Thischaptershouldbecitedasfollows:

Wilson,J,Thorp,Jr.,J,Glob.libr.women'smed.,
(ISSN:17562228)2008;DOI10.3843/GLOWM.10115
UnderreviewUpdatedue2017
SubstanceAbuseinPregnancy
JillK.Wilson,MD

DepartmentofObstetricsandGynecology,UniversityofNorthCarolinaSchoolofMedicine,ChapelHill,Nor
JohnM.Thorp,Jr.,MD

ProfessorofObstetricsandGynecology,DivisionofMaternalFetalMedicine,UniversityofNorthCarolinaS
INTRODUCTION

EPIDEMIOLOGYOFSUBSTANCEABUSEINPREGNANCY

DEFINITIONSOFSUBSTANCEUSEBASEDONCRITERIAOFTHEDIAGNOSTIC
ANDSTATISTICALMANUALOFMENTALDISORDERS,4THEDITION

BIOLOGYANDETIOLOGYOFSUBSTANCEABUSE

DETECTINGSUBSTANCEABUSE

DIFFERENTIALDIAGNOSIS

PROGNOSISOFSUBSTANCEABUSE

EFFECTSOFSUBSTANCEABUSEONTHEWOMANANDHERFETUS

ALCOHOLABUSEDURINGPREGNANCY

COCAINEABUSEDURINGPREGNANCY

MARIJUANAUSEDURINGPREGNANCY

SEDATIVE/HYPNOTICUSEDURINGPREGNANCY

NARCOTICABUSEDURINGPREGNANCY

SCREENINGFORMATERNALDRUGUSEDURINGPREGNANCY

MANAGEMENTANDTREATMENT

CAREAFTERDETOXIFICATION

CONCLUSIONS

REFERENCES
divstyle="width:700px"
INTRODUCTION
Substanceabuseduringpregnancyismoreprevalentthancommonlyrealized,withupto25%
ofgravidasusingillicitdrugs.1Infact,substanceabuseismorecommonamongwomenof
reproductiveagethanamongthegeneralpopulation.2Theaveragepregnantwomanwilltake

fourorfivedrugsduringherpregnancy,with82%ofpregnantwomentakingprescribed
substances and 65% using nonprescription substances, including illicit drugs.1 Substance
abuseduringpregnancyisdifficulttodetectbecausethesignsandsymptomsofthisbehavior
areoftensubtle,selfreportsofsubstanceusemaybemisleadingorinfrequentlyelicited,
physiciansmayfailtoroutinelyscreenforuse,andsubstanceabusingpregnantwomenmay
seeklittleornoprenatalcare.Oncedetected,substanceabuseduringpregnancyconfrontsthe
physician with issues regarding treatment, management, and maternal and fetal
complications.Becausepregnantwomenwithsubstanceuseproblemsaremorelikelythan
nonpregnantfemalestoseekassistancefromahealthcareproviderandtobemotivatedfor
substance abuse treatment, pregnancy offers the physician a unique opportunity for both
detecting and treating substance abuse. Some would describe pregnancy as a treatable
moment for mothers who use and abuse substances. In this chapter, we address the
epidemiology,basicdefinitionsdescribingsubstanceusebehaviors,biologyandetiology,
detection and differential diagnosis, prognosis, maternal and fetal complications, use of
specific substances, screening, management, and treatment of substance abuse during
pregnancy.
ARTICLEBODY
EPIDEMIOLOGYOFSUBSTANCEABUSEINPREGNANCY
Approximately26millionAmericanswillsufferwithasubstanceabuseproblemduringtheir
lifetime.3Theincidenceofsubstanceabuseamongwomenofreproductiveagecontinuesto
increase,thuscontributingtothegrowingproblemofsubstanceabuseduringpregnancy.The
highestratesofalcoholanddruguseareamongwomenintheirchildbearingyears,with6
millionwomenexperiencingalcoholproblems,andmorethan5millioncurrentlyusingillicit
substances.3 Greaterthan50%ofwomenaged18to35yearsrespondingtotheNational
InstituteonDrugAbuseHouseholdSurveyreportedthattheyhadusedalcoholinthepast
month, and 5% reporting illicit drug use in the same interval, with marijuana the most
frequentlyusedsubstance.4Theincidenceofsubstanceabuseduringpregnancyrangesfrom
0.5%to25%dependingonthetypeofscreeningmethodutilized,suchasurinedrugscreens
versusselfreportsofsubstanceuse,andtheintensityofthescreeningprogram,withinherent
biases in those screening only certain subpopulations of pregnant women. The largest
populationbased survey of29,000urinesamples atdeliveryestimatedthe prevalenceof

