
==== Front
AJOG Glob Rep
AJOG Glob Rep
AJOG Global Reports
2666-5778
Elsevier

S2666-5778(24)00078-9
10.1016/j.xagr.2024.100384
100384
Original Research
Implementation of universal screening for substance use in pregnancy in a public healthcare system
White Alesha MD Alesha.white@utsouthwestern.edu
12⁎
Afsari Macy 1
Balakrishnan Harini 1
Chapa Emilia 1
Kim Meredith 1
Mehra Shubhangi 1
Faucher Mary Ann PhD, CNM, FACNM 2
Miller Joyce DNP, APRN, WHNP-BC 2
Cordova Polly DNP, APRN, CNM 2
Duryea Elaine L. MD 12
Nelson David B. MD 12
Ambia Anne M. MD 12
Mcintire Donald D. PhD 1
Adhikari Emily H. MD 12
1 Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX (White, Afsari, Balakrishnan, Chapa, Kim, Mehra, Duryea, Nelson, Ambia, Mcintire, Adhikari)
2 Department of Obstetrics and Gynecology at Parkland Health, Dallas, TX (White, Duryea, Nelson, Ambia, Adhikari, Faucher, Miller, Cordova)
⁎ Corresponding author: Alesha White, MD Alesha.white@utsouthwestern.edu
27 7 2024
8 2024
27 7 2024
4 3 100384© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Objective

Screening questionnaires are one option for identification of at-risk substance use and substance use disorder (SUD) during pregnancy. We report the experience of a single institution following universal implementation of a brief screening tool for self-reported substance use at the first prenatal encounter.

Study Design

This is a prospective implementation study evaluating screening for substance use in pregnancy in a large safety net healthcare system. Universal screening with the National Institute of Drug Abuse (NIDA) Quick Screen V1.0 was integrated into the electronic medical record (EMR) and administered at the first point of contact with the healthcare system. SUD was identified initially with diagnosis within the EMR by a healthcare provider and was confirmed with toxicology (maternal or neonatal) results corroborating a pattern of substance use and maternal and neonatal ICD-10 codes for SUD. Patients identified with SUD were then classified as moderate or severe SUD based on criteria established by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition. We measured rates of NIDA implementation across different healthcare settings, evaluated NIDA concordance with ascertainment of SUD, and compared adverse pregnancy outcomes associated with moderate and severe SUD.

Results

From July 28, 2021, through June 25, 2022, 14,634 unique pregnant individuals accessed care at ambulatory and acute care sites. Universal implementation of the NIDA Quick Screen identified at-risk substance use in 2146 (14.7%) of those who accessed our system, or 17.1% of 12,550 screened across the system, with greater screen completion in ambulatory over acute care settings. SUD was identified in 256 (1.7%) of 14,634 individuals and moderate or severe SUD was identified in 184 (1.3%). Among those with moderate or severe SUD, 90 (48.9%) were NIDA positive, 22 (12.0%) NIDA negative, and 72 (39.1%) unscreened. Of 94 individuals with NIDA discordance or who were unscreened 76 (81%) accessed initial care through an acute care setting. Of 96 individuals with opioid use disorder, 68 (70.8%) were treated with medication-assisted therapy, and 56 (58.3%) were screened with the NIDA Quick Screen. Among delivered individuals with available outcomes, those with moderate or severe SUD were less likely to seek prenatal care (71 (76%) vs 9852 (98%), <0.001)) and more likely to deliver before 37 weeks, (18 (20%) vs 909 (9%), RR (95% CI) 2.13 (1.40, 3.24)) compared to individuals without SUD. Neonates exposed to moderate or severe SUD were more likely to have birth weight <10th centile for gestational age (20 (22%) vs 1147 (12%), RR (95% CI) 1.92 (1.29, 2.85)) and require admission to the neonatal intensive care unit (NICU) (19 (21%) vs 964 (10%), RR (95%) 1.95 (1.30, 2.93)).

