Accuracy of five self‐report screening instruments for substance use in pregnancy

Abstract

Background and aimsThe accuracy of current screening instruments for identification of substance use in pregnancy is unclear, particularly given methodological shortcomings in existing research. This diagnostic accuracy study compared five existing instruments for ability to identify illicit drug, opioid and alcohol use, under privacy expectations consistent with applied practice and using a gold standard incorporating toxicological analysis.DesignProspective cross‐sectional screening accuracy study.SettingThree sites encompassing four prenatal care clinics in the United States.ParticipantsConvenience sample of 1220 racially, ethnically and socio‐economically diverse pregnant women aged 18 years and over.MeasurementsIn Phase I, participants completed the five screening instruments in counterbalanced order. Instruments included the Substance Use Risk Profile—Pregnancy (SURP‐P), CRAFFT (acronym for five‐item screener with items related to car, relax, alone, forget, friends and trouble), 5Ps (parents, peers, partner, pregnancy, past), Wayne Indirect Drug Use Screener (WIDUS) and the National Institute on Drug Abuse (NIDA) Quick Screen. In Phase II, participants provided a urine sample and completed a calendar recall‐based interview regarding substance use. These screeners were tested, using receiver operating characteristic (ROC) analysis and accuracy statistics, against a reference standard consisting of substance use in three classes (illicit drugs, opioids and alcohol), considered positive if use was evident via 30‐day calendar recall or urine analysis.FindingsThree hundred and fifteen of 1220 participants (26.3%) met reference standard criteria for positivity. The single‐item screening questions from the NIDA Quick Screen showed high specificity (0.99) for all substances, but very poor sensitivity (0.10–0.27). The 5Ps showed high sensitivity (0.80–0.88) but low specificity (0.35–0.37). The CRAFFT, SURP‐P and 5Ps had the highest area under the curve (AUC) for alcohol (0.67, 0.66 and 0.62, respectively), and the WIDUS had the highest AUC for illicit drugs and opioids (0.70 and 0.69, respectively). Performance of all instruments varied significantly with race, site and economic status.ConclusionsOf five screening instruments for substance use in pregnancy tested (Substance Use Risk Profile—Pregnancy (SURP‐P), CRAFFT, 5Ps, Wayne Indirect Drug Use Screener (WIDUS) and the National Institute on Drug Abuse (Quick Screen), none showed both high sensitivity and high specificity, and area under the curve was low for nearly all measures.

<p>Perceived Risk of Weekly Cannabis Use, Past 30-Day Cannabis Use, and Frequency of Cannabis Use Among Pregnant Women in the United States</p>

“…cognitive-behavioral therapy; 52 however, availability of screening tests with both a high sensitivity and specificity for pregnant women remains an issue. 58 As expected and previously reported, 5 early pregnancy was associated with use and frequency of use in the past 30 days. This finding is of concern as use in the first months of pregnancy may compromise embryonic development, specifically neuronal development.…”

“…Based on our findings, as well as other previous literature [49][50][51] co-use of cannabis with other substances, occurs among pregnant women; therefore, additional screening and intervention development and implementation efforts are a priority. Typically, substance use screening and intervention are not integrated into routine prenatal care, [52][53][54][55][56][57][58] and pregnant women, who are more likely to be in need for these services, are less likely to receive them compared to non-pregnant women. 55 In addition, drug screening and effective interventions for cannabis use prevention during pregnancy are underdeveloped.…”

Obstetrician–gynecologists’ practices and attitudes on substance use screening during pregnancy

“…Utilization of verbal validated screening tools, such as 4P's, NIDA Quick Screen, and CRAFFT to identify drug and alcohol use among pregnant women is recommended by ACOG (12). A recent study validated five commonly used screening tools against biological samples and found that sensitivity and specificity for each screening tool differed by substance and that no tool had both high sensitivity and specificity (33).…”

Maternal Substance Use: Consequences, Identification and Interventions

“…26,40 The World Health Organization (WHO) guidelines for the identification and management of substance use and substance use disorder during pregnancy list the Substance Use Risk Profile-Pregnancy (SURP-P) scale, 41 the proprietary 4P's Plus © , 42 and the National Institute on Drug Abuse (NIDA) Quick Screen-Modified Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) 43 as potential screening measures for pregnant women, even though not all of these instruments had been evaluated among that population at the time of its recommendation. 44 Several recent studies have evaluated the accuracy of various screening tools for prenatal substance use. In one prospective cross-sectional study conducted in Baltimore, MD, with 500 pregnant women, stratified by trimester and use of prenatal care, researchers administered three index tests and compared them to reference tests.…”