Substance Abuse in Pregnancy
Substance use disorder (SUD) is considered by many obstetricians to be a problem best managed by other disciplines. However, it is inevitably our problem as well. All physicians have likely contributed to overprescribing habit-forming medications to women of childbearing age.1 Obstetrician-gynecologists are uniquely positioned to be champions for those affected by SUD as the structure of prenatal care lends itself to an intense time of engagement in medical care during which women are uniquely motivated to optimize their health.2 With the proper education and tools, obstetricians stand to be fully equipped to identify and treat SUD.
SUD affects women disproportionately. A 2014 Substance Abuse and Mental Health Services Administration (SAMHSA) report showed female treatment admissions for opioid pain relievers (as the primary substance of abuse) outnumber male admissions in all age categories.3 The rate of opioid use during pregnancy is ∼5.6 per 1000 live births,4 with one study reporting >85% of pregnancies in women with opioid use disorder were unintended.5 Not only has opioid use disorder significantly impacted maternal and child health, but the financial impact to society is high as well. In 2009, the cost of neonatal abstinence syndrome alone was $720,000,000 which increased to $1.5 billion in 2015.4,6 Of that, ∼80% of cost is incurred by Medicaid systems.
To optimize the care of pregnant women with SUD, it is important to understand it as a disease process independent of pregnancy. SUD is a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Similar to other chronic diseases such as chronic hypertension, type II diabetes, and asthma, without treatment or engagement in recovery activities, SUD is progressive and can result in disability or premature death. Such chronic diseases, including SUD, carry similar hallmarks: they are treatable with medications and intervention, they are prone to relapse at a rate of 50% to 60%, and when combined with lifestyle changes, health status can be optimized. These diseases are not likely to be cured, but they can be managed to reduce or eliminate symptoms.
SUD is associated with more stigma than other chronic diseases. As such, some people with SUD will not seek treatment and some doctors refuse to treat patients with addiction. Similarly, some pharmaceutical companies will not work toward developing new treatments for addicts, which has limited options for women with this chronic disease.7,8 Over time, it is our hope that as a result of public education and broader acceptance of addiction as a chronic and treatable disease, that stigma will become less of a barrier to those who need treatment for SUD.9
In this issue of Clinical Obstetrics and Gynecology, we highlight that SUD is a chronic disease so that we can begin to medicalize our approach, rather than stigmatize pregnant women with SUD. We must remember that pregnancy is an acute and self-limited process imposed upon a chronic disease. In the same way that some women have suboptimal control of blood sugars in pregnancies affected by diabetes, some women with SUD will relapse during pregnancy. As such, relapse should be considered part of the SUD disease process, rather than a transgression that builds barriers between health care providers and pregnant women.
This symposium intends to bring our readers up to date with regard to the chronic disease model of addiction and the pathophysiology underlying the neurobiology of addiction. In addition, we review the current knowledge that exists regarding the use of opiates, stimulants, marijuana, alcohol, and benzodiazepines in pregnancy and while breastfeeding. The authors have put forth excellent reviews that stand to benefit the reader in an impactful way.
Opiates are the current focus of SUD nationally. Previous decades have been impacted by cocaine or methamphetamines, and, without a doubt, a new, or recurring, illicit drug of abuse is on the horizon. It is our hope that lessons learned in this symposium will be of benefit to patients and health care providers by providing a framework for counseling and treating pregnant women with all types of SUD.
1. Kolodny A, Courtwright DT, Hwang CS, et al. The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction. Annu Rev Public Health. 2015;36:559–574.
2. Crozier SR, Robinson SM, Borland SE, et al. Do women change their health behaviours in pregnancy? Findings from the Southampton Women’s Survey. Paediatr Perinat Epidemiol. 2009;23:446–453.
3. SAMHSA. Behavioral Health Barometer: United States, 2015 Report. Rockville: Substance Abuse and Mental Health Services Administration; 2015.
4. Patrick SW, Schumacher RE, Benneyworth BD, et al. Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009. JAMA. 2012;307:1934–1940.
5. Heil SH, Jones HE, Arria A, et al. Unintended pregnancy in opioid-abusing women. J Subst Abuse Treat. 2011;40:199–202.
6. Patrick SW, Davis MM, Lehman CU, et al. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. J Perinatol. 2015;35:650–655.
8. McLellan AT, Lewis DC, O’Brien CP, et al. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA. 2000;284:1689–1695.
9. National Academies of Sciences, Engineering, and Medicine. Ending Discrimination Against People With Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press; 2016:170.