substanceabuseduringpregnancyas5.2%andalcoholuseas6.7%.4Ofthe4millionwomen
whobecomepregnanteachyear,atleast20%smokecigarettes,19%drinkalcohol,20%use
legaldrugs,and10%useillicitdrugsduringtheirpregnancy.3Thus,substanceuseishighly
prevalentinpregnantwomen.
DEFINITIONS OF SUBSTANCE USE BASED ON CRITERIA OF THE
DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS, 4TH
EDITION
Thefourgeneralcategoriesofsubstancesabusedbypregnantwomenarecentralnervous
system depressants, including alcohol, sedatives, anxiolytics, and hypnotics; stimulants,
including cocaine and amphetamines; opiates; and hallucinogens/psychotomimetics,
includinglysergicaciddiethylamide(LSD)andphencyclidine(PCP).Withtheexceptionof
caffeine and nicotine, these substances are associated with both abuse and dependence
disorders.3
Intoxication and withdrawal represent the most common substancerelated disorders.
Intoxication,definedasthedevelopmentofareversiblesubstancespecificsyndromeduring
oraftersubstanceuse,becomesaclinicalproblemwhensignificantmaladaptivepatternsof
behaviorleadtodistressandimpairment.Withdrawal,anothersubstancespecificsyndrome,
occurswhenthechronicintakeofasubstanceisabruptlydiscontinued.Toleranceisdefined
as the need to use an increasing amount of the drug to attain the desired effects or the
decreasedintensityineffectsexperiencedwiththecontinueduseofthesameamountofthe
substance.Thetermaddictioncombinesthequalitiesofbothtoleranceandwithdrawal.Drug
addiction,aprimarydiseasewiththepotentialtobeprogressiveandlifethreatening,presents
asapreoccupationwithandinabilitytocontrolsubstanceuse.
Substancedependenceincludestolerance,withdrawal,takingthedruginlargeramountsover
longerperiodsthanoriginallyintended,thedesireorineffectiveattemptstoreduceorcease
druguse,extensiveamountsoftimeinvolvedwithsubstanceuse,andpersistentusedespite
problemsattributedtothesubstance. Substanceabuse isamaladaptivepatternofusethat
results in clinically significant functional impairment without satisfying the criteria for
substance dependence. Abuse is indicated by any one of the following: failure to fulfill
reasonableobligations,druguseindangeroussituations,andcontinuedusedespiterecurrent

legal,social,andpsychologicalproblemsassociatedwiththesubstance.3
BIOLOGYANDETIOLOGYOFSUBSTANCEABUSE
Dependingontheclass ofagentingested,druguseappears toactivateordeactivatethe
limbicsystem,withdopamineservingasthemajorneurotransmitterinthereinforcementof
substanceuse.3Althoughtheetiologyofsubstanceabuseremainsunclearatthepresenttime,
studieshaverevealedasignificantgeneticbasisforalcoholism,withapenetranceof50%to
60%.4 Otherfactors thatmaybeinvolvedinincreasingones susceptibilitytosubstance
abuseproblemsincludelifestressorswithpoorcopingskills,limitedsocialsupportsystems,
easy access to alcohol and illicit substances, previous traumatic crises, and identity/self
esteemproblems.Thoseindividualswithmentalhealthdisorders,reproductiveproblems,and
eating disorders appear more likely to develop substance abuse problems. In fact, the
prevalenceofallpsychiatricdiagnosesishigheramongfemalealcoholicsthannonalcoholics.
TheEpidemiologicCatchmentAreasamplediscoveredthat37%ofwomenwithalcohol
problems have comorbid mental illness, with major depression the most frequently
diagnosed.4
DETECTINGSUBSTANCEABUSE
Before discussing characteristics more frequently observed among substance abusers, we
mustremindthereaderthatmostwomenwithsubstanceabuseproblemsdonotmanifestany
ofthefollowingconditions.Indicatorssuggestingsubstanceabuseduringpregnancyinclude
selfreported use, avoidance of prenatal care, premature labor and delivery, placental
abruption, and fetal death. Advancedstage substance abusers commonly live chaotic
lifestyles, characterized by frequent changes in residence/employment, longstanding
substance abuse, and domestic violence.5 Risk factors for frequent drinking during the
periconceptionalperiodincludebeingunmarried,asmoker,Caucasian,25yearsorolder,and
a college graduate.6 A detailed history and physical examination followed by pertinent
laboratorystudiesassistthephysicianindetectingthosepregnantwomenwithsubstance
abuseproblems.
Whenperformingasubstanceusehistory,thephysicianshouldaskthepatientaboutthetype,

