Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine

Abstract

The American College of Obstetricians and Gynecologists supports the value of this clinical document as an educational tool, March 2019. The American College of Obstetricians and Gynecologists supports the value of this clinical document as an educational tool, March 2019. Although perinatal substance use disorders, particularly those that involve opioids, have become a major public health issue in the United States, comprehensive, evidence-based guidance for the prevention and management of these disorders during pregnancy is lacking. Leaders in obstetric care, addiction medicine, mental health, and pediatrics gathered for a 2-day workshop, “Substance Use Disorders in Pregnancy,” that was held in conjunction with the Society for Maternal-Fetal Medicine’s 38th Annual Pregnancy Meeting. Given what has recently been termed an opioid epidemic, much of the workshop centered on identification and management of opioid use disorder (OUD) that included appropriate strategies to limit both opioid use and OUD. Goals of the workshop were to discuss critical issues that pertain to perinatal substance use disorders, with a focus on OUD in particular; to draft preliminary recommendations regarding screening, pain management, and medication-assisted therapy (MAT) for OUD during pregnancy; and to delineate research gaps. Epidemiologic evidence that was presented at the workshop demonstrated that rates of substance use in pregnancy have increased significantly in the past decade and that rates of OUD in pregnant and postpartum women have increased in parallel:•One study reported that 21.6% of pregnant women enrolled in Medicaid receive a prescription for opioids.1Desai R.J. Hernandez-Diaz S. Bateman B.T. Huybrechts K.F. Increase in prescription opioid use during pregnancy among Medicaid-enrolled women.Obstet Gynecol. 2014; 123: 997-1002Crossref PubMed Scopus (124) Google Scholar•From 2000–2009, antepartum maternal opiate use increased from 1.19 (95% confidence interval (CI), 1.01–1.35) to 5.63 (95% CI, 4.40–6.71) per 1000 hospital births per year.2Patrick S.W. Schumacher R.E. Benneyworth B.D. Krans E.E. McAllister J.M. Davis M.M. Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009.JAMA. 2012; 307: 1934-1940Crossref PubMed Scopus (511) Google Scholar•In 1 study, 85.4% of women filled an opioid prescription after a cesarean delivery. The average number of pills dispensed was 40; the median number of pills consumed was 20; and the average number of leftover pills was 15. Most women (95.3%) did not dispose of their leftover medications.3Bateman B.T. Cole N.M. Maeda A. et al.Patterns of opioid prescription and use after cesarean delivery.Obstet Gynecol. 2017; 130: 29-35Crossref PubMed Scopus (57) Google Scholar•One study reported that 4.7% of pregnant women reported using an illicit substance in the past month.4Substance Abuse and Mental Health Service AdministrationResults From the 2015 National Survey on Drug Use and Health: Detailed Tables. 2016; (Available at:) (Accessed April 23, 2019)https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.pdfGoogle Scholar•One study reported that 1 in 300 women will become dependent on opioids after a cesarean delivery.5Bateman B.T. Franklin J.M. Bykov K. et al.Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naive women.Am J Obstet Gynecol. 2016; 215: 353.e1-353.e18Abstract Full Text Full Text PDF PubMed Google Scholar•The incidence of neonatal opioid withdrawal syndrome (NOWS) ∗The term neonatal abstinence syndrome has also been used for this condition; however, it is a general term that refers to neonatal withdrawal from other types of substances in addition to opioids. has increased; the cost of NOWS treatment in the United States reached approximately $1.5 billion in 2015.6Patrick S.W. Davis M.M. Lehman C.U. Cooper W.O. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012.J Perinatol. 2015; 35: 667Crossref PubMed Scopus (48) Google Scholar∗The term neonatal abstinence syndrome has also been used for this condition; however, it is a general term that refers to neonatal withdrawal from other types of substances in addition to opioids.•Substance use plays a role in pregnancy-associated deaths (deaths of women while pregnant or within 365 days of pregnancy from any cause related to or aggravated by pregnancy). In Texas, Maryland, and Alaska, 17%, 15%, and 22% of pregnancy-associated deaths, respectively, were attributed to substance use.7Maryland Department of Health and Mental Hygiene Prevention and Health Promotion Administration. Maryland Maternal Mortality Review 2016 Annual Report. 