by ACOG to include (3, 5): Learn and incorporate into routine practice the process of screening, brief intervention and referral to treatment (SBIRT), in order to provide patient benefit and nurture the therapeutic relationship. Encourage healthy behaviors by providing appropriate information and education. Adhere to safe prescribing practices. Identify referral resources and develop other members of the health care team to assist with counseling, referral and treatment. Evaluate at-risk patients for associated medical and social problems such as partner violence, sexually transmitted diseases, and other medical complications of substance abuse such as cardiac and respiratory compromise. Be aware of local legal reporting obligations. Screening Considerations Screening for at-risk use of alcohol, drugs and tobacco is carried out by asking directed questions. The use of a standardized questionnaire at regular intervals in pregnancy is recommended as the most effective method of implementing screening into routine practice. Biochemical testing should never be employed as a stand alone screening method. Several questionnaires have been developed for use as screening tools, but there is not consensus regarding which tool is most ideal for use in the pregnant population. Various tools may be too sensitive, or too specific, may not be ideal for pregnant populations, or may screen for alcohol only, and not other substances. Some tools may be proprietary, while others may not be recognized by regulatory agencies as valid for billing purposes. Each unit must determine which screening tool is optimal, given the local needs and circumstances. A comprehensive description of screening tools can be found at (6): http://www.dbhds.virginia.gov/documents/scrn-perinatal-instrumentschart.pdf Several screening questionnaires have been recommended for use in pregnant women. The T- ACE (Tolerance, Annoyance, Cut Down, Eye Opener) (7) and TWEAK (Tolerance, Worried, Eye-openers, Amnesia, K[C] Cut Down) (8) are two screening questionnaires that have been 2

shown to be effective in pregnant populations, but they primarily screen for heavy alcohol use. Chasnoff has validated a questionnaire that screens for drug and alcohol use, as well as at-risk behaviors or circumstances (4Ps plus) (9, 10). As such, the sensitivity of the screen is higher (more identified as at-risk), but the specificity is lower (fewer actually exhibit substance abuse). The 5Ps is a modification of the 4Ps (11) validated questionnaire, developed by the Massachusetts Institute of Health and Recovery, designed to be a brief 6-question screen for tobacco, alcohol and drug use(12). The AUDIT-C is an abbreviated 3 question screen for at-risk alcohol use that has been validated for use in female populations (13). It does not screen for drug use. The DAST-10 is a 10- question drug abuse screen, validated for use in a general female population (14). As validated questionnaires, their use in screening programs, when combined with brief intervention, is recognized by CPT and reimbursement may be available. Yonkers, et al have described an analysis of multiple screening questions and suggest that directed questions about past use of marijuana, pre-pregnancy use of alcohol or drugs, and a perceived need to cut down on use are the most sensitive at identifying an at-risk patient (SURP- P) (15). Biochemical testing of pregnant patients is most practically achieved through urine toxicology testing. Urine toxicology testing has several limitations, including those related to the short time interval for detection of the presence of a substance (1-3 days in most cases), false negative and false positive results, and susceptibility to tampering and falsification. There is conflicting evidence regarding the clinical utility of universal urine toxicology testing as part of a screening program (16, 17, 18, 19, 20, 21). Urine drug testing often identifies patients using substances when they do not admit to use, and this is especially the case in high risk populations. Some prenatal screening programs incorporate routine urine toxicology testing along with the use of screening questionnaires (22). Others recommend urine toxicology testing when a woman denies use, but high risk circumstances are present (23). Biochemical testing should not be used to replace or substitute for other forms of screening, but rather should be used as an adjunct to a comprehensive program of screening and referral. Circumstances associated with substance abuse include (23): Partner is a substance abuser Legal problems and arrests Multiple missed appointments Stigmata of drug use: perforated nasal septum, intravenous track scars, skin abscesses Homelessness Family history of drug or alcohol abuse History of/or ongoing psychiatric treatment Previously delivered children not living with the mother Unexplained history of obstetrical or neonatal problems: abruption of placenta, IUGR, prematurity Late presentation for prenatal care History of/or ongoing treatment for chronic pain 3

