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Accuracy of Three Screening Tools for Prenatal Substance Use

Coleman-Cowger, Victoria H., PhD; Oga, Emmanuel A., MD, MPH; Peters, Erica N., PhD; Trocin, Kathleen E., MPH; Koszowski, Bartosz, PharmD, PhD; Mark, Katrina, MD

doi: 10.1097/AOG.0000000000003230
Substance Use Disorder: Original Research: PDF Only

OBJECTIVE: To compare and evaluate the accuracy of three screening tools in identifying illicit drug use and prescription drug misuse among a diverse sample of pregnant women.

METHODS: This prospective cross-sectional study enrolled a consecutive sample of 500 pregnant women, stratified by trimester, receiving care in two prenatal clinical settings in Baltimore, Maryland, from January 2017 to January 2018. All participants were administered three index tests: 4P's Plus, NIDA Quick Screen-ASSIST (Modified Alcohol, Smoking and Substance Involvement Screening Test), and the SURP-P (Substance Use Risk Profile-Pregnancy) scale, and administered reference tests (urine and hair drug testing) at the in-person baseline visit. To assess test–retest reliability of the index tests, screening tool administrations were repeated 1 week later by telephone. For each screening tool, sensitivity, specificity, positive predictive value, negative predictive value and test–retest reliability were computed. Results were stratified by age, race, and trimester of pregnancy.

RESULTS: Of the 500 enrolled pregnant women, 494 completed the index screening tools, 497 completed reference testing, and 453 underwent test–retest analysis. For the 4P's Plus, sensitivity=90.2% (84.5, 93.8), and specificity=29.6% (24.4, 35.2). For the NIDA Quick Screen-ASSIST, sensitivity=79.7% (71.2, 84.2), and specificity=82.8% (78.1, 87.1). For the SURP-P, sensitivity=92.4% (87.6, 95.8) and specificity=21.8% (17.4, 27.2). Test–retest reliability (phi correlation coefficients) was 0.84, 0.77, and 0.79 for the 4P's Plus, NIDA Quick Screen-ASSIST and the SURP-P, respectively. For all screening tools, there were differences in validity indices by age and race, but no differences by trimester.

CONCLUSION: The SURP-P and 4P's Plus had high sensitivity and negative predictive values, making them more ideal screening tests than the NIDA Quick Screen-ASSIST. A clear recommendation for a clinically useful screening tool for prenatal substance use is crucial to allow for prompt and appropriate follow-up and intervention.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

After comparing results of three prenatal substance use screening tools with biochemical verification, two were found to have satisfactorily high sensitivity and the third had greater specificity.

Battelle Memorial Institute and the University of Maryland Medical School, Baltimore, Maryland.

Corresponding author: Victoria H. Coleman-Cowger, PhD, The Emmes Corporation, 401 N. Washington Street, 7th Floor, Rockville, MD 20850; email:

The research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number R01DA041328 (PI-Coleman-Cowger). The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health.

Financial Disclosure The authors did not report any potential conflicts of interest.

Each author has confirmed compliance with the journal's requirements for authorship.

Peer reviews and author correspondence are available at

Received December 06, 2018

Received in revised form February 07, 2019

Accepted February 14, 2019

© 2019 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.