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. Author manuscript; available in PMC: 2026 May 1.
Published in final edited form as: Psychol Addict Behav. 2024 Jul 18;39(3):301–310. doi: 10.1037/adb0001017

Prenatal Substance Use and Mental Health Comorbidities Predict Continued Use

Eric Kruger 1, Andrea Rodriguez 2, Lawrence Leeman 3, Pilar M Sanjuan 3
PMCID: PMC11747925  NIHMSID: NIHMS2023537  PMID: 39023997

Abstract

Objective.

Prenatal substance use is common and can affect maternal and infant health. Additionally, prenatal substance use is associated with mental health comorbidities (depression, anxiety and PTSD). Unremitting prenatal substance use disorders and mental health comorbidities are associated with poor health outcomes for mothers and exposed infants. The purpose of this study was to examine how any substance use, type of substance use (polysubstance use vs. single substance use) and combinations of mental health comorbidities predict continued use during pregnancy (i.e., use in the 30 days prior to delivery).

Method.

Health records of patients enrolled in a comprehensive prenatal program for women with substance use disorders were retrospectively analyzed (N=281). Urine drug screen records were used to determine substance use, and diagnostic codes were used to identify mental health comorbidities.

Results.

37% of the sample (n=105/281) tested positive for substances at admission and 42% (n=119/281) demonstrated continued use. 30% of the sample (n=85/281) had depression, anxiety, and PTSD, 27% (n=76/281) had two of the three mental health comorbidities, 26% (n=73/281) had one of the three comorbidities, and 17% (n=47/281) did not have a mental health comorbidity. Any substance use at admission or having all three mental health conditions were associated with continued use.

Conclusions.

Substance use at admission and number of mental health conditions were independent predictors of continued use, although substance use was the stronger predictor.

Introduction

Substance use disorder (SUD) during pregnancy is common. From 2014 to 2019 among pregnant women in the United States (U.S.), 5.8% reported illicit drug use and 9.5% reported alcohol use in the past month (Substance Abuse and Mental Health Services Administration, 2020). Pregnant women with SUD commonly lack access to treatment and recovery resources and are socially vulnerable and stigmatized (Kahila et al., 2010; King et al., 2015). These women disproportionately suffer from high rates of posttraumatic stress (PTSD), anxiety, and major depressive (MDD) disorders (Erickson & Tonigan, 2008; Le Strat et al., 2011; Moylan et al., 2001; Sanjuan et al., 2019, 2020). Postpartum maternal mental illness, independent of substance use, is associated with mental health diagnoses in partners (Hoffman et al., 2017), strains on the mother-fetus relationship during the perinatal period (Delavari et al., 2018; López Seco, 2016; Wan & Green, 2009), and difficulty with long-term parental functioning and mental health (López Seco, 2016; M. Park et al., 2018; Stein et al., 2014; Wan & Green, 2009).

Many pregnant women in SUD treatment are able to reduce or completely abstain from substance use following pregnancy recognition as they are motivated to protect fetuses from harm (Forray et al., 2015). However, women with deliveries complicated by alcohol and/or drugs are 38 times more likely than other women to die within nine years of giving birth (Kahila et al., 2010). In addition to risk of maternal harm, unremitted substance use during pregnancy presents risk to fetuses (Tuten et al., 2009; Wendell, 2013). The sequelae of prenatal alcohol use are particularly well documented (Huizink, 2015), while there are established treatments that reduce the fetal risks of prenatal opioid use disorder (OUD; i.e., methadone, buprenorphine). Prenatal benzodiazepine exposure in the third trimester is associated with neonatal abstinence syndrome (NAS), while prenatal methamphetamine exposure is associated with multiple poor obstetric outcomes including preeclampsia, fetal growth restriction, intrauterine fetal death, placental abruption, preterm birth, neonatal death, and infant death (Bellantuono et al., 2019; Cox et al., 2008; Gorman et al., 2014; Oei et al., 2012; Shyken et al., 2019; Wright et al., 2015).