Conclusion

Universal screening was implemented across a large public healthcare system at a high rate, with higher rates of implementation in ambulatory settings. NIDA successfully identified at-risk substance use in 17% of the SUD cohort but failed to identify more than 50% of patients with moderate or severe SUD. Patients with moderate and severe SUD accessed care primarily through the emergency department and experienced higher rates of adverse obstetric and neonatal outcomes. Future efforts to identify, engage, and retain this highest-risk group are needed.

Key words

methamphetamines
NIDA
opioid use
prescription drugs
screening
substance use disorder
substance use in pregnancy
==== Body
pmc AJOG Global Reports at a Glance

Why was this study conducted?

We report a single-center experience implementing a universal 4-question NIDA Quick Screen tool for self-reported substance use at the first prenatal encounter across a large public healthcare system. Objectives were to (1) evaluate rates of implementation across different clinical sites, (2) characterize success in identifying substance use disorder (SUD) in pregnancy, and (3) compare pregnancy outcomes among those with and without moderate and severe SUD in pregnancy.

Key findings

Universal implementation of a 4-question NIDA Quick Screen identified at-risk substance use in 17.1% screened individuals across the system, with greater screen completion in ambulatory over acute care settings.

NIDA Quick Screen identified about half of individuals with moderate or severe SUD in pregnancy ascertained by medical record review, with others screening negative or unscreened. Most unscreened individuals accessed care through acute or emergent care settings.

Of individuals who delivered in our system, those with moderate or severe SUD were less likely to access early prenatal care and had higher preterm birth, low birth weight, and neonatal intensive care unit admission compared to those without moderate or severe SUD.

What does this add to what is known?

Universal screening for self-reported substance use facilitates identification of at-risk substance use for early intervention but may fail to identify patients with moderate or severe SUD who are less likely to access traditional prenatal care.

Our results support findings in other studies that pregnant individuals with moderate or severe SUD are less likely to seek or maintain prenatal care and have increased maternal and neonatal morbidity. Future efforts to engage and retain this highest-risk group outside the traditional prenatal care system may be needed.

Introduction

According to the 2022 National Survey on Drug Use and Health (NSDUH), rates of substance use among pregnant women include 9.6% illicit drugs, 8.4% tobacco and 11% alcohol.1 Although opioid use disorder (OUD) has been a recent major focus, rates of overall illicit drug use have also risen. According to NSDUH, between the years of 2021 and 2022, illicit drug use rose from 7.9% to 9.6% among U.S. pregnant female adults between the ages of 15 and 44.1 One possible contributor to the rise of substance use disorder (SUD) in pregnancy in this time period is the COVID-19 pandemic given its association with higher rates of financial hardship, isolation and anxiety.2 Among contributors to preventable pregnancy-related deaths in the U.S., mental health conditions, including deaths due to overdose or poisoning-related to SUD, made up the largest percentage at 23% in the 2017–2019 Maternal Mortality Review Committee findings, surpassing previously more common causes to include hemorrhage and infection.3 SUD in pregnancy is associated with poorer maternal and neonatal outcomes to include neonatal abstinence syndrome, low birth weight and increased rates of neonatal and maternal mortality.4, 5, 6, 7

Globally, drug use is one of the most common causes of preventable death, injuries and disabilities.8 The United States Preventative Services Task Force, a task force made up of a panel of experts in primary care and prevention that make recommendations for clinical preventative services, recommends screening for substance use via patient interview for all adults over the age of 18.9 Given the rise in SUD and its effects on pregnancy outcomes, the American College of Obstetricians and Gynecologists and the World Health Organization recommend screening for substance use at the first prenatal visit for all patients as a part of comprehensive and universal obstetric care.6,10 Validated screening questionnaires such has 4Ps,11 National Institute on Drug Abuse (NIDA) Quick Screen12 and CRAFFT13 among others have been recommended for detection of at-risk substance use during pregnancy in order to link patients to appropriate care given their ability to detect substance use and misuse.14 The purpose of these screening questionnaires is to detect at risk substance use and SUD early on but does not formally provide a diagnosis.15 Coleman-Cowger et al demonstrated 80% to 90% sensitivity with adaptations of the 4Ps and NIDA Quick Screen administered by providers when validated with urine and hair drug testing.16 Generalizability of studies may be limited by self-selection bias, or because participants may be inherently more likely to admit use and seek treatment services as well as prenatal care. Alternatively, identification of substance use through self-report may underestimate true prevalence given the stigma associated with substance use in pregnancy.17 Extrapolation of findings from studies of screening in ambulatory settings likely do not apply to individuals with SUD who inherently have other barriers to prenatal care.4,18, 19, 20 Limited real-world evidence exists to measure success in implementing a universal brief screening tool across all healthcare settings to identify substance use, and whether this practice also identifies SUD in a medically underserved pregnant population.

