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How extensively should physicians screen for opioid exposure among pregnant women?
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Biologic testing should only supplement screening through patient-provider communication.
The American College of Obstetricians and Gynecologists (ACOG) recommends that all women be screened and evaluated for cigarette, drug and/or alcohol use during pregnancy. Screening should occur during the initial obstetric visit as well as throughout pregnancy if any signs or symptoms suggestive of substance use, abuse or misuse occur.
The evaluation of substance use should consist of a conversation between the patient and her provider about the frequency and quantity of past and current alcohol, cigarette and illicit drug use and the nonmedical use of prescription drugs. A caring, non-judgmental approach and use of validated screening tools (eg 4Ps, CRAFFT, T-ACE, TWEAK) can facilitate patient-provider communication and build patient-provider rapport. Urine and/or blood toxicology screening should not be used as the primary method of identifying substance use and should only augment patient-provider discussions.
Although biologic testing may seem to compensate for a patient’s failure to disclose drug use, inconsistent drug use and variable cutoff concentrations for semisynthetic opioids (eg oxycodone, fentanyl) limit the sensitivity of biological tests to capture the true prevalence of drug use and can contribute to false negative results. Likewise, cross-reactivity among non-opioid drugs (eg quinolone antibiotics, trazodone) and some foods (eg poppy seeds) can result in false positive results and subject patients to unnecessary scrutiny.
Universal biologic testing also has legal and ethical implications. Many states have enacted mandatory reporting laws designed to penalize pregnant women with positive screening results. Punitive legislation prevents women from engaging in drug treatment, prenatal care and other necessary preventative health care services during pregnancy and is associated with adverse maternal and neonatal health outcomes. Therefore, before ordering any laboratory screening test for drug use during pregnancy, the reasons for testing should be discussed with the patient, informed consent should be obtained and potential legal ramifications, specific to state and local laws, should be explained in detail.
Elizabeth E. Krans, MD, MSc, is an assistant professor in the department of obstetrics, gynecology & reproductive sciences at the Magee-Womens Hospital of the University of Pittsburgh Medical Center. Disclosure: Krans reports no relevant financial disclosures.
Compulsory testing is expensive, and may undermine patient confidence in provider.
Determining which infants are likely to develop NAS can be important: Prenatal identification allows for time to prepare parents for the stresses of caring for a baby with NAS, to teach effective non-pharmacologic interventions and in some circumstances, to work with child protective services to determine the best disposition for the baby.
What kind of screening is necessary to identify these at-risk infants? Wexelblatt, and colleagues noted that 20% of opioid-exposed infants were not identified using risk factors and were only identified by testing the mothers. The authors recommended universal maternal drug testing in areas with a high incidence of opioid use. However, instituting compulsory testing is not justified by preventing a risk of proven danger, and it is also fraught with ethical concerns. First, compulsory testing is usually reserved for situations in which the infant would be in grave danger without an early diagnosis. Although there are concerns about discharging an infant who will first develop withdrawal signs at home, namely, the risk that a parent would experience greater-than-usual stress in caring for a baby exhibiting NAS symptoms, and thereby be more likely to shake the baby, there is no evidence supporting bad outcomes in this situation.
Second, it is expected that obstetricians will discuss opioid use with mothers during prenatal visits and refer them to medication-assisted treatment programs if indicated. If we ask mothers about opioid use but conduct compulsory tests anyway, we send a strong message of distrust. At best, this insults the mother; at worst, it may undermine the future medical treatment of the baby with NAS. We have found that the key to successfully treating infants with NAS is through engaging and empowering the parents to provide the necessary nonpharmacological care. Successful treatment of NAS requires a trusting and respectful relationship between the parents and the care team. Compulsory testing would undermine that trust.
Testing all parents for drug use is expensive, is not justified by an evidentiary basis of specific harm prevention and may significantly undermine the trust between parents and the care team.
The urgency that we may feel for universal testing would be put to better use if harnessed to reform the way we talk to and care for mothers using opioids. We must work to create a stigma-free environment in which mothers who report opioid use are met with support. The overall goal in caring for infants with NAS should be to create a strong parent-child bond. That starts with respecting and empowering the parents in the care of their child. We can — and should — champion that effort as our first priority.
Matthew R. Grossman, MD, is assistant professor of pediatrics and Quality and Safety Officer at Yale-New Haven Children’s Hospital. Disclosure: Grossman reports no relevant financial disclosures.