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

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.

Alright, 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 Abuse’s “Tobacco, Alcohol, Prescription medications, and other Substance screen”, or TAPS screen, which takes about 5 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 3 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 TACE screen. It stands for tolerance, annoyance, cut down, and 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.

Okay, 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 in 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 teratogen, 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 recommendation 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 1 standard drink per day, is unlikely to have adverse effects on an infant.

Alright now on to patients with a positive screen for tobacco use in pregnancy. Here, you’ll start with the 5 As 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 5 As include: Ask about past and current use of nicotine; Advise patients to stop, provide advice about quitting, such as a quitline 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 orofacial clefts, fetal growth restriction, placenta previa, placental abruption, decreased maternal thyroid function, preterm prelabor rupture of membranes or PPROM, low birth weight, perinatal mortality, and ectopic pregnancy.