2016Google Scholar, 8McLaughlin J. Castrodale L. Pregnancy-associated mortality in Alaska, 2000-2011. Department of Health and Social Services, Division of Public Health.2013Google Scholar, 9Texas Health and Human Services/Texas Department of State Health Services. The Role of Opioid Overdoses in Confirmed Maternal Deaths, 2012-2015. December 2017. Available at: https://www.dshs.texas.gov/mch/pdf/Confirmed-Maternal-Deaths-Due-to-Drug-Overdose.pdf. Accessed November 20, 2018.Google Scholar Following presentations on epidemiology, prenatal screening, pain management, and treatment modalities of OUD in pregnancy, workshop participants were assigned to 1 of 3 breakout groups to discuss the following key issues in greater depth and to make preliminary recommendations: (1) screening and testing for substance use disorder, including OUD, in pregnancy; (2) pain management during the antepartum, intrapartum, and postpartum periods; and (3) management modalities for pregnant women with OUD. The following key findings emerged from the workshop discussions:•All pregnant women should be screened for substance use at the first prenatal visit with the use of a validated questionnaire, such as the National Institute on Drug Abuse (NIDA) Quick Screen Tool.•Biologic testing, when performed, should be undertaken only with the woman’s informed consent and when its benefits outweigh any potential harms, which include those related to mandatory state reporting laws.•For opioid-naïve women, nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, unless contraindicated, should be given as first-line treatments for pain after a routine vaginal birth. A short course of low-dose opioids can be considered for severe pain that is not managed effectively by nonopioid options. Severe pain after vaginal delivery is unusual and should prompt an evaluation for unrecognized complications.•For opioid-naïve women, NSAIDs and acetaminophen, unless contraindicated, should be given as first-line treatments for pain after cesarean delivery. The addition of opioids to the pain management regimen should be considered if pain persists.•On discharge from the hospital, if an opioid-naïve woman requires opioids for persistent pain, she should be counseled about the benefits and risks of opioids, side-effects, and potential for misuse; a limited number of opioid pills should be prescribed.•All pregnant women with OUD should be offered maintenance therapy with methadone or buprenorphine. The choice of agent and dosages for therapeutic maintenance should be made with the use of an individualized, patient-centered approach that is based on the disease model of substance use disorder.•Although the US Food and Drug Administration (FDA) has approved naltrexone for the treatment of OUD, data are insufficient to support the initiation of naltrexone therapy during pregnancy. Naltrexone may be continued for those patients who already are taking this medication and who become pregnant after a careful assessment and communication of the risks of discontinuing naltrexone (eg, risk of relapse) and the limitations of data surrounding its use in pregnancy.•Pain management for women who are taking opioids for chronic pain or who have OUD during pregnancy and during and after delivery involves a multidisciplinary approach that may include an anesthesia consultation. Neuraxial analgesia during labor should be encouraged. Postpartum pain should be managed with the use of a multimodal approach that starts with nonopioid pain relief. If pain persists for >24 hours, a full opioid agonist (eg, fentanyl or hydromorphone) may be ordered.•Although MAT for women with OUD is considered the standard of care, some women may prefer or be motivated to undergo medication-assisted withdrawal during pregnancy. This option should be undertaken only with careful patient selection, close supervision, and appropriate behavioral and social support resources that extend into the postpartum period.•Management of OUD during pregnancy requires an approach that involves a wide range of health-care, social, and behavioral services to address the complex needs of this patient population. Two models of care that have been proposed are a collaborative care model and a “1-stop shop” model; both models have unique advantages and disadvantages. Workshop participants acknowledged that significant research gaps in evidence to guide best-practice care of this population remain. Each of the following sections also includes suggested areas that require future research. It is hoped that this workshop will provide the first step toward the development of comprehensive, evidence-based guidelines that focus on the unique needs of pregnant and postpartum women with OUD and will create an opportunity for education that dispels myths surrounding care and management and leads to the creation of validated and workable solutions for this population. Screening is used on a population level to determine who is at high risk for a disease. Ideally, it should take place only when interventions are available to prevent or treat the disease state. Screening is efficient if the background prevalence of the disease state warrants screening. Given that substance use