We report the experience of a single institution following universal implementation of a brief screening tool (NIDA Quick Screen) for self-reported substance use at the first prenatal encounter. Our objectives were to measure rate of implementation across different healthcare settings, characterize NIDA success in identification of SUD, and compare adverse pregnancy outcomes associated with moderate and severe SUD in pregnancy.

Materials and methods

This is a prospective implementation study evaluating screening for substance use among pregnant individuals who accessed care in a large safety net healthcare system. Universal screening with the NIDA Quick Screen V1.0 for frequency of past-year use of tobacco, alcohol, illicit drugs, and prescription drugs for nonmedical reasons was integrated into the electronic medical record (EMR) and administered at the first point of contact with the healthcare system beginning July 28, 2021 (Supplemental Figure). Although other screening questionnaires have been found to have higher sensitivity and negative predictive values when compared to NIDA,16 we chose to use the NIDA screen in our population because we felt it was the most succinct of the screening questionnaires and thus would allow for higher compliance with screening at all of our prenatal care sites. Sites for screening included 10 community-based prenatal clinics known as women's health centers (WHC), a centralized referral Maternal-Fetal Medicine (MFM) clinic with colocated SUD treatment services, and acute care settings including the emergency department (ED) for pregnancies <20 weeks of gestation, and Labor and Delivery Triage (L&D) for pregnancies 20 weeks of gestation or greater.

NIDA was administered by a healthcare educator or provider, with any response other than “Never” considered positive for at-risk substance use and followed by a targeted brief intervention and education on risks in pregnancy.21 Individuals reporting use of prescription drugs for nonmedical reasons or illegal drugs were either referred to a specialized MFM clinic for individuals with SUD or evaluated immediately in an emergency care setting by a specialized multidisciplinary team known as the Perinatal Intervention Program (PIP). This team functioned throughout the acute care hospital and centralized MFM clinic to provide comprehensive treatment and recovery services during pregnancy and coordinate referrals to SUD programs postpartum. For eligible patients with OUD electing MAT, buprenorphine was prescribed to eligible candidates by the PIP team in both inpatient and ambulatory settings or methadone therapy was initiated inpatient with referral to one of several local methadone clinics for maintenance MAT.

We first measured rate of NIDA implementation at the first pregnancy encounter across our different healthcare sites. Next, we evaluated concordance of NIDA screening positivity with ascertainment of SUD across the healthcare system. SUD was initially identified via documentation of SUD in the EMR by a healthcare provider with formal assessment by our PIP team when available. Toxicology (maternal or neonatal) results corroborating a clinical diagnosis of substance use during pregnancy, and maternal and neonatal ICD-10 codes for SUD (F11.XX for maternal codes, and P96.1, P04.49, or P04.14 for neonates) were used as supplementary sources to identify maternal SUD. Urine toxicology was performed as a diagnostic tool to confirm reported substance use before initiation of MAT, or in workup of suspected intoxication, but was not used as a screening method. Behaviors excluded from the SUD group included medically indicated chronic opioid use, tobacco use (as this is difficult to ascertain retrospectively), intermittent (less than 3 times weekly) cannabis use, and alcohol use that stopped with recognition of pregnancy.