amount, and frequency of substance use in a nonjudgmental manner, with emphasis on

formingapatientphysicianalliance.Itisimportanttoobtaininformationregardingtheexact
amount of alcohol and/or drugs being used at the time the patient discovered she was
pregnant,searchingforsignsofpolysubstanceabuse.Byincorporatingquestionsregarding
substanceuseintoonesgeneralhistorytakingtemplate,onecandiminishtheirnoveltyand
putthepatientatease.Onemaybeginthesubstanceusehistorywithquestionsregarding
drugusepriortoconceptiontolessentheshamethatmanywomenfeelregardingcurrentuse.
Then the consequences of substance use should be explored, with emphasis on physical
symptoms,relationshipandemploymentproblems,andemotional/psychologicalissues.Input
frompartners,closefamilymembers,andfriendsmayhelpbetterdefinethemagnitudeofthe
patientssubstanceabuseproblem,especiallyforthosepatientsindenial.
TheCAGE(cutdown,annoyedbycriticism,guiltyaboutdrinking,eyeopenerdrinks)and
TACE(tolerance,annoyedbycriticism,cutdown,eyeopenerdrinks)questionnaires,MAST
(Michigan Alcoholism Screening Test), DAST (Drug Abuse Screening Test), and ASI
(AddictionSeverityIndex)arefrequentlyused,relativelyeffectivemethods fordetecting
substanceuse.TheCAGEscreeningtool,composedoffourquestionstoidentifythosewith
alcohol problems, will accurately identify 80% to 90% of male alcoholics, yet its
applicability to pregnant women is unclear.2 TACE, designed to identify those women
drinkingheavilyenoughtocausepotentialdamagetothefetus,cancorrectlyidentify70%of
women with alcohol problems during pregnancy.7 The TACE questions include the
following:
1

ToleranceHowmanydrinksdoesittakeforyoutofeelhigh?

AnnoyedHavepeopleannoyedyoubycriticizingyourdrinking?

CutdownHaveyoufelttheneedtocutdownonyourdrinking?

EyeopenerDoyouneedtohaveaneyeopenertogetstartedinthemorning?
MASTandDAST,selfreportquestionnairesthatcontainweighteditems,arepronetofalse
positiveresultsandshouldbeadministeredconcomitantlytodetectpolysubstanceabuse.
ASI,amultifactorialdiagnosticprocedure,providesawaytoassesstheimpactofsubstance
useonthepatientslife.5Althoughthesequestionnairesareuseful,Colmorgenandassociates
haveshownthatselfreportaloneisanincompletemethodforidentifyingmaternaldrug
abuse.7

