Alcohol, tobacco, cannabinoid, and substance use in pregnancy: Clinical sciences

Watch video only
During pregnancy. Screening for the use of alcohol, tobacco cannabinoids and other substances such as opioids is important and should be completed for all patients at least once during each pregnancy.
Use of any of these substances may cause pregnancy complications including fetal malformations, abnormal fetal development and poor pregnancy outcomes.
Providing education and behavioral counseling to your patients is essential as they need continued care and support during pregnancy and postpartum.
All right, universal screening for alcohol, tobacco cannabinoids and other substances such as opioids should be completed for all pregnant patients regardless of age race, ethnicity or socioeconomic status.
The ideal time for screening is during the preconception period. So that interventions can be made prior to pregnancy.
However, screening should be completed or repeated during pregnancy as well. There are many different screening tests available, but it's best to have a thorough direct conversation with your patient or use a validated questionnaire with which you are familiar.
One simple and comprehensive questionnaire is the two part National Institute on drug abuses, tobacco, alcohol, prescription medications and other substance screen or taps screen which takes about five minutes.
Part one of this questionnaire quantifies the use of tobacco alcohol, prescription medications and illicit substances such as cannabinoids, cocaine methamphetamines and hallucinogens.
Over the last 12 months, part two assesses use over the past three months as well as a patient's desire to continue use, concerns about use and attempts to stop use.
Each category has its own scoring scale. But in general, the higher a patient scores, the greater the severity of their use.
Another easy to remember screening tool for alcohol use disorder is the four question taste screen. It stands for tolerance, annoyance, cut down an eye opener with questions.
Assessing each category at the end of the day, choose a screening questionnaire you're comfortable with and stick to it.
These questionnaires are meant to assess your patient's level of use and risks associated with pregnancy. Plus, open the door for a conversation aimed at providing education and support.
Here's a clinical pearl. While urine drug tests are available, they should only be performed with your patient's informed consent.
After discussing the potential legal and social consequences of a positive test as such, urine drug tests can be offered, but they are in no way mandatory.
Ok, let's talk about what to do if your patient has a positive screen for alcohol use. Your first step is to educate your patient on the risks associated with alcohol use during pregnancy.
Ideally, this would occur during a preconception visit. However, education is very important during pregnancy too.
Be sure they understand that alcohol is a terragen and that prenatal alcohol exposure can affect a fetus at any stage of development.
It's also important to stress that there's no safe amount of alcohol in pregnancy. Alcohol use can cause growth deformities, facial abnormalities, central nervous system impairment, behavioral disorders and impaired intellectual development.
The most severe result of consuming alcohol while pregnant is fetal alcohol syndrome, which includes central nervous system abnormalities, growth defects and facial dysmorphia.
It's important to discuss that these alcohol related birth defects are preventable. The next important thing is behavioral counseling, discussing risks and the recommendations to abstain from alcohol use in pregnancy may lead to your patient making behavior modifications.
While another option is to have your patient. See a counselor, if your patient is alcohol dependent, they should have priority access to treatment along with counseling and medical support during withdrawal.
This support should continue throughout pregnancy and postpartum. Here's a clinical pearl.
Best practice encourages patients to abstain from alcohol use while breastfeeding but moderate consumption defined as up to one standard drink per day is unlikely to have adverse effects on an infant.
All right. Now, on to patients with a positive screen for tobacco use in pregnancy.
Here you'll start with the five A intervention which is a series of questions to determine your patient's current tobacco use and interest in cessation.
It can also be used to encourage behavioral modifications. The five A s include ask about past and current use of nicotine, advise patients to stop provide advice about quitting such as a quit line number or a referral to a counselor that specializes in tobacco cessation and inform patients about the risks of tobacco use in pregnancy.
Assess your patient's willingness to quit, assist your patient if they are interested in quitting and arrange follow up visits to track progress.
If your patient has cut back or quit, offer continued support throughout pregnancy and postpartum. As before education on perinatal risks is very important.