After identification of documented SUD, diagnosis of moderate or severe SUD was identified using criteria established by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V).22 Moderate SUD was diagnosed when 4 to 5 criteria of the 11 criteria outlined by the DSM-V were met and severe SUD was diagnosed when 6 or more criteria were met. Cannabis use was excluded from this cohort as diagnosis of SUD using the DSM-V criteria retrospectively was difficult. Ultimately, demographic characteristics (including the mean Area Deprivation Index23,24), prenatal care, and pregnancy and neonatal outcomes of those patients with moderate and severe SUD were compared to all other patients without SUD that delivered at our institution during this time period. This study was approved by the institutional review board at UT Southwestern in Dallas, Texas.

Statistical analysis

Categorical variables were summarized with frequencies and percentages. Means and standard deviations were reported for normally distributed variables, and median with interquartile ranges were reported for data not normally distributed. Data was analyzed using chi-square for categorical data, Student's t test for normally distributed continuous data, and Wilcoxon rank-sum test for continuous data not normally distributed. Effect sizes are presented as relative risk (95% confidence interval) for categorical responses, mean difference ± standard deviation for normally distributed continuous responses, and Hodges–Lehmann (95% confidence interval) for continuous responses not assumed as normally distributed. Calculations were performed using SAS version 9.4, SAS Institute (Cary, NC). Statistical significance was indicated by P<.05. If multiple pregnancies for one patient were identified, the delivery data for the first pregnancy was included in data analysis if all pregnancies were affected by maternal SUD. If only one pregnancy was affected by maternal SUD this was the pregnancy that was included in data analysis.

Results

From July 28, 2021, through June 25, 2022, 14,829 pregnancies occurred among 14,634 unique individuals. Among these, a first encounter occurred in a community-based prenatal clinic for 9221 (63.01%). Across the healthcare system, 12,550 (85.8%) of 14,634 individuals were screened with NIDA. The majority (70.5%) of NIDA screens were completed in the community-based prenatal clinics, where NIDA was completed for 96.2% of individuals attending a first prenatal visit. Rates of implementation of universal screening were less if first access to care occurred in acute care settings, where NIDA screening occurred for 67.8% in the ED and 57.1% for L&D Triage.

Of 14,634 individuals, NIDA was positive for any past-year substance in 2146 (14.7%) (Figure 1). Positive screens included at-risk alcohol use (4 or more drinks per day) in 59%, illegal drugs in 44%, tobacco use in 35%, and prescription drugs for nonmedical reasons in 5%. Of 1269 screens positive for alcohol use, 1043 (82.2%) were positive for infrequent use, defined as monthly or less. Of 950 screens positive for illegal drugs 336 (35.3%) were positive only for cannabis, with 188 of 336 (56%) of these patients with infrequent use (less than 3 times weekly). Most positive screens after further chart review were not found to meet criteria for SUD given frequency of use or use outside of pregnancy that stopped when pregnancy was recognized.Figure 1 Flow diagram of NIDA Screening during first encounter in pregnancy, identification of substance use disorder, and pregnancy outcomes available among individuals accessing care at Parkland Health, July 28, 2021, through June 25, 2022.

Figure 1White. Implementation of universal screening for substance use in pregnancy. AJOG Glob Rep 2024.

SUD was identified in 256 (1.7%) of the total cohort. Based on review of DSM-V criteria, 184 (1.3%) patients met criteria for moderate or severe SUD. NIDA screening completion and results varied within this group, with 90 (48.9%) NIDA positive, 22 (12%) NIDA negative, and 72 (39.1%) unscreened (Table 1). Of the 2108 individuals with positive NIDA screens, 128 (6%) of 2108 were noted to have SUD for reasons alluded to above. Of individuals with moderate and severe SUD who were screened, the majority were screened in the WHC. Discordance in screening was identified for 22 of the 112 (19.6%) NIDA-screened patients identified to have moderate and severe SUD; that is, 22 individuals who screened negative for past-year substance use were identified to have SUD through the other methods described. Of these, 9 (40.9%) had first contact with the health system through an acute or emergent care setting (ED or L&D Triage). Of the 72 unscreened individuals with moderate and severe SUD, 67 (93.1%) had their first and sometimes only contact with our healthcare system in an emergent care setting. Within the moderate and severe SUD population, the most common primarily used drugs were nonprescription opioids (45.1%) followed by methamphetamines (22.8%) and alcohol (13%) (Figure 2). Of 96 individuals with OUD, 68 (70.8%) were treated with MAT with either buprenorphine or methadone. Of these 96, 56 (58.3%) were screened with NIDA. A total of 43 (76.8%) of 56 NIDA-screened patients with OUD were initiated on MAT during the included index pregnancy.Table 1 NIDA Quick Screen results for any past-year substance use compared with documented moderate to severe SUD in pregnancy

