Q&A: Pregnancy is ‘very important period’ to identify, treat substance use disorder

Key takeaways:

• Overdose death among postpartum women is common with most 6 to 12 months after delivery.
• Understanding the neurobiological basis of addiction can help OB/GYNs curtail biases and provide critical treatment.

BALTIMORE — Addressing substance use disorders during pregnancy with compassion and understanding is imperative for women’s health providers, according to a speaker at the ACOG Annual Clinical & Scientific Meeting.

“It helps me to understand the neurobiological basis of the disease of addiction as a provider,” Caitlin E. Martin, MD, MPH, assistant professor in obstetrics and gynecology and director of OB/GYN Addiction Services at Virginia Commonwealth University in Richmond, told Healio.

Remembering that addiction rewires the brain — that executive function and reward system are “hijacked” — can help clinicians curtail their biases when treating women who cannot limit substance use during pregnancy, she said.

Overdose is now the most common pregnancy-related cause of death among postpartum women, Martin said. Most of these deaths occur well after the 6-week postpartum visit in the 6 to 12 months after delivery.

Caitlin E. Martin, MD, MPH

“Pregnancy is a very important period, but postpartum in our world of substance use disorders, I would argue, is even more important, because that is when women are dying of overdose-related deaths,” Martin said.

Healio spoke with Martin about how to identify substance use disorder during pregnancy to get women and families life-saving help.

Healio: When we talk about substance use disorder in pregnancy, what are the most commonly used substances?

Martin: Substance use disorders refer to any type of substance — alcohol and drugs. Nicotine is an addictive substance, too; but from a terminology standpoint and from our history of tobacco in this country, people usually refer to nicotine use disorder separately, but that is still under the same umbrella. What I focused on [in my presentation] at ACOG is drugs and alcohol with a sub-focus on opioids. That’s typically where I get questions, because we have FDA-approved medications for treatment.

Also, we've transitioned from referring to an “opioid crisis” to an “overdose crisis” mainly because it's not just opioids anymore. When you see those terrible graphs on the news of overdose deaths across the country, more and more of those overdose deaths involve multiple substances. No. 1 is the synthetic opioids like fentanyl. Then, use of methamphetamine is on the rise and cocaine is on the rise.

But actually, the most common substance use disorder across all people, pregnant or not pregnant, women or men, is alcohol use disorder.

Healio: What defines substance use as a disorder? Does the definition change for use during pregnancy?

Martin: There is a huge difference between substance use and substance use disorder. You might use cocaine or alcohol or even caffeine, like we all do, but you won't necessarily have a substance use disorder. We use the [Diagnostic and Statistical Manual of Mental Disorders, fifth edition] criteria to determine that just like we do for other psychiatric conditions, but the short story is you have a conversation with the patient and if they illustrate in their history and their story that they've had continued use of a substance despite adverse consequences, that’s pathognomonic generally for a substance use disorder. That's how I teach my residents how to identify it.

In pregnancy, that gets complicated with a lot of things substance use-related due to social factors, institutional systemic factors and, of course, patient-level factors. From a medical perspective, generally, most women using a substance will decrease or eliminate use of that substance when they become pregnant. They will stop having a glass of wine at dinner, they will reduce or eliminate cigarette smoking during pregnancy.

For people who are unable to stop use during pregnancy, that is commonly a marker that that patient probably does have a substance use disorder. Now, again, we only diagnose that by a verbal conversation with the patient. We use DSM-5 criteria, but in general, if you're just trying to see if a particular patient is someone you should maybe assess a little bit more, ask some more questions, maybe get a colleague involved who knows a little more about this — if that patient has continued use despite adverse consequences and tells you they're having trouble cutting down on their use after pregnancy, that patient is high risk. And most importantly, if they're talking to you about it, that means they want help and they're feeling open and comfortable with you.

Healio: You alluded to after pregnancy.

