A C TA Obstetricia et Gynecologica
AOGS COM M ENT A R Y
What is substance abuse? And should we screen all pregnant women for substance abuse? ULRIK S. KESMODEL Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
Key words Substance abuse, opioids, cannabis, urine screening Correspondence Ulrik S. Kesmodel, Department of Obstetrics and Gynecology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark. E-mail: [email protected] Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article. Please cite this article as: Kesmodel US. What is substance abuse? And should we screen all pregnant women for substance abuse?. Acta Obstet Gynecol Scand 2015; 94: 451–452. Received: 24 February 2015 Accepted: 27 February 2015 DOI: 10.1111/aogs.12627 Abbreviations:
NSC, UK National Screening Committee.
In the February issue of Acta Obstetricia et Gynecologica Scandinavica Rausgaard et al. (1) presented results from a survey of 608 pregnant Danish women (88% of those invited) who accepted anonymous urinary screening for “substance abuse.” Gas chromatography/mass spectrometry was used to confirm that the tested substance was the cause of the positive result. Forty-two urine samples were positive on urinary screening, of which 22 samples proved positive for opioids or cannabis (3.6%), and 20 could not be confirmed. The authors suggested that urine screening and maternal self-reporting of substance abuse should be implemented at the time of nuchal translucency ultrasound scanning at 12 weeks of gestation (1). The article raises at least two interesting questions: Is urinary screening of all pregnant women for use of substances or drugs a good idea? And is any use of drugs necessarily abuse? The UK National Screening Committee (NSC) has set up a list of criteria for appraising the viability, effectiveness and appropriateness of a screening program (2). The criteria relate to the condition being screened for, the test,
the treatment, and the screening program itself. With respect to the test:
• •
It should be simple, safe, precise and validated. The distribution of test values in the target population should be known and a suitable cut-off level defined and agreed. • The test should be acceptable to the population. • There should be an agreed policy on the further diagnostic investigation of individuals with a positive test result and on the choices available to those individuals. Screening for use or abuse of substances presents several problems in relation to the test. First, the sensitivity of the test used is poor, as shown by the authors. It is problematic that the sensitivity differs so much from that reported by the manufacturer (52% compared with 98%). The test, or any other test, needs to be further validated in a neutral clinical setting to establish the actual performance of the diagnostic tool before considering implementation. Secondly, if the sensitivity is poor and many women are falsely accused of substance abuse, this is likely to lead to low participation in a screening program, which will not help the case for screening. Finally, the high and very commendable participation rate in the study by Rausgaard et al. (1) is likely to have been due to the anonymity offered. However, in clinical practice, screening will not be anonymous. This will also most likely lower the participation rate, especially among those with a problematic use of substances or drugs. Hence, it is likely that criteria 1–3 are not met by the current test. With respect to the screening program as a whole, the NSC suggests that:
• •
There should be evidence from high quality randomized controlled trials that the screening program is effective in reducing mortality or morbidity. There should be evidence that the complete screening program (test, diagnostic procedures, treatment/intervention) is clinically, socially and ethically acceptable to health professionals and the public.
ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 451–452
451
Substance abuse in pregnancy
• •
The benefit from the screening program should outweigh the physical and psychological harm (caused by the test, diagnostic procedures and treatment). There should be a plan for managing and monitoring the screening program and an agreed set of quality assurance standards.