in pregnancy is common, that the consequences of substance misuse are substantial, and that treatment interventions are available, screening pregnant women for drug and alcohol use is warranted. Screening tests should be easily administered, acceptable to patients, and economical. In this report, we refer to screening as a universally administered questionnaire designed to ascertain who is at high risk for having a substance use disorder in pregnancy. Biologic testing of urine, blood, or hair is discussed as a test and not as a screening technique. A biologic test may be useful only in selected situations. Universal biologic testing to screen pregnant women is not recommended. Ideally, screening for substance use disorder should occur when clinicians in a health-care system first recognize a pregnancy. In most cases, this would be the first prenatal visit. However, emergency rooms, primary care offices, and urgent care centers are all places where pregnancies are diagnosed. Clinicians can facilitate early substance use disorder treatment by considering the use of a basic screening questionnaire coupled with a list of treatment options in any setting in which a woman may be newly diagnosed. Screening should be implemented with every pregnant woman, regardless of whether the provider has suspicions of substance use. The goal of screening is to identify those women with substance use disorders and to help all such women receive treatment if needed; many women with substance use disorder will be missed if screening is based only on provider suspicions. Further, provider suspicions are subject to conscious and unconscious biases that may both overburden some groups and leave other groups undiagnosed. If, separate from universal screening, objective clinical findings or reported history increase a provider’s concern during pregnancy or the postpartum period, repeat screening at that time or consideration for testing is warranted. Indeed, in situations in which a provider has specific concerns about an individual patient, biologic testing may be a better choice (eg, an obtunded patient), although this should be undertaken, as discussed later, only with the patient’s consent with the goal of providing comprehensive care. The American College of Obstetricians and Gynecologists (ACOG) advocates the administration of a brief substance use screening questionnaire to all pregnant women that would trigger a brief behavioral intervention and referral, if warranted.10American College of Obstetricians and GynecologistsAt-risk drinking and illicit drug use: ethical issues in obstetric and gynecologic practice. Committee Opinion No. 422.Obstet Gynecol. 2008; 112: 1449-1460Crossref PubMed Scopus (0) Google Scholar, 11American College of Obstetricians and GynecologistsOpioid use and opioid use disorder in pregnancy. Committee Opinion No. 711.Obstet Gynecol. 2017; 130: 488-489Crossref PubMed Scopus (3) Google Scholar Among the advantages of such brief self-reports are that they can provide longitudinal information about the use of a variety of substances over time and provide a broader window of detection than biologic tests, for which detection may be limited by the half-life of substance metabolites in tested tissue. Given the short window of detection for some substances (eg, cocaine or alcohol), self-report can identify active use among persons whose toxicology test results are negative. However, there are several limitations with questionnaire-based screening. Health-care professionals may be hesitant to inquire about substance use or misuse because of perceptions that patients will be “insulted” if asked about substance use; clinicians may also have limited time to screen, advise, and refer patients.12Goodman D.J. Wolff K.B. Screening for substance abuse in women’s health: a public health imperative.J Midwifery Womens Health. 2013; 58: 278-287Crossref PubMed Scopus (0) Google Scholar Additionally, underreporting of substance use by patients is common,13Magura S. Kang S.-Y. Validity of self-reported drug use in high risk populations: a meta-analytical review.Subst Use Misuse. 1996; 31: 1131-1153Crossref PubMed Google Scholar particularly during pregnancy.14Strano-Rossi S. Methods used to detect drug abuse in pregnancy: a brief review.Drug Alcohol Depend. 1999; 53: 257-271Crossref PubMed Scopus (0) Google Scholar, 15Beatty J.R. Chase S.K. Ondersma S.J. A randomized study of the effect of anonymity, quasi-anonymity, and certificates of confidentiality on postpartum women’s disclosure of sensitive information.Drug Alcohol Depend. 2014; 134: 280-284Crossref PubMed Scopus (0) Google Scholar, 16Markovic N. Ness R.B. Cefilli D. Grisso J.A. Stahmer S. Shaw L.M. Substance use measures among women in early pregnancy.Am J Obstet Gynecol. 2000; 183: 627-632Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 17Grekin E.R. Svikis D.S. Lam P. et al.Drug use during pregnancy: validating the drug abuse screening test against physiological measures.Psychol Addict Behav. 