The current opioid epidemic has now become a national crisis, and the associated increased rates of opioid use disorder (OUD) in pregnancy have resulted in rising rates of neonatal opioid withdrawal syndrome (NOWS) and have spurred substantial research on OUD and NOWS (Patrick et al., 2015, 2020; Tolia et al., 2015). Opioids are often used in conjunction with other psychoactive substances, particularly benzodiazepines, methamphetamine, and alcohol (Davie-Gray et al., 2013; Sanjuan et al., 2019). Polysubstance use is routinely observed among patients receiving prenatal medical and substance use treatment (Davie-Gray et al., 2013; Delano et al., 2013; Sanjuan et al., 2019) and carries unique risks, including increased risk of overdose for some substance combinations (e.g., benzodiazepines & opioids, benzodiazepines & alcohol, opioids & alcohol) (Gladden et al., 2019).

Mental health diagnoses and SUD often co-occur, as mental health diagnoses are often associated with substance use, and populations with high prevalence of mental health disorders also have high incidence of substance use and SUD diagnoses (Lin et al., 2021). Greater psychiatric severity and emergency department admissions are associated with worse SUD treatment outcomes (Manhapra et al., 2018). In pregnancy, substance use is associated with a greater likelihood of experiencing or developing perinatal depression and/or anxiety disorders (Pentecost et al., 2021). Additionally, perinatal depression and anxiety are associated with polysubstance use during the perinatal period (V. E. Metz et al., 2018; Pentecost et al., 2021).

On its own, mental health care during pregnancy presents a unique challenge to providers, and prenatal treatment plans are less likely to follow guidelines set for standard populations (Eakley & Lyndon, 2022). The more complex the mental health disorders and substance use are, the less likely an individual is to receive treatment for each of their diagnoses, regardless of pregnancy status (Eakley & Lyndon, 2022; Lin et al., 2021). This likelihood of treatment may be dependent upon the complexity of comorbid diagnoses (Lin et al., 2021) and patients’ accessibility to specialized treatment options (V. E. Metz et al., 2018). Women reporting anxiety symptoms at the start of treatment show higher rates of premature treatment discontinuation compared to women with depression only symptoms (Benningfield et al., 2012).

Medication for opioid use disorder (MOUD) is the standard of care for prenatal OUD (The American College of Obstetricians and Gynecologists, 2017). Patients with polysubstance use are less likely to receive MOUD treatment than patients with just OUD (Saloner & Karthikeyan, 2015; Smart et al., 2023). This may be due to the widespread but unsubstantiated belief that MOUD is not effective in people with polysubstance use (Lin et al., 2021; Morgan et al., 2018; Valente et al., 2020). There is conflicting data about the association between polysubstance use and MOUD treatment outcomes. The use of buprenorphine for people with OUD and methamphetamine use had decreased efficacy compared to its use for people with OUD but no methamphetamine use (Kratina-Hathaway et al., 2023), On the other hand, patients with polysubstance use do not differ from patients with only OUD in buprenorphine treatment retention (Cunningham et al., 2013). Additionally, polysubstance use was not associated with opioid relapse, or craving in other research (Bunting et al., 2022). Yet, a meta-analysis of opioid treatment program research found that overall, people with polysubstance use showed worse treatment outcomes (e.g., opioid abstinence and treatment retention) compared to people who exclusively used opioids (Blondino et al., 2020). The conflicting nature of the current body of research suggests more investigation is needed to understand how polysubstance use affects treatment outcomes, especially in special populations such as perinatal patients.

Factors that may be associated with prenatal polysubstance use (e.g., mental health comorbidity) remain understudied in the scientific literature (Y. Park et al., 2023). Moreover, identifying factors related to continued substance use during pregnancy will inform the development of treatment plans better targeting those factors and may improve the physical and mental health outcomes of women and their children. The aim of this study was to determine the association between the continued prenatal use of opioids, methamphetamine, and/or benzodiazepines; maternal mental health comorbidities; and type of substance use (polysubstance use versus single substance use) during pregnancy. We hypothesized that women with greater mental health comorbidities and polysubstance use would be more likely to experience continued use during pregnancy compared to women without a mental health diagnosis or to those without polysubstance use.

