Guidelines for Screening & Testing for Substance Abuse in Pregnancy and Referral to Treatment

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Guidelines for Screening Testing for Substance
Abuse in Pregnancy and Referral to Treatment

• Stephanie Nicodemus, CNM, Chair
• Sub-Committee on Medical Guidelines
• WV Perinatal Partnership 2008

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Objectives

• At the completion of this presentation , the
  participant will be able to
• Name the core components of substance abuse
  evaluation
• Apply these core components to the pregnant
  patient antepartum, intrapartum postpartum
• Discuss the legal implications of screening
  testing for substance abuse in pregnancy and
  referral to treatment
• Begin to identify resources in your own community
  for treatment of substance abuse in pregnancy

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The Core Components of Substance Abuse
Evaluation(www.samhsa.org)SBIRT
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Screening(www.samhsa.org)

• Identifies individuals at risk for alcohol and
  or/drug use
• Screening can be through interview and
  self-report (Questionnaires/Screening
  instruments)
• Follow-up Assessments include Laboratory Testing

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Benefits of Screening

• Increases the identification of substance users
• Allows for early intervention
• Improves provider skills and comfort with
  addressing the issue
• Provides opportunity for education
• Enhances public awareness and may prevent future
  use/abuse

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Screening Guidelines

• Once each trimester
• All women
• Document
• Findings
• Patient response
• Counseling
• Plan of care
• Training

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TraditionalScreening Tools

• CAGE
• MAST
• NET
• T-ACE

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4-Ps Screening Tool

• Parents
• Partner
• Past
• Pregnancy

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4-Ps Screening Tool

• 1. Has either one of your Parents had a problem
  with alcohol or drugs?
• 2.Does your Partner have problem with alcohol or
  drugs?
• 3. Have you had a problem with alcohol or drugs
  in the Past?
• 4. Have you used any drugs or alcohol during the
  Pregnancy?

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Follow-up Assessment

• 5. What kind of alcohol (beer, wine,
  liquor)/drugs (heroin, cocaine, prescription
  drugs, methamphetamines, marijuana) do you use?

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Follow-up Assessment

• 6. During the month before you were pregnant, how
  many times a week did you drink____ (alcohol)
  /use____ (drugs)

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Follow-up Assessment

• 7. And how many bottles/cans/shots/glasses of
  ____(alcohol) /how much ____(name the drug) did
  you use each time you drank/used drugs during the
  month before you were pregnant?

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Laboratory Testing

• Universal Screening of women and newborns for
  substance abuse using biological specimens is NOT
  recommended.
• (AAP, ACOG, Guidelines for Perinatal Care, 2007)

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Laboratory Testing

• Must inform the patient
• reason for doing the test
• procedures involved
• Document her consent
• Review test results with her
• Document her response

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Medical Indications for Testing

• Previous Positive Urine Toxicology
• Methadone or Subutex use
• HIV or Hepatitis B or C
• Premature Labor and/or Delivery
• Abruption
• IUGR
• PROM
• Frequent requests for RX drugs
• Noncompliance with Prenatal Care
• Third trimester IUFD

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Screening Testingfor Substance Abuse in
Pregnancy

• Universal screening through the 4Ps
• If yes to any question, patient is at risk for
  use
• Yes to Past or Pregnancy requires f/u assessment
• Follow-up Assessment
• What kind? How many times/wk? How much?
• Laboratory Testing
• screen or medical indications

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Antepartum
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Screening and TestingIntrapartum
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Screening and TestingPostpartum
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Screening and TestingRandom Hospital Visits
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Brief Interventions

• Educational messages during the OB visit
• Negative screening
• review the benefits of abstinence
• continue to screen once per trimester
• Positive screening
• discuss benefits of treatment and referral
• state risks for the mother and the baby
• emphasize total abstinence and zero tolerance

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Brief Treatment

• Outpatient Substance Abuse Counseling
• Educational messages at each visit plus
• Referral to outpatient community services such as
  a 12-Step Program, Community Mental Health
  Center, private Behavioral Health provider, etc.
  (refer to handout)

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Referral(www.samhsa.org)

• Follows a screening result of severe or
  dependence
• Referral to a chemical dependency treatment
  facility for inpatient treatment (refer to
  handout)

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Legal Implications of Screening, Testing and
Referral to Treatment

• This process is voluntary.
• Communications and information obtained in the
  course of treatment or evaluation of any client
  or patient are confidential.

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Uniform Maternal Risk Screening Act of 2008

• Uniform maternal risk screening tool
• Advisory council will develop
• Strong confidentiality language
• Passed in the House but stalled in the Senate
• Cautious optimism for next legislative session

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PRISI West Virginia Right From the Start
Prenatal Risk Screening Instrument
(www.wvdhhr.org.rfts)

• Do you drink alcohol (wine, beer, mixed drinks)?
  yes no If yes, daily weekly occasionally
• Does your partner drink alcohol? yes no
• If yes, daily weekly occasionally
• Have you used recreational drugs during the
  pregnancy?
• yes no If yes, what type

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Screening

• Screening Tools are THE most effective initial
  method of determining risk for substance abuse
• Serum alcohol testing and urine toxicologies are
  ineffective initial screening tools for
  determining substance abuse.

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SBIRTThe Core Components of Substance Abuse
Evaluation

• Screening with the 4Ps
• Follow-up Assessment (In-depth questionnaire)
• Laboratory Testing
• Brief Intervention
• Educational Messages during the OB visit
• Brief Treatment
• Educational Messages plus
• Outpatient Substance Abuse Counseling
• Referral to Chemical Dependency RX Facility

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References

• AAP, ACOG (2007). Guidelines for Perinatal Care,
  Sixth Edition
• ACOG Committee Opinion Number 294 (2004). At-Risk
  Drinking and Illicit Drug Use Ethical Issues in
  Obstetric and Gynecologic Practice
• Christmas, J., Knisely, J., Dawson, K., Dinsmoor,
  M., Weber, S., Schnoll, S. (1992).Comparison of
  questionnaire screening and urine toxicology for
  detection of pregnancy complicated by substance
  abuse. Obstetrics and Gynecology, 80750-754
• Chasnoff, I.J., McGourty, R.F. (2006). I am
  Concerned A Brief Treatment Intervention for
  the Primary Prenatal care Setting, NTI Upstream
• Chasnoff, I.J., McGourty, R.F., Bailey, G.W.,
  Hutchins, E., Lightfoot, S.O., Pawson, L.L.,
  Fahey, C., May, B., Brodie, P., McCulley, L.,
  Campbell, J.(2005). The 4Ps Plus Screen for
  Substance Use in Pregnancy Clinical Applications
  and Outcomes. Journal of Perinatalogy. 25 (6),
  368-374.

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References

• Chasnoff, I.J., Neuman, K., Thornton, C.,
  Callaghan, M.A. (2001). Screening for substance
  use in pregnancy A practical approach for the
  primary care physician. American Journal of
  Obstetrics and Gynecology. 184 (4) 752-758
• Morse, B., Genshan, S., Hutchins, E. (1998).
  Screening for Substance Abuse During Pregnancy
  Improving Care, Improving Health. Arlington, VA
  National Center for Education n Maternal Child
  Health
• NTI Upstream http//www.ntiupstream.com
• US Department of Health and Human Services,
  Substance Abuse and Mental Health Services
  Administration, Center for Substance Abuse
  treatment. http//www.samhsa.org
• Washington State Department of Health, Maternal
  Child Health, (Revised Edition 2002).DOH Pub
  950-135 Substance Abuse During Pregnancy
  Guidelines for Screening. Olympia, WA