Screening for Substance Abuse in Women's Health: A Public Health Imperative

Abstract

Alcohol and drug use is a significant public health problem with particular implications for the health and safety of women. Women who abuse these substances are more likely to have untreated depression and anxiety and are at higher risk for intimate partner violence, homelessness, incarceration, infectious disease, and unplanned pregnancy. Substance abuse during pregnancy places both mother and fetus at risk for adverse perinatal outcomes. Data regarding the prevalence of substance abuse in women are conflicting and difficult to interpret. On the clinical level, strong arguments exist against routine urine drug testing and in favor of the use of validated instruments to screen women for drug and alcohol use both in primary women's health care and during pregnancy. A number of sex-specific screening tools are available for clinicians, some of which have also been validated for use during pregnancy. Given the risks associated with untreated substance abuse and dependence in women, the integration of drug and alcohol screening into daily clinical practice is imperative. This article reviews screening tools available to providers in both the prenatal and primary women's health care settings and addresses some of the challenges raised when women screen positive for drug and alcohol abuse.

State Responses to Alcohol Use and Pregnancy: Findings From the Alcohol Policy Information System

“…From this perspective, one of the harshest uses of child welfare policies occurs in states that treat positive toxicology screens or other evidence of prenatal alcohol or drug exposure alone as sufficient evidence of child abuse, neglect, or its equivalent (Schroedel & Fiber, 2001). Others do not view reporting to CPS and removal of children as punishment (Barth, 2001; Ondersma et al, 2000); instead, they view CPS reporting as a strategy to ensure the provision of early intervention services for infants and substance abuse treatment for women (Ondersma et al, 2000) and as a possible pathway to treatment and other services (Goodman & Wolff, 2013; Jacobson, Zellman, & Fair, 2003; Young et al, 2009). …”

“…Third, policies such as requirements for reporting maternal alcohol use during pregnancy to Child Protective Services (CPS) could drive women from prenatal care, as has been found for drug use during pregnancy (Murphy & Rosenbaum, 1999; Roberts & Pies, 2010). Fourth, by creating an environment of mistrust between women and providers, policy contexts that allow criminal justice prosecutions or require CPS reporting related to alcohol use during pregnancy may influence the effectiveness of alcohol-related interventions such as screening and brief interventions, which are widely recommended for pregnant women (Anthony, Austin, & Cormier, 2010; Goodman & Wolff, 2013; Roberts & Nuru-Jeter, 2010), particularly for women who drink at risk levels (ACOG, 2011b). Such an environment of mistrust may make women less likely to disclose alcohol use to providers and may lead women to disengage emotionally and physically from prenatal care, especially if reporting to CPS is a possible result of screening (Roberts & Nuru-Jeter, 2010).…”

Adolescent Substance Use and Unplanned Pregnancy

“…While many evidence-based office tools exist to assist clinicians in screening for substance use (reviewed in Burns et al, 2010 and Goodman and Wolff, 2013), including brief screens such as the T-ACE (Sokol et al, 1989) and TWEAK (Russell and Bigler, 1979) for use in pregnant women, among assessments we recommend use of the CRAFFT screening tool which was designed specifically for use in adolescents and has been validated in multiple community and hospital-based clinical contexts (Knight et al 1999, 2002, 2003; Dhalla et al, 2011). It has also been effectively used to detect preconception substance use in a small cohort of pregnant women age 17 to 25 (Chang et al, 2011).…”

Substance Use and Preconception Care: A Review of the Literature

“…When men participate in PCC, they develop reproductive life plans to determine when they want to become fathers, which enables them to be financially, emotionally, and physically equipped for fatherhood (47,50 (52), only the 4P's Plus and the Substance Use Risk Profile-Pregnancy Scale are screening tools developed specifically for use with pregnant women. This means that the other 6 tools can be used for screening during times of non-pregnancy ,including the PCC period.…”

“…MI is an effective technique to elicit change. The objective of this intervention, which has roots in cognitive-behavioral approaches, is to provide individuals with sufficient education and knowledge regarding the severity of preconception risk behaviors on future birth outcomes, with the hope that, as a result, individuals will become introspective and self-motivated to change (51,52,(64)(65)(66). SAMHSA offers online training to develop or enhance motivational interviewing skills, integrating the six elements of the FRAMES model into brief interventions, optimizing the motivation to change.…”