EXECUTIVE SUMMARY

OB/GYNs and family planning clinicians should screen all patients for substance use disorders, as recommended by researchers and professional guidelines.

  • Substance use disorders affect people in all demographics, ethnicities, and economic backgrounds.
  • Addiction occurs when a person is unable to stop a behavior. It is not necessarily related to physical withdrawal symptoms.
  • Clinicians should avoid using the term “substance abuse.” Instead, they should describe it as substance use, misuse, and addiction.

Around 20 million Americans have a substance use disorder, and one out of eight adults struggle with both alcohol and drug use disorders at the same time, according to data from American Addiction Centers.1

Recent guidelines from the American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice recommend anyone who enters a physician’s office for reproductive health services receive a screening for a substance use disorder (SUD).2

“The most important thing for folks to know is substance use disorders cut across all demographics and all ethnicities and layers of society,” says Marcela Smid, MD, MA, MS, assistant professor in the division of maternal fetal medicine at the University of Utah Health. “Some populations are more affected, and screening is more important to do universally, especially in this time when we have heightened awareness and are doing a lot of reflection on the way it has discriminated against certain groups of people. If we screen, we need to do it universally. We don’t know who is at high risk and who is not, so everyone should be considered high risk.”

The other important point is to think of substance use disorders as a medical problem like any other medical condition, Smid notes. “We’re trying to identify and treat it so we can help people live healthier, happier lives. Everyone deserves that,” she adds.

Clinicians should think of substance use as a continuum, says Mishka Terplan, MD, MPH, FACOG, associate medical director at Friends Research Institute in Baltimore. Terplan also serves as adjunct faculty at the University of California, San Francisco, where he is a Substance Use Warmline clinician at its Clinical Consultation Center. “There is use, misuse, and addiction,” he says. “Use should be self-evident; misuse is using a substance in a way that is potentially harmful.”

The most salient feature of addiction is when a person cannot stop a behavior, and it is not necessarily related to physical withdrawal symptoms. “The American Society of Addiction Medicine has a two-sentence definition, which I helped write,” he adds.

The society’s definition calls addiction a “treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences.”3

“There certainly is a strong role for reproductive health providers to assess behavioral health conditions like substance use, misuse, and addiction,” Terplan says. “One reason is that there is a parallel overlay between ages in which people use and misuse substances and ages when people seek reproductive health services. Another reason is that some people get almost all of their healthcare through reproductive healthcare.”

Providers Can Collaborate

Behavioral health issues can overlap with reproductive health objectives. “There is resonance between behavioral health, substance use, and other domains of reproductive health, including sexual risk-taking, adherence or nonadherence to contraception, etc.,” Terplan says.

Terplan has worked on several collaboration projects that could require training OB/GYN and family planning staff to screen and assess patients for SUD. They also need to connect with local providers, he says.

“For example, we had a small grant to integrate reproductive health into drug treatment,” Terplan explains. “I had a mobile clinic that provided reproductive healthcare directly into their facility.”

These kinds of programs might begin with grant money, but the goal could be to use Title X or other state or federal funding and place a dedicated professional in charge. (See story on collaboration between contraceptive services and substance use treatment centers in this issue.)

When screening for substance use, clinicians should communicate clearly that these are questions they ask all of their patients. They can say, “We want to identify if there is anything we can help you with, and we would like to ask these questions,” Smid suggests.

Most providers fail to screen for substance use, partly due to misperceptions and partly because they believe prescreening questions about smoking, drinking, and drugs are the same thing as screening, Smid explains.

“Also, many providers did not receive a great education about substance use disorders in their training,” she adds.

Clinicians sometimes assume women with SUD are not interested in or do not care about contraceptives or their reproductive health. This assumption is a mistake, says Sarah H. Heil, PhD, professor of psychiatry and psychological science at the University of Vermont in Burlington. “They are interested, and they do want to be able to make decisions around their reproductive health,” she says. “Giving them a chance is important.”

