The landscape of perinatal substance use: Prevalence, outcomes and interventions

Kimberly Yonkers

Although substance use is less prevalent among pregnant women than nonpregnant women, use during pregnancy has significant adverse effects on maternal, as well as fetal, neonatal and childhood health outcomes, according to a presenter at the American Psychiatric Association Spring Highlights Meeting.

“The good news is that hazardous substance use decreases in pregnancy and throughout pregnancy,” Kimberly Yonkers, MD, director of psychological medicine and the Center for Wellbeing of Women and Mothers at Yale School of Medicine, said during the presentation. “I like to think of that as a very important opportunity for everybody to try and understand what it is about the pregnant woman that may help us get a handle on controlling substance use and may help our patients control their substance use. The flip side is that after [women with substance use disorders] deliver, about 80% will relapse to drug or alcohol use. We refer to this time as a pause in hazardous substance use.”

According to results of a cross-sectional study Yonkers and colleagues conducted across three sites, self-reported data from the National Study on Drug Use and Health has likely led to underestimated rates of substance use among pregnant women, particularly for tobacco, cannabis and opioid use. Yonkers noted particularly significant rates of tobacco, cannabis and opioid use among the study’s 1,220 pregnant participants.

Regarding decreases in use during pregnancy by specific substance, alcohol is generally stopped earlier than other substances and cigarettes are more likely to be used longer into term or not stopped at all, according to Yonkers.

Relapse rates also differ according to substance.

“We start to see people relapsing to cigarettes almost as soon as they deliver, but [these rates] are closely linked to relapses for other substances, like marijuana and alcohol,” Yonkers said. “In [one] particular data set, we were fortunate that we saw lower rates of relapse for cocaine. People still relapsed, but at a much, lower rate. We'd like to be able to understand what it is about this whole process that enabled that relative period of wellness.”

Residual toxicity from cocaine use during pregnancy has significant adverse effects on infants, including jitteriness, abnormal electroencephalogram readings, seizures, poor habituation, sleep disturbances, excessive sucking and hypertonicity, according to Yonkers.

For overall maternal substance use, Yonkers highlighted several possible sources of confounding, including:

• type of substance exposure;

• co-use of other substances;

• pre- and postnatal environment; and

• genetic factors.

Another major area of concern for the pregnant population is the opioid crisis.

“Rates of opioid use disorder have gone up in the general population, and pregnant women are not immune to this,” Yonkers said. “[Use may result in] smaller [infants] born earlier with a number of complications ... [namely], neonatal opioid withdrawal syndrome, [which may affect] about 50% to 80% of these infants.”

The legalization of cannabis also has directly affected pregnant women, since this population has exhibited significant preconception, prenatal and postpartum prevalence rates, according to Yonkers.

Maternal nicotine use also presents significant perinatal risks, including fetal growth restriction, ectopic pregnancy, placental disorders and fetal or infant death, Yonkers said.

Beyond health effects, women who cause fetal substance use exposure also may face legal ramifications, with 45 states having attempted to prosecute them on these grounds, according to Yonkers, who referenced a study that reviewed 24 appellate court decisions. Researchers found that 86% of these cases were overturned or dismissed on appeal.

“There are states that have advocated to make a fetus a child [in a legal sense],” Yonkers said. “This would change the entire landscape with regard to risk for women who are addicted and trying to control their addiction but maybe can't.”

Alabama and South Carolina have successfully convicted women for drug use during pregnancy, Yonkers noted.

Pregnant women with substance use disorders have several effective options for intervention, according to Yonkers. These include brief psychological interventions, medication-assisted treatment and cognitive behavioral therapy for substance use.

“We really need to employ health equity and universal approaches to address these problems, as well as standard and novel treatments for this unique population,” Yonkers said. – by Joe Gramigna

Reference:

Yonkers K. Substance use disorders in perinatal women. Presented at: American Psychiatric Association Spring Highlights Meeting; April 25-26, 2020 (virtual meeting).

Disclosures: Yonkers reports royalties from UpToDate and grants from the National Institute on Alcohol Abuse and Alcoholism, CDC, the Doris Duke Foundation and one additional organization.