Substance Use

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• Tobacco is the leading preventable cause of premature death for women residing in the U.S. While smoking rates have declined tobacco remains a leading risk for women of childbearing age and beyond.
  • In 2018, 12% of adult women smoked cigarettes (CDC, 2019)
  • In the 2019, 4.1% of female high school students smoked cigarettes; 6.2% smoked cigars and 1.8% used smokeless tobacco (CDC, 2019)
  • Use of e-cigarettes has increased rapidly in the past few years, with large increases particularly among youth and young adults. In 2019, 27.4% of female high school students reported using e-cigarettes. (CDC, 2019)
• Alcohol-related mortality represents the third leading cause of preventable death for women in the U.S.
  • Based on 2011-2013 data from the Behavioral Risk Factor Surveillance System, among nonpregnant women aged 18‐44 years, 53.6% used alcohol in the past 30 days, as did 10.2% of pregnant women of the same age.
  • The prevalence of binge drinking in the past 30 days was estimated to be 18.2% among nonpregnant women and 3.1% among pregnant women.
• Non-medical use of prescription drugs is the third most common drug category of abuse after marijuana and tobacco. Accidental over-doses are amongst the most lethal consequences of prescription drug abuse.
  • Approximately 18 million Americans over the age of 11 used prescription painkillers for non-medical purposes in 2017.
  • In 2011, illicit drug use among women ages 12 and older was 6.5%: 4.9% reported using marijuana; 2.2% reported non-medical use of prescription drugs; 0.4% reported cocaine use and 0.3% reported using hallucinogens.

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• Pregnancy-related consequences from substance use can occur before the woman realizes she is pregnant
• Alcohol consumption in pregnancy is the only cause of fetal alcohol spectrum disorders (FASD) which are estimated to affect at least 1% of all births in the United States.
• Fetal alcohol syndrome (FAS) is the most severe and disabling form of FASD. FAS only occurs if the embryo is exposed to alcohol in the first 8 weeks of gestation.
• NO amount of alcohol has proven safe for every embryo/fetus.
• Many tobacco related complications of pregnancy (ectopic pregnancy, abnormal placentation, spontaneous abortion) occur or are determined in the earliest weeks of gestation.

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• Quick valid screening questions exist for use in the primary care setting to assess tobacco, alcohol, and other drug exposures.
• This NIDA tool (which includes an API link for EMR application) is available at www.drugabuse.gov/nmassist/. The NIDA Quick Screen is:
  • In the past year how often have you used the following?
    • 4 or more drinks of alcohol in a day (never, once or twice, monthly, weekly, daily or almost daily) [NOTE: since no amount of alcohol has been proven safe in pregnancy, women of childbearing potential should first be asked, “Do you ever drink beer, wine or mixed drinks?” before the first NIDA Quick Screen query]
    • Tobacco products (never, once or twice, monthly, weekly, daily or almost daily).
    • Prescription drugs for non-medical reasons (never, once or twice, monthly, weekly, daily or almost daily)
    • Illegal drugs (never, once or twice, monthly, weekly, daily or almost daily).