Table 1	NIDA screen positive			
	Yes	No	Not screened	Total	
Moderate to severe SUD identifieda					
Yes	90 (48.9)	22 (12.0)	72 (39.1)	184	
No	2018 (14)	10,369 (72.1)	1991 (13.8)	14,378	
Total	2108	10,391	2063	14,562	
N in each column represents total pregnancies per subgroup. Data reported as n (%).

NIDA, National Institute on Drug Abuse; SUD, substance use disorder.

a SUD identified through medical record review, toxicology results, maternal and neonatal diagnostic codes, and referrals to a specialized addiction medicine team, moderate and severe SUD identified via chart review using DSM-V criteria. Numbers reported here represent moderate and severe SUD.

White. Implementation of universal screening for substance use in pregnancy. AJOG Glob Rep 2024.

Figure 2 Primary drug identified among individuals with illicit moderate and severe SUD in pregnancy (n=184), (regardless of NIDA Quick Screen results), Parkland Health, July 28, 2021, through June 25, 2022.

Figure 2White. Implementation of universal screening for substance use in pregnancy. AJOG Glob Rep 2024.

Among 14,634 individuals in the cohort, 10,201 delivered at our institution with available pregnancy outcomes including 94 (51.1%) of 184 with moderate and severe SUD and 10,066 (69.5%) of 14,378 without SUD. Maternal characteristics, delivery, and neonatal outcomes differed for patients with moderate and severe SUD (Table 2). Compared to those without SUD, individuals with moderate and severe SUD were more likely to be Black, non-Hispanic (16% vs 14%) or White, non-Hispanic (21% vs 3%) (P<.001). The mean ADI was higher in the group without SUD although both groups had ADIs in the range of 50 to 60. Individuals with moderate and severe SUD were less likely to have prenatal care (71 (76%) vs 9852 (98%), <0.001) with a lower mean (±SD) number of prenatal visits (5.7 ± 4.7 vs 9.8 ± 3.7, mean difference 3.9 (3.1, 4.7), P<.001) (Table 3). After adjusting for race, those with moderate and severe SUD were more likely to experience prelabor rupture of membranes (29 (32%) vs 2208 (22%), RR (95% CI) 1.43 (1.05, 1.93)) and preterm delivery less than 37 weeks (18 (20%) vs 909 (9%), RR (95% CI) 2.09 (1.37, 3.19)). Neonates born to mothers with moderate or severe SUD were more likely to have birth weight less than the 10th percentile (20 (22%) vs 1147 (12%), RR 1.92 (1.29, 2.85)), were twice as likely to be admitted to the NICU (19 (21%) vs 964 (10%), RR 1.95 (1.30, 2.93)) and were more likely to require extended hospitalization (10 days [4, 21] vs 3 days [3, 4], mean difference (Q1, Q3) in days 9 (7, 11)) (Table 4).Table 2 Characteristics of delivered individuals with and without identified moderate to severe SUD

Table 2Characteristic	Moderate to severe SUD	No moderate to severe SUD	P value	
Delivered (n)	94	10,066	–	
Age, y	29.4 ± 5.1	27.7 ± 6.4	.002	
Race and ethnicity			<.001	
 Black, non-Hispanic	15 (16)	1395 (14)		
 White, non-Hispanic	20 (21)	306 (3)		
 Hispanic	58 (62)	8123 (81)		
 Other	1 (1)	242 (2)		
Nulliparous	26 (28)	3046 (30)	.58	
Early pregnancy loss	2 (2)	125 (1)	.44	
Stillbirth	0 (0)	44 (0)	.52	
ADI	56.6±18.9	60.6±16.9	.02	
Prenatal carea	71 (76)	9852 (98)	<.001	
N in each column represents total deliveries per subgroup. Data reported as n (%) and mean +/– SD as appropriate.

