Screening, Prenatal Care, and Treatment
All people should be assessed for substance use disorders (SUDs) using a validated screening tool to identify drug and alcohol use. Incorporating a screening, brief intervention and referral to treatment (SBIRT) approach can lead to early engagement in treatment and avoidance of adverse outcomes for pregnant and parenting people and the baby.
Providers should identify IHS, tribal, and local SUD treatment facilities to ensure that treatment programs meet patient and family resource needs including plans of safe care and wrap-around services such as housing, child care, transportation and home visitation.
It is imperative to incorporate family planning, breastfeeding, pain management and infant care counseling, education and resources into prenatal, intrapartum and postpartum care.
Patient screening in people of reproductive age offers opportunities for early identification and assessment of substance use disorders. All people of child-bearing age should be routinely screened for alcohol and drug use (including tobacco, prescription, and illicit drugs) as well as for depression and intimate partner violence. Screening should be conducted before pregnancy, in early pregnancy, and routinely throughout the pregnancy. Screening should be universal for all patients and should use a validated screening tool.
Validated screening tools include 4Ps[PDF - 102 KB], NIDA Quick Screen , and CRAFFT (for adolescents and young adults). These tools have been well studied and demonstrate high sensitivity for detecting substance use and misuse. Pregnant people should be informed that these questions are asked of all pregnant patients to ensure they receive the care they require.
Screening, brief intervention, and referral for treatment (SBIRT) is a comprehensive, integrated, public health approach to identify, reduce, and prevent problematic substance use disorders. SBIRT consists of three major components.
Screening — a healthcare professional assesses a patient for risky substance use behaviors using standardized screening tools
Brief Intervention — a healthcare professional engages a patient showing risky substance use behaviors in a short conversation, providing feedback and advice
Referral to Treatment — a healthcare professional provides a referral to brief therapy or additional treatment to patients who screen in need of additional services
In addition, all pregnant people with opioid use disorder should be screened and evaluated for commonly occurring comorbidities including infectious disease (e.g. HIV, Hepatitis, and sexually transmitted infections), psychiatric disorders, physical and sexual violence.
For more information on SBIRT, please visit SAMHSA
For additional clinical guidance on screening, access the ACOG Best Practice Recommendation Report [PDF - 1.1 MB] - ACOG Committee on AI/AN Women’s Health
For information on how to document 4 Ps in IHS RPMS EHR, access the 4 Ps Screening Tool How-To Guide [PDF - 400 KB]
American Indian/Alaska Native belief systems and traditional practices hold that children are a gift from the Creator and that well-being brings harmony and balance. Women are honored and respected as they are the givers of this sacred life, and a pregnant woman’s maternal instinct is to take care of herself and the life inside her.
Regular appointments with a healthcare provider throughout pregnancy are important to ensure the health of the pregnant person and the baby. Prenatal care is an important part of any pregnancy, especially in those with substance use disorder. The sooner prenatal care begins, the healthier the pregnant parent and baby will be. Prenatal care includes not only caring for the body in pregnancy, but also for the mind and spirit.The following should be considered when combining prenatal care with treatment for opioid use disorder:
- Testing for Sexually Transmitted Infections and other infectious agents such as HIV, hepatitis B and C, chlamydial infection, gonorrhea, syphilis, and tuberculosis should be considered. Repeat testing in the third trimester may be indicated if considered at increased risk. Hepatitis B vaccination is recommended for pregnant people who are HBsAg negative but at high risk of hepatitis B infection.
- Screening for depression and other behavioral health conditions should be conducted at least once every 3 months throughout the pregnancy with timely referrals to behavioral health services to connect to services and support early intervention and encourage retention in care.
- Screening for fetal size - Consideration of interval ultrasounds in pregnant people on medication-assisted therapy (MAT) or who are using prescribed or illicit opioids.
- Consultations as needed with anesthesia, addiction medicine specialists, pain management specialists, pediatrics, maternal–fetal medicine, behavioral health, nutrition, and social services.
- Screening for use of other substances, including tobacco use, alcohol, and methamphetamine. Screening with validated tools and discussion about other substances is important, and cessation services should be offered.
- Integrating social support into prenatal and recovery-based care may include the use of peer recovery coaches, community health worker models, and group prenatal care.
