ACOG Committee Opinion
Number 422, December 2008
(Replaces No. 294, May 2004)


Committee on Ethics
PDF Format

At-Risk Drinking and Illicit Drug Use: Ethical Issues in Obstetric and Gynecologic Practice


Drug and alcohol abuse is a major health problem for American women regardless of their socioeconomic status, race, ethnicity, and age. It is costly to individuals and to society. Among 18–25-year-old women, 34% binge drink and 10% are heavy drinkers. These rates are lower among women aged 26 years or older (12.8% binge drink and 2.4% are heavy drinkers), but 6.3% of females aged 12 years or older have been classified as dependent on alcohol or illegal drugs (1). Heavy drinking (five or more drinks on one occasion on five or more days in the last 30 days) carries a higher risk of cardiac and hepatic complications for women than men. The alcohol-associated mortality rate is 50–100 times higher, and there is an increased burden of mental and physical disability (2). Among pregnant women aged 15–44 years, 11.8% admit to drinking some alcohol during the previous month (1), which may put the fetus at risk for fetal alcohol syndrome (FAS), the leading cause of mental retardation in the United States (3), and 0.7% reported heavy drinking (1). Maternal alcoholism is one of the leading preventable causes of fetal neurodevelopmental disorders (4). The economic costs of FAS for 2003 are estimated at $5.4 billion. Each case prevented is predicted to save $860,000 in lifetime direct and indirect costs (5). Illicit drug use has major physical and mental health consequences and is associated with increased rates of sexually transmitted infections in women, including hepatitis and human immunodeficiency virus (HIV), as well as depression, domestic violence, poverty, and significant prenatal and neonatal complications (6, 7). Overall, 10% of nonpregnant women and 4% of pregnant women report illicit drug use, but among pregnant women aged 15–17 years, the rate of use is 15.5% (8). Drug abuse costs are estimated at more than $180 billion yearly, including $605 million associated with health care costs for drug-exposed newborns (9).

As a result of intensive research in addiction over the past decade, evidence-based recommendations have been consolidated into a protocol for universal screening questions, brief intervention, and referral to treatment (10). The abstinence rate after drug abuse treatment (the treatment success rate) is now comparable to the level of medication compliance achieved in diabetes, hypertension, or other chronic illnesses (11). Brief physician advice has been shown unequivocally to be both powerful and feasible in a clinical office setting (10, 12, 13). The American Medical Association has endorsed universal screening (14), and health services researchers have determined that treatment saves $7 for every dollar spent (15). For these reasons, the American College of Obstetricians and Gynecologists (ACOG) collaborated with the Physician Leadership on National Drug Policy at Brown University to produce a slide–lecture presentation that addresses the identification and treatment of drug abuse (16). The presentation was distributed to obstetric–gynecologic clerkship and residency program directors and is available at http://www.acog.org.

Physicians have been slow to implement universal screening, and rates of detection and referral to treatment among nonpregnant women remain very low (17). Studies using simulated patients have demonstrated that women are less likely than men to be screened or referred (18, 19). Physicians lack accurate knowledge about physiology (ie, the equivalency of 1.5 oz of distilled spirits, 12 oz of beer or wine cooler, and 5 oz of wine), risk factors, and sex differences in problem presentation and treatment response (20). These knowledge gaps are compounded by state laws designed to criminalize drug use during pregnancy, by women's fears that they might lose custody of their children, and by the social stigma experienced by women who abuse alcohol or use illicit drugs (21, 22). In one study, for example, the physicians surveyed defined “light drinking” as an average of 1.2 drinks per day, an amount that exceeds the National Institute on Alcohol Abuse and Alcoholism's (NIAAA) guidelines for at-risk drinking for women (23). Furthermore, communicating about difficult issues takes time, requires skills, and is poorly reimbursed by procedure-oriented insurance coverage. Physicians are concerned about the consequences of legally mandated reporting, they lack familiarity with treatment resources, and they do not have the extensive time required to make an appropriate referral (11). These are all problems that must be solved in order to provide medically appropriate and ethically necessary care to women who engage in at-risk drinking or use illicit drugs.

Many physicians are understandably reluctant to take on a new responsibility in the context of time constraints and the already intense demands of practice (24), but there are practical measures that can be taken to make screening and brief intervention feasible for many, if not all, patients. Universal screening can be accomplished by adding a few questions to a standard intake form (see box “Substance Abuse Screening”). In an office practice, 1 in 20 patients will require further intervention (25, 26). Intervention for these patients can be started effectively in 5 minutes, as demonstrated in a busy academic emergency department setting (27). Referrals can be provided as a handout, with a nurse or office assistant available to help the patient make contact with treatment if desired. Because more women than men are hidden drinkers, and many see the obstetrician or gynecologist as their principle source of care, the opportunity to screen and intervene, with benefits to women, their children, and society, are too great to be missed. In recognition of the importance of this activity, Current Procedural Terminology and Healthcare Common Procedure Coding System (Medicare) codes have been established for screening, brief intervention, and referral performed by a physician or by an educator under the physician's direction. Further, the Centers for Medicare & Medicaid Services and many non-Medicare payers provide coverage for these services.

Substance Abuse Screening

Substance abuse presents complex ethical issues and challenges. This Committee Opinion proposes an ethical rationale for universal screening questions, brief intervention, and referral to treatment in both obstetric and gynecologic practice, offers a practical aid for incorporating such care (see box “BNI-ART Institute Intervention Algorithm”), and provides guidelines for resolving common ethical dilemmas that arise in the clinical setting.