Methods

Study Design

This study is a retrospective cohort design using medical records of pregnant women with SUDs. Data were extracted from the electronic health record via the Clinical Data Warehouse at the University of New Mexico Health Sciences Center (UNM HSC) for encounters between July 1st, 2019, and June 31st, 2022. Institutional review board approval was obtained prior to the extraction of data. Patients were identified based on their participation during pregnancy in the Milagro Program and delivery of a live infant. The Milagro Program is an integrated maternity care and SUD treatment program, which provides outpatient and hospital care through a multidisciplinary team of primary care physicians, nurse midwives, psychiatrists, and counselors. Mental health trauma-informed counseling is optional, and patients may also receive counseling outside of the program. Patients with OUD are offered MOUD and a mental health counselor is available to all patients, but many patients do not engage in routine counseling at the clinic. Records of those who experienced fetal demise, had an early termination, or who did not deliver at UNM Hospital were excluded from the dataset.

Analytical Strategy

Of the 441 initially identified women, 31 had more than one pregnancy. If the mother had more than one pregnancy during the search window, only the first pregnancy was analyzed, resulting in 410 women who satisfied inclusion criteria. A 60-day “admission window” (defined as ± 30 days from first Milagro appointment) was used to capture substance use at admission to the outpatient Milagro Program and a 30-day window prior to delivery date was used to determine continued use during pregnancy (i.e., use during the period approaching delivery). Therefore, women must have received care for a minimum time of 60 days prior to delivery to determine use at admission and later continued use. Applying this criterion, further reduced the sample to 286 women. We excluded women who had not been administered any drug screens, resulting in a final sample of 281.

Mental health categories (MHC) were identified by ICD-10 codes. Because multiple ICD-10 codes could be used for an MHC, the following MHCs were created: depression, anxiety, and PTSD based on aggregation of multiple ICD-10 codes in those categories. See Table 1 for a description of each ICD-10 code analyzed and linked to the MHCs.

Table 1.

Diagnoses by ICD-10 codes and Aggregate Mental Health Comorbidity Category

ICD-10 code Description Mental Health Comorbidity Category N (%)
F32 Depressive episode Depression 177 (62.99%)
F33 Recurrent depressive disorder Depression 34 (12.10%)
F34 Persistent mood (affective) disorders Depression 9 (3.20%)
F38 Other mood (affective) disorders Depression 0 (0%)
F39 Unspecified mood (affective) disorder Depression 14 (4.98%)
F40 Phobic anxiety disorders Anxiety 4 (1.42%)
F41.0 Panic disorder Anxiety 0 (0.00%)
F41.1 Generalized anxiety disorder Anxiety 60 (21.35%)
F41.2 Mixed anxiety and depressive disorder Anxiety 0 (0.00%)
F41.3 Other mixed anxiety disorders Anxiety 1 (0.36%)
F41.8 Other specified anxiety disorders Anxiety 52 (18.51%)
F41.9 Anxiety disorder unspecified Anxiety 209 (74.38%)
F42 OCD Anxiety 7 (2.49%)
F43.1 PTSD PTSD 134 (47.69%)
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Only urine drug screens were analyzed, and a drug screen was considered positive if the mother tested positive for opioids/opiates, barbiturates, amphetamines, cocaine, benzodiazepines, or MDMA. Positive drug screens for medications used for MOUD treatment, e.g., methadone and buprenorphine, were not considered positive for “opioids/opiates”. Confirmatory drug tests are not commonly performed at the clinic and our data included quick tests in the clinic as well as tests performed by a laboratory. Positive marijuana/THC and alcohol urine screens were not included in the analysis because of the long durations of positivity for THC urine tests and short durations of positivity for alcohol urine tests (Hadland & Levy, 2016; National Center on Substance Abuse and Child Welfare, 2011). “Substance use category” was defined as polysubstance use versus single substance use. Polysubstance use at admission was defined as testing positive for more than one substance during the admission window. “Continued use” was defined as testing positive for any substance after the admission window during pregnancy up to the delivery date.

