eLetters to:

ARTICLES: Melissa O'Donnell, Natasha Nassar, Helen Leonard, Ronnie Hagan, Richard Mathews, Yvonne Patterson, and Fiona Stanley Increasing Prevalence of Neonatal Withdrawal Syndrome: Population Study of Maternal Factors and Child Protection Involvement Pediatrics 2009; 123: e614-e621 [Abstract] [Full text] [PDF]

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Prenatal care should include drug testing

Jacqueline A. Hobbs, Noni A. Graham, Mark S. Gold   (4 May 2009)

Prenatal care should include drug testing 4 May 2009
Jacqueline A. Hobbs, Assistant Professor & Director of Women's Health Clinic and Residency Training Program University of Florida College of Medicine, Department of Psychiatry, Noni A. Graham, Mark S. Gold Send letter to journal: Re: Prenatal care should include drug testing jahobbs{at}ufl.edu Jacqueline A. Hobbs, et al.	We read with interest the article by O’Donnell and colleagues, sincerely applaud their efforts and wholeheartedly agree: early identification and intervention of drug use is of utmost importance, especially for the affected children. This is not a purely Australian issue; it applies to the U.S. and likely the globe. Drug abuse and dependence are most prominent among women of childbearing age as are most co-morbid mental illnesses such as major depression [1]. We strongly advocate for preventive practices but believe that these alone will not work and agree that accurate survey data on drug use is greatly needed. Beyond this, part of the answer lies in drug testing of the mother, especially within the setting of a prenatal exam. However, several questions arise which has led to the issue largely being ignored: “If my pregnant patient tests positive for drug use, doesn’t that leave me with some responsibility to do something about it?, Who will pay for this testing?, How can I fit this into my busy workday?” The authors began to address some of this in their concluding that a multidisciplinary approach to healthcare is required to tackle such complex issues. The significant increase in the birth prevalence of neonatal withdrawal from ~1 to ~42 per 10,000 live births highlights the obvious increase in poorly treated or untreated drug abuse/dependence and likely other comorbid mental illnesses such as depression and bipolar disorder in the pregnant population. We advise routine prenatal urine drug testing including tobacco (cotinine), alcohol, codeine/morphine, amphetamine/methamphetamine, PCP, marijuana, and cocaine that can all be done rapidly in the obstetrician’s office [2]. Testing should be performed at the first prenatal visit and particularly when there are overt signs/symptoms of drug intoxication/abuse or other high risk factors (e.g. family history) [3, 4, 5]. Drug testing may have to be done at delivery as this may for some women with poor prenatal care access be the only time to intervene. Reimbursement is now possible for alcohol/drug screening and brief office-based interventions thus reducing payment issues [6]. Positive testing should lead to early education, support, and referral for treatment. The involvement of pre/post-natal care teams that include addiction medicine physicians and psychiatrists with expertise in the evaluation and treatment of addiction and psychiatric disorders during pregnancy is highly recommended as there is likely no more complicated case than a pregnant woman with bipolar disorder or psychosis who is addicted to cocaine (for example). The education of psychiatry resident and addiction medicine fellow trainees should focus more on this critical period as it affects not only the mother but also the infant/child for possibly many years, and the use of psychoactive medications during pregnancy requires specialized knowledge of risks to the fetus and an overall understanding of the physiological/hormonal changes that accompany pregnancy and postpartum that alter drug metabolism and risk of psychiatric illness. REFERENCES 1. Blehar MC. Public health context of women’s mental health research. Psychiatr Clin North Am 2003; 26(3):781-99. 2. American College of Obstetricians and Gynecologists Committee on Ethics. At-risk drinking and illicit drug use: Ethical issues in obstetric and gynecological practice. Committee on Opinion no. 294: ACOG: Washington DC, 2004 pp 1-11. 3. Agarwal P, Rajadurai VS, Bhavani S, Tan KW. Perinatal drug abuse in KK Women’s and Children’s Hospital. Ann Acad Med Singapore 1999; 28(6):765-9. 4. Armstrong MA, Lieberman L, Carpenter DM, Gonzales VM, Usatin MS, Newman L, Escobar GJ. Early start: An obstetric clinic-based, perinatal substance abuse intervention program. Qual Manag Health Care 2001; 9(2):6- 15. 5. Goler NC, Armstrong MA, Taillac CJ, Osejo VM. Substance abuse treatment linked with prenatal visits improves perinatal outcomes: a new standard. J Perinatol 2008; 28(9):597-603. 6. Barclay L. Medicaid Codes will allow billing for alcohol, drug screening and brief intervention. Medscape Medical News 2006. Available at: http://www.medscape.com/viewarticle/544548_print Conflict of Interest: None declared