ADI, area deprivation index; SUD, substance use disorder.

a Prenatal care represents that the patient attended at least one prenatal care visit.

White. Implementation of universal screening for substance use in pregnancy. AJOG Glob Rep 2024.

Table 3 Delivery outcomes among individuals with and without identified moderate to severe SUD who delivered live-born infants

Table 3Outcome	Moderate to severe SUD N=92	No moderate to severe SUD N=9897	P value	RR (95% CI) or mean difference ± SD	
Nulliparous	24 (26)	3007 (30)	.37	0.84 (0.59, 1.18)	
Prenatal care					
 Enrolled in 3rd trimester	20 (22)	1102 (11)	<.001	2.13 (1.47, 3.09)	
 Number of PNC visits	5.7 ± 4.7	9.8 ± 3.7	<.001	3.9 ± 3.1	
 GA at enrollment	20.3 ± 9.1	14.7 ± 7.9	<.001	5.0 ± 6.9	
Pregestational diabetes	1 (1)	227 (2)	.44	0.50 (0.07, 3.57)	
Chronic hypertension	8 (9)	548 (6)	.19	1.50 (0.77, 2.92)	
Prelabor rupture of membranes	29 (32)	2208 (22)	.03	1.43 (1.05, 1.93)	
Chorioamnionitis	9 (10)	1039 (10)	.82	0.95 (0.51, 1.77)	
Cesarean delivery	35 (38)	2922 (30)	.07	1.26 (0.97, 1.64)	
Gestational age at delivery <37 wk	18 (20)	909 (9)	<.001	2.09 (1.37, 3.19)	
PPH (EBL >1000 mL)	7 (8)	981 (10)	.46	0.75 (0.35, 1.58)	
Transfusion after delivery	5 (5)	523 (5)	.95	1.01 (0.40, 2.41)	
N in each column represents total liveborn infants excluding stillbirths and early pregnancy losses. Data reported n (%) or mean ± standard deviation (SD) with effect size of mean difference ± SD. RR adjusted for difference in race.

PPH, postpartum hemorrhage; SUD, substance use disorder.

White. Implementation of universal screening for substance use in pregnancy. AJOG Glob Rep 2024.

Table 4 Neonatal outcomes of live-born infants of individuals with and without identified moderate to severe SUD

Table 4Outcome	Moderate to severe SUD N=132	No moderate to severe SUD N=9897	P value	RR (95% CI)	
5 min Apgar <4	2 (2)	64 (0.6)	.07	2.85 (0.69, 11.75)	
Umbilical artery pH <7.0	1 (1)	42 (0.4)	.31	2.84 (0.39, 20.77)	
Infant birth weight <10th percentile	20 (22)	1147 (12)	.003	1.92 (1.29, 2.85)	
Infant ventilator or CPAP, first 24 h	3 (3)	343 (3)	.91	0.90 (0.30, 2.88)	
NICU admission	19 (21)	964 (10)	<.001	1.95 (1.30, 2.93)	
Exclusive breastfeeding	20 (22)	3844 (42)	.01	0.64 (0.44, 0.94)	
Length of stay, d	10 [4, 21]	3 [3, 4]	<.001	9.4 (7.4, 11.3)	
N in each column represents total liveborn infants, excluding stillbirths and early pregnancy losses. Data reported n (%) or median [interquartile range] with P value from Wilcoxon rank-sum test and effect size as Hodges–Lehmann mean shift (95% CI). RR adjusted for difference in race.

