Adopt Universal Screening for Pregnant People

Introductory Paragraph

With substance use disorder and the opioid epidemic rising, so is the use of prenatal substance use. While pregnancy can be exciting for others, for those with an SUD, diagnosed or not, there is an immense amount of stress added to their lives. Not only do they face negative health consequences for their unborn baby and themselves, they face public scrutiny and shame along with potential legal repercussions depending on their local and state laws. There is no current uniform protocol for substance testing among pregnant patients, with localities and hospitals patch-working their own models. They argue against universal screening on the fear that pregnant women won’t seek out or continue prenatal care out of fear of prosecution or having their child removed from their care. However, risk-based screening has been shown to lead to implicit bias, with practitioners using previous “red-flag” history information to decide if a patient is at risk for an SUD (11). A 2017 study showed that practitioners who used risk-based screening showed “as much implicit bias as the public” and the results were poor prenatal care treatment (11,12). Universal screening is a way to combat implicit bias that negatively impacts the most vulnerable pregnant women, along with early detection and treatment interventions.

Relevant Research

 In Kaiser Permanente's Early Start program, pregnant women were screened for substance abuse risk at the first prenatal visit by a self-administered questionnaire and by urine toxicology testing (with signed consent). Universal screening facilitates early identification and treatment of substance use.

Early Start: An Integrated Model of Substance Abuse Intervention for Pregnant Women - Kaiser Permanente
Overview of program:

• Universally screen all pregnant women
• No mandated reporting for toxicology
• Mental health provider apart of obstetric care
• Use video conferencing and telephone to provide care to immediate and remote care

Outcome Successes:

• Show decrease in morbidity for mothers and babies
• Cost beneficial
• Reduces all barriers to care, including in prenatal care

The role of screening, brief intervention, and referral to treatment in the perinatal period -- Tricia E. Wright, MD, MS
Method:

Screening Instruments:

• CAGE -- Cut down, Annoyed, Guilt, Eye opener
• T-ACE -- Takes, Annoyed, Cut down, Eye opener
• TWEAK -- Tolerance, Worry, Eye opener, Amnesia, Cut down
• 4Ps -- Past, Present, Parents, Partner
• NIDA Quick Screen -- Uses 3 open-ended questions regarding alcohol, tobacco, and other drugs

Key Screening Conclusions:

• Screening should be done for all pregnant women and throughout pregnancy for those at risk
• Screening can be done by a provider using a validated instrument during follow-up or by asking standardized questions during interview
• Screening must be nonjudgemental and open-ended
• Urine toxicology should not be used in place of screening

Promising Practices for Standardized Screening

Indiana State Department of Health

In 2014, because of the high rate of opioid prescriptions, the Indiana General Assembly charged the Indiana State Department of Health (ISDH) to: develop a standard clinical definition of NAS and a standardized process of identifying it, identify the resources hospitals need to do this, and then establish a voluntary pilot program with hospitals to implement this standardized NAS identification. As of 2016, 26 of 89 Indiana Birthing Hospitals are taking part in this pilot screening program

  To understand and address perinatal substance use, accurate data needed to be collected through standardized screening and testing:

• When any pregnant arrives at the hospital for delivery, hospital personnel conduct a standardized and validated verbal screening regarding substance use.
• Any woman with a positive verbal screen at any point during pregnancy, including at presentation for delivery, is requested to consent to a urine toxicology screening.
• Babies whose mothers had a positive verbal screen or toxicology screen, or babies whose mothers did not consent to the toxicology screen will be tested for evidence of maternal substance use using the infant’s umbilical cord.
  • Note: Umbilical cord testing, not meconium stool, was used on all infants.
• Babies also have modified Finnegan scoring initiated to observe for signs and symptoms of NAS.

ISDH noted that universal screening in a non-punitive environment would allow us to understand the true prevalence of Perinatal Substance Use and NAS.

See Improve Identifying and Data Collecting on NAS for more information on defining, testing, and reporting data about NAS.

Sources

1. [1]
2. [2]