2010; 24: 719-723Crossref PubMed Scopus (36) Google Scholar Indeed, women have many reasons to be reluctant to disclose substance use in pregnancy. They may worry about legal sanctions and child custody issues as well as the stigma of being a mother who uses substances. Such fears can discourage them from seeking prenatal care altogether.12Goodman D.J. Wolff K.B. Screening for substance abuse in women’s health: a public health imperative.J Midwifery Womens Health. 2013; 58: 278-287Crossref PubMed Scopus (0) Google Scholar, 18Zizzo N. Comments and reflections on ethics in screening for biomarkers of prenatal alcohol exposure.Alcohol Clin Exp Res. 2013; 37: 1451-1455Crossref PubMed Scopus (0) Google Scholar, 19American College of Obstetricians and GynecologistsCommittee Opinion No. 473: substance abuse reporting and pregnancy: the role of the obstetrician-gynecologist.Obstet Gynecol. 2011; 117: 200-201Crossref PubMed Scopus (0) Google Scholar An additional issue in considering screening instruments for substance use disorders is that the validity, reliability, and clinical utility of standardized questionnaires that are used in screening for illicit drug use have received only limited evaluation in pregnancy.20US Preventative Services Task Force. Screening for illicit drug use: US Preventive Services Task Force Final Recommendation Statement. Available at: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/drug-use-illicit-screening. Accessed April 23, 2019.Google Scholar Many tools that are used outside of pregnancy attempt to identify individuals with a substance use disorder. However, substances that are used in pregnancy may be prescribed or recommended for recognized and appropriate medical indications; thus, their use does not qualify as disordered.21Substance Abuse and Mental Health Service AdministrationNational survey on drug use and health. results from the 2013 national survey on drug use and health: detailed tables. Substance Abuse and Mental Health Services Administration, Rockville (MD)2014Google Scholar Furthermore, screening may not indicate active use because many women attempt to temporarily limit or curtail their use during pregnancy.22Substance Abuse and Mental Health Service AdministrationNational survey on drug use and health report: substance use among women during pregnancy and following childbirth. Substance Abuse and Mental Health Services Administration, Rockville (MD)2009Google Scholar Accordingly, indicators of actual use are more appropriate as a screen for substance use in pregnancy, although past use is a risk for current use. Although screening measures for alcohol use or abuse in pregnancy have received the greatest attention, screeners for illicit drug use or prescription drug misuse or for broad measures of substance use are far less developed. At least 6 measures have been assessed for overall screening of substance use in pregnancy, and further evaluation of their utility in the identification of the use of opioids in pregnancy is ongoing. An explanation of these 6 measures is provided below. The Drug Abuse Screening Test (DAST-10) is a 10-item general substance use screening questionnaire.23Bohn M. Babr T. Krensler H. Validity of the drug abuse screening test (DAST-10) in inpatient substance abusers: problems of drug dependence. Department of Health and Human Services, Rockville (MD)1991Google Scholar It has been evaluated by comparing its results with results of biologic testing of urine and hair samples that were obtained from a sample of 300 low-income, postpartum women.17Grekin E.R. Svikis D.S. Lam P. et al.Drug use during pregnancy: validating the drug abuse screening test against physiological measures.Psychol Addict Behav. 2010; 24: 719-723Crossref PubMed Scopus (36) Google Scholar Twenty-four percent of the sample scored positive on the DAST but had negative toxicology results, whereas 19% of the sample had positive toxicology results but denied drug use on the DAST. Measures of merit of the DAST-10 (with the cutoff score of 1) for any drug use showed a sensitivity of 47%, specificity of 82%, positive predictive value of 43%, and negative predictive value of 84%.17Grekin E.R. Svikis D.S. Lam P. et al.Drug use during pregnancy: validating the drug abuse screening test against physiological measures.Psychol Addict Behav. 