CPAP, continuous positive airway pressure; NICU, neonatal intensive care unit; SUD, substance use disorder.

White. Implementation of universal screening for substance use in pregnancy. AJOG Glob Rep 2024.

Comment

Principle findings

There were three principal findings. First, universal implementation of the NIDA screen for at-risk substance use had higher rates of implementation in ambulatory prenatal clinics, and less successful in acute or emergent care settings. Second, while NIDA screening identified at-risk substance use in approximately 15% of our prenatal cohort, SUD was identified in 1.7%, with more than half of those with moderate and severe SUD either screening negative or going unscreened, and the majority accessing care through acute or emergent care settings. Finally, neonatal outcomes associated with moderate and severe SUD include prematurity, small for gestational age, NICU admission, and extended hospital stay.

Results in the context of what is known

Our prevalence estimates of at-risk substance use based on the NIDA screen are similar to those published by other recent National Surveys.1 This contrasts to our rate of SUD which is lower than the national rate.25 This can be explained by differences in the racial and ethnic makeup of our population compared to other areas, differences in methods of diagnosis including use of biologic tests, not used at our institution and underreporting. Our population is primarily Hispanic but SUD has been reported to be more prevalent in White, non-Hispanic, and Black populations.25,26

Underreporting of SUD of up to 60% has been reported when comparing screening tools to documented urine drug screens, especially in cases of cannabis and opioid use.27,28 Stigma associated with SUD in pregnancy, compounded by fear of being reported, likely contributes to underreporting of SUD and lack of prenatal care in this population.5 For our population specifically, legal ramifications associated with use of recreational cannabis in our state likely also contributed to underreporting. Individuals with SUD and no prenatal care were found in one study to be 12 times more likely to deliver preterm and 14 times more likely to have an infant with low birth weight when compared to individuals without SUD.29

With high rates of street opioid use measured among those with SUD, we are not immune to the recently documented rises in the prevalence of fentanyl in the United States,30 which demands allocation of considerable resources to fully augment needed treatment and recovery resources, with education of the public and healthcare systems alike. We demonstrated that individuals who were identified to have OUD and were screened with NIDA had a high rate of MAT. This demonstrates, as supported by screening and treatment literature, that screening can identify patients with SUD and thus can aid in connecting them to appropriate treatment.31, 32, 33

Clinical implications

We demonstrate overall high rates of implementation of a universal screening tool to identify at-risk substance use behaviors, primarily in the ambulatory clinic setting. Our study highlights challenges in implementing universal screening for SUD in a high-volume ED setting, as it is more designed for diagnosis and management of acute intoxication or withdrawal. Just as screening did not take place equally in all healthcare settings, not all healthcare settings were equally accessed by patients with SUD. Lack of prenatal care and thus lack of screening due to different patterns of health care utilization may be contributors to lack of treatment. Although most individuals with SUD went unscreened in the ED, a proportion underwent screening which was negative. Thus, successful implementation of screening and patient comfort with responding honestly about substance use are separate challenges.

Our study was not designed to measure sensitivity and specificity of NIDA screening compared to an objective test, and we continue to avoid universal screening with urine toxicology to reduce fear of punitive reporting and increase attendance to prenatal care. Screening questionnaires such as the NIDA screen reduce bias of providers as it is used universally with all patients and relies on patient self report.34 Following implementation across a large safety-net healthcare system, we found that universal screening with brief intervention and targeted referral functions best for ambulatory prenatal settings, and that identification and engagement of pregnant individuals with SUD with treatment and recovery services may require creative solutions in the ED and even outside the traditional healthcare system.

Research implications

Further evidence regarding the effect of substance use screening and brief intervention on pregnancy outcomes is needed. The optimal method for engagement of pregnant individuals with SUD in treatment and recovery services as well as prenatal care is unknown and may differ across different communities. While evidence supporting initiation of MAT for OUD in the ED setting is building,35 additional research is needed to determine whether MAT initiation in the ED in pregnant individuals with OUD is acceptable to providers and improves pregnancy outcomes. Finally, we recognize the need for evidence-based programs focused on measuring impact and interventions aimed at not only those that use substances in pregnancy but also at those who are secondarily affected by substance use (ie surrounding family and friends), which requires social support networks and community-based organizations outside the scope of this work.

