No. 349-Substance Use in Pregnancy

Abstract

ObjectivesTo improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers. OptionsThis guideline reviews the use of screening tools, general approach to care, and recommendations for the clinical management of problematic substance use in pregnancy. OutcomesEvidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation. EvidenceUpdates in the literature were retrieved through searches of Medline, PubMed, and The Cochrane Library published from 1996 to 2016 using the following key words: pregnancy, electronic cigarettes, tobacco use cessation products, buprenorphine, and methadone. Results were initially restricted to systematic reviews and RCTs/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English. Additional articles were located by hand searching through article reference lists. ValuesThe quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report. Benefits, Harms, and CostsThis guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders. Improved access to health care and assistance with appropriate addiction care lead to reduced health care costs and decreased maternal and neonatal morbidity and mortality. Recommendations1.All pregnant women and women of child-bearing age should be asked periodically about alcohol, tobacco, prescription, and illicit drug use (III-A).2.When testing for substance use is clinically indicated, urine drug screening is the preferred method (II-2A). Informed consent should be obtained from the woman before maternal drug toxicology testing is ordered (III-B).3.Policies and legal requirements with respect to drug testing of newborns may vary by jurisdiction, and caregivers should be familiar with the regulations in their region (III-A).4.Health care providers should employ a flexible and harm reduction approach to the care of pregnant women who use alcohol, tobacco, or drugs. Pregnant women at risk for problematic substance use should be offered brief interventions and referral to community resources for further psychosocial interventions (II-2B).5.Women should be counselled about the risks of periconception, antepartum, and postpartum substance use (III-B).6.Health care providers should offer smoking cessation interventions to all pregnant smokers. Psychosocial interventions should be considered first-line (I-A). Nicotine replacement therapy and/or pharmacotherapy can be considered if counselling is not successful (I-A).7.The standard of care for the management of opioid use disorders during pregnancy is opioid agonist treatment with methadone or buprenorphine. Other sustained-release opioid preparations are also an option if methadone or buprenorphine is not available (I-A).8.Opioid detoxification should be reserved for selected women because of the high risk of relapse to opioids (II-2B).9.Opioid-dependent women should be informed that neonates exposed to heroin, prescription opioids, methadone, or buprenorphine during pregnancy are monitored closely for symptoms and signs of neonatal withdrawal (neonatal abstinence syndrome) (II-2B). Hospitals providing obstetric care should develop a protocol for assessment and management of neonates exposed to opioids during pregnancy (III-B).10.Women who become pregnant while on methadone should continue on methadone maintenance therapy and should not switch to buprenorphine due to the risk of opioid withdrawal (I-A).11.Women who become pregnant while on buprenorphine/naloxone should be switched to buprenorphine monoproduct. Combination product should be continued until the monoproduct becomes available. Women taking buprenorphine should only switch to methadone if the buprenorphine monoproduct is not accessible and/or the woman feels that she is not responding to the current treatment (II-1A).12.Health care providers should advise pregnant women to abstain from or reduce cannabis use during pregnancy to prevent negative long-term cognitive and behaviour outcomes for exposed children (II-1A).13.Antenatal planning for intrapartum and postpartum analgesia may be offered for all women in consultation with appropriate health care providers (III-B).14.Pregnant women on opioid agonist treatment should be encouraged to breastfeed regardless of the maternal dose, in the absence of an absolute contraindication (II-2B). Women with active substance use should be encouraged to discontinue alcohol or other drug use while breastfeeding, and the risks and benefits of breastfeeding versus breast milk exposure to substances should be discussed (II-2B).