A Moment In Time

Pregnancy offers a unique opportunity for treating substance use disorder as a women’s healthcare issue, before it becomes a newborn substance exposure issue.

by Joseph Salerno

The beginning of a child’s life comes with countless uncertainties. Sadly, for some children, one of those unknowns is what substances they were exposed to in their mother’s womb. When this is the case, it becomes a mission to find the answer, ultimately to improve the welfare of that child going forward. Drug testing of newborn specimens, such as umbilical cord and meconium, is the primary tool for answering that question.

Yet, we sometimes get so caught up in the idea of testing babies for substance exposure that we forget there is an opportunity to make a difference sooner. We miss the opportunity to extend our mission and help mothers fight the disease of addiction before the baby is born. Why wait to find out if a child was exposed to drugs, alcohol, or cigarettes in utero, when we can try to stop it before it happens?

Substance use by pregnant women has increased over the past three decades. In the United States, more than 225,000 children are born each year with prenatal exposure to illicit substances. This is a conservative estimate, and does not include the number of newborns exposed to alcohol and cigarette smoking in utero.  According to the most recent statistics from the National Survey on Drug Use and Health, 5.4% of pregnant women between the ages of 15-44 years will use an illicit substance during their pregnancy. In that same group, 9.4% will consume alcohol while pregnant; 2.3% will consume enough alcohol to raise their blood alcohol level above the level of 0.08% blood alcohol concentration. 15.4% of pregnant women will smoke during their pregnancy, not including the use of vaporizer electronic cigarettes, for which there is currently no data.

Addiction is a serious disease that can improve with treatment. Pregnancy may be the one time in a woman’s life when she would be open to treating important issues like drug and alcohol abuse. Pregnant women are more likely to seek any assistance from a healthcare provider, offering physicians a unique opportunity to help women contend with substance abuse. Regard for the welfare of a growing child is a powerful driving force to help a woman make positive decisions for her own health and future.

Even in the best of circumstances, relapse can occur during substance abuse treatment. Tracking a person’s treatment progress using biomarker testing can provide powerful, practical incentive for patients to stay on course and help them withstand urges to return to patterns of abuse. Biomarker testing can inform physicians early on if relapse has occurred, potentially alerting them to the need for adjustment to a patient’s treatment plan.

Substance use treatment plans typically rely on maternal self-report, use of a universal screening tool (questionnaire), or positive urine toxicology results. Maternal self-report can be severely limited by patient concerns about social stigma or possible legal implications of substance abuse. Questionnaire screening tools require skill and training to develop effective interview techniques, and yet, can still be limited by social stigmas and patients’ legal concerns. 

Urine toxicology is not an effective tool in identifying alcohol abuse and has limited value with other substances of abuse. With the exception of marijuana, urine generally provides only a 1-3 day window of exposure for substance use. The most effective antenatal drug or alcohol treatment program includes objective drug and alcohol biomarker testing to support the patient’s progress.

Changes for the Better

Expecting mothers under the influence of substance dependence are often part of high risk populations that require a greater degree of support during pregnancy. Biomarker testing during substance abuse treatment has the potential to provide reinforcing milestones that keep patients on course.

The effects of substance abuse on a mother’s child are certainly worth avoiding. Children exposed to alcohol in the womb run the risk of suffering from Fetal Alcohol Spectrum Disorders (FASD), including Fetal Alcohol Syndrome (FAS), the most extreme case. FASD and FAS may require a lifetime of extra support services for children born with those conditions.

Babies exposed to nicotine in the womb may be born premature or with low birth weight. Congenital anomalies, such as cleft lip, have been linked to in utero cigarette exposure. Some studies have linked smoking during pregnancy with restricted growth for a child later in life, as well as behavioral changes that may last well into adulthood.

Newborns exposed to drugs in the womb may also be born premature or with low birth weight. Some substances can cause Neonatal Abstinence Syndrome in newborns, who may experience severe drug withdrawal once they are no longer exposed to a narcotic from their mother’s system. Cognitive delays have been linked to prenatal drug exposure. A limited number of studies have also linked drug exposure in the womb to an increased predisposition to addiction later in a child’s life.

Alcohol Biomarker Testing

Alcohol biomarker testing can be accomplished in several ways. The most effective testing measures the molecule phosphatidylethanol (PEth) in blood specimens. PEth is an abnormal phospholipid formed in the membranes of red blood cells when they are exposed to ethanol. It identifies hazardous drinking levels (enough to raise blood alcohol levels up to or above 0.08% blood alcohol concentration) occurring within the previous 2-3 weeks prior to testing. The PEth test is simple, and can even be done using blood drops from a finger stick such as those used for insulin testing.

Ethyl glucuronide (EtG) testing in fingernails and hair is another alternative for alcohol testing. EtG is produced in the liver, and can identify hazardous drinking within the three months prior to the test. Testing is carried out using fingernail or hair specimens. Fingernails are the preferred specimen, since they eliminate testing bias that can occur due to some cosmetic hair treatments and hair pigmentation.

Nicotine and Drug Biomarker Testing

Testing for illicit substance abuse and cigarette use can also be accomplished using fingernail and hair specimens. For substances other than alcohol, fingernails can provide a window of detection up to six months prior to testing. Hair samples are able to look back on a three month history of use. As with alcohol biomarker testing, fingernails are the preferred specimen, to eliminate bias that occurs when testing some substances.

There is an opportunity that exists early on, to provide substance dependent mothers with the tools to positively impact their own health and the health of their children. Changes for the better can be made before the mother or child face the consequences of in utero substance exposure. How much better would it be to give a mother a chance to support her own healthful changes now, and reduce the impact on her child later?

References

1. American Society of Addiction Medicine. (2011). Public Policy Statement on Women, Alcohol and Other Drugs, and Pregnancy. Chevy Chase, MD.

2. The American College of Obstetricians and Gynecologists. (2012). Committee opinion: Opioid Abuse, Dependence, and Addiction in Pregnancy. (Number 524). Washington, DC: Committee on Health Care for Underserved Women and the American Society of Addiction Medicine.

3. Behnke, M., Smith, V.C., Committee on Substance Abuse, and Committee on Fetus and Newborn. (2013). Prenatal Substance Abuse: Short- and Long-term Effects on the Exposed Fetus. Pediatrics, 131, e1009-e1024.

4. Helmbrecht, G.D. and Thiagarajah, S. (2008). Management of Addiction Disorders in Pregnancy. Journal of Addiction Medicine, 2(1), 1-16.

5. Kwak, H., Han, J., Choi, J., Ahn, H., Ryu, H., Chung, H., Cho, D., Shin, C., Velazquez-Armenta, E.Y. and Nava-Campo, A.A. (2014). Characterization of phosphatidylethanol blood concentrations for screening alcohol consumption in early pregnancy. Clinical Toxicology, 52, 25-31.

6. Keegan, J., Parva, M., Finnegan, M., Gerson, A., and Belden, M. (2010). Addiction in Pregnancy. Journal of Addictive Diseases, 29, 175-191.

7. Montag, A.C., Brodine, S.K., et al. (2015). Preventing Alcohol-Exposed Pregnancy Among an American Indian/Alaskan Native Population: Effect of a Screening, Brief Intervention, and Referral to Treatment Intervention. Alcoholism Clinical and Experimental Research, 39(1), 126-135.

8. Wilson, J.K. and Thorp, Jr., J.M. (2008). Substance Abuse in Pregnancy. (ISSN: 1756-2228). Global Library of Women’s Medicine.