It is relevant for providers to adequately assess patients for any type of substance use or abuse during the initial prenatal interview. The patient should be routinely asked about drug and alcohol use, as well as any type of medication used for nonmedicinal purposes. This should be done both prior to and during pregnancy. This also gives the clinician an opportunity to provide information about abuse intervention and to refer the woman for specialized treatment. The patient should be interviewed in a nonjudgmental way so that she does not feel stigma or guilt, as she may from friends or family. The patient may also be more forthcoming and disclose more information if the provider remains open-minded. It is important to let the patient know that these are routine questions asked of all persons who seek prenatal care.

To build stronger rapport, facilitate effective communication, and precipitate trust, providers must have an attitude of care and remain neutral about the patient’s addiction. This method eases patient anxiety, assists the patient with effective coping, improves attendance to prenatal appointments, and provides better patient-provider interaction.1 Jones and colleagues1 suggested that the gold standard for screening for substance abuse is verbal, written, or computer-assisted questioning. The American College of Obstetrics and Gynecology recommends using screening tools such as CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) screening, published by Boston Children’s Hospital.3


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It is also important to assess all pregnant patients regarding other substances of abuse, such as tobacco and alcohol, and to assess for any mental health conditions and any other social services needs. It is not uncommon for pregnant patients who abuse illicit substances to also abuse other drugs, be involved in abusive relationships, and engage in activity that places them at risk for sexually transmitted infections. In addition to the associated lifestyle factors, patients may also deal with coexisting psychiatric illness, homelessness, or incarceration. Theft, violence, and prostitution are part of a drug subculture in which many pregnant women using illicit drugs may also be engaged. These high-risk behaviors expose women to sexually transmitted diseases and put them at risk of becoming a victim of violence and legal consequences.3 Park and colleagues4 found that between 53% and 76% of pregnant women who abuse opiates also have psychiatric illnesses. The presence of a mental health disorder requires an immediate specialty referral to a psychiatry practice.

The World Health Organization prefers the terminology “psychoactive substance misuse” to describe using a substance for a purpose inconsistent to legal or medical guidelines, such as using prescription medications for nonmedical use.5 The term projects a less judgmental attitude than the word “abuse.” Dependence or addiction may develop with repeated and continued use of heroin or prescription opioids; an enjoyable euphoric sensation occurs as opioids bind to the opioid receptors of the brain. Addiction may be characterized by compulsive drug-seeking behavior, physical dependence, and a tolerance that leads to the need to seek ever higher dosages.3

Withdrawal symptoms usually occur with discontinuation once the physical dependence has developed. Symptoms may develop within 4 to 6 hours of last dose and may progress up to 72 hours, finally subsiding after approximately 1 week. Depending on the class of opiates, symptoms of withdrawal may be seen within 24 to 36 hours of last dose and may last for several weeks. There is a high risk of relapse as obsessive thinking and drug cravings may last for years. Withdrawal of heroin and opiates is not fatal to healthy adults; however, fetuses can experience growth restriction, placental abruption, fetal death, and preterm labor if the mothers are not treated for the addiction.3