Intervention Algorithm

The Ethical Rationale for Universal Screening Questions, Brief Intervention, and Referral to Treatment

Support for universal screening questions, brief intervention, and referral to treatment is derived from four basic principles of ethics. These principles are 1) beneficence, 2) nonmaleficence, 3) justice, and 4) respect for autonomy.

Beneficence

Therapeutic intent, or beneficence, is the foundation of medical knowledge, training, and practice. Experts at the NIAAA and the National Institute on Drug Abuse confirm that addiction is not primarily a moral weakness, as it has been viewed in the past, but a “brain disease” that should be included in a review of systems just like any other biologic disease process (28). A medical diagnosis of addiction requires medical intervention in the same manner that a diagnosis of diabetes requires nutritional counseling or therapeutic agents or both. Positive behavior change arises from the trust implicit in the physician– patient relationship, the respect that patients have for physicians' knowledge, and the ability of physicians to help patients see the links between substance use behaviors and real physical consequences. Brief physician advice has been shown to be as effective as conventional treatment for substance abuse and can produce dramatic reductions in drinking and drug use, improved health status, and decreased costs to society (10, 13, 15, 17, 29–31). The Center for Substance Abuse Prevention has now implemented more than 147 projects for pregnant and postpartum women and their children (32), and there are several different successful models for prevention and treatment for women and their families: AR-Cares (34), Choices (35), SafePort (36), Early Start (37), and the Mom/ Kid Trial (38).

Given this capacity for dramatic improvement in health status, physicians have an obligation to be therapeutic—in this case to learn the techniques of screening and brief intervention—and to inform themselves as they would if a new test or therapy were developed for any other recognized disease entity. The practice of universal screening questions, brief intervention, and referral to treatment falls well within the purview of the obstetrician–gynecologist's role as a provider of primary care to women and has potential for major impact on recognized obstetric and gynecologic outcomes. Furthermore, if the topic is raised respectfully, the physician–patient relationship may be substantially enhanced, even if no substantive changes in lifestyle are achieved immediately. Therapy is called “patient care” because both physicians and patients recognize and value the commitment of the medical profession to engage in a nurturing relationship in the course of providing carefully selected therapeutic modalities. Nurturance of healthy behaviors through universal screening questions, brief intervention, and referral to treatment is, thus, part of the traditional healing role and an appropriate focus for the obstetrician–gynecologist's role as a primary care provider.

Nonmaleficence

The obligation to do no harm, or nonmaleficence, also applies to universal screening questions, brief intervention, and referral to treatment. Medical care can be compromised if physicians are unaware of a patient's alcohol or drug abuse and, thus, miss related diagnoses or medication interactions with alcohol or illegal substances. If the problem is not identified, major health risks, such as HIV exposure and depression, also may be missed. These are examples of harms that may occur as a result of omission (nondetection of a serious problem). Furthermore, patients may be harmed when substance abuse is treated by a physician as a moral rather than medical issue (38). Women who abuse alcohol or use illicit drugs are more likely than men to be stigmatized and labeled as hopeless (39). In particular, physicians should avoid using humiliation as a tool to force change because such behavior is ethically inappropriate, engenders resistance, and may act as a barrier to successful treatment and recovery.

Justice

The ethical principle of justice governs access to care and fair distribution of resources. Elimination of health disparities and promotion of quality care for all are at the top of the list of goals for Healthy People 2010, the nation's health agenda. Injustice may result from a variety of sources.

Physicians may fail to apply principles of universal screening. When women are less likely to be screened or referred for treatment, their burden of disability is increased and health status decreased. The principle of justice requires that screening questions related to alcohol and drug use should be asked equally of men and women, regardless of race or economic status. It also requires that women be screened with tests such as TWEAK, T-ACE, or the NIAAA quantity and frequency questions that are more accurate in detecting women's patterns of substance abuse, which differ from those of men (40) (see box “Substance Abuse Screening”). Women, for example, are more likely to be hidden drinkers and frequently underreport alcohol use, especially during pregnancy. Tests to detect the problem in women must include questions about tolerance, which are not included in the most commonly used screen, CAGE, which has a sensitivity of only 75% compared with 87% for TWEAK (41).

Pregnant women are more likely to be screened than nonpregnant women. Although the vulnerability of the fetus is an important concern, the lives of nonpregnant women also have compelling value, and there is much evidence to suggest that women who abuse alcohol or use illicit drugs have coexisting or preexisting conditions (ie, mental health disorders, domestic violence, stress, childhood sexual abuse, poverty, and lack of resources) that put them in a vulnerable status (6, 42, 43). Universal application of screening questions, brief intervention, and referral to treatment eliminates these disparities related to justice.

Additionally, failure to diagnose and treat substance abuse with the same evidence-based approach applied to other chronic illnesses reduces patients' access to health services and resources. Justice requires that physicians counsel patients who have drug or alcohol problems and refer them to an appropriate treatment resource when available. No physician would withhold hypertension therapy because the medication adherence rate is only 60%. Physicians who detect the serious medical condition of addiction are equally obligated to intervene.

