Prevalence and Consequences of Perinatal Substance Use—Growing Worldwide Concerns

Perinatal substance use remains a global public health concern. Global epidemiologic surveys indicate that 8% of women smoke cigarettes during pregnancy with higher prevalence rates in the Americas (16%) and Europe (22%).¹ Up to 10% of pregnant women consume alcohol and 3% binge drink during pregnancy.^2–5 In addition, an estimated 2% of pregnant women report illicit opioid use including both prescription opioids and heroin.³ Although many women quit or reduce substance use once pregnancy is diagnosed, a significant number continue to use throughout their pregnancy contributing to several negative outcomes for both mother and baby. Furthermore, these potential outcomes are compounded by inadequate prenatal care and other complex psychosocial factors.

Obstetrical complications include an increased risk of miscarriage, intrauterine growth restriction, premature labor, and even intrauterine fetal demise.⁶ However, the risks of substance use disorders extend beyond pregnancy to the newborn. Alcohol is a known teratogen leading to fetal alcohol spectrum disorder (FASD) which is associated with numerous primary and secondary disabilities.⁶ The growing trend for opioid use disorders is particularly alarming due to the associated neonatal withdrawal syndrome also known as neonatal abstinence syndrome (NAS). Recent estimates identified an increase in the rate of neonatal intensive care unit (NICU) admissions in the United States for NAS from 7 cases to 27 cases per 1000 admissions leading to an increase from 0.6% to 4% of all NICU days being attributed to NAS.⁷ The long-term effects of alcohol and smoking have been well established, whereas long-term implications of in utero opioid exposure remain to be determined. Despite numerous interventions, there exist a significant proportion of substance-exposed pregnancies with possible reversible outcomes.

Current Knowledge and Challenges

We are excited to highlight advances in alcohol, nicotine, and opioid use disorders among perinatal populations from preconception to postpartum. The literature in the field of perinatal addictions consists of lower quality studies with small sample size resulting in multiple gaps in the optimal approach to these disorders. Identification of substance use disorders remains challenging. There is no single screening question or tool to diagnose all perinatal substance use disorders. Therefore, timely identification of exposures in utero can be problematic. Best practices for the management of substance use disorders are also debated especially in terms of effectiveness of psychosocial interventions and safety of pharmacotherapeutic agents. Advances in prevention and management of alcohol, tobacco, and opioid use disorders are critical in reducing negative consequences of in utero exposures.

Advances in Prevention and Management of Perinatal Substance Use Disorders

The articles in this supplement address the most prevalent substances used by pregnant women including alcohol, nicotine, and opioids. One article addresses contraception planning and prevention of unplanned substance-exposed pregnancies. Two articles address prevention of alcohol use disorders through a review of a Canadian 4-part framework for FASD prevention and approaches to becoming FASD-informed in planning community-level and system-level programs. One article is focused on a novel approach to smoking cessation for women of childbearing years. Three articles address the various management controversies of opioid use disorders.

Prevention of Substance-Exposed Pregnancies

The literature review by Black and Day⁸ highlights that unintended pregnancies are high among all women but even more prevalent among women with substance use disorders. Women with risky substance use face numerous barriers to effective contraception including misconceptions and stigma at the personal and system levels. It also emphasizes mechanisms to increase contraception knowledge and uptake through efforts such as incorporating on-site family planning and contraceptive services into addiction clinics especially in opioid substitution treatment programs, and more generally, provision of preconception care. Given the growing number of cases, this review calls for integrated service delivery as an optimal model for meeting the needs of women attending drug treatment programs.

Responding to Fetal Alcohol Spectrum Disorder

Poole and colleagues report on a Canada-wide consultative process to map 4 levels of responses to FASD in Canada, from prevention to treatment.⁹ This paper reflects the varying levels of service and system development across Canada and documents the many initiatives underway. However, it also highlights serious gaps and needs for future development, including the provision of more specialist treatment opportunities for pregnant women and new mothers with addiction issues.

Many individuals with FASD are undiagnosed and face serious challenges when engaging with health, social, or educational programs. Therefore, an FASD-informed approach should take into consideration the permanent neurological disability secondary to FASD by adopting several key principles. Rutman¹⁰ documents the components of an FASD-informed approach at the individual or practitioner level and also recommends its application at a policy or system level. Finally, the development of integrated programs to support women with FASD and their families is suggested.

Advances in Smoking Cessation Interventions for Women

Better practices for smoking cessation among pregnant and postpartum women are in need of new, integrated approaches. Psychosocial interventions have documented benefits when implemented during pregnancy and postpartum; however, the most effective type of counseling for women is yet to be determined.¹¹ A novel behavioral strategy consisting of blogging about smoking cessation efforts was assessed by Minian and colleagues.¹² Blogging by pregnant or postpartum women was found to be an opportunity for self-reflection and distraction from cravings. Blogging also fostered support for smoking cessation. These short-term findings need to be followed to determine the benefits of this type of behavioral intervention over time and its relationship to other components of better practices.

Best Practices for Management of Opioid Use Disorders

The demographics of opioid use disorders have been changing, especially among rural populations. Specifically, increased heroin use has been found in rural areas, as well as a change from oral/intranasal to intravenous use.¹³ A review by Jumah¹³ of the management of opioid use in rural areas demonstrated that rural opioid-dependent pregnant women required lower doses of opioid agonist treatment (OAT). Barriers to care for rural women are unique and related primarily to access and availability of programs in these communities, as well as stigma and gendered responsibilities such as childcare. These findings highlight the desperate need for an appropriate gender-informed response to the growing rural opioid use epidemic among women.

