Pregnancy is a “very important period” for identifying and treating substance use disorder

Key takeaway :

• Overdose death among postpartum women is common between 6 and 12 months after delivery.
• Understanding the neurobiological basis of addiction can help OB/GYNs reduce bias 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 ACOG’s Annual Clinical and Scientific Meeting.

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

Remembering that addiction rewires the brain, that executive function and the reward system are “hijacked,” may help doctors reduce their biases when treating women who are unable to limit substance use during pregnancy, she said.

Overdose is now the most common cause of pregnancy-related death among postpartum women, Martin said. Most of these deaths occur well after the 6-week postpartum visit in the 6 to 21 months after delivery.

Caitlin E. Martin, MD, MPH

“Pregnancy is a very important period, but I would say that postpartum in our world of substance use disorders is even more important, because that’s when women die from overdoses,” Martin said.

Healio spoke with Martin about how to identify substance use disorder during pregnancy to get vital help for women and families.

healthy: When we talk about substance use disorder in pregnancy what are they most commonly used substances?

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

Also, we’ve gone from referring to an “opioid crisis” to an “overdose crisis,” mainly because it’s not just about 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. Number 1 is synthetic opioids like fentanyl. Then methamphetamine use is on the rise and cocaine is on the rise.

But in reality, the most common substance use disorder among all people, pregnant or not pregnant, female or male, is alcohol use disorder.

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

Martin: There is a big difference between substance use and substance use disorder. You can use cocaine, 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 for determining 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 chart and their history that they’ve had continued use of a substance despite adverse consequences, that is generally pathognomonic for a substance use disorder. This is how I teach my residents how to identify it.

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

For people who are unable to stop using during pregnancy, that is often a marker that the patient likely has a substance use disorder. Now, again, we only diagnose that through a verbal conversation with the patient. We use the DSM-5 criteria, but in general, if you’re just trying to see if a particular patient is someone, maybe you should test a little more, ask more questions, maybe involve a colleague who knows a little more about this: if that patient continues to use it despite the adverse consequences and tells you that she has trouble cutting back after pregnancy, that patient is at high risk. And more importantly, if they’re talking to you about it, that means they want help and feel open and comfortable with you.

healthy: You alluded after pregnancy.

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

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

healthy: How can substance use disorder affect the baby perinatally?

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 parents, the family will do well. It is the same with addiction. As much as we can make moms healthier with this chronic disease of addiction, the better their babies will be and the stronger their families will be.

Unfortunately, the historic war on drugs means that substance use disorder has many legal aspects, and structural systemic factors discriminate against people with substance use disorders, especially women of color and people who have lived in communities historically marginalized. The systemic and structural factors working against these communities are magnified when addiction is added. It leads to some complications of the psychosocial and socio-ethnological context. I feel like when my patients are with me in the exam room, it’s just the two of us, but sometimes I feel like I’m in a battlefield as soon as they walk out of the exam room. When they leave my clinic, they are faced with a whole war.

That needs to change. I think some people feel overwhelmed and think they can’t change anything. Actually, we all can. Each individual patient a provider identifies compassionately and nonjudgmentally helps them get what that person wants for their recovery at that time. That’s one more person who has a little more confidence and has been able to participate a little more in the health care system and that little bit is going to help.

healthy: What is the role of drug detection? Are some demographic groups being tested more frequently for substance use than others, perhaps unfairly?

Martin: Yes, detection is tricky. Most people have the 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 anyone has continued use and if this has any adverse consequences. I need to see if they are having challenges to reduce or eliminate their substance use when they want to.

You can’t determine that from a drug test. A drug test will tell you if anyone has used cocaine in the last 3 days. If you need to know that for a medical reason, there you have it. Be sure to always obtain consent for a drug test. But if you’re trying to test someone to see if they’re at high or low risk for a chronic disease, you need to talk to that patient and not do a drug test.

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

Healio: Anything else you want to add?

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

Reference:

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

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Annual Clinical and Scientific Meeting of the American College of Obstetrics and Gynecology