Respect for Autonomy

No person has a right to use illegal drugs, and a pregnant woman has a moral obligation to avoid the use of both illicit drugs and alcohol in order to safeguard the welfare of her fetus. At the same time, effective intervention with respect to substance abuse by a pregnant or a nonpregnant woman requires that a climate of respect and trust exist within the physician–patient relationship. Patients who begin to disclose behaviors that are stigmatized by society may be harmed if they feel that their trust is met with disrespect. Criticism and shaming statements actually increase resistance and impede change. Effective interventions, as summarized in the NIAAA Treatment Improvement Protocol number 35, are designed to increase motivation to change by respecting autonomy, supporting self-efficacy, and offering hope and resources (10).

Effective intervention also requires that universal screening questions, brief intervention, and referral to treatment be conducted with full protection of confidentiality. Patients who fear that acknowledging substance abuse may lead to disclosure to others will be inhibited from honest reporting to their physicians (44). A difficult dilemma is created by state laws that require physicians to report the nonmedical use of controlled substances by a pregnant woman or that require toxicology tests after delivery when there is evidence of possible use of a controlled substance (eg, Minnesota statutes 626.5561 and 626.5562). Although such laws have the goals of referring the pregnant woman for assessment and chemical dependency treatment if indicated and of protecting fetuses and newborns from harm, these laws may unwittingly result in pregnant women not seeking prenatal care or concealing drug use from their obstetricians. Although it is always appropriate for a physician to negotiate with a patient about her willingness to accept a medical recommendation, respect for autonomy includes respect for refusal to be screened.

Special Responsibilities to Pregnant Patients

Federal warnings about the need to abstain from alcohol use in pregnancy were first issued in 1984. The American College of Obstetricians and Gynecologists recommended screening early in pregnancy in its 1977 Standards for Ambulatory Obstetric Care, and a pamphlet was issued in 1982 entitled “Alcohol and Your Unborn Baby.” Screening during pregnancy was subsequently supported in a variety of documents and is recommended in a joint publication issued by ACOG and the American Academy of Pediatrics (AAP) (45). Although obstetricians report screening 97% of pregnant women for alcohol use, only 25% used any of the standard screening tools, and only 20% of those surveyed knew that abstinence is the only known way to avoid all four adverse pregnancy outcomes (spontaneous abortion, nervous system impairment, birth defects, and FAS). This is a particularly significant gap in knowledge because there is no level of alcohol use, even minimal drinking, that has been determined to be absolutely safe. More than one half of the respondents (63%) reported that they lacked adequate information about referral resources (46). Screening rates for illicit drugs are lower than for alcohol (89%, according to unpublished ACOG survey data).

Ethical issues related to beneficence and nonmaleficence and the ethics of care (47) are similar for pregnant and nonpregnant women and for women who do and do not have children. In each of these cases, universal screening questions, brief intervention, and referral to treatment enables physicians to collaborate with patients to improve their own health, reduce the likelihood of preterm birth and neonatal complications in both current and future pregnancies, and improve the parenting capacity of the family unit.

As noted previously, autonomy issues are particularly challenging in pregnancy. In a survey of obstetricians, pediatricians, and family practice physicians, more than one half of the respondents believed that pregnant women have a legal as well as moral responsibility to ensure that they have healthy newborns (48). Although 61% were concerned that fear of criminal charges would be a barrier to receiving prenatal care, more than one half supported a statute that would permit removal of children from any woman who abused alcohol or drugs (48). This position is particularly troubling because these physicians did not state that there needed to be evidence of physical or emotional neglect (adverse effects on basic needs and safety) for children to be so removed. Both ethical and legal perspectives require that the best interests of the child be served, which requires both protecting children and assisting their mothers to be healthy so as to provide an optimal situation for growth and development.

Physicians' concerns about mothers who abuse alcohol or drugs undoubtedly reflect a desire to protect children. However, recommended screening and referral protocols may be perceived as punitive measures when they are connected with legally mandated testing, or reporting, or both. Such measures endanger the relationship of trust between physician and patient, place the obstetrician in an adversarial relationship with the patient, and possibly conflict with the therapeutic obligation. If pregnant women become reluctant to seek medical care because they fear being reported for alcohol or illegal drug use, these strategies will actually increase the risks for the woman and the fetus rather than reduce the consequences of substance abuse. Furthermore, threats and incarceration have proved to be ineffective in reducing the incidence of alcohol or drug abuse, and removing children from the home may only subject them to worse risks in the foster care system (49). Treatment is both more effective and less expensive than restrictive policies (50), and it results in a mean net saving of $4,644 in medical expenses per mother–infant pair (51). Moreover, women who have custody of their children complete treatment at a higher rate than those who do not. Putting women in jail, where drugs may be available but treatment is not, jeopardizes the health of pregnant women and that of their existing and future children (52).

Referral to treatment, especially if combined with training in parenting skills, is the clinically appropriate recommendation, both medically and ethically (37). Criminal charges against pregnant women on grounds of child abuse have been struck down in almost all cases because courts have upheld the right to privacy, which includes the right to decide whether to have a child, the right to bodily integrity, and the right to “be let alone” (53), and have found that states could better protect fetal health through “education and making available medical care and drug treatment centers for women” (54). The United States Supreme Court recognized the importance of privacy to the physician–patient relationship when it ruled in 2001 to prohibit a public hospital from performing nonconsensual drug tests on pregnant women without a warrant and providing police with positive results (55). Despite more than a decade of efforts and the 1992 passage of a federal Alcohol Drug Abuse and Mental Health Administration Reorganization Act explicitly prohibiting pregnancy discrimination, few treatment programs focus on the needs of pregnant women. In the absence of appropriate and adequate drug treatment services for pregnant women, criminal charges on grounds of child abuse are unjust in that they indict women for failing to seek treatment that actually may not be available to them.

