Adopt Universal Screening for Pregnant People
Return toExpand Steps to Minimize Opioid Use During Pregnancy or Pregnancy During Opioid Use
Return to ZOOM MAP - Expand Steps to Minimize Opioid Use During Pregnancy or Pregnancy during Opioid Use
Another potential strategy is to universally screen all pregnant women for substance abuse. 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.[1]
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
- SBIRT -- Screening, Brief Intervention, and Referral to Treatment --> Figure 2: SBIRT Flow Chart
- Components of Interview: raise subject, provide feedback, enhance motivation, negotiate plan
- Purpose of screening for substance abuse is to stratify women into zones of risk given their pattern of use --> Use "risk pyramid" seen in Figure 1.
Screening Instruments:
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- 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.[2]
See Improve Identifying and Data Collecting on NAS for more information on defining, testing, and reporting data about NAS.
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