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All Patients Should be Asked About Alcohol and Drug Abuse

December 12, 2008

Washington, DC -- Drug and alcohol abuse is a major health problem for American women, cutting across all income levels, ages, and races/ethnicities. In a committee opinion issued today, The American College of Obstetricians and Gynecologists (ACOG) is calling for ob-gyns to ask all of their patients about drug and alcohol use and to help women get the help they need. Although time constraints, unfamiliarity with treatment resources, poor reimbursement, and legal reporting requirements are all legitimate concerns, substance abuse is a medical issue and a physician's responsibility. Universal substance abuse screening can be as simple as adding a few questions to a standard patient intake form.

Overall, 10% of nonpregnant women report illegal drug use. More than 6% of females 12 and older are dependent on alcohol or illegal drugs. Among women ages 18-25, 34% binge drink and 10% are heavy drinkers. Heavy drinking is defined as five or more drinks on one occasion on five or more days in the last 30 days.

Among pregnant women ages 15-44, nearly 12% admit to drinking at least some alcohol during the previous month, which may put the fetus at risk for fetal alcohol syndrome (FAS), the leading cause of mental retardation in the US. Four percent of pregnant women report illicit drug use; the rate is even higher, at 15.5%, among pregnant women ages 15-17.

"There is a lot moral judgment around the use of alcohol and drugs, especially during pregnancy," said Anne D. Lyerly, MD, chair of ACOG's Committee on Ethics. "We want to emphasize that drug and alcohol dependence are medical issues and that physicians have an obligation to ask patients about use and to facilitate referral for appropriate treatment." Brief physician advice has been unequivocally shown to be powerful and feasible in the office setting.

Heavy drinking carries a higher risk of heart and liver complications for women than men and the alcohol-associated mortality rate for women is 50-100 times higher than it is for men. Illegal drug use also has major physical, social, and mental health consequences for women, including increased rates of STDs such as hepatitis and HIV, as well as depression, domestic violence, poverty, and significant prenatal and neonatal complications.

According to ACOG, federal government warnings about the need to abstain from alcohol use in pregnancy were first issued in 1984. ACOG has recommended screening for alcohol early in pregnancy since 1977.

"Routinely asking our patients, both pregnant and nonpregnant, about substance abuse is imperative to improving the overall health of women and their families," said Dr. Lyerly. "Once identified, women should be referred to treatment. And treatment, rather than punishment, is key." Punitive measures may endanger trust in the physician-patient relationship, place the ob-gyn in an adversarial relationship with the patient, and conflict with the physician's obligation to help patients.

Physicians should capitalize on the skills of social workers, nurses, and other staff to develop a list of treatment resources for patients. Patients with substance abuse problems should be treated with dignity and respect in order to foster a trusting, therapeutic relationship. Physicians should protect confidentiality, whenever possible, within the requirements of legal obligations by informing patients, in advance, what information can and cannot be protected.

Committee Opinion #422, "At-Risk Drinking and Illicit Drug Use: Ethical Issues in Obstetric and Gynecologic Practice," is published in the December 2008 issue of Obstetrics & Gynecology.

The American College of Obstetricians and Gynecologists is the national medical organization representing over 52,000 members who provide health care for women.