Justice issues also are problematic in that punitive measures are not applied evenly across sex, race, and socioeconomic status. Although several types of legal sanctions against pregnant women who abuse alcohol or drugs are being tested in the courts, there has been no attempt to impose similar sanctions for paternal drug use (56), despite the significant involvement of male partners in pregnant women's substance abuse (57). In a landmark study among pregnant women anonymously tested for drug use, drug prevalence was similar between African-American women and white women, but African-American women were 10 times more likely than white women to be reported as a result of positive screen results (58). Similar patterns of injustice have been noted for the types of drugs for which sanctions exist in the legal system. For example, mandatory incarceration and more severe penalties are applied to crack cocaine, which is primarily used by African Americans, than to powder cocaine or heroin, which is primarily used by whites. In the case of Ferguson v. City of Charleston, an overwhelming majority of the pregnant women arrested in the immediate postpartum period because of cocaine-positive drug screen results were African American. When the results of similarly drawn drug screens were positive for methamphetamine or heroin, which were more commonly used by white patients, physicians were more likely to refer to social services rather than to the courts (55).

Some physicians are reluctant to record information related to alcohol or drug abuse in medical records because of competing obligations. On the one hand, the physician may be concerned about nonmaleficence. Because medical records may not be safe from inappropriate disclosure despite federal and state privacy protections, the patient may experience real harms—such as job loss unrelated to workplace performance issues, eviction from public housing, or termination of insurance—if a diagnosis of dependency is recorded in the medical record. Although legal redress for harms that result from inappropriate transfer of information may be possible, it may not be feasible for a woman in straitened circumstances. On the other hand, the principle of beneficence often requires disclosure of information needed by the medical team to provide appropriate medical care. Without this disclosure, a physician treating the patient for a problem unrelated to pregnancy or an emergency department physician seeing the patient for the first time may miss a major complication related to substance abuse. Concerns about protection of confidentiality and nonmaleficence can be addressed most appropriately by including only medically necessary, accurate information in the medical record and informing the patient about the purpose of any disclosure.

Responsibilities to Neonates

The use of illicit drugs and alcohol during pregnancy has demonstrated adverse effects on the neonate, and these newborns are subsequently at risk for altered neurodevelopmental outcome and poor health status (59). Detection and treatment are essential precursors of appropriate therapeutic intervention in the immediate setting. Early recognition of parental substance abuse also may lead to interventions designed to decrease associated risks to a child's physical and psychologic health and safety (32–37). Doing so may obviate the necessity for placement in an already overburdened foster care system (60). Underrecognition of prenatal alcohol and drug effects is common, however (61). A toxicology screen and scoring for craniofacial features suggestive of FAS should be performed by the neonate's physician whenever clinically indicated. According to the AAP's statement on neonatal drug withdrawal (62), maternal characteristics that suggest a need for biochemical screening of the neonate include no prenatal care, previous unexplained fetal demise, precipitous labor, abruptio placentae, hypertensive episodes, severe mood swings, cerebrovascular accidents, myocardial infarction, and repeated spontaneous abortions. Infant characteristics that may be associated with maternal drug use include preterm birth, unexplained intrauterine growth restriction, neurobehavioral abnormalities, congenital abnormalities, atypical vascular incidents, myocardial infarction, and necrotizing enterocolitis in otherwise healthy term infants. The legal implications of testing and the need for maternal consent vary from state to state; therefore, physicians should be aware of local laws that may influence regional practice.

Biophysical testing, however, has major limitations (63–65). Both urine and meconium screens have a high rate of false-negative results because of factors related to the timing and amount of the last maternal drug use (for urine) and the failure to detect drug metabolites (for meconium). Hair is associated with a substantial false-positive rate because of passive exposure to minute quantities of illicit substances in the environment. Physicians and nurses often fail to recognize the physical manifestations of FAS (66). Maternal self-report of use or consent to testing, elicited using nonjudgmental, supportive interview techniques within a physician–patient relationship of trust, can thus provide the best information for guiding neonatal treatment and the best prognosis for family intervention. Maternal substance abuse does not by itself guarantee child neglect or prove inadequate parenting capacity (67, 68). Parenting skills programs, assistance with employment and housing issues, and access to substance abuse treatment have been shown to be successful support mechanisms for families of affected neonates, and these elements should be part of a comprehensive approach to substance abuse problems. If there is evidence to suggest the likelihood of neglect or abuse, referral to children's protective services may be indicated (69). A children's protective services referral should never be undertaken as a punitive measure, but with the aim of evaluating circumstances, protecting the child, and providing services to maintain or reunify the family unit if at all possible.