DIFFERENTIALDIAGNOSIS
Whencontemplatingthediagnosisofsubstanceabuse,otherconditionsshouldbeconsidered,
including depression, anxiety, personality disorders, and posttraumatic stress disorder.
Symptomsofanxietyanddepressionmaybesideeffectsofsubstanceuse;thusthediagnosis
ofapsychiatricillnessisdifficulttomakeuntilthepatienthasbeenabstinentforseveral
weeks.
PROGNOSISOFSUBSTANCEABUSE
Theprognosisisrelativelygoodyetvariesfromindividualtoindividual.Thelongerthe
substanceabuseproblem,themoredifficultitistoeradicate.Themorebarriersthepatient
hastotreatment,thelesslikelysheistoremainabstinent.Commonbarrierstotreatment
includeapartnerwhoalsousesalcoholordrugs,achaoticlifestyle,apoorsocialsupport
system,andlackofsafeandaffordablechildcareservices.Thosewomenwhohavebeenin
multipletreatmentprogramsyetsubsequentlyrelapsemayberecalcitranttogeneraltreatment
methods.
EFFECTSOFSUBSTANCEABUSEONTHEWOMANANDHERFETUS
Theeffectsofsubstanceabuseduringpregnancymaybeclassifiedintothreecategories:
effectsonthemother,effectsonthecourseofpregnancyanddelivery,andeffectsonthe
fetus,newborn,anddevelopingchild.8
Maternal complications may be respiratory, such as bacterial infections; cardiovascular,
including hypertension and endocarditis; neurologic, with seizures, cerebrovascular
accidents, and psychoses; infectious, such as sexually transmitted diseases and human
immunodeficiency virus; renal and gastrointestinal, including acute tubular necrosis and
hepatitis;and/ormetabolic,suchasmalnutritionandvitamindeficiencies.8 However,other
thansexuallytransmitteddiseasesandpsychiatriccomorbidity,majormedicalcomplications
arerareinpregnantwomenwithsubstanceabuseproblemsandfewwillexperienceend
organdamagesecondarytosubstanceuse.

Obstetricandfetalcomplicationsassociatedwithmaternalsubstanceabuseincludeplacenta
previa, abruptio placentae, premature rupture of membranes, spontaneous abortion,
intrauterinegrowthretardation,prematuredelivery,birthdefects,andneonatalandlongterm
developmentaleffects.8Whethertheseobstetricandfetalproblemsarecausedbysubstance
abuseorjustassociatedwithuseremainsanactiveareaofdiscussionandinvestigation.
Neonataleffectsofsubstanceabusedependontheparticularsubstancebeingabusedandare
discussedindividuallyinlatersectionsyetgenerallyincludecongenitalanomalies,neonatal
medical complications, and neurobehavioral changes.9 Specific neonatal medical
complicationsofmaternalsubstanceabuseincludesuddeninfantdeathsyndrome(SIDS),
neonatalabstinencesyndrome(NAS),andrespiratorydistresssyndrome.
ALCOHOLABUSEDURINGPREGNANCY
Chronicalcoholuseduringpregnancy,definedastheingestionoftwoormoredrinksper
day,isassociatedwithincreasedratesofspontaneousabortion,higherratesoflowbirth
weightinfants,placentalabruption,increasedperinatalmortality,amnionitis,andathreefold
increaseinpretermdeliveries.4 Someevidencesuggeststhatalcoholimpairstheplacental
transferofessentialaminoacidsandzinc,thusincreasingtheriskforintrauterinegrowth
retardationbyinhibitingproteinsynthesis.10Fetalalcoholsyndrome(FAS),theonlycause
ofmental retardation thatin theoryis entirely preventable, effects 1to 3ofevery1000
newborns,withanother3to5per1000exhibitinglessseverefetalalcoholeffects.3FASis
characterized by varying degrees of craniofacial dysmorphism, impaired prenatal and
postnatalgrowth,centralnervoussystemabnormalities,andcardiacdefects.Fetalalcohol
effectsincludecongenitalmalformations,genitourinarydefects,andlearningdisabilities.4
Dayandcoworkersperformedaprospectivestudyof650womenandtheirnewbornsthat
showedthatlowbirthweight,decreasedheadcircumferenceandlength,andanincreasedrate
offetalalcoholeffectswerecorrelatedwithexposuretoalcoholduringthefirst2monthsof
pregnancy. They found that 30% to 40% of the offspring of women who abuse alcohol
exhibitFAS,whichwasassociatedwithbothchronic,heavydrinkingandbingedrinking.11
Inarecentstudyutilizingmagneticresonanceimagingtoexaminetheeffectsofalcohol
exposureonthefetalbrain,findingsrevealedthatsevereprenatalalcoholexposureproduces
aspecificpatternofbrainhypoplasia.12