Analyses were conducted using R version 4.3 (R Core Team, 2023). Descriptive statistics were used to characterize and compare women with and without continued use throughout their pregnancy. First, unadjusted associations between characteristics and continued use were examined using Fishers exact test, chi-square analyses, and t-tests. Secondly, adjusted risk ratios (RR) were calculated via multivariate modified Poisson regression with log link function and a sandwich estimator were used to estimate the association of MHCs, substance use category, and continued use, while also including age, race, and ethnicity as covariates (Zou, 2004). The predictors of continued use were added in a stepwise manner. In step one, demographic covariates were added (race, ethnicity and age). In step 2, MHCs were added, then in step 3, substance use categories were added. The relative change in pseudo R2 was evaluated to determine which step resulted in the greatest increase R2 (Nagelkerke, 1991). Based on the patterns of MHCs, we decided to only examine the aggregate total of MHCs (i.e., 0, 1, 2 or 3 MHCs) as opposed to examining MHCs separately; see Table 2 for patterns of MHCs.

Table 2.

Characteristics of Patients by Continued Use

Entire Sample Continued Use No Continued Use p-value
N = 281 N = 119 N = 162
Age 28.86 (4.74) 28.83 (4.74) 28.88 (4.98) 0.921a
Race
AI/AN 19 (6.76%) 8 (6.72%) 11 (6.79%) 1x
Black 12 (4.27%) 5 (4.20%) 7 (4.32%) 1x
White 240 (85.41%) 101 (84.87%) 139 (85.80%) 0.96x
Unavailable 10 (3.56%) 5 (4.20%) 5 (3.09%) 1x
Ethnicity
Hispanic/Latinx 198 (70.46%) 89 (74.79%) 109 (67.28%) 0.219x
Non-Hispanic/Latinx 77 (27.40%) 28 (23.53%) 49 (30.25%) 0.266x
Unavailable 6 (2.14%) 2 (1.68%) 4 (2.47%) 1f
Gestational Age of First Apt. (weeks) 14.12 (7.49) 13.39 (6.47) 14.66 (8.13) 0.159a
Birth Age (weeks) 37.86 (2.34) 37.83 (2.26) 37.88 (2.41) 0.859a
Mental Health Comorbidities
Depression Only 11 (3.91%) 5 (4.20%) 6 (3.70%) 1f
PTSD Only 10 (3.56%) 2 (1.68%) 8 (4.94%) 0.199f
Anxiety Only 52 (18.51%) 20 (16.81%) 32 (19.75%) 0.636x
Depression & Anxiety 51 (18.15%) 25 (21.01%) 26 (16.05%) 0.363x
Depression & PTSD 6 (2.14%) 1 (0.84%) 5 (3.09%) 0.407f
PTSD & Anxiety 19 (6.76%) 6 (5.04%) 13 (8.02%) 0.457x
Depression & Anxiety & PTSD 85 (30.25%) 45 (37.82%) 40 (24.69%) 0.025x
0 MHC 47 (16.73%) 15 (12.61%) 32 (18.75%) 0.154x
1 MHC 73 (25.98%) 27 (22.69%) 46 (28.40%) 0.347x
2 MHC 76 (27.05%) 32 (26.89%) 44 (27.16%) 1x
3 MHC 85 (30.25%) 45 (37.82%) 40 (24.69%) 0.025x
Substance Use*
Amphetamines** 71 (25.27%) 62 (52.10%) 9 (5.56%) <0.001x
Barbiturates 6 (2.14%) 5 (4.20%) 1 (0.62%) 0.086f
Benzodiazepine 16 (5.69%) 13 (10.92%) 3 (1.85%) 0.001f
Cocaine 18 (6.41) 17 (14.29%) 1 (0.62%) <0.001f
MDMA 10 (3.56%) 10 (8.40%) 0 (0%) <0.001f
Opioids 116 (41.28%) 94 (78.99%) 22 (13.58%) <0.001x
Opioids Only 53 (18.86%) 38 (31.93%) 15 (9.26%) <0.001x
No Substance Use at Admission 176 (62.63%) 43 (36.13%) 133 (82.10%) <0.001x
Single Substance Use at Admission 69 (24.55%) 47 (39.50%) 22 (13.58%) <0.001x
Poly Substance Use at Admission 36 (12.81%) 29 (24.37%) 7 (4.32%) <0.001x
Poly Substance Use after Admission 48 (17.08%) 48 (40.34%) 0 (0%) -------
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Note.