Special Issues for Girls and Young Women

Use of alcohol and illicit drugs among youth is prevalent, and studies that included both male and female youth indicate that age of first use is decreasing. Youth who begin drinking at age 14 years are at least three times more likely to experience dependence (using criteria from the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition) than those who delay drinking to age 21 years (70). Early onset of drinking increases the likelihood of alcohol-related unintentional injuries (71), motor vehicle crash involvement after drinking (72), unprotected intercourse (73), and getting into fights after drinking, even after controlling for frequency of heavy drinking, alcohol dependence, and other factors related to age of onset (74). A study among a large community sample of lifetime drinkers showed that those who reported first drinking at the ages of 11–14 years experienced a rapid progression to alcohol-related harm, and 16% developed dependence by age 24 years (75). Among youth aged 21–25 years surveyed in 2006, 27.3% drove under the influence of alcohol (1). The use of alcohol and illicit substances by youth and the impact of parental alcohol and substance use on children have adverse health outcomes (76, 77). Prevention (universal screening questions, brief intervention, and referral to treatment) has thus been described by leaders in obstetrics and gynecology and by pediatricians as a moral obligation (78). In 1993, the AAP developed substance abuse guidelines for clinical practice. These guidelines have now been refined and developed into competencies that provide practical direction for clinicians engaged in educating, supporting, and treating patients and families affected by substance abuse (79).

Confidentiality is as essential to the physician– patient relationship with children as it is with adults. Many state laws protect the confidentiality of minors with regard to substance abuse detection and treatment (79). Autonomy issues are of particular importance in the detection and treatment of substance abuse for adolescents, who are at a developmental stage in which it is a normative task to test new identities and engage in risk-taking in the process (80). The ACOG Committee on Adolescent Health Care lists the following key points concerning informed consent, parental permission, and assent (81):

  • Concern about confidentiality is a major obstacle in the delivery of health care to adolescents. Physicians should address confidentiality issues with the adolescent patient to build a trusting relationship with her and to facilitate a candid discussion regarding her health and health-related behaviors.
  • Physicians also should discuss confidentiality issues with the parent(s) or guardian(s) of the adolescent patient. Physicians should encourage their involvement in the patient's health and health care decisions and, when appropriate, facilitate communication between the two.
  • The right of a “mature minor” to obtain selected medical care has been established in most states.

In a document about testing for drugs of abuse in children and adolescents, AAP states that the goal of care is a therapeutic, rather than adversarial, relationship with the child and, therefore, makes the following recommendations (82):

  • Screening or testing under any circumstances is improper if clinicians cannot be reasonably certain that the laboratory results are valid and that patient confidentiality is ensured.
  • Diagnostic testing for the purpose of drug abuse treatment is within the ethical tradition of health care, and in the competent patient, it should be conducted noncovertly, confidentially, and with informed consent in the same context as for other medical conditions.
  • Parental permission is not sufficient for involuntary testing of the adolescent with decisional capacity.
  • Suspicion that an adolescent is using a psychoactive drug does not justify involuntary testing, and testing adolescents requires their consent unless 1) the patient lacks decision-making capacity or 2) there are strong medical indications or legal requirements to do so.
  • Minors should not be immune from the criminal justice system, but physicians should not initiate or participate in a criminal investigation, except when required by law, as in the case of court-ordered drug testing or child abuse reporting.

Guidance for Physicians

The health care system as it is currently constituted creates barriers to the practice of universal screening questions, brief intervention, and referral to treatment for alcohol and drug abuse. Because of a lack of medical school curricular content about addiction, physicians often are unfamiliar with screening procedures. Many institutions do not have appropriate protocols in place for intervention and referral. Time constraints, mandatory reporting laws, and lack of treatment resources may impede both screening and referral, and some of these problems may be beyond the ability of the individual physician to modify. Nevertheless, in fulfillment of the therapeutic obligation, physicians must make a substantial effort to:

  • Learn established techniques for rapid, effective screening, intervention, and referral, and practice universal screening questions, brief intervention, and referral to treatment in order to provide benefit and do no harm. Where possible, create a team approach to deal with barriers of time limitations, using the skills of social workers, nurses, and peer educators for universal screening questions, brief intervention, and referral to treatment. Use external resources (eg, hospital social worker, health department, addiction specialist) to develop a list of treatment resources. ty and respect in order to form a therapeutic alliance.
  • Protect confidentiality and the integrity of the physician–patient relationship wherever possible within the requirements of legal obligations, and communicate honestly and directly with patients about what information can and cannot be protected. In states where there are laws requiring disclosure, inform patients in advance about specific items for which disclosure is mandated.
  • Recognize that the most effective safeguard for children is treatment for family members who have a substance abuse problem.
  • Balance competing obligations carefully, consulting with other physicians or an ethicist if troubling situations arise.
  • Participate, whenever possible, in the policy process at institutional, state, and national levels as an advocate for the health care needs of patients.
  • Consider whether elements of personal beliefs and values may be resulting in biases in medical practice. Be aware that some physicians minimize the universality and impact of alcohol or prescription drug abuse to protect against evaluating their own alcohol or substance abuse problems. A physician who has questions about his or her own use should seek help.

Conclusion

Substance abuse is a common medical condition that can have devastating physical and emotional consequences for women and their children. The traditional role of healer, the contemporary role of medical expert, and the newer role of primary care physician all require obstetrician–gynecologists to develop an evidence-supported knowledge base about methods for detection and treatment of substance abuse. The close working relationship between the physician and the patient that is both a goal of care and a means to improved health outcomes offers tremendous potential to influence patients' lifestyles positively. Despite this relationship, physicians seldom practice universal screening because of a lack of appreciation of prevalence, misunderstandings about treatment success rates, unfamiliarity with treatment resources, and inadequate knowledge about sex differences in presentation and the course of the disease. However, common barriers to universal screening questions, brief intervention, and referral to treatment can and should be addressed. Physicians have an ethical obligation to learn and use techniques for universal screening questions, brief intervention, and referral to treatment in order to provide patients and their families with medical care that is state-of-the-art, comprehensive, and effective.