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• Evidence-based interventions appropriate to busy primary care practices are available to address these exposures include:
  • the 5A approach for women who screen positive for tobacco use (see below);
  • the SBIRT approach for women who screen positive for alcohol, non-medical use of prescription drugs and illegal (see below)
  • useful guidance is available at www.drugabuse.gov/nmassist/
• The 5A Approach
  • The “5-A” model has been shown to markedly increase cessation rates compared to no professional engagement. (ACOG Women’s Health Care, 3rd ed, 2007).
  • Use of the 5 A’s can take less than 3 minutes.
  • The model can be employed by physicians, nurses, dentists, psychologists, social workers and others:
    • Ask about tobacco use:
      • Identify and document tobacco use status for every patient at every visit. [This can be achieved by preparing the person who collects and records the vital signs to add a query on tobacco use to their routine responsibilities].
    • Advise to quit:
      • In a clear, strong, and personalized manner, urge every tobacco user to quit. This can be achieved by the primary care provider stating something such as “Quitting is one of the most important things you can do for your health today and long into the future”; if the woman desires pregnancy or is at risk for an unintended pregnancy, the provider might state, “Quitting is one of the most important things you can do for your own health, the health of any pregnancies in your future and the health of your infant and child”.
    • Assess willingness to make a quit attempt:
      • Is the tobacco user willing to make a quit attempt at this time? [This can be achieved by asking something direct such as “What would you like to do about your smoking?” If she is ready to quit, encourage her to set a quit date within the next 30 days].
    • Assist in quit attempt:
      • For the patient willing to make a quit attempt, offer medication and provide or refer for counseling or additional treatment to help the patient quit. [This can be achieved by the primary care provider doing this themselves or referring the woman to a specific person in the clinical setting who has been designated the office champion for smoking cessation. This person can them provide the woman with specific strategies for becoming tobacco free (including the options of using local support groups, the state’s quit line, the option of pharmacotherapy, etc.]. For patients unwilling to quit, reinforce the health benefits and indicate you and your staff are there to provide support when she is ready. If your office has appointed an office champion for smoking cessation, the clinician could suggest the patient meet with her to discuss personal barriers to becoming smoke free.
    • Arrange follow-up:
      • For the patient willing to make a quit attempt, arrange for follow-up contacts, beginning within the first week after the quit date. [The provider should develop a reminder system to assure follow-up occurs at the designated time; the follow-up call can be made by the office champion or some other person in the office; if the latter, the woman should be advised of who will be calling them]. For patients unwilling to make a quit attempt at the time, address tobacco dependence and willingness to quit at next clinic visit.
  • The SBIRT Approach:
    • “Screening, Brief Intervention, Referral to Treatment” (SBIRT) is designed for use by providers who do not specialize in addiction treatment.
    • The SBIRT approach is easy to learn relative to other behavioral treatment techniques. Go to http://www.bu.edu/bniart/sbirt-in-health-care/  to learn how to use this approach in your office.
    • SBIRT has been demonstrated to be effective in reducing risky alcohol use when provided by a primary care provider or other qualified health care professional (e.g. registered nurse, social worker, physician assistant).
      • Screening:  (Discussed in previous section) Quickly assesses the degree of alcohol use and identifies the appropriate level of treatment (brief intervention and/or referral).
      • Brief Intervention:
        • Focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change.
        • Gives information about their substance use based on their risk assessment scores.
        • Advises in clear, respectful terms to decrease or abstain from substance use.
        • Encourages to set goals to decrease substance use and to identify specific steps to reach those goals.
        • Teaches behavior change skills that will reduce substance use and limit negative consequences.
      • Referral to Treatment: 
        • Provides those identified as needing more extensive treatment with access to specialty care.
        • The primary care practice should have established linkages to specialty addiction care to allow quick and seamless referral for women who continue risky drinking behaviors or show signs of alcohol dependence.
        • Providers in underserved areas without appropriate referral resources should not be dissuaded from the “screening and brief intervention” portions of the approach as they have been demonstrated to have their own impact on individuals engaged in or approaching risky alcohol intake.

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• Be clear and direct in advising smoking cessation (e.g. “It is my recommendation for your health and the health of any children you may have that you stop using all tobacco. I know this is a difficult process but my team and I are here to help you when you are ready. Can we talk about your readiness and some strategies today?”
• Help women understand that supports for discontinuing smoking are greatest prior to conception and that some of the complications caused by tobacco may exercise their influence even before she is aware she is pregnant.
• Be very clear with every woman who indicates she ever drinks any beer, alcohol or wine that no amount of alcohol has been proven safe in pregnancy and that some of alcohol’s most severe harms occur before women are aware they have conceived — therefore, the safest choice is to avoid ALL alcohol if she might become pregnant (having intercourse without using an effective contraceptive method).
• The partners’ use of alcohol, tobacco, and illegal drugs may have a big influence on the woman’s ability to discontinue use. This influence should be explored in women reticent to discontinue use and in women who are unsuccessful.
• Second hand smoke is linked to compromised health outcomes for fetuses, newborns, children and adults. Therefore, strategies to reduce exposures, especially if partner smokes, should be explored for all women and especially for women planning to become pregnant. Possible strategies to diminish risk are:
  • No smoking in cars where woman is passenger
  • Making inside the home a “no smoking” zone
  • Avoiding enclosed spaces where smoking takes place such as parties, etc.