2010; 24: 719-723Crossref PubMed Scopus (36) Google Scholar Given these metrics, the clinical utility of the DAST-10 as a screening instrument is not strong, although it may be suited for the detection of substance use disorders rather than use in pregnancy. An additional limitation is that, with 10 questions, many may find it too lengthy. The 4Ps screen was first developed by Hope Ewing in 1990.24Ewing H. A practical guide to intervention in health and social services with pregnant and postpartum addicts and alcoholics: theoretical framework, brief screening tool, key interview questions, and strategies for referral to recovery resources. The Born Free Project, Contra Costa County Department of Health Services, Martinez (CA)1990Google Scholar Since then, the measure has evolved along 2 paths. The first path is the 4Ps Plus (NTI Publishing), which includes 5 questions, is copyrighted, and only available for a fee. The utility of this screening tool was reported in a study of 228 pregnant women.25Chasnoff I.J. Wells A.M. McGourty R.F. Bailey L.K. Validation of the 4P’s plus screen for substance use in pregnancy validation of the 4P’s plus.J Perinatol. 2007; 27: 744-748Crossref PubMed Scopus (0) Google Scholar Compared with results from a clinical interview, the 4Ps Plus correctly identified the status of participants as using or not using substances 78% of the time. The sensitivity was 87%; specificity was 76%; positive predictive value was 36%, and negative predictive value was 97%.25Chasnoff I.J. Wells A.M. McGourty R.F. Bailey L.K. Validation of the 4P’s plus screen for substance use in pregnancy validation of the 4P’s plus.J Perinatol. 2007; 27: 744-748Crossref PubMed Scopus (0) Google Scholar The instrument has not been validated against biologic measures. The second path for development of this screener has been the 5Ps Prenatal Substance Abuse Screen for Alcohol and Drugs, as adapted by the Massachusetts Institute for Health and Recovery,26Watson E. The 5 Ps. Cambridge (MA): Institute for Health and Recovery; 1999.Google Scholar and is available for use without a fee. The wording of questions is slightly different from the 4Ps Plus, but it conveys similar content. Although at present in wide use in Massachusetts, California, Maine, Virginia, and South Carolina, the 5Ps has not been subject to rigorous, systematic study (eg, comparison with a criterion standard, calculation of measures of merit). The 4Ps Plus screening questions are as follows: (1) Parents: Did either of your parents have a problem with alcohol or drug use?(2) Peers: Do you any of your friends have a problem with alcohol or other drug use?(3) Partner: Does your partner have a problem with alcohol or drugs?(4) Past: Have you ever drunk alcohol?(5) Pregnancy: In the month before you knew you were pregnant: How many cigarettes did you smoke? How much wine/beer/liquor did you drink? How much marijuana did you smoke? How much medication for pain, anxiety, or depression, such as Vicodin, Valium, or Oxycontin, did you take? (© NTI Upstream, 2008. Reprinted with permission of the publisher. May not be copied or reproduced without express written consent of NTI Upstream. www.ntiupstream.com.) The Substance Use Risk Profile-Pregnancy includes 3 questions: (1) Have you ever smoked marijuana? (2) In the month before you knew you were pregnant, how many beers, how much wine, or how much liquor did you drink? (3) Have you ever believed that you needed to cut down on your drug (including the nonmedical use of prescription medications) or alcohol use? Individuals are classified into low (score=0), moderate (score=1), or high risk (score=2).27Yonkers K.A. Gotman N. Kershaw T. Forray A. Howell H.B. Rounsaville B.J. Screening for prenatal substance use: development of the substance use risk profile-pregnancy scale.Obstet Gynecol. 2010; 116: 827-833Crossref PubMed Scopus (0) Google Scholar More than 1 alcoholic drink equals 1 point, as does any “yes” answer. The 3-question Substance Use Risk Profile-Pregnancy was developed in a training sample of 1610 pregnant women and cross-validated in a separate validation sample of 1704 pregnant women. In this evaluation, it identified alcohol use with a sensitivity of 48% and specificity of 85% and identified marijuana use with a sensitivity of 68% and specificity of 86%.27Yonkers K.A. Gotman N. Kershaw T. Forray A. Howell H.B. Rounsaville B.J. Screening for prenatal substance use: development of the substance use risk profile-pregnancy scale.Obstet Gynecol. 2010; 116: 827-833Crossref PubMed Scopus (0) Google Scholar The CRAFFT Screening Tool for Adolescent Substance Abuse was designed for screening in adolescents.28Knight J.R. Sherritt L. Shrier L.A. Harris S.K. Chang G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients.Arch Pediatr Adolesc Med. 2002; 156: 607-614Crossref PubMed Google Scholar It includes 6 “yes/no” questions, with each “yes” scoring 1 point. A score of ≥2 is generally considered to be a positive screening test result. The CRAFFT questions are as follows:C—Have you ever ridden in a car driven by someone (including yourself) who was “high” or had been using drugs or alcohol?R—Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?A—Do you ever use alcohol or drugs while you are by yourself, alone?F—Do you ever forget things that you did while using alcohol or drugs?F—Does your family or friends ever tell you that you should cut down on your drinking or drug use?T—Have you ever