Download the Plans of Safe Care Toolkit which offers a guide for clinicians on improving outcomes for American Indian and Alaska Native pregnant and parenting people and their infants, partners, and families, a variety of handouts for pregnant and parenting people and their supports, and eye catching posts to share on organizational social media accounts.
Read Tapping Tribal Wisdom: Providing Collaborative Care for Native Pregnant Women with Substance Use Disorders and Their Infants [PDF - 1 MB] lessons learned from listening sessions with five tribes in Minnesota, Fall 2018, developed with SAMHSA'S The National Center on Substance Abuse and Child Welfare.
Watch the webinar Learning with the Expert: A Dialogue with Dr. Ira Chasnoff. Participants will learn how health care systems, in collaboration with community providers and systems, can focus on prevention, screening, assessment and Plans of Safe Care for infants with prenatal substance exposure, pregnant women, and their families. This webinar addresses practices such as the Screening Brief Intervention and Referral to Treatment (SBIRT), assessment and treatment approaches for newborns affected by prenatal substance exposure, and systems-wide collaboration to ensure children and families access appropriate services.
SAMHSA defines recovery as a process of change through which people improve their health and wellness, live self-directed lives, and strive to reach their full potential. Hope, the belief that these challenges and conditions can be overcome, is the foundation of recovery. The process of recovery is highly personal and occurs in many different ways. Recovery is characterized by continual growth and improvement in one’s health and wellness that may involve occasional setbacks. Because setbacks are a natural part of life, resilience becomes a key component of recovery.
In addition to medical care, it is important to address the needs of the entire person for recovery to be successful. Holistic care combines western medicine with traditional healing to promote health and well-being by treating the:
Mind: Working to bring the natural balance back to your life. Identify the events that led to your substance use, understand triggers, and create a recovery plan.
Body: Opioid use during pregnancy can be treated with medications and comprehensive treatment planning to include wrap-around support. Pregnant people that use substances during pregnancy may need more frequent follow-up and assistance coordinating available resources to begin the wellness journey. Engaging in early prenatal care and starting Medication Assisted Treatment to aid recovery can help improve outcomes for the baby and help to keep families together.
American Indian/Alaska Natives have always had a close connection with the earth. MAT can often be combined with traditional plant medicines and foods. Always talk with your health care provider before starting any medications, herbal remedies, or supplements during pregnancy.
Spirit: Healing services including spiritual growth and development as well as cultural awareness. Examples of traditional healing approaches may include incorporating sweat lodges, songs, music, and dance into wellness; participation in talking or healing circles; story-telling; and journeys that blend connectedness to the earth and environment to overall healing and wellness.
The greatest strength for recovery comes from hope, hope that improved relationships between family, community, and self can guide a promising start to healing.
- AAP Neonatal Opioid Withdrawal Syndrome (NOWS) Recommendation Report [PDF - 556 KB]
- ACOG Best Practice Recommendation Report [PDF - 1.1 MB]
- ACOG Opioid Use Disorder in Pregnancy
- Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants - Substance Abuse and Mental Health Services Administration
- Finnegan's Neonatal Abstinence Syndrome Scoring form
- IHS Baby Friendly Breast Feeding Promotion and Support
- NAS Nursing Staff Education [PDF - 694 KB]
- The National Maternal Mental Health Hotline provides 24/7, free, confidential support, resources and referrals to any pregnant and postpartum mothers facing mental health challenges and their loved ones. The service is available via phone and text in English or Spanish.
- Obstetric Care for Women with Opioid Use Disorder - Council on Patient Safety in Women's Health Care
- Plans of Safe Care Toolkit - The Northwest Portland Area Indian Health Board (NPAIHB)
- Rates of New Persistent Opioid Use After Vaginal or Cesarean Birth Among US Women - JAMA Network
- Serving Native Families Affected by Substance Use Disorder: Active Efforts and Plans of Safe Care — Children and Family Futures organization
- Your Words Matter: Language Showing Compassion and Care for Women, Infants, Families, and Communities Impacted by Substance Use Disorder Providing Collaborative Care for Native Pregnant Women With Substance Use Disorders and Their Infants [PDF - 102 KB]