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• As with every primary care patient, ask every woman if she drinks alcohol and if she smokes cigarettes or uses other tobacco products (to ascertain exposure).
• Use a standard process to assess the degree to which women use tobacco, alcohol, prescription drugs for nonmedical reasons and illegal drugs. A screening tool that has been demonstrated to work well in busy primary care settings is the NIDA Quick Screen Tool:
  • In the past year how often have you used the following?
    • 4 or more drinks of alcohol in a day (never, once or twice, monthly, weekly, daily or almost daily)
    • Tobacco products (never, once or twice, monthly, weekly, daily or almost daily)
    • Prescription drugs for nonmedical reasons (never, once or twice, monthly, weekly, daily or almost daily)
    • Illegal drugs (never, once or twice, monthly, weekly, daily or almost daily).
• If a woman screens positive for any alcohol use:
  • Educate every woman that NO amount of alcohol has been proven safe for every woman-embryo-fetus and that the safest choice is to avoid ALL alcohol whenever there is a possibility she is or could become pregnant.
  • If woman screens positive for risky alcohol consumption use brief intervention and, when indicated, refer for therapy as outlined in the SBIRT approach (http://www.bu.edu/bniart/sbirt-in-health-care/sbirt-educational-materials/sbirt-videos/). After providing clear recommendations to the woman the brief interventions may be delegated to another appropriately trained member of your clinical team. Additional information on the SBIRT approach is available in the Substance Use Background section of this toolkit.
  • Advise woman that avoidance of pregnancy until she has achieved alcohol abstinence is her safest choice; provide contraceptive strategies as desired.
  • Women who disclose symptoms of addiction should receive a referral for more extensive treatment.
  • Arrange follow-up in your practice regarding status of alcohol use, timing of pregnancy and other health concerns.
• If a woman screens positive for tobacco use she has responded positively to the first A in the 5A model (Ask). Employ the remaining “A”s in the 5A model: (Additional information on the 5A model is available in the Substance Use Background section of this toolkit.)
  • Advise that while smoking cessation is very important for her own health, it is especially important given desires to become pregnant (associated with infertility, spontaneous abortion, abnormal placentation, prematurity, fetal death, sudden infant death syndrome).
  • Explain that the best quit rates result from a combination of counseling support and pharmacotherapy, the latter of which is not approved for use in pregnancy.
  • Assess willingness to quit
  • Assist to quit (may be delegated to another member of clinical team)
  • Arrange follow-up and support (may be delegated to another member of clinical team; every state has a smoking cessation support service which can offer telephone and other help to women as they quit using tobacco)
• If a woman screens positive for prescription drug use (for non-medical reasons) or for illegal drug use:
  • Advise woman that avoidance of pregnancy until she has achieved abstinence is her safest choice; provide contraceptive strategies as desired.
  • Use brief interventions such as the 5A or SBIRT. After providing clear recommendations to the woman, the brief interventions may be delegated to another appropriately trained member of your clinical team.
  • Additional information on the 5A approach and on SBIRT is available in the Substance Use Background section of this toolkit.
  • Refer women who disclose symptoms of addiction for more extensive treatment.
  • Arrange follow-up in your practice regarding status of drug exposures, timing of pregnancy and other health concerns.

ACOG: Women and Alcohol – Clinician Resources (2011).
http://www.acog.org/alcohol

ACOG (2008). Committee Opinion No. 422: At risk drinking and illicit drug use: ethical issues in obstetric and gynecologic practice. Obstetrics & Gynecology, 112(6), 1449-1460.

CDC: Preconception Clinical Care for Women: Exposures (2013).
http://www.cdc.gov/preconception/careforwomen/exposures.html .

NIDA Tool for Providers to Screen for Substance Exposures (2012).
www.drugabuse.gov/nmassist/ .

Boston Medical College: Resources/Videos on SBIRT.

http://www.bu.edu/bniart/sbirt-in-health-care/

The Brief Negotiated Interview and Active Referral to Treatment (BNI-ART) is an approach to engaging patients in discussing and addressing substance use. To access materials on using this approach go to the site listed above and then to “What we do” on the menu at the left; scroll to bottom to “SBIRT Materials” and Select BNI Tools. You can then review and download, if desired, “Adult BNI Algorithm”. The algorithm includes guidance on ways to:

• To raise the subject and ask permission to discuss
• Providing feedback on the screening tools results
• How to enhance motivation
• Negotiating and advising

US DHHS Substance Abuse and Mental Health Services Administration (SAMHSA) (2012). SBIRT Opportunities for Implementation and Points for Consideration.
http://www.integration.samhsa.gov/SBIRT_Issue_Brief.pdf

National Institute on Alcohol Abuse and Alcoholism (NIAAA): Helping Patients Who Drink Too Much: A Clinician’s Guide (2007).
http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm .

National Institute on Alcohol Abuse and Alcoholism (NIAAA): Helping Patients Who Drink Too Much: Pocket Guide (2007).
http://pubs.niaaa.nih.gov/publications/Practitioner/pocketguide/pocket_guide.htm (Pocket Version) .

Resource Guide: Screening for Drug Use in General Medical Settings (2012).
http://www.drugabuse.gov/publications/resource-guide .

5 A’s Intervention for Advising Patients on Smoking Cessation (2012)
http://www.etsu.edu/tips/participating/intervention.aspx.