References

  1. Substance Abuse and Mental Health Services Administration. Results from the 2006 National Survey on Drug Use and Health: national findings. Office of Applied Studies, NSDUH Series H-32, DHHS Publication No. SMA 07-4293. Rockville (MD): SAMHSA; 2007. Available at: http://www.oas.samhsa.gov/nsduh/2k6nsduh/2k6Results.pdf 2k6Results.pdf. Retrieved January 23, 2008.
  2. Smith WB, Weisner C. Women and alcohol problems: a critical analysis of the literature and unanswered questions. Alcohol Clin Exp Res 2000;24:1320–1.
  3. Fetal alcohol exposure and the brain. National Institute on Alcohol Abuse and Alcoholism. Alcohol Alert 2000;50:1–6.
  4. Fetal alcohol syndrome and alcohol-related neurodevelopmental disorders. American Academy of Pediatrics. Committee on Substance Abuse and Committee on Children with Disabilities. Pediatrics 2000;106:358–61.
  5. Substance Abuse and Mental Health Services Administration. The financial impact of fetal alcohol syndrome. Rockville (MD): SAMHSA; 2003. Available at: http://www.fascenter.samhsa.gov/publications/cost.cfm. Retrieved May 28, 2008.
  6. Amaro H, Fried LE, Cabral H, Zuckerman B. Violence during pregnancy and substance use. Am J Public Health 1990; 80:575–9.
  7. Hutchins E, DiPietro J. Psychosocial risk factors associated with cocaine use during pregnancy: a case-control study. Obstet Gynecol 1997;90:142–7.
  8. Substance Abuse and Mental Health Services Administration. 2006 National Survey on Drug Use and Health: detailed tables. Rockville (MD): SAMHSA; 2007. Available at: http://www.oas.samhsa.gov/NSDUH/2k6NSDUH/tabs/Sect7peTabs48to93.htm. Retrieved May 28, 2008.
  9. Office of National Drug Control Policy. The economic costs of drug abuse in the United States, 1992-2002. Publication No. 207303. Washington, DC: Executive Office of the President; 2004. Available at: http://www.whitehousedrugpolicy.gov/publications/economic_costs/economic_costs.pdf. Retrieved January 23, 2008.
  10. Substance Abuse and Mental Health Services Administration. Enhancing motivation for change in substance abuse. Treatment Improvement Protocol (TIP) series; 35. Rockville (MD): SAMHSA; 1999.
  11. McLellan AT, Lewis DC, O'Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA 2000;284:1689–95.
  12. Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems: a review. Addiction 1993;88:315–35.
  13. Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL. Benefit-cost analysis of brief physician advice with problem drinkers in primary care settings. Med Care 2000;38:7–18.
  14. Blum LN, Nielsen NH, Riggs JA. Alcoholism and alcohol abuse among women: report of the Council on Scientific Affairs. American Medical Association. J Womens Health 1998;7:861–71.
  15. Hubbard RL, French MT. New perspectives on the benefit-cost and cost-effectiveness of drug abuse treatment. NIDA Res Monogr 1991;113:94–113.
  16. Chez RA, Andres RL, Chazotte C, Ling FW. Illicit drug use and dependence in women: a slide lecture presentation. Washington, DC: American College of Obstetricians and Gynecologists; 2002. Available at: http://www.acog.org/http://www.acog.org/~/media/Departments/Health%20Care%20for%20Underserved%20Women/DependenceinWoment.ashx. Retrieved January 23, 2008.
  17. Fleming MF, Barry KL. The effectiveness of alcoholism screening in an ambulatory care setting. J Stud Alcohol 1991;52:33–6.
  18. Wilson L, Kahan M, Liu E, Brewster JM, Sobell MB, Sobell LC. Physician behavior towards male and female problem drinkers: a controlled study using simulated patients. J Addict Dis 2002;21:87–99.
  19. Volk RJ, Steinbauer JR, Cantor SB. Patient factors influencing variation in the use of preventive interventions for alcohol abuse by primary care physicians. J Stud Alcohol 1996;57:203–9.
  20. Gearhart JG, Beebe DK, Milhorn HT, Meeks GR. Alcoholism in women. Am Fam Physician 1991;44:907–13.
  21. Gomberg ES. Women and alcohol: use and abuse. J Nerv Ment Dis 1993;181:211–9.
  22. Marcenko MO, Spense M. Social and psychological correlates of substance abuse among pregnant women. Soc Work Res 1995;19:103–9.
  23. Abel EL, Kruger ML, Friedl J. How do physicians define “light,” “moderate,” and “heavy” drinking? Alcohol Clin Exp Res 1998;22:979–84.
  24. Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health 2003;93:635–41.
  25. Bernstein J, Bernstein E, Tassiopoulos K, Heeren T, Levenson S, Hingson R. Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug Alcohol Depend 2005;77:49–59.
  26. Fleming M, Manwell LB. Brief intervention in primary care settings. A primary treatment method for at-risk, problem, and dependent drinkers. Alcohol Res Health 1999;23: 128–37.
  27. The impact of screening, brief intervention, and referral for treatment on emergency department patients' alcohol use. Academic ED SBIRT Research Collaborative. Ann Emerg Med 2007;50:699–710, 710.e1–6.