Alcohol withdrawal in pregnant women, which may be treated with benzodiazepines or

phenobarbital, is rare, and withdrawal in affected infants is even rarer. When neonatal
withdrawal does occur, it is characterized by agitation and hyperactivity, with marked
tremorslastingfor72hours,followedby48hoursoflethargy,beforerecovery.10
COCAINEABUSEDURINGPREGNANCY
Cocaineuseduringpregnancy,affecting1%to5%ofneonates,isassociatedwithdecreased
uterinebloodflowleadingtopoorfetaloxygenationandincreasedfetalbloodpressureand
heart rate. Cocaine use during early gestation is associated with an increased risk of
spontaneous abortion, whereas later use is associated with premature labor and delivery,
placental abruption, low birth weight, SIDS, intrauterine growth retardation, low Apgar
scores, meconium staining, fetal death, microcephaly, neurodevelopmental delay, and
structural/congenitalanomalies,especiallyinvolvingthegastrointestinalandrenalsystems.8
Theincreasedriskformeconiumstainingandnonreassuringfetalhearttracingsassociated
withmaternalcocaineusemaybeduetothefactthatthenormalcatecholaminesurgeinthe
newbornthatoccursduringlabormayoverwhelmthemyocardiuminthecocaineexposed
infant. Studies on cocaine abuse indicate that maternal cocaine use during pregnancy is
associatedwithanincreasedincidenceofhighmaternalgravidity,poorprenatalcare,and
pretermbirth.13
Withregardtothelongtermneurodevelopmentaleffectsthatmaternalcocaineusemayhave
on the fetus, a recent systematic review concluded that among children aged 6 years or
younger, there is no convincing evidence that prenatal cocaine exposure has effects
significantlydifferentfromthoseattributedtootherprenatalexposures,includingmaternal
tobaccoandalcoholuse.14 However,thisremainsanareainneedofmoreresearchwith
welldesignedstudies.
Although maternal cocaine use rarely requires specific treatment regimens, psychotic
symptomsmayoccurandshouldbetreatedwithantipsychotics.
MARIJUANAUSEDURINGPREGNANCY
Marijuana is a commonly abused substance, with greater than 25% of women in their

reproductiveyearsadmittingtopastorcurrentmarijuanause.Althoughmarijuanauseduring
pregnancy has been associated with few shortterm or longterm effects on the exposed
neonate, its risks are dosedependent, with an increased incidence of intrauterine growth
retardationandSIDSseenintheinfantsborntoheavyusers.11,15,16Theuseofmarijuana
maybemostbeneficialasanindicatorofpolysubstanceabuseandlowersocioeconomic
statusthatmayinfluencebothprenatalcareandthehomeenvironment.17
SEDATIVE/HYPNOTICUSEDURINGPREGNANCY
Maternaluseofsedatives/hypnoticsleadstophysicaldependencyinthefetuscharacterized
bytheneonatalabstinence/withdrawalsyndrome.Drugsthatareassociatedwithneonatal
withdrawal include heroin/methadone, caffeine, cocaine, ethanol, marijuana, PCP, and
nicotine. The NAS includes behavioral and autonomic nervous system dysfunction plus
gastrointestinal, respiratory, and central nervous system abnormalities.11 Women using
sedatives/hypnotics during pregnancy may need to be hospitalized during detoxification
becausetheriskforseizuresandothercentralnervoussystemeffectsisrelativelyhigh.
NARCOTICABUSEDURINGPREGNANCY
Narcotic abuse during pregnancy is associated with a higherthannormal incidence of
prematurelabor,chorioamnionitis,SIDS,prematureruptureofthemembranes,meconium
staining,preeclampsia,andplacentalabruption.8 AccordingtoOstreaandChavez,infants
exposedtoheroinareathigherriskforcongenitalabnormalities.
Heroin abuse during pregnancy is associated with a 50% incidence of lowbirthweight
infants,withupto50%oftheseinfantsbeingsmallforgestationalage,manyofwhom
experiencerespiratorydepressionandlowApgarscores.8,10Themajorityofinfantsbornto
heroindependentmothersexhibitsomesignsofaddiction,withupto75%showingclinical
signs of withdrawal within the first 48 hours after birth. NAS is characterized by a
conglomeration of central nervous system, gastrointestinal, metabolic, respiratory, and
vasomotorinvolvement.Commonsymptomsincludetremors,hyperirritability,fever,poor
feeding,diarrhea,respiratorycompromise,andweightloss.18 Treatmentforsymptomatic
infants may include one of the following: 0.2 mL paregoric every 4 hours, 0.1 to 0.5