Breastfeeding initiation rates among women on OAT are low due to multiple factors affecting feeding choices.¹⁴ A review of the evidence by Graves and colleagues¹⁵ points toward the safety of breastfeeding and its potential impact on reducing the severity of NAS. Education of both women on OAT and their health care providers is critical to increase breastfeeding rates among this patient population.

With a growing epidemic of NAS, best practice recommendations for the management of NAS consist of a standardized scoring tool to assess the severity of symptoms and signs. The optimal clinical assessment tool is unknown. Chisamore and colleagues¹⁶ investigated different strategies for evaluation and treatment of NAS comparing a weight-based versus symptom-only–based approach. Results indicate that a higher proportion of newborns received morphine in the symptom-only model. However, those infants who received morphine in either models of morphine delivery had no statistical difference in their time of onset of morphine, total accumulative morphine, or length of stay. Further research is needed to determine an optimal NAS scoring tool and treatment protocol not only because of the current dearth of literature but also in gleaning recommendations from observational data that has its own limitations. Accordingly, Chisamore and colleagues also suggest a structured sharing of resources to manage the intense treatment required for NAS.

Conclusions

Several themes emerge from the studies published in this supplement. There is a focus on the need for the integration of multiple resources for childbearing women with substance use disorders and to link these services into improved systems of care. This suggestion includes primary to tertiary prevention efforts for women of childbearing age and their children as a means of reducing the short-term and long-term harm associated with perinatal substance use disorders. Furthermore, there is a call for the geographical expansion of services to increase access for rural women to appropriate, local, gendered services for pregnant and postpartum women with substance use disorders. Innovative approaches are also being investigated for augmenting smoking cessation and responding to the secondary consequences of OAT. Future research efforts should focus on preconception care, improved system design, and more optimal prevention and management of substance-using women and their infants.

Lead Guest Editor DR. ALICE ORDEAN

Dr. Alice Ordean is an Associate Professor of Family and Community Medicine at University of Toronto. She completed her medical training and Master of Health Science at the University of Toronto. Dr. Ordean is also a Diplomate of the American Board of Addiction Medicine. Her clinical area of interest is in addiction medicine and obstetrics and is the Medical Director of the Toronto Centre for Substance Use in Pregnancy at St. Joseph’s Health Centre in Toronto. Dr. Ordean is the author or coauthor of 40 published papers and book chapters and has provided >50 presentations at international, national and local conferences, and holds editorial appointments at the Canadian Journal of Addiction Medicine and the Austin Journal of Drug Abuse and Addiction. Learn more about Dr. Ordean by visiting her institutional webpage here: www.stjoestoronto.ca.

Email: AOrdean@stjoestoronto.ca

Guest Editors

DR. LISA GRAVES

Dr. Lisa Graves is a family physician. She is a graduate of the University of Ottawa. She completed her residency in family medicine and enhanced skills training in maternal and child health at McGill University. At McGill she occupied a number of positions including clerkship chair. From 2010–2013, she was the Associate Dean Undergraduate Medical Education at the Northern Ontario School of Medicine. She is currently the Associate Dean Faculty Affairs at Western Michigan University Homer Stryker MD School of Medicine in Kalamazoo Michigan where she is also Professor in the Department of Family and Community Medicine. Her clinical, teaching and research interests include medical education, maternal/child health and vulnerable populations.

Email:

Guest Editors

DR. BRIAN CHISAMORE

Dr. Brian Chisamore is an Assistant Professor in Paediatrics at the University of Toronto. He currently works at St Joseph’s Health Centre in Toronto and completing a second term as the Chief of the level 2 neonatal intensive care unit. Dr. Chisamore was responsible for formalizing the protocol for the assessment and treatment of neonatal opioid withdrawal in our NICU in 1999. He graduated medical school 9T2 from the University of Toronto. His Paediatric Fellowship was granted in 1996 and his sub-speciality certificate in Neonatology conferred in 1997. He has a Masters of Health Science in Health Management, Evaluation and Policy from the University of Toronto. He is an active teacher, and frequently awarded for teaching to medical and nurse-practitioner students, and post-graduate residents in Paediatrics and Family and Community Medicine. Learn more about Dr. Chisamore by visiting his institutional webpage here: www.stjoestoronto.ca.

Email: BChisamore@stjoestoronto.ca

Guest Editors

DR. LORRAINE GREAVES

Dr. Lorraine Greaves is a Clinical Professor at the Faculty of Medicine at the University of British Columbia and Senior Investigator at the Centre of Excellence for Women’s Health. She completed her PhD at Monash University in Melbourne, Australia and previously worked at the Ontario Ministry of Health and Long-Term Care, and the Centre for Research on Violence Against Women and Children. She now works primarily in research and knowledge transfer in gender and health, substance use and tobacco. Dr. Greaves is the author or co-author of 10 books and 95 published papers and has presented at several hundred conferences. Learn more about Dr. Greaves by visiting her institutional webpage here: www.bccewh.bc.ca.

Email: lgreaves@cw.bc.ca

Guest Editors

DR. ADRIAN DUNLOP

Dr. Adrian Dunlop is a Conjoint Associate Professor of Medicine at University of Newcastle, Australia. He completed his MBBS at University of Melbourne and his PhD at University of New South Wales. He has previously worked at Turning Point Alcohol and Drug Centre, Australia. He now works primarily as the Chief Addiction Medicine Specialist, NSW Ministry of Health and is the Area Director of Drug and Alcohol Clinical Services, Hunter New England Local Health District. Dr. Dunlop is the author or co-author of 129 published papers and has presented at 55 conferences, and holds editorial appointments at Drug & Alcohol Review. Learn more about Dr. Dunlop by visiting his institutional webpage here: https://www.newcastle.edu.au/profile/adrian-dunlop.

Email: Adrian.Dunlop@hnehealth.nsw.gov.au