*

Substance use for specific substances is reported for use at any point during the mother’s pregnancy.

**

Including methamphetamine use. The following superscripts next to the p-value indicate the type of test performed

a

= one-way ANOVA

f

= Fischer exact test

x

= chi-squared test

Transparency and Openness

This study was exploratory in nature and therefore power was not calculated prior to analysis. Post hoc analysis of power of the largest effect achieved a power of 1.0 (polysubstance use at clinic admission vs no substance use) and 0.94 for the smallest effect (3 vs 1 MHCs at clinic admission). All data exclusions and measures are reported in our results, and we followed JARS guidelines (Kazak, 2018). Data utilized in this study was extracted from electronic health records and is not available to the public. This data has not been reported or published elsewhere. This study was not preregistered.

Results

Characteristics of Women

Frequency and proportion of sample ICD-10 codes, their description, and MHC are displayed in Table 1. Anxiety disorder unspecified (F41.9, 74.38%), depressive episode (F32, 62.99%), and PTSD (F43.1, 47.69%) were the three most prevalent ICD-10 codes. Table 2 shows the clinical and demographic characteristics of the total sample. The table describes the characteristics of women who experienced continued use and those who did not experience continued use throughout their pregnancy. The total sample included 281 unique pregnancies. The sample was primarily White (N = 240, 85.4%) and Hispanic (N = 198, 70.4%). The mean age of the sample was 28.8 years (SD = 4.74). The average entrance into the maternity and SUD care program was at 14.1 gestational weeks (SD = 7.49) and mean gestational age at birth was 37.86 weeks (SD = 2.34). Table 2 also displays the patterns of MHCs, substance use categories, and the unadjusted associations between MHCs and substance use categories and continued use during pregnancy. Anxiety was most prevalent within the sample (N = 207, 73.66%) followed by depression only (N = 153, 54.44%), and PTSD (N = 120, 42.70%). The sample showed considerable rates of comorbid depression, anxiety, and PTSD, 57% of the sample demonstrating two or more MHCs, and having all three MHCs was associated with continued use (p = 0.025). The most frequently used substances were opioids (N = 116, 41.28%) and amphetamines (N = 71, 25.27%). With the exception of barbiturates, all positive tests had a greater proportion in the continued use group (p ≤ 0.001). A greater proportion of those who experienced continued use also tested positive for substances in addition to opioids (60%), compared to those who did not experience continued use (32%).

Substance Use Patterns

The pattern of substance use by urine drug screen positivity at any point during pregnancy is displayed in Table 3. The most prevalent pattern in women was use of opioids exclusively (36%; N = 53), followed by amphetamines in combination with opioids (26%; n = 38) and amphetamines exclusively (7%; n = 11). The remaining types of substance use patterns were observed in 31% (n = 102) of women with positive drug tests during pregnancy.

Table 3.

Substance Use Patterns as Measured by Urine Drug Test

Substance Use Combination N % Total
Opioids 53 35.81
Amphetamines, Opioids 38 25.68
Amphetamines 11 7.43
Cocaine 6 4.05
Cocaine, Opioids 6 4.05
Benzodiazepines 6 4.05
Amphetamines, MDMA, Opioids 6 4.05
Amphetamines, Benzodiazepines, Opioids 5 3.38
Barbiturates 4 2.70
Amphetamines, Cocaine, Opioids 4 2.70
Amphetamines, Benzodiazepines 2 1.35
Benzodiazepines, Opioids 1 0.68
Barbiturates, MDMA 1 0.68
Amphetamines, MDMA 1 0.68
Amphetamines, Cocaine, MDMA, Opioids 1 0.68
Amphetamines, Benzodiazepines, MDMA, Opioids 1 0.68
Amphetamines, Benzodiazepines, Cocaine, Opioids 1 0.68
Amphetamines, Barbiturates 1 0.68
Total 148 100.00
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Note. Use for each substance class was considered as positive if a mother tested positive on urinalysis for that substance at any point during her pregnancy. Patients were counted as positive only once per substance class regardless of how many individual positive urine tests they had for that substance type during pregnancy.