You Quit Two Quit: Healthcare Professional Smoking Cessation Counseling (2013).
http://youquittwoquit.com/guide-for-counseling-women-who-smoke/

US DHHS Substance Abuse and Mental Health Services Administration (SAMHSA): Behavior Health Treatment Facility Locator (2013).
http://findtreatment.samhsa.gov/TreatmentLocator/faces/quickSearch.jspx

The Smoke Free Women website supported by the Federal Office of Women’s Health provides many excellent resources to all women about tobacco.

American College of Nurse-Midwives (ACNM): Smoking and Women’s Health: Tips of Why and How to Quit (2011). http://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000000730/Smoking%20and%20Women%27s%20Health%20-%20Tips%20on%20Why%20and%20How%20to%20Quit.pdf

You Quit Two Quit: Quitting Smoking for Pregnant Women and New Moms (2012). https://youquittwoquit.org/pregnant-women-mothers-and-families/ While this is a site relevant to pregnant women, many of the strategies are equally applicable to non-pregnant women, especially those planning to become pregnant.

March of Dimes: Alcohol During Pregnancy (2012). http://www.marchofdimes.com/pregnancy/alcohol-during-pregnancy.aspx

Centers for Disease Control. Alcohol Use in Pregnancy (2010). http://www.cdc.gov/ncbddd/fasd/alcohol-use.html.
This link explains the effects of alcohol on fetal development and infant outcomes.

US DHHS Substance Abuse and Mental Health Services Administration (SAMHSA): Behavior Health Treatment Facility Locator (2013).
http://findtreatment.samhsa.gov/TreatmentLocator/faces/quickSearch.jspx.

American College of Obstetricians and Gynecologists (2007). Guidelines for Women’s Health Care: A Resource Manual (3rd ed). Washington, DC: ACOG.

American College of Obstetricians and Gynecologists (2011). At-risk drinking and alcohol dependence: obstetric and gynecologic implications. Committee Opinion No. 496, Obstetrics & Gynecology 118 (2 Pt 1), 383-388.

CDC (2015). Alcohol use and binge drinking among women of childbearing age – United States, 2011–2013. Morbidity and Mortality Weekly Report; 64(37); 1042-1046.

CDC (2011). Vital Signs: Overdoses of Prescription Opioid Pain Relievers-United States, 1999-2008. Morbidity and Mortality Weekly Review. 60(43);1487-1492.

Creamer MR, Wang TW, Babb S, et al. Tobacco Product Use and Cessation Indicators Among Adults – United States, 2018. Morbidity and Mortality Weekly Report 2019, 68(45);1013-1019

Fiore, et al. (2008). Treating Tobacco Use and Dependence-2008 Update. Clinical Practice Guideline, Washington DC: U.S Department of Health and Human Services, Public Health Service. Available at: http://bphc.hrsa.gov/buckets/treatingtobacco.pdf

Floyd, R.L., Jack, B.W., Cefalo, R.C., et.al. (2008). The clinical content of preconception care: alcohol, tobacco and illicit drug exposures. American Journal of Obstetrics and Gynecology, 199 (6B), S333-339.

Marchetta, C.M., Denny, C.H., Floyd, R.L., Cheal, N.E., Sniezek, J.E., & McKnight-Eily, L.R.  (2010). Alcohol Use and Binge Drinking Among Women of Childbearing Age — United States, 2006–2010. Morbidity and Mortality Weekly Review(MMWR), 61:534-538.

Moos, M.K.., Dunlop, A.L., Jack, B.W., et. al. (2008). Healthier women, healthier reproductive outcomes: recommendations for the routine care of all women of reproductive age. American Journal of Obstetrics and Gynecology, 199 (6B), S80-289.

Moyer, V.A. & Preventive Services Task Force (2013). Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. Preventive Services Task Force Recommendation. Annals of Internal Medicine, 159 (3), 210-218.

Patrick. S.W., et al. (2012). Neonatal abstinence syndrome and associated health care expenditures: United States, 2000-2009. Journal of the American Medical Association (JAMA). 307(18):1934-40.

Thorogood M., Hillsdon M., Summerbell C. (2006). Changing behavior. Clinical Evidence (online) August 1, 2006.
Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907629

US DHHS Substance Abuse and Mental Health Services Administration (SAMHSA) (2012). Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville, MD: Substance Abuse and Mental Health Services Administration.

U.S. Preventive Services Task Force (2010). Counseling and interventions to prevent tobacco use and tobacco-caused disease in adults and pregnant women: reaffirmation recommendation statement. American Family Physician. 82(10):1266-1268.