Substance use in pregnancy

It is the booking visit nobody has prepared for. She is 23, two pregnancies in two years, smells of stale tobacco, has not taken folic acid, is unsure of her dates, and she shuts down the moment you ask about her partner. The registrar reaches for a urine drug screen and a judgment; the consultant reaches for the same screen, a cup of tea, and an AUDIT-C. Substance use in pregnancy is common, hidden, stigmatised, and — when you stop moralising and start managing — highly treatable. This topic is that shift.^[1][15]

Overview and definition

Substance use in pregnancy spans everything from a glass of wine at conception to daily injected heroin, and the response is the same in shape: identify, engage, harm-reduce, treat, and plan the birth and the postnatal period together. ^[1][15]

• Substance use — any use of alcohol, tobacco, cannabis, opioids, stimulants, sedatives or other psychoactive drugs.
• Hazardous use — patterns that increase the risk of harm (the AUDIT-C catch).
• Substance use disorder (SUD) — the chronic, relapsing brain disease defined by DSM-5 criteria: impaired control, social impairment, risky use, pharmacological tolerance and withdrawal.
• Opioid use disorder (OUD) in pregnancy is a specific diagnosis with a specific, evidence-based answer: opioid agonist therapy, not detox.^[1]

The single most important conceptual move is to decriminalise the consultation in your own head. RANZCOG C-Obs 53 frames substance use as a health condition; ACOG Committee Opinion 524 says exactly the same. A woman who fears she will be reported, judged or have her baby removed will minimise or lie, and you will miss the window to intervene.^[1][15]

References16ShowHide

1. [1]ACOG Committee on Health Care for Underserved Women, American Society of Addiction Medicine ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancy Obstet Gynecol, 2012.PMID 22525931
2. [2]Jones HE, Kaltenbach K, Heil SH, et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure N Engl J Med, 2010.PMID 21142534
3. [3]Minozzi S, Amato L, Jahanfar S, et al. Maintenance agonist treatments for opiate-dependent pregnant women Cochrane Database Syst Rev, 2020.PMID 33165953
4. [4]Zankl A, Martin J, Davey JG, et al. Opioid treatment for opioid withdrawal in newborn infants Cochrane Database Syst Rev, 2021.PMID 34231914
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14. [14]Bush K, Kivlahan DR, McDonell MB, et al. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test Arch Intern Med, 1998.PMID 9738608
15. [15]American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women ACOG Committee Opinion No. 343: psychosocial risk factors: perinatal screening and intervention Obstet Gynecol, 2006.PMID 16880322
16. [16]McQueen K, Taylor C, Murphy-Oikonen J Systematic Review of Newborn Feeding Method and Outcomes Related to Neonatal Abstinence Syndrome J Obstet Gynecol Neonatal Nurs, 2019.PMID 31034790