Predictors of Continued Use

The model for continued use that included just demographics had an R2 of 0.01, adding MHCs to the model increased the R2 to 0.04, and, finally, adding types of substance use increased the R2 to 0.26. Therefore, the greatest change in R2 (ΔR2 = 0.22) for continued use was due to adding type of substance use as predictors. The appendix containing Supplementary Table 1 displays regression coefficients and complete model fit statistics for all models. The final model, which includes all predictors, was used in reporting the adjusted risk ratio of continued use.

The probability of continued use by number of MHCs is displayed in Table 4. Having all three MHC types significantly increased the likelihood of continued use compared to having zero, one, or two MHCs (RR = 1.92, p < 0.001; RR = 1.45, p = 0.04; RR = 1.53, p = 0.002, respectively). No other comparisons resulted in significant differences.

Table 4.

Probability of Continued Use by Number of MHCs

95% CI Vs. 0 MHC Vs. 1 MHC Vs. 2 MHC
# MHC Probability SE Lower Upper RR SE p RR SE p RR SE p
3 0.66 0.13 0.45 0.97 1.92 0.47 <0.001 1.45 0.26 0.04 1.53 0.21 <0.01
2 0.43 0.09 0.29 0.65 1.25 0.32 0.37 0.94 0.17 0.75
1 0.46 0.11 0.29 0.72 1.33 0.37 0.30
0 0.34 0.09 0.20 0.58
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Note. RR = relative risk, SE = standard error, CI = confidence interval, and MHC = mental health category.

The probabilities of continued use during pregnancy by type of substance use at clinic admission are reported in Table 5. Polysubstance use at admission was associated with an increased probability of continued use during pregnancy compared to no use at clinic admission, 72% vs 21% for No Use (RR = 3.40; p < 0.0001). However, when compared to exclusive single substance use, polysubstance use was not associated with a significantly increased probability of continued use during pregnancy, 72% polysubstance vs 64% single use (RR = 1.14; p = 0.27). Exclusive single substance use compared to no use was also associated with an increased probability of continued use, 64% vs. 21%, respectively (RR = 2.99; p<0.0001).

Table 5.

Probability of Continued Use by Substance Use Category

95% CI Vs. No Use Vs. Single Use
Substance Use Probability SE Lower Upper RR SE p RR SE P
Poly Use 0.72 0.14 0.49 1.00 3.40 0.53 <0.0001 1.14 0.13 0.27
Single Use 0.64 0.12 0.44 0.93 2.99 0.46 <0.0001
No Use 0.21 0.05 0.14 0.33
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Note. RR = relative risk, SE = standard error, CI = confidence interval, Poly Use = polysubstance use, Single = single substance use, and No Use = no substance use.

Discussion

The present work evaluated associations between continued use of substances during pregnancy, mental health, and type of substance use. Through a careful examination of electronic medical record data for P281 unique pregnancies, mental health diagnoses were found to be highly prevalent within the study sample. Moreover, multiple diagnoses across mental health diagnostic categories were associated with higher rates of continued use during pregnancy. Being diagnosed with all three MHCs was associated with a greater likelihood of continued use during pregnancy versus being diagnosed with fewer MHCs. Positive urine drug screens at clinic admission were associated with a higher likelihood of substance use during the remainder of pregnancies compared to either negative urine tests at admission.