Recent study has shown that some women are mistrustful of providers efforts to discover drug use, especially when urine testing is used (24). Interviews with substance using women revealed they expected untoward consequences of being identified, including feelings of maternal failure, judgment by providers, and reports to legal authorities. As a result women took steps to protect themselves, including avoiding or disengaging from prenatal care. All screening methods should be employed with informed consent of the patient. The proper management of the patient with a positive screen will foster a relationship of trust. Information regarding positive screening, drug testing results or a diagnosis of substance abuse should be communicated to the patient privately, and then only to the necessary members of the health care team. Patients should be confidentially counseled about the dissemination of information regarding the results of screening. Each hospital should be able to identify community resources for referral and treatment. A comprehensive guideline for screening pregnant women for substances of abuse has been developed by the Vermont Child Health Improvement Program and is available at: (23) https://www.med.uvm.edu/vchip/downloads/vchip_1%20treatment_vt_guidelines.pdf Screening the Pregnant Patient for Substance Abuse All pregnant patients should undergo screening for the use of tobacco, alcohol or other drugs using one of several validated questionnaires. NNEPQIN offers the following methodology for the use of the 5Ps Prenatal Substance Abuse Screen for Alcohol, Drugs and Tobacco (Appendix 2) (11, 12). 1. All pregnant patients will undergo the 5Ps screen at the initial obstetrical visit, and upon admission to labor and delivery: Did any of your parents have a problem with using alcohol or drugs? Do any of your friends (peers) have problems with drug or alcohol use? Does your partner have a problem with drug or alcohol use? In the past have you had difficulty in your life due to alcohol or other drugs, including prescription medications? Present: In the past month, how often did you drink beer, wine, wine cooler or liquor or use any king of drug? (How many times a day, week or month.) How much did you smoke before you knew you were pregnant? 2. A positive response to any of the questions on the 5Ps is a positive screening result, and should trigger further directed questioning. A more comprehensive history of drug or alcohol use is needed to determine whether a substance use disorder or substance abuse is present. Evaluation of the perceived health and emotional effects of substance use is an important part of history taking. 3. A urine toxicology test should be considered when the maternal patient presents with risk factors including, but not limited to, the following: No or inadequate prenatal care. Exhibited signs and symptoms of drug and/or alcohol use or withdrawal. Drug seeking behavior, repeated use of prescription narcotics. 4

Personal history of domestic violence, incarceration, or previous DCF/DCYF referral. Maternal history of Hepatitis B/C, HIV-positive status, or active STD s. Unexplained medical complications of pregnancy such as: preterm labor, placenta abruption, IUGR, and hypertension. 4. All patients are monitored during prenatal care for risk factors as noted above, and should they develop, repeat screening with or without urine drug testing should be performed. 5. All necessary members of the health care team should be informed of the results of screening. A member of the health care team should notify the patient of the results of testing and discuss any implications for care. 6. Patients with positive toxicology results should be counseled about the risks and benefits of breastfeeding. 7. If the patient with a positive toxicology test denies using, consideration should be given to performing confirmatory testing. Continue with the policy and procedure as outlined for positive screen results. 8. All members of the healthcare team are responsible for reporting suspected abuse or neglect of children to the DCF/DCYF within 24 hours. Positive toxicology test results will be reported to DCF/DCYF by a member of the healthcare team. See Appendix 4 for screening algorithm Managing the Results of Screening Screening methods are primarily designed to identify an increased risk of abuse of alcohol, illicit substances or tobacco. A positive screen does not necessarily identify substance abuse or significant use that would confer risk to the mother or fetus. A positive screen should be followed by: More directed inquiry about use of substances and their effects on the patient s physical and emotional health. Education of the patient about the health effects of substance use, and recommendation that she either stop using or seek treatment if drug dependent. An assessment of preparedness for cessation or treatment. An assessment of associated medical and social problems. Referral for directed counseling and treatment, as indicated. ACOG suggests that obstetrical providers learn the skills of brief intervention and active referral to treatment, as actions that can direct and encourage substance abusing patients to engage in treatment (3). The Boston University School of Public Health has developed an effective program of algorithms, tools and demonstration videos that can be employed to learn these skills in the clinic or hospital setting (25). The Brief Negotiated Interview (BNI) helps providers quickly explore a patient s motivation to change behavior, while eliciting action steps from the patient. The Active Referral to Treatment (ART) involves initiating the treatment plan with the assistance of the patient. The BNI ART Institute web site may serve as a resource for providers to offer these important intervention and referral services: www.bu.edu/bniart/ 5

Proposed Performance Measure The percentage of patients for whom screening and documentation has been completed upon admission for labor and delivery. Appendix: 1. Criteria for Evaluation of Studies 2. 5P s Prenatal Substance Abuse Screen for Alcohol, Drugs and Tobacco. 3. AUDIT-C Questionnaire 4. DAST-10 Questionnaire 5. Algorithm for Substance Abuse Screening in Pregnancy Appendix 1 Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventative Services Task Force I Evidence obtained from at least one properly designed randomized controlled trial. II 1 Evidence obtained from well designed controlled trials without randomization. II 2 Evidence obtained from well designed cohort or case control analytic studies, preferably from more than one center or research group. II 3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence. III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories: Level A Recommendations are based on good and consistent scientific evidence. Level B Recommendations are based on limited or inconsistent scientific evidence. Level C Recommendations are based primarily on consensus and expert opinion. 6