  28. National Institute on Drug Abuse. NIDA for teens: the science behind drug abuse: mind over matter. Bethesda (MD): NIDA; 2005. Available at: http://teens.drugabuse.gov/mom/index.asp. Retrieved January 23, 2008.
  29. Chang G, Goetz MA, Wilkins-Haug L, Berman S. A brief intervention for prenatal alcohol use: an in-depth look. J Subst Abuse Treat 2000;18:365–9.
  30. Bernstein E, Bernstein J, Levenson S. Project ASSERT: an ED-based intervention to increase access to primary care, preventive services, and the substance abuse treatment system. Ann Emerg Med 1997;30:181–9.
  31. Manwell LB, Fleming MF, Mundt MP, Stauffacher EA, Barry KL. Treatment of problem alcohol use in women of childbearing age: results of a brief intervention trial. Alcohol Clin Exp Res 2000;24:1517–24.
  32. Rosensweig MA. Reflections on the Center for Substance Abuse Prevention's pregnant and postpartum women and their infants program. Womens Health Issues 1998;8:206–7.
  33. Whiteside-Mansell L, Crone CC, Conners NA. The development and evaluation of an alcohol and drug prevention and treatment program for women and children. The AR-CARES program. J Subst Abuse Treat 1999;16:265–75.
  34. Ingersoll K, Floyd L, Sobell M, Velasquez MM. Reducing the risk of alcohol-exposed pregnancies: a study of a motivational intervention in community settings. Project CHOICES Intervention Research Group. Pediatrics 2003; 111: 1131–5.
  35. Metsch LR, Wolfe HP, Fewell R, McCoy CB, Elwood WN, Wohler-Torres B, et al. Treating substance-using women and their children in public housing: preliminary evaluation findings. Child Welfare 2001;80:199–220.
  36. Armstrong MA, Gonzales Osejo V, Lieberman L, Carpenter DM, Pantoja PM, Escobar GJ. Perinatal substance abuse intervention in obstetric clinics decreases adverse neonatal outcomes. J Perinatol 2003;23:3–9.
  37. Peterson L, Gable S, Saldana L. Treatment of maternal addiction to prevent child abuse and neglect. Addict Behav 1996;21:789–801.
  38. Boyd CJ, Guthrie B. Women, their significant others, and crack cocaine. Am J Addict 1996;5:156–66.
  39. Ehrmin JT. Unresolved feelings of guilt and shame in the maternal role with substance-dependent African American women. J Nurs Scholarsh 2001;33:47–52.
  40. Chang G, Wilkins-Haug L, Berman S, Goetz MA, Behr H, Hiley A. Alcohol use and pregnancy: improving identification. Obstet Gynecol 1998;91:892–8.
  41. Cherpitel CJ. Screening for alcohol problems in the emergency department. Ann Emerg Med 1995;26:158–66.
  42. Berenson AB, Wiemann CM, Wilkinson GS, Jones WA, Anderson GD. Perinatal morbidity associated with violence experienced by pregnant women. Am J Obstet Gynecol 1994;170:1760–6; discussion 1766–9.
  43. Sheehan TJ. Stress and low birth weight: a structural modeling approach using real life stressors. Soc Sci Med 1998;47:1503–12.
  44. Poland ML, Dombrowski MP, Ager JW, Sokol RJ. Punishing pregnant drug users: enhancing the flight from care. Drug Alcohol Depend 1993;31:199–203.
  45. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for perinatal care. 6th ed. Elk Grove Village (IL): AAP; Washington, DC: ACOG; 2007.
  46. Diekman ST, Floyd RL, Decoufle P, Schulkin J, Ebrahim SH, Sokol RJ. A survey of obstetrician-gynecologists on their patients' alcohol use during pregnancy. Obstet Gynecol 2000;95:756–63.
  47. Ethical decision making in obstetrics and gynecology. ACOG Committee Opinion No. 390. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:1479–87.
  48. Abel EL, Kruger M. Physician attitudes concerning legal coercion of pregnant alcohol and drug abusers. Am J Obstet Gynecol 2002;186:768–72.
  49. Drug exposed infants: recommendations. Center for the Future of Children. Future Child 1991;1:8–9.
  50. Rydell CP, Everingham SS. Controlling cocaine: supply versus demand programs. Santa Monica (CA): RAND; 1994.
  51. Svikis DS, Golden AS, Huggins GR, Pickens RW, McCaul ME, Velez ML, et al. Cost-effectiveness of treatment for drug-abusing pregnant women. Drug Alcohol Depend 1997;45:105–13.
  52. Paltrow LM. Punishing women for their behavior during pregnancy: an approach that undermines the health of women and children. In: Wetherington CL, Roman AB, editors. Drug addiction research and the health of women. Rockville (MD): National Institute on Drug Abuse; 1998. p. 467–501. Available at: http://www.nida.nih.gov/PDF/DARHW/467-502_Paltrow.pdf. Retrieved January 23, 2008.
  53. Olmstead v. U.S., 277 U.S. 438 (1928).
  54. Gostin LO. The rights of pregnant women: the Supreme Court and drug testing. Hastings Cent Rep 2001;31:8–9.
  55. Ferguson v. City of Charleston, 532 U.S. 67 (2001).
  56. Nelson LJ, Marshall MF. Ethical and legal analyses of three coercive policies aimed at substance abuse by pregnant women. Charleston (SC): Medical University of South Carolina, Program in Bioethics; 1998.