These include oral facial clefts, fetal growth restriction, placenta, praevia, placental abruption, decreased maternal thyroid function, preterm, prelabor, rupture of membranes or P prom, low birth weight, prenatal mortality and ectopic pregnancy.
Next offer behavioral counseling and pharmacologic interventions like nicotine replacement products. However, there's limited available information comparing the potential risks versus benefit of nicotine replacement products.
So, individualized counseling is encouraged as always continue to provide support throughout pregnancy and postpartum. Ok.
On to patients with a positive screen for cannabinoid use in pregnancy. Again, a main area of focus is on education.
The two most common cannabinoids in cannabis are CBD or cannabidiol and THC or tetrahydrocannabinol. THC is the main psychoactive compound and is responsible for the euphoric feeling or high that people experience cannabinoid use is discouraged during pregnancy.
As there are concerns regarding impaired fetal neurodevelopment, there is no safe amount in pregnancy and no medical indication for either THC or CBD use.
Discussing this with your patient can lead to significant behavioral changes which is increasingly important as cannabinoids are becoming more accessible with legalization.
In many states, cannabinoid use is also discouraged during lactation as there's insufficient data to evaluate the effects of cannabinoid use on infants.
Again, continue to provide support throughout pregnancy and postpartum. Next, let's talk about patients with a positive screen for opioid use.
Universal screening of all patients is important along with education about the risks of use in pregnancy, opioid use is often associated with depression, anxiety, history of trauma and posttraumatic stress disorder, untreated opioid use disorders are also associated with other high risk activities such as sex work and trading sex for drugs.
Risks associated with untreated opioid use disorders include poor prenatal care, fetal growth restriction, placental abruption, preterm, labor, intrauterine passage of meconium and fetal demise.
Here's a high yield fact, although the terms opioids and opiates are often used interchangeably, they're actually different.
Opioids can be synthetic such as methadone or fentaNYL, semi synthetic like oxyCODONE or HYDROmorphone and natural including opiates like heroin, morphine and codeine.
In summary. While all opiates are opioids, not all opioids are opiates.
Treatment is multidisciplinary. With a focus on behavioral counseling, supervised maternal withdrawal during pregnancy is not recommended for those with opioid dependence as it is associated with high rates of relapse.
Instead, referral for treatment with opioid agonists like methadone and buprenorphine is preferred. These medications work by preventing withdrawal symptoms, reducing relapse risk, increasing adherence to prenatal care and reducing obstetrical complications all of which improve maternal and fetal outcomes.
Keep in mind that patients using opioids or even maintenance therapy are at risk of overdose. So they may benefit from having naloxone kits readily available, which can be lifesaving.
Also be sure to counsel your patient on neonatal abstinence syndrome or NAS, which is a treatable drug withdrawal syndrome of the newborn.
Nas, newborns may experience a variety of symptoms related to drug withdrawal after delivery including irritability, high pitched cry, poor sleep and uncoordinated sucking reflexes associated with poor feeding.
Nas is expected in infants born to patients using opioids or taking opioid agonists. So be sure to monitor the newborn for symptoms.
Nas may initially be confused for other conditions if a patient's opioid use is unknown, finally continued support throughout pregnancy and postpartum is crucial.
You should encourage your patients to breastfeed as long as they are stable on opioid agonists and do not have any other contraindications.
Here's another clinical pearl, maternal doses of opioid agonists may need to be adjusted as pregnancy progresses due to increased drug metabolism to avoid withdrawal symptoms.
Doses should not be minimized to prevent NAS as the severity and duration of NAS symptoms are not tied to the maternal opioid agonist dose.
Let's wrap this up with one last clinical pearl. Certain over the counter products or herbal supplements like kratom may produce opioid like effects.
Thus, it's advised to avoid these products during pregnancy. All right, as a quick recap screening for alcohol, tobacco cannabinoids and other substances such as opioids is important and should be done universally for all pregnant patients, regardless of age, sex, race, ethnicity or socioeconomic status.
Treatment. For those who screen positive revolves around education on the associated risks of use as these substances can cause a multitude of pregnancy complications.
The next important thing is behavioral counseling for all patients as well as continuing to support them throughout pregnancy and postpartum.