Appendix 2 5 Ps: Prenatal Substance Abuse Screen for Alcohol, Drugs and Tobacco. 1. Did any of your parents have a problem with using alcohol or drugs? No Yes No response If yes, explain/comments: 2. Do any of your friends (peers) have problems with drug or alcohol use? No Yes No response If yes, explain/comments: 3. Does your partner have a problem with drug or alcohol use? No Yes No response If yes, explain/comments: 4. In the past have you had difficulty in your life due to alcohol or other drugs, including prescription medications? No Yes No response Comment: 5. Present: In the past month, how often did you drink beer, wine, wine cooler or liquor or use any king of drug? (How many times a day, week or month.) No use Has used Comment: 6. How much did you smoke before you knew you were pregnant? packs a day. Comment: Date/Time: Name (Print): Signature: From the Massachusetts Institute of Health and Recovery http://www.mhqp.org/guidelines/perinatalpdf/ihrintegratedscreeningtool.pdf 7

Appendix 3 AUDIT-C Questionnaire 1. How often did you have a drink containing alcohol in the past year? Never (0 points) If you answered never, score questions 2 and 3 as zero. Monthly or less (1 point) 2 to 4 times a month (2 points) 2 or 3 times per week (3 points) 4 or more times a week (4 points) 2. How many drinks did you have on a typical day when you were drinking in the past year? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more (0 points) (1 point) (2 points) (3 points) (4 points) 3. How often did you have 6 or more drinks on one occasion in the past year? Never Less than monthly Monthly Weekly Daily or almost daily (0 points) (1 point) (2 points) (3 points) (4 points) The maximum score is 12. A score of 4 identifies 86% of men who report drinking above recommended levels or meets criteria for alcohol use disorders. A score of > 2 identifies 84% of women who report hazardous drinking or alcohol use disorders. WHO Publication 8

Appendix 4 DAST-10 Questionnaire 1. Have you used drugs other than those required for medical No Yes reasons? 2. Do you abuse more than one drug at a time? No Yes 3. Are you unable to stop using drugs when you want to? No Yes 4. Have you ever had blackouts or flashbacks as a result of drug No Yes use? 5. Do you ever feel bad or guilty about your drug use? No Yes 6. Does your spouse (or parents) ever complain about your No Yes involvement with drugs? 7. Have you neglected your family because of your use of drugs? No Yes 8. Have you engaged in illegal activities in order to obtain drugs? No Yes 9. Have you ever experienced withdrawal symptoms (felt sick) No Yes when you stopped taking drugs? 10. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)? No Yes Skinner, Harvey A. and the Center for Addiction and Mental Health, Toronto Canada 9

Appendix 4 Algorithm for Substance Abuse Screening in Pregnancy Initial Visit for Prenatal Care Screen All with 5Ps Questions. If Antenatal Risk Factors* Present, Order Urine Drug Screen and Perform Ongoing Assessment with Periodic Repeat Screening. Negative Screen Substance Abuse or Dependence Identified Routine Prenatal Care Monitor All for Antenatal Risk Factors* Associated With Substance Use. If Present, Repeat 5Ps and Consider Urine Drug Screening. Comprehensive Assessment and Treatment. Monitor for Relapse. Fetal Monitoring as Indicated. Urine Drug Screen at Regular Intervals and on Any Admission Admission for Delivery Negative Screen, No Complications Routine Care and Discharge Screen All with 5Ps Questions If Antenatal Risk Factors* Present, Order Urine Drug Screen Substance Abuse or Dependence Identified Comprehensive Assessment and Treatment, NAS Scoring Declines Screening, or Negative Screening, but Presence of Neonatal Complications Associated with Substance Use (Positive NAS Scoring, Anomalies Suggestive of Drug or Alcohol Exposure, Vascular Accidents, MI, NEC at Term): Perform Maternal and Neonatal Biochemical Screening and Start/Continue NAS Scoring. *Antenatal Risk Factors: No or Inadequate Prenatal Care, Exhibited Signs and Symptoms of Drug and/or Alcohol Use or Withdrawal, Drug Seeking Behavior, Repeated Use of Prescription Narcotics, Personal History of Domestic 10 Violence, Incarceration, or Previous DCF/DCYF Referral, Hepatitis B/C, HIV-Positive Status, or Active STD s, Unexplained Preterm Labor, Placenta Abruption, IUGR, Hypertension.

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