mg/kg/dayofmethadone,8mg/kg/dayofphenobarbital,or1to2mg/kgofdiazepamevery8
hours.19
Methadone, along with producing fetal dependence and withdrawal in the majority of
exposedinfants,isassociatedwithhigherratesofneonatalmorbidityandmortality,yetthe
average birth weight for methadoneaddicted neonates is higher than that for heroin
dependentinfants.Neonatalwithdrawalfrommethadonemaybetreatedwith1to2mgof
methadone giventwicedaily.8 Conversely, nursing mothers whocontinueonmethadone
maintenanceinthepuerperiummaypreventnewbornwithdrawalbytransferringnarcotic
metabolitesviatheirbreastmilk.
Researchershaveconcludedthattheincreasedrelativeriskofneonatalmortalityseenfor
thosewomenabusingheroinand/ormethadoneduringpregnancy,comparedwiththoseon
methadonemaintenancetherapy,maybemoreassociatedwiththechaotic,highrisklifestyle
seen in narcotic abusers than with drug exposure.20 Others have found that, although
methadone maintenance alone is associated with an improved neonatal outcome, those
womenwhocontinuetouseheroinwhilereceivingmethadonemaintenancetherapymay
counteract the birth weight advantages seen with the use of methadone alone. Thus,
methadone maintenance may be reserved for those women who refrain from heroin use
duringpregnancy.21
SCREENINGFORMATERNALDRUGUSEDURINGPREGNANCY
Aftercomparingthesensitivityandspecificityofmaternalinterview,maternalhairanalysis,
andmeconiumanalysisindetectingperinatalexposuretoopiates,cocaine,andmarijuana,a
studyconcludedthatbothmeconiumandhairanalysesyieldedthehighestsensitivitiesfor
detecting perinatal use of opiates and cocaine. Maternal hair analysis, although a good
screening test for detecting maternal drug use during the previous 3 months with drug
metabolitespersistingforupto3monthsintheinfantshairafterbirth,isfalselypositivein
thosewomenexposedpassivelytosecondhandsmokefromcrackcocaineandmarijuana.11
Althoughtheoreticallyuseful,hairanalysis isunavailabletomostclinicians onaroutine
basis.Theyconcludedthatmeconiumanalysis,whichiseasilyperformed,givesapictureof
thedrugusepatternduringthelatterhalfofpregnancyandmaybetheidealscreeningtestfor
maternaldruguse.22Becausemeconiumcanbeattainedonlyatdelivery,itisnotusefulfor