The reasons for continuation of substance use during pregnancy are multifactorial and may occur due to the role of stressors, avoidance of negative emotions, lack of self-efficacy, and a limited understanding of the harms caused by substances (Latuskie et al., 2019). Moreover, the intersection of race, class, gender, mental health/substance use stigma, and other social environmental factors work together to increase risk for those patients with more complex mental health presentations (Collins et al., 2019; Seng et al., 2012). For example, the vast majority of patients in the Milagro Program receive Medicaid and many lack access to stable housing and/or reliable and affordable transportation, which are structural issues that can make it difficult to obtain adequate mental health care (for more information on the role of structural factors in pregnancy and maternal health see: Martin et al., 2023; Preis et al., 2020a, 2020b; Simoncic et al., 2022). Consistent with the literature, the more complex mental health presentation associated with having diagnoses across three psychiatric diagnostic categories was a risk factor for continued substance use during pregnancy in this study. Pregnancy is a period during which patients are at higher risk of exacerbation of existing psychiatric disorders as well as the onset of new psychiatric disorders (Fisher et al., 2012; Gavin et al., 2005; Heron et al., 2004; Oates, 2003). These intersectional challenges are exacerbated in the context of substance use disorders (King et al., 2015; Raffi et al., 2021).

We found in our data that having diagnoses across all three mental health diagnostic categories was the only pattern of MHCs associated with increased risk of continued substance use during pregnancy. However, a large portion of the sample did have this pattern of mental health diagnoses across all three categories (30.25%), thus this risk was highly prevalent among patients in the integrated maternity and substance use care program. Our data also showed that PTSD was more likely to occur with depression and anxiety, suggesting that PTSD may potentially play a central role in mental health challenges, including substance use, experienced during pregnancy. This is in alignment with other research supporting that comorbid mental health disorders, such as PTSD, anxiety, or depression, may put pregnant women at a greater risk of continued polysubstance use during pregnancy and also of continued or reinstated postpartum substance use (Chapman & Wu, 2013; Huizink, 2015; Morland et al., 2007; Sanjuan et al., 2019, 2020; Sutter et al., 2017). Clinically, this supports the practice of screening for mental health and SUD problems prenatally (American College of Obstetricians and Gynecologists, 2018, 2021), and providing prenatal mental health treatment, especially for those patients with these more complex mental health presentations.

This study focused on the role of polysubstance use while much of the research on substance use and substance use disorders (SUD) has focused on single psychoactive substances. Forty-six percent of our sample had evidence of polysubstance use. The majority of polysubstance use involved a combination of amphetamines and opioids (55%), but there was also a wide variety of other substance use patterns. Board et al. (Board et al., 2023) similarly found a wide variety of polysubstance use patterns during pregnancy and, similarly to our sample, found a high prevalence of co-use of opioids and amphetamines.

In non-pregnant populations, the trajectories of SUD treatment outcomes have been shown to differ based on the use of use multiple substances compared to those who use only one (Sahker et al., 2016). In our sample, polysubstance use was not uniquely predictive of continued use above that of single use. Both polysubstance use and exclusive substance use were more closely associated with continued substance use during pregnancy than abstinence at clinic admission. This showed that being stable (i.e., abstinence), usually with MOUD, at entry to integrated prenatal/substance use care was protective against substance use later in pregnancy, despite mental health comorbidity and/or pregnancy-related stressors.

Limitations

The study was conducted with data from electronic medical records using ICD-10 codes and the provenance of the diagnoses were not analyzed (e.g., advanced practice provider, physician, or psychologist). Therefore, there may be sources of error between symptom presentations and mental health diagnoses assigned by providers and the healthcare system. Additionally, substance use was only assessed via urine drug screens. Urine drug screens provide an objective measurement of use, but they are also limited because they require in person visits for assessment. In person visits were restricted during this period of this study due to COVID-19 restrictions that were in place starting in March 2020 and continued in some form through much of the study period. Therefore, we cannot rule out that the reporting of substance use may have been impacted by COVID-19 restrictions. Additionally, we can only determine that pregnant women had continued use, but cannot determine relapse. Those who we defined as having continued use but who did not have a positive test at admission, are presumed to have had use at some point prior to admission (possibly years prior) to the Milagro Program because of the nature of the Milagro Program. Another limitation of the EHR data is that we cannot determine details about the receipt of mental health treatment nor whether patients were receiving mental health care outside of the University health system, which is common for patients in this clinic.