To screen patients for substance use disorders, use a validated screening tool, Smid says. One example is the NIDA-Modified ASSIST tool, developed by the National Institute on Drug Abuse (NIDA), to screen for drug use in general medical settings.4

“A few tools focus on women of reproductive age, and many are validated,” she adds. “The important thing is to understand that screening is not asking patients if you use drugs — that’s prescreening, It’s not drug testing on urine.”

While drug testing on urine can be a useful tool, it is not a good screening tool, Smid says. If biologic testing is used or suggested, patients need to be aware of potential harm.

“It can be useful, but it also can be incredibly harmful, particularly for pregnant and parenting women because of laws that criminalize drug use in pregnancy and parenting women,” Smid explains. “It’s important the clinician and patient have an understanding of when biologic testing will be used, how it is used, and what the results will be used for.”

If an open and honest discussion about the testing is held, and patients understand what the testing is used for, then it can be helpful in monitoring patients. If clinicians do not fully disclose how the testing is used, then there could be circumstances in which women are criminalized for substance use and even have their children taken away, Smid adds.

“That’s why I advocate, especially in a family planning centers where many women are parenting and are seeking services to plan their families, that we use a validated screening tool for identification of substance use and to offer referrals and services for those women,” she explains.

Treat Patients with Respect

Family planning providers should keep in mind that women with SUD sometimes have been treated poorly by healthcare professionals. When they enter a new provider’s office or clinic, they might be worried about being stigmatized or treated badly, Heil says. They might fear being talked into a birth control method they do not want to use, or even being coerced into a tubal ligation.

“Treating them nicely and with respect goes a really long way,” Heil says. “Being more flexible with them in terms of appointments and things like that also helps.”

Heil often hears women with SUD say their providers will no longer see them after the women missed several appointments.

“These women are living very chaotic lives, having difficulty finding child care, and have trouble with transportation,” Heil says. “They have issues with unstable housing and having to get enough food.”

Also, the women might have competing demands from social services agencies. For instance, a woman might have to show up at the Women, Infants, and Children office at a certain time of the day, or meet with her probation officer or face being jailed. Those appointments might conflict with a reproductive health visit.

“If they don’t show up, then it’s likely that they don’t care,” Weil explains. “It’s more likely there are circumstances beyond their control.”

Clinicians should be willing to meet patients however they can. If patients miss appointments, then clinicians could keep trying.

“They’re often very happy to get to the appointment, and they often really do want family planning and try to make the best decisions they possibly can and get professional input to meet those goals,” Weil says.

Some substance use treatment centers and reproductive health clinicians are collaborating to make contraceptives and reproductive health services more readily available to women with SUD.

Terminology can be important when dealing with substance use issues, particularly because it can increase stigmatization when used without sensitivity. (See story on stigma in this issue.) For instance, clinicians might use the word “assessment” instead of “screening,” because it’s a broader term, Terplan says.

A term clinicians should avoid is “substance abuse.” Instead, refer to substance use, misuse, and addiction. This is a change over the past five years.

“Use ‘addiction’ or ‘substance use disorder’ as terminology,” Terplan suggests. “The term ‘abuse’ is considered stigmatizing, and there are randomized, controlled trial data showing that when we use the term ‘abuse,’ people are more likely to endorse punitive responses and not a biomedical model.”

REFERENCES

  1. American Addiction Centers. Alcohol and drug abuse statistics. Last reviewed Oct. 5, 2020. https://americanaddictioncenters.org/rehab-guide/addiction-statistics
  2. American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice. Opioid use and opioid use disorder in pregnancy. August 2017. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy
  3. American Society of Addiction Medicine. Definition of addiction. Sept. 15, 2019. https://www.asam.org/quality-practice/definition-of-addiction
  4. National Institute on Drug Abuse. NIDA Drug Screening Tool: NIDA-Modified ASSIST (NM ASSIST). https://archives.drugabuse.gov/nmassist/