antepartum screening. In clinical practice, urine toxicology assays are more frequently
ordered.Althoughtheseassayscandetectmaternaldrugusewithinthepast48to72hours,
theymaymisstheinfrequentusersandcannotquantifythefrequencyoramountofdrug
used.23Somephysiciansrelymoreheavilyonthesubstanceabusehistory,oftencombining
itwiththeurinedrugscreen.Frankandcolleaguesfoundthatrelyingsolelyonthesubstance
abusehistoryresultsinthefailuretodetectover25%ofwomenabusingcocaineduring
pregnancy.Surveysmaymissmanyabusersbecausethewomenoftenfeelguiltyordeny
theirsubstanceuse,fearinglossofcustody.23Theseresearchersalsofoundthatwhenurine
drugscreensareusedalone,upto50%ofthepatientsaremissed;thus,urinedrugscreens
and substance abuse histories should be used concomitantly to detect women using
substancesduringpregnancy.9Biologicscreeningforsubstanceabuseshouldbeperformed
onlywithinformedconsentfromthemotherandforthepurposeoftreatingthesubstance
abusedisorderonceidentified.
MANAGEMENTANDTREATMENT
Abstinenceshouldbetheultimategoalofthemanagementandtreatmentofsubstanceabuse
during pregnancy. Researchers have found that participating in prenatal care alone can
improvetheoutcomeofthesubstanceabusepregnancyandthatceasingsubstanceuseduring
thepregnancycanfurtherdecreaseperinatalmorbidity.Mostinfantsexposedtosubstances
still have good outcomes, and early neonatal interventions can prevent or lessen future
neurodevelopmentalproblems.9Commonobstaclestotreatmentincludepoorsocialsupport
systems, failure to identify substance abusers during pregnancy, inadequate financial
resources,and fearofcustodyloss withadmissiontoproblems ofsubstanceabuse.4 To
attract enrollment, treatment should include multidisciplinary health care, family therapy,
childcare,vocational/parentingskillstraining,andpsychiatricservices.4
Thereisstillashortageoftreatmentprogramsforpregnantwomen.In1989,of78drug
treatmentfacilitiesinNewYorkCity,54%refusedtotreatpregnantwomen,67%denied
treatmenttowomenonMedicaid,and87%deniedtreatmenttopregnantwomenaddictedto
crack cocaine.4 Finkelstein has documented the shortage of substance abuse treatment
servicesavailabletowomen,specificallymothersandpregnantwomen.23 Morerecently,
Breibartandassociatesconductedastudytoassessavailabilityofsubstanceabusetreatment

programsforpregnantwomeninfiveU.S.cities,findingthatonly80%oftheprograms
surveyedacceptedpregnantwomen;thus,barrierstotreatmentstillremain.23
According to Schrager and coworkers, a residential treatment program combined with
consistentoutpatientfollowupisthebestwaytopreventordecreasematernalsubstance
use.23 Other treatment options include formal counseling programs, selfhelp groups,
womensshelters,andhalfwayhouses.Involuntarytreatmentshouldbeconsideredwhenthe
substance abuser refuses to enter a treatment program and when her behavior creates
significantproblemsforherselfandthefetus.
CAREAFTERDETOXIFICATION
Thepregnantdrugabusershouldbeseenfrequently,ideallyat2weekintervalsuntil32to34
weeks,thenweekly,withurinedrugscreensobtainedateachvisit.1Rehabilitationservices
includeeducationalsessions,groupandindividualcounseling,and12stepgroups.5 Reed
suggests that services individually address the womans unique treatment needs, reduce
barrierstointerventionandrecovery,expressgoalscompatiblewiththepatientslifestyle,
andconsiderthespecialissuesassociatedwithpregnancy.5
CONCLUSIONS
Astheincidenceofsubstanceuseamongwomenofreproductiveagecontinuestoincrease,
substanceabuseduringpregnancyisagrowinghealthissuebecauseitaffects thefuture
generationsofourcountry.Becausesubstanceabuseduringpregnancyisoftendifficultto
detect,thephysicianshouldincludeadetailedsubstanceabusehistoryineverynewpatient
encounter, with followup questions performed during subsequent visits. Once detected,
substance abuse during pregnancy confronts the physician with issues regarding
management,treatment,andpotentialmaternal,fetal,andpregnancyrelatedcomplications,
yetalsoprovidesthephysicianwithauniqueopportunityforinterventionatatimewhenthe
womanmaybemostamenabletochange.Manymanagementandtreatmentoptionsexist
withtheultimategoalofabstinenceandshouldbedesignedtomeettheneedsandaddressthe
concernsoftheindividual.Byincreasingtheawarenessofsubstanceabuseduringpregnancy
amongthemedicalcommunity,physiciansmaybetterrecognizeandaddressthisproblem,

thusimprovingtheoverallhealthofthispopulation.
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