Drug and Alcohol Screening Patterns Among Pregnant Women During Ambulatory Care Visits
Introduction: Early detection of substance use among pregnant women, including drugs and alcohol, allows for intervention to potentially reduce adverse outcomes for the mother and fetus. Preventable conditions related to maternal substance use include subsequent cognitive impairments for the child, neonatal abstinence syndrome, and low birth weight. Additionally, detecting substance use can result in the diagnosis and treatment of substance use disorders among pregnant women. Pregnant women with substance use disorders who engage in treatment have higher infant birth weight along with a greater likelihood for substance use abstinence during pregnancy. The use of validated screening tools to detect substance use is recommended in pregnancy[3,4]. We sought to estimate the prevalence of substance use (alcohol and other drug) screening among pregnant women in the United States.
Methods: We used the National Ambulatory Medical Care Survey, a nationally representative cross-sectional survey of ambulatory care visits in the United States, to estimate the prevalence of screening for drug or alcohol use. Our population was limited to pregnant women, ages ≥12, who had a visit during 2014-2016, the most recent years available. We analyzed the data accounting for the complex survey design to estimate an average annual prevalence of screening. The primary outcome was the use of a validated screening instrument for either drug or alcohol use. We modeled the relationship between screening and covariates with a logistic regression. Covariates included age, race, insurance status, whether patients were seen before, presence of chronic conditions, tobacco use status, and living in a metropolitan statistical area. The analysis was completed in R using the “survey” package.
Results: An average of 33,770,000 (95% CI 27,358,000 – 40,180,000) annual visits by pregnant women occurred. The average age was 29.0 years (95% CI 28.2 – 29.7). Screening occurred in an average of 1.6% (95% CI 0.7% - 2.6%) visits annually. In the adjusted analysis, Non-Hispanic Black women had 3.6 (95% CI 1.6 – 7.8) increased odds of being screened compared to Non-Hispanic White women. The presence of a chronic medical condition led to a 3.8 (95% CI 1.1 – 12.5) increased odds of screening compared to an absence of a chronic condition. Former tobacco smokers had a 0.2 (0.0 – 0.8) decrease in the odds of screening compared to never smokers. There were no significant differences in the screening among the remaining covariates.
Conclusions: The prevalence of screening for substance use in pregnant women attending ambulatory care visits is woefully low. This is despite the estimated prevalence of alcohol use being 15%, while cannabis use is 7%, and opioid use is 2.5% among pregnant women. We found significant differences in screening by race and ethnicity. Overall, these results potentially suggest a missed opportunity to detect substance use during ambulatory care visits. Future studies are needed to elucidate how to best implement routine substance use screening of pregnant women during ambulatory care visits to ensure optimal maternal and fetal health.
References: 1Rayburn WF. Maternal and fetal effects from substance use. Clinics in Perinatology. 2007;34(4):559-571. doi:https://doi.org/10.1016/j.clp.2007.09.001
2Staudt M. Best Practices for Enhancing Substance Abuse Treatment Retention by Pregnant Women. Best Practices in Mental Health. 2018;14(2):48-63. https://eds-b-ebscohost-com.ezproxy.umgc.edu/eds/pdfviewer/pdfviewer?vid=6&sid=5edb0749-09ee-4b30-9a2e-dd7a2cb8a168%40pdc-v-sessmgr06
3US Preventive Services Task Force. Screening and Behavioral Counseling Interventions to Reduce Unhealthy Alcohol Use in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;320(18):1899–1909. doi:10.1001/jama.2018.16789
4US Preventive Services Task Force. Screening for Unhealthy Drug Use: US Preventive Services Task Force Recommendation Statement. JAMA. 2020;323(22):2301–2309. doi:10.1001/jama.2020.8020
5Chang G, Ondersma SJ, Blake-Lamb T, Gilstad-Hayden K, Orav EJ, Yonkers KA. Identification of substance use disorders among pregnant women: A comparison of screeners. Drug and Alcohol Dependence. 2019;205. doi:https://doi.org/10.1016/j.drugalcdep.2019.107651
Learning Objective: The annual prevalence of screening for drug and alcohol use among pregnant women attending ambulatory care visits was 1.6% (95% CI 0.7%-2.6%), from 2014 – 2016.