Martin: I focus on chronic diseases, like diabetes and hypertension, and addiction is no exception. As with any chronic disease, I think of pregnancy as a period in the life course. Of course, as OB/GYNs, we have to think about medications and exposures, but I think of pregnancy as a period in the life course and how I can tailor my evaluation and my treatment to this period of the life course.

In the research, the strongest factor associated with better outcomes postpartum, which is when women are dying and families are being torn apart, is getting into treatment earlier in pregnancy. That’s a great window of opportunity for OB/GYNs to have compassion and learn more about this chronic disease so you can be non-judgmental and help patients get the help that they want and need. Treatments tailored to their needs in pregnancy set them up for better health, especially in that really high-risk postpartum period.

Healio: How can substance use disorder perinatally affect the infant?

Martin: We have to think about the mother-child dyad during pregnancy and postpartum. We know that for many other mental health and even physical health conditions, if you are helping the parent, the family is going to do well. It's the same with addiction. As much as we can get moms healthier with this chronic disease of addiction, the better their babies are going to be and the stronger their families are going to be.

Unfortunately, the historical war on drugs means substance use disorder has a lot of legal aspects to it, and structural systemic factors do discriminate against people with substance use disorder, especially women of color and people who have lived in historically marginalized communities. The systemic and structural factors that work against those communities get magnified when you add in an addiction. It leads to some complications from the psychosocial and the socio-ethnological context. I feel like when my patients are with me in the exam room, it's just the two of us, but I sometimes feel like I'm on a battlefield as soon as they leave that exam room. When they leave my clinic, they're up against a whole war.

That needs to change. I think some people get overwhelmed and think they can’t change anything. Actually, we all can. Every single patient who a provider identifies with compassion and without judgment helps them get what that person wants for their recovery at that time. That's one more person that has a little bit more trust and has been able to engage in the health care system a little bit more and that little bit is going to help.

Healio: What is the role of drug screening? Are some demographics screened more often for substance use than others, perhaps unfairly?

Martin: Yes, screening is complicated. Most people have a perception that screening for a substance use disorder is done with a urine test or some type of drug test. But that doesn't make sense, because addictions are a chronic disease. To diagnose a use disorder — not if someone is using — I have to have a conversation. I need to see if someone has continued use and if this has adverse consequences. I need to see if they’re having challenges to cutting down or eliminating substance use when they want to.

You can't determine that from a drug test. A drug test will tell you if someone used cocaine in the last 3 days. If you need to know that for a medical reason, there you go. Make sure you always get consent for a drug testing. But if you're trying to screen someone to see if they're a high or low risk for chronic disease, you need to talk with that patient and not do a drug test.

Two examples of validated screening tools are on the National Institute on Drug Abuse website and on the Substance Abuse and Mental Health Services Administration website, but there are others. Some are tailored to pregnancy where you have a little bit more of that stigma related to substance use, so you do need to tweak your questions a little bit more during pregnancy.

Healio: Anything else you’d like to add?

Martin: You might think “I'm an OB/GYN, why do I need to know about substance use disorder?” It helps me to understand the neurobiological basis of the disease of addiction as a provider. Because when someone walks into my office and they're continuing to use despite adverse consequences — and those adverse consequences could be they lost their children, they lost their job, their spouse left them, whatever it is — my biases still come to the forefront, especially when I'm tired or it's Friday afternoon clinic and everyone has been late. We all have those things and biases come up just like they do for other areas. Your reaction might be “Stop doing this, you're throwing your life away. Why are you not listening to me?” Those are our biases coming out. I'm not a neuroscientist, but I can take a step back, recognize my biases, put them aside and re-present myself to be there for the patient. This is evidence-based and so it is medically appropriate and patient-centered at that time.

Reference:

• Martin C. The Donald F. Richardson Memorial Lecture: Addressing Substance Use Disorder as a Chronic Disease: How to Apply Actionable, Evidence-Based Tools - EL02. Presented at: ACOG Annual Clinical & Scientific Meeting; May 19-21, 2023; Baltimore.