Strengths and limitations

Strengths of this study include data collection across a large public hospital system with integrated EMR throughout multiple settings. Our study involved review of over 14,000 medical records, most of whom delivered at our hospital and for whom delivery and neonatal outcomes were available. Standardized screening and referral practices across 10 community-based clinics to a centralized MFM clinic with colocated treatment and recovery services by a specialized team will facilitate long-term measurement of outcomes associated with these practices. Finally, gestational age-specific criteria for triage to ED and L&D facilitate pregnancy-specific protocols for future program development.

Limitations of this study include its observational design and lack of a comparative analysis to test a performance of a specific intervention or practice. We did not use a biologic test to validate our diagnosis of SUD. Additionally, we used maternal ICD-10 codes for opioid use for confirmation of SUD diagnosis but did not include ICD-10 codes for other substances. However, we did use neonatal ICD-10 codes that were for exposure to all substances for diagnosis confirmation. Findings may not be generalizable to other healthcare systems and this study may not be reflective of other regions of the country as rates of SUD and population demographics differ. Additionally, screening questionnaires alone may be limited in their ability to identify SUD across all healthcare settings.21 We did not compare individuals who were and were not screened in the current study. Brief intervention at the time of screening for patients identified to have at-risk substance use is shown to have a favorable impact on drug abstinence and pregnancy outcomes,20 but we did not measure the impact of the initial brief intervention in the current study. As well, our study was not designed to measure the effect of MAT on pregnancy outcomes among individuals with OUD nor was it designed to compare outcomes between those with treated and untreated SUD. This study took place during the COVID-19 pandemic which may have contributed to limited or no prenatal care but the effects of the pandemic were not assessed in this study.

Conclusions

Universal implementation of the NIDA Quick Screen successfully identified at-risk substance use in a large urban prenatal system in ambulatory settings but failed to identify 50% of patients with moderate and severe SUD, who were identified primarily through the ED and lacked prenatal care. Significant adverse obstetric and neonatal outcomes are associated with moderate and severe SUD. Future efforts to engage and retain this highest-risk group in treatment and recovery services and prenatal care to improve adverse outcomes are needed.

CRediT authorship contribution statement

Alesha White: Writing – review & editing, Writing – original draft, Visualization, Supervision, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Macy Afsari: Writing – review & editing, Data curation, Conceptualization. Harini Balakrishnan: Writing – review & editing, Data curation. Emilia Chapa: Writing – review & editing. Meredith Kim: Writing – review & editing, Data curation. Shubhangi Mehra: Writing – review & editing, Data curation. Mary Ann Faucher: Writing – review & editing. Joyce Miller: Writing – review & editing. Polly Cordova: Writing – review & editing. Elaine L. Duryea: Writing – review & editing, Conceptualization. David B. Nelson: Writing – review & editing, Conceptualization. Anne M. Ambia: Writing – review & editing, Conceptualization. Donald D. Mcintire: Writing – review & editing, Formal analysis, Data curation. Emily H. Adhikari: Writing – review & editing, Writing – original draft, Validation, Supervision, Methodology, Investigation, Formal analysis, Conceptualization.

Appendix Supplementary materials

Image, application 1

Patient consent is not required because no personal information or details are included.

Paper Presentation Information: Presented as a poster at the 43rd Annual Pregnancy Meeting, SMFM, San Francisco, California, February 6 to 11, 2023.

Condensation/Tweetable Statement: Universal screening for self-reported substance use identified at-risk substance use in approximately half of individuals with substance use disorders in ambulatory over acute care settings.

Funding: None.

The authors report no conflict of interest.

Supplementary material associated with this article can be found in the online version at doi:10.1016/j.xagr.2024.100384.
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