gotten into trouble while you were using alcohol or drugs? Although developed for screening of adolescents, the CRAFFT has been preliminarily tested in in small pilot study of young pregnant women as well (n=30).29Chang G. Orav E.J. Jones J.A. Buynitsky T. Gonzalez S. Wilkins-Haug L. Self-reported alcohol and drug use in pregnant young women: a pilot study of associated factors and identification.J Addict Med. 2011; 5: 221-226Crossref PubMed Scopus (0) Google Scholar With the use of calendar-based recall as the standard, CRAFFT had a positive predictive value of 90% and a negative predictive value of 80%. Compared with a standard elicited from a diagnostic interview, the positive predictive value was 58% and the negative predictive value was 83%.29Chang G. Orav E.J. Jones J.A. Buynitsky T. Gonzalez S. Wilkins-Haug L. Self-reported alcohol and drug use in pregnant young women: a pilot study of associated factors and identification.J Addict Med. 2011; 5: 221-226Crossref PubMed Scopus (0) Google Scholar The Wayne Indirect Drug Use Screener includes 6 “true/false” items and was developed specifically for use in perinatal populations30Ondersma S.J. Svikis D.S. LeBreton J.M. et al.Development and preliminary validation of an indirect screener for drug use in the perinatal period.Addiction. 2012; 107: 2099-2106Crossref PubMed Scopus (9) Google Scholar: (1) I am currently married.(2) In the past year, I have been bothered by pain in my teeth or mouth.(3) I have smoked at least 100 cigarettes in my entire life.(4) Most of my friends smoke cigarettes.(5) There have been times in my life, for at least 2 weeks straight, where I felt like everything was an effort.(6) I get mad easily and feel a need to blow off some steam. In a validation study, the sensitivity of the Wayne Indirect Drug Use Screener was 76%, and specificity was 68%. In this study, the instrument was found to outperform the DAST-10, and scores showed a strong linear association with toxicology results.30Ondersma S.J. Svikis D.S. LeBreton J.M. et al.Development and preliminary validation of an indirect screener for drug use in the perinatal period.Addiction. 2012; 107: 2099-2106Crossref PubMed Scopus (9) Google Scholar The NIDA Quick Screen31National Institute on Drug AbuseNIDA Quick Screen.2012Google Scholar has been recommended by NIDA for use in primary care settings and only recently has been evaluated in pregnant women.32Coleman-Cowger V.H. Oga E.A. Peters E.N. Trocin K.E. Koszowski B. Mark K. Accuracy of three screening tools for prenatal substance use.Obstet Gynecol. 2019; 133: 952-961Crossref PubMed Scopus (6) Google Scholar It is a simple instrument that includes 4 questions that ask directly about the frequency of substance use, with response options being “never,” “once or twice,” “monthly,” “weekly,” “daily,” or “almost daily”: In the past year, how often have you:(1) had ≥4 drinks a day?(2) used tobacco products?(3) used prescription drugs for nonmedical reasons?(4) used illegal drugs? Although the component questions of the NIDA Quick Screen have been validated separately for the identification of the use of individual substances, the package of 4 questions has not yet been examined as a whole for pregnancy screening.33Smith P.C. Schmidt S.M. Allensworth-Davies D. Saitz R. A single-question screening test for drug use in primary care.Arch Intern Med. 2010; 170: 1155-1160Crossref PubMed Scopus (0) Google Scholar, 34Smith P.C. Schmidt S.M. Allensworth-Davies D. Saitz R. Primary care validation of a single-question alcohol screening test.J Gen Intern Med. 2009; 24: 783-788Crossref PubMed Scopus (219) Google Scholar, 35Saitz R. Cheng D.M. Allensworth-Davies D. Winter M.R. Smith P.C. The ability of single screening questions for unhealthy alcohol and other drug use to identify substance dependence in primary care.J Stud Alcohol Drugs. 2014; 75: 153-157Crossref PubMed Google Scholar Many questions remain for future research and evaluation of screening tools for substance use disorders in pregnancy, including which screening instrument is most effective and whether implementation of universal screening will improve outcomes. Until further study indicates that 1 of these 6 tests or another screening test for substance use disorder is clearly superior to the others, the public availability and ease of use of the NIDA Quick Screen, 4Ps, and CRAFFT argue for their preference. In the meantime, integration of substance use screening in prenatal care is a logical first step toward the identification of substance use and reduction of harmful effects for mothers and babies. When a pregnant woman is identified by screening to be at high risk for a substance use disorder, follow-up evaluation is required. Follow-up starts with a conversation that reviews the results of the screening tool, risk factors, and history of substance use and asks the patient about active use of individual substances and the frequency of their