Understanding the Scope and Impact of Perinatal Substance Use

This research overview explores the issue of substance use disorder (SUD) during pregnancy including factors such as prevalence, potential causes, adverse outcomes, and the importance of universal screening and intervention to ensure healthy outcomes for both mother and child.

Perinatal substance use is a significant public health issue globally, particularly in the US, as a large percentage of people during their reproductive years are at high risk for substance use disorder and frequently use tobacco, alcohol, marijuana, cocaine, and opioids during pregnancy. 

Stigmatization and barriers to evidence-based treatments create challenges for pregnant people who use substances, emphasizing the importance of an interprofessional team in promoting healthy outcomes through universal screening and access to effective interventions. 

Generally, pregnant people do not intentionally start using potentially toxic substances. Factors including genetics, environment, psychology, biology, and socioeconomic status contribute to an individual's susceptibility to substance use disorder, and commonly available legal substances can contribute to addiction. Illicit drugs, poor nutrition, unsafe housing, poverty, low education, and domestic violence are also associated with the diagnosis of substance use disorder.

Between 2005 and 2014, 11.5% of pregnant adolescents and 8.7% of pregnant adults reported using alcohol, and 23% of pregnant adolescents and 14.9% of pregnant adults used tobacco. Retrospective reviews have also shown that 2.5% of all pregnant people (about 20% of those with US Medicaid insurance) received one or more prescriptions for opioids during their pregnancy. 

“SUD is rarely an isolated diagnosis. It is associated with increased rates of psychiatric conditions, including major depressive, bipolar, posttraumatic stress, and panic disorder,” said researchers. “Comorbid human immunodeficiency virus (HIV), hepatitis B and C, tuberculosis, and sexually transmitted infections occur due to an association with multiple sex partners, sharing drug paraphernalia, homelessness, and increased incarceration rates.” 

Pregnant people may be reluctant to disclose this sensitive information due to fear of repercussions, judgmental treatment, and social services involvement. 
“Criminalizing substance use will not lead to improved clinical outcomes for mothers or their children,” said researchers.

In the absence of a stated history of substance use, aspects of the medical history such as a history of endocarditis, HIV, hepatitis C, sexual and/or physical abuse, and psychiatric conditions can indicate its presence. Pregnant people who have had late or no prenatal care may have intentionally avoided appointments out of concern for disclosing their substance use and the potential negative outcomes like arrest, prosecution, or losing custody of their child.

Hypertension and nasal septal perforation may indicate cocaine or amphetamine use, while underweight patients may be malnourished due to drugs or alcohol. Signs of obtunded behavior, agitation, sleepiness in women, dilated or constricted pupils, injection marks on the skin, and bruises should be noted. While screening is recommended, routine drug or alcohol testing is not unless specific situations require it, and testing should be based on medical criteria rather than profiling demographics.

For pregnant people with SUD, comprehensive and non-judgmental prenatal care such as counseling and risk education is crucial. For smoking during pregnancy, the greatest benefit is seen when cessation occurs by 15 weeks of gestation. If behavioral counseling is ineffective, medications like varenicline, bupropion, and nicotine replacement can be considered, but their safety during pregnancy has not been established. Alcohol and benzodiazepine use disorder can be managed through detoxification with diazepam or lorazepam taper, while medications like naltrexone, disulfiram, and acamprosate are approved but lack safety data for use during pregnancy.

Methadone or buprenorphine is recommended over medically supervised withdrawal, as the latter is associated with higher rates of relapse during pregnancy. Naltrexone is an approved treatment, but more research is needed to determine its safety during pregnancy. However, access to such treatment can be challenging for pregnant people with OUD, especially those in rural areas, non-English speakers, and those without health insurance.

The Mainstreaming Addiction Treatment (MAT) Act is a provision that expands access to evidence-based treatment for the opioid epidemic by allowing all health care providers to hold a controlled substance license to prescribe buprenorphine for OUD. 

Treatment with methadone and buprenorphine during pregnancy can reduce the severity of neonatal opioid withdrawal syndrome (NOWS), previously known as neonatal abstinence syndrome (NAS), a manageable condition in newborns with prenatal opioid exposure. Medication-assisted treatment during pregnancy has not been associated with congenital malformations or long-term neurodevelopmental adverse outcomes in exposed infants. 

Breastfeeding is beneficial for postpartum pain management, reducing the severity of NOWS symptoms, and decreasing the need for pharmacotherapy in affected newborns. However, breastfeeding is not recommended for women using illicit substances, including marijuana, due to potential traces found in breast milk. 

Appropriate SUD treatment involves differentiating between occasional or prescription substance usage and SUD, evaluating for single versus polysubstance use, searching for comorbid conditions, diagnosing psychiatric conditions, addressing poor nutrition and dental hygiene, and initiating timely management. 

Both abstinence and medication-assisted treatment significantly improve outcomes for pregnant people and their children. Those with OUD engaged in medication-assisted treatment typically remain sober until delivery through a comprehensive program including behavioral counseling and psychosocial support; however, postpartum relapse is common, particularly for tobacco, marijuana, and alcohol. Rates may be as high as 80% in the first year after giving birth, as the combination of sleep deprivation, hormonal shifts, and infant care increases stress. 

Research suggests that all childbearing-aged people should receive information about the dangers of prenatal substance use because many pregnancies are unplanned. Women whose newborns are at risk for NOWS benefit from learning what to expect after delivery. 

“Broadly defined, patient education includes information and access to resources for transportation, safe housing, food security, childcare, and contraception,” said researchers. “Trauma-informed counseling and peer recovery support groups can also improve the chances of sobriety following delivery.” 

A comprehensive approach to care involves multidisciplinary rounds and social workers addressing societal factors impacting prenatal health. Additionally, a successful model at Dartmouth-Hitchcock Medical Center combines midwifery services and addiction treatment, resulting in improved access to care and family planning services for this unique population.

“Implementing universal screening, overcoming barriers to treatment, addressing psychosocial needs, establishing an early diagnosis, and initiating medication-assisted treatment when appropriate will result in healthier outcomes for mothers and their children,” said researchers. 

Reference

Prince MK, Daley SF, Ayers D. Substance Use in Pregnancy. StatPearls Publishing. Published January 21, 2023. ncbi.nlm.nih.gov/books/NBK542330/