  57. Frank DA, Brown J, Johnson S, Cabral H. Forgotten fathers: an exploratory study of mothers' report of drug and alcohol problems among fathers of urban newborns. Neurotoxicol Teratol 2002;24:339–47.
  58. Chasnoff IJ, Landress HJ, Barrett ME. The prevalence of illicit-drug or alcohol use during pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida. N Engl J Med 1990;322:1202–6.
  59. Wagner CL, Katikaneni LD, Cox TH, Ryan RM. The impact of prenatal drug exposure on the neonate. Obstet Gynecol Clin North Am 1998;25:169–94.
  60. United States General Accounting Office. Foster care: health needs of many young children are unknown and unmet. GAO/HEHS-95-114. Washington, DC: GAO; 1995. Available at: http://www.gao.gov/archive/1995/he95114.pdf. Retrieved January 23, 2008.
  61. Stoler JM, Holmes LB. Under-recognition of prenatal alcohol effects in infants of known alcohol abusing women. J Pediatr 1999;135:430–6.
  62. Neonatal drug withdrawal. American Academy of Pediatrics Committee on Drugs [published erratum appears in Pediatrics 1998;102:660]. Pediatrics 1998;101: 1079–88.
  63. Lester BM, ElSohly M, Wright LL, Smeriglio VL, Verter J, Bauer CR, et al. The Maternal Lifestyle Study: drug use by meconium toxicology and maternal self-report. Pediatrics 2001;107:309–17.
  64. Millard DD. Toxicology testing in neonates. Is it ethical, and what does it mean? Clin Perinatol 1996;23:491–507.
  65. Ostrea EM Jr, Knapp DK, Tannenbaum L, Ostrea AR, Romero A, Salari V, et al. Estimates of illicit drug use during pregnancy by maternal interview, hair analysis, and meconium analysis. J Pediatr 2001;138:344–8.
  66. Lyons Jones K. Early recognition of prenatal alcohol effects: A pediatrician's responsibility. J Pediatr 1999;135:405–6.
  67. Davis SK. Comprehensive interventions for affecting the parenting effectiveness of chemically dependent women. J Obstet Gynecol Neonatal Nurs 1997;26:604–10.
  68. Smith BD, Test MF. The risk of subsequent maltreatment allegations in families with substance-exposed infants. Child Abuse Negl 2002;26:97–114.
  69. MacMahon JR. Perinatal substance abuse: the impact of reporting infants to child protective services. Pediatrics 1997;100(5):E1.
  70. Grant BF. The impact of a family history of alcoholism on the relationship between age at onset of alcohol use and DSM-IV alcohol dependence: results from the National Longitudinal Alcohol Epidemiologic Survey. Alcohol Health Res World 1998;22:144–7.
  71. Hingson RW, Heeren T, Jamanka A, Howland J. Age of drinking onset and unintentional injury involvement after drinking. JAMA 2000;284:1527–33.
  72. Hingson R, Heeren T, Zakocs R, Winter M, Wechsler H. Age of first intoxication, heavy drinking, driving after drinking and risk of unintentional injury among U.S. college students. J Stud Alcohol 2003;64:23–31.
  73. Hingson R, Heeren T, Winter MR, Wechsler H. Early age of first drunkenness as a factor in college students' unplanned and unprotected sex attributable to drinking. Pediatrics 2003;111:34–41.
  74. Substance Abuse and Mental Health Services Administration. The relationship between mental health and substance abuse among adolescents. National Household Survey on Drug Abuse Series: A-9. Rockville (MD): SAMHSA; 1999. Available at: http://www.oas.samhsa.gov/NHSDA/A-9/comorb3c.htm. Retrieved January 23, 2008.
  75. DeWit DJ, Adlaf EM, Offord DR, Ogborne AC. Age at first alcohol use: a risk factor for the development of alcohol disorders. Am J Psychiatry 2000;157:745–50.
  76. Alcohol use and abuse: a pediatric concern. American Academy of Pediatrics: Committee on Substance Abuse. Pediatrics 2001;108:185–9.
  77. Fishman M, Bruner A, Adger H Jr. Substance abuse among children and adolescents. Pediatr Rev 1997;18:394–403.
  78. Chasnoff IJ. Silent violence: is prevention a moral obligation? Pediatrics 1998;102:145–8.
  79. Adger H Jr, Macdonald DI, Wenger S. Core competencies for involvement of health care providers in the care of children and adolescents in families affected by substance abuse. Pediatrics 1999;103:1083–4.
  80. Donovan JE, Jessor R, Costa FM. Adolescent problem drinking: stability of psychosocial and behavioral correlates across a generation. J Stud
  81. American College of Obstetricians and Gynecologists. Health care for adolescents. Washington, DC: ACOG; 2003.
  82. Testing for drugs of abuse in children and adolescents. American Academy of Pediatrics Committee on Substance Abuse. Pediatrics 1996;98:305–7.

Copyright © December 2008 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.

Requests for authorization to make photocopies should be directed to: Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400.

At-Risk Drinking and Illicit Drug Use: Ethical Issues in Obstetric and Gynecologic Practice. ACOG Committee Opinion No.422. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008; 112:1449–60.