Our criterion for identifying substance use at admission to Milagro and delivery resulted in a minimum episode of care prior to delivery of 60 days. Therefore, women that began care less than 60 days prior to delivery were excluded. Importantly, this could include women with more complex presentations than in our sample, such as those with little prenatal care. Future research should explore outcomes in women that have relatively late entry into prenatal care programs such as Milagro.

Polysubstance use was determined through urine screenings, and importantly, may not reflect the daily patterns of use among patients who typically engage in polysubstance use, or the co-use of different psychoactive substances at the same time (e.g., cocaine + heroin = speedball, benzodiazepines to boost heroin effects) or alternating between substances across time either within the same day (e.g., methamphetamine to get high then benzodiazepines to come back down, alcohol to relax then cocaine to stay awake) or across days (e.g., heroin every day and methamphetamine when it’s available) (Gladden et al., 2019; Yamamoto et al., 2019).

The current study did not include THC or alcohol for analysis. THC was not included in this analysis because (1) THC’s long duration within the body especially for heavy/consistent users (Hadland & Levy, 2016; National Center on Substance Abuse and Child Welfare, 2011), (2) there is a growing belief that THC/cannabis may help with nausea during pregnancy, though research is mixed (T. D. Metz et al., 2022; Stith et al., 2022), and (3) with the legalization of marijuana in the United States, usage trends have increased alongside the increasing accessibility of cannabis and cannabis by-products, including amongst pregnant women (Brown et al., 2017). Alcohol was not examined in this study because of its short duration within the body and likelihood that it would not consistently show up in urine screens despite usage (National Center on Substance Abuse and Child Welfare, 2011). Further, the alcohol urine screen is not routinely administered and has less clinical utility (Hadland & Levy, 2016; Van De Luitgaarden et al., 2020).

Finally, this study only examined records from pregnant women who delivered babies at the same hospital system as the integrative clinic at which they were being provided care during the perinatal period. Patients who experienced pregnancy losses or who gave birth elsewhere were not included in the sample. Important relationships between mental health and substance use therefore were not examined in these women.

Conclusions

Pregnant women with diagnoses across all three categories of depression, anxiety and PTSD were more likely to continue to use substances during pregnancy than patients with fewer types of mental health disorders. Both polysubstance and single substance use were associated with continued use. However, contrary to our hypothesis, polysubstance use did not predict continued opioid use over and above that already predicted by single substance use, and this finding warrants continued examination. These findings support early prenatal screening for mental health disorders, including substance use, followed by appropriate referrals to treatment and supportive services, and continued monitoring of patients’ psychological well-being throughout pregnancy. Referrals may include services addressing structural barriers to care, e.g., financial, housing, and transportation assistance.

Supplementary Material

Graphics

Public health significance.

This study supports the public health importance of identifying substance use, and mental health comorbidities, strongly influences the early in pregnancy to prevent continued prenatal substance use. This insight highlights the urgent need for screening and targeted interventions to address both substance use and mental health challenges in pregnant women, to mitigate the risks to maternal and child health.

Funding.

The current study was funded by The University of New Mexico Substance Use Grand Challenge and by a pilot award from the UNM Center for Clinical and Translational Science Center (CTSC) through National Center for Advancing Translational Sciences, National Institutes of Health under grant number UL1TR001449. Dr. Sanjuan was also supported by K23AA025094 from the National Institutes of Health.

Footnotes

Disclosure statement. The authors do not have any conflicts of interest.

Data availability.

Data was obtained from retrospective electronic patient health records and therefore is not publicly available.

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Supplementary Materials

Graphics
NIHMS2023537-supplement-Graphics.docx (17.4KB, docx)

Data Availability Statement

Data was obtained from retrospective electronic patient health records and therefore is not publicly available.

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