There seem to be no randomized controlled trials evaluating the effects of a screening program for drug use, nor is there any evidence that a non-anonymous screening program is socially acceptable in the general population. In fact, if screening were to be introduced in connection with the ultrasound scan in gestational weeks 12–13, one might be worried that this would lower the participation rate of the prenatal screening program itself, i.e. involving the ultrasound scan (combined screening) at that time. Would that affect the number of fetuses currently diagnosed with Down’s syndrome at 12–13 weeks? If so, what screening procedure should be prioritized? Do women who are falsely accused of substance abuse, feel stigmatized? And if so, what effect does that have on the pregnancy? If implemented, how should the screening program be monitored? According to the NSC, ideally all of the criteria above and many more (2) should be met before screening for a condition is initiated. Currently, most of the above questions have not been answered and cannot currently be answered in relation to screening for substance abuse among pregnant women. It would seem appropriate to seek the answers before suggesting the initiation of a screening program. A final, but important question: What substances should be screened for? What constitutes abuse? Throughout the article, Rausgaard et al. explicitly use the term “substance abuse,” but no explicit definition is provided of what that entails. The urinary samples were screened for opiates, cannabis, benzodiazepines, amphetamine, methamphetamine, cocaine and methadone, so one may assume that use of and detection of these substances would have constituted abuse, whether legal or illegal. They also defined intake of >3 alcohol-containing drinks/week or ≥2 episodes of alcohol binge drinking during pregnancy as constituting possible abuse (1). The latter is interesting for several reasons. American gynecologists have been shown not to consider a mean
452
U.S. Kesmodel
intake of four to five drinks/week to be harmful (3), and only approximately 50% of Danish general practitioners and midwives believe that pregnant women should completely abstain from alcohol (4). In Australia only 57–67% of general practitioners and obstetricians and 41% of community nurses caring for pregnant women routinely asked pregnant women about alcohol use. The question has previously been raised whether alcohol use is synonymous with alcohol abuse (5). It has even been suggested that the well-known fetal alcohol syndrome could more appropriately be termed fetal alcohol abuse syndrome in order to better reflect the relation between that disorder and its etiology (6). Here the parallel question should be asked: Is substance use synonymous with substance abuse? The authors’ answer is clear: “We use the term substance abuse rather than the more adequate term substance use. . .” (1). But why use inadequate terminology? If we really want to opt for screening for substances and alcohol among pregnant women, perhaps we should start by defining our vocabulary. What is use? And when does use become abuse? References 1. Rausgaard NLK, Ibsen IO, Jørgensen JS, Lamont RF, Ravn P. The prevalence of substance abuse in pregnancy among Danish women. Acta Obstet Gynecol Scand. 2014;94:215–9. 2. UK National Screening Committee. Programme Appraisal Criteria. Available online at: http://screening.nhs.uk/criteria (accessed February 22, 2015). 3. 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. 4. Kesmodel US, Kesmodel PS. Alcohol in pregnancy: attitudes, knowledge and information practice among midwives in Denmark 2000 to 2009. Alcohol Clin Exp Res. 2011;35:2226–30. 5. Kesmodel U. Are users of alcohol in pregnancy necessarily alcohol abusers? Am J Obstet Gynecol. 2003;188:296–7. 6. Abel EL. Fetal alcohol abuse syndrome. New York: Plenum Press, 1998.
ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 451–452
AOGS COM M ENT A R Y
What is substance abuse? And should we screen all pregnant women for substance abuse? ULRIK S. KESMODEL Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
Key words Substance abuse, opioids, cannabis, urine screening Correspondence Ulrik S. Kesmodel, Department of Obstetrics and Gynecology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark. E-mail: [email protected] Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article. Please cite this article as: Kesmodel US. What is substance abuse? And should we screen all pregnant women for substance abuse?. Acta Obstet Gynecol Scand 2015; 94: 451–452. Received: 24 February 2015 Accepted: 27 February 2015 DOI: 10.1111/aogs.12627 Abbreviations:
NSC, UK National Screening Committee.
In the February issue of Acta Obstetricia et Gynecologica Scandinavica Rausgaard et al. (1) presented results from a survey of 608 pregnant Danish women (88% of those invited) who accepted anonymous urinary screening for “substance abuse.” Gas chromatography/mass spectrometry was used to confirm that the tested substance was the cause of the positive result. Forty-two urine samples were positive on urinary screening, of which 22 samples proved positive for opioids or cannabis (3.6%), and 20 could not be confirmed. The authors suggested that urine screening and maternal self-reporting of substance abuse should be implemented at the time of nuchal translucency ultrasound scanning at 12 weeks of gestation (1). The article raises at least two interesting questions: Is urinary screening of all pregnant women for use of substances or drugs a good idea? And is any use of drugs necessarily abuse? The UK National Screening Committee (NSC) has set up a list of criteria for appraising the viability, effectiveness and appropriateness of a screening program (2). The criteria relate to the condition being screened for, the test,
the treatment, and the screening program itself. With respect to the test:
• •
It should be simple, safe, precise and validated. The distribution of test values in the target population should be known and a suitable cut-off level defined and agreed. • The test should be acceptable to the population. • There should be an agreed policy on the further diagnostic investigation of individuals with a positive test result and on the choices available to those individuals. Screening for use or abuse of substances presents several problems in relation to the test. First, the sensitivity of the test used is poor, as shown by the authors. It is problematic that the sensitivity differs so much from that reported by the manufacturer (52% compared with 98%). The test, or any other test, needs to be further validated in a neutral clinical setting to establish the actual performance of the diagnostic tool before considering implementation. Secondly, if the sensitivity is poor and many women are falsely accused of substance abuse, this is likely to lead to low participation in a screening program, which will not help the case for screening. Finally, the high and very commendable participation rate in the study by Rausgaard et al. (1) is likely to have been due to the anonymity offered. However, in clinical practice, screening will not be anonymous. This will also most likely lower the participation rate, especially among those with a problematic use of substances or drugs. Hence, it is likely that criteria 1–3 are not met by the current test. With respect to the screening program as a whole, the NSC suggests that:
• •
There should be evidence from high quality randomized controlled trials that the screening program is effective in reducing mortality or morbidity. There should be evidence that the complete screening program (test, diagnostic procedures, treatment/intervention) is clinically, socially and ethically acceptable to health professionals and the public.
ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 451–452
451
Substance abuse in pregnancy
• •
The benefit from the screening program should outweigh the physical and psychological harm (caused by the test, diagnostic procedures and treatment). There should be a plan for managing and monitoring the screening program and an agreed set of quality assurance standards.
There seem to be no randomized controlled trials evaluating the effects of a screening program for drug use, nor is there any evidence that a non-anonymous screening program is socially acceptable in the general population. In fact, if screening were to be introduced in connection with the ultrasound scan in gestational weeks 12–13, one might be worried that this would lower the participation rate of the prenatal screening program itself, i.e. involving the ultrasound scan (combined screening) at that time. Would that affect the number of fetuses currently diagnosed with Down’s syndrome at 12–13 weeks? If so, what screening procedure should be prioritized? Do women who are falsely accused of substance abuse, feel stigmatized? And if so, what effect does that have on the pregnancy? If implemented, how should the screening program be monitored? According to the NSC, ideally all of the criteria above and many more (2) should be met before screening for a condition is initiated. Currently, most of the above questions have not been answered and cannot currently be answered in relation to screening for substance abuse among pregnant women. It would seem appropriate to seek the answers before suggesting the initiation of a screening program. A final, but important question: What substances should be screened for? What constitutes abuse? Throughout the article, Rausgaard et al. explicitly use the term “substance abuse,” but no explicit definition is provided of what that entails. The urinary samples were screened for opiates, cannabis, benzodiazepines, amphetamine, methamphetamine, cocaine and methadone, so one may assume that use of and detection of these substances would have constituted abuse, whether legal or illegal. They also defined intake of >3 alcohol-containing drinks/week or ≥2 episodes of alcohol binge drinking during pregnancy as constituting possible abuse (1). The latter is interesting for several reasons. American gynecologists have been shown not to consider a mean
452
U.S. Kesmodel
intake of four to five drinks/week to be harmful (3), and only approximately 50% of Danish general practitioners and midwives believe that pregnant women should completely abstain from alcohol (4). In Australia only 57–67% of general practitioners and obstetricians and 41% of community nurses caring for pregnant women routinely asked pregnant women about alcohol use. The question has previously been raised whether alcohol use is synonymous with alcohol abuse (5). It has even been suggested that the well-known fetal alcohol syndrome could more appropriately be termed fetal alcohol abuse syndrome in order to better reflect the relation between that disorder and its etiology (6). Here the parallel question should be asked: Is substance use synonymous with substance abuse? The authors’ answer is clear: “We use the term substance abuse rather than the more adequate term substance use. . .” (1). But why use inadequate terminology? If we really want to opt for screening for substances and alcohol among pregnant women, perhaps we should start by defining our vocabulary. What is use? And when does use become abuse? References 1. Rausgaard NLK, Ibsen IO, Jørgensen JS, Lamont RF, Ravn P. The prevalence of substance abuse in pregnancy among Danish women. Acta Obstet Gynecol Scand. 2014;94:215–9. 2. UK National Screening Committee. Programme Appraisal Criteria. Available online at: http://screening.nhs.uk/criteria (accessed February 22, 2015). 3. 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. 4. Kesmodel US, Kesmodel PS. Alcohol in pregnancy: attitudes, knowledge and information practice among midwives in Denmark 2000 to 2009. Alcohol Clin Exp Res. 2011;35:2226–30. 5. Kesmodel U. Are users of alcohol in pregnancy necessarily alcohol abusers? Am J Obstet Gynecol. 2003;188:296–7. 6. Abel EL. Fetal alcohol abuse syndrome. New York: Plenum Press, 1998.
ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 451–452
