What are substance use disorders?
A substance use disorder (SUD) is a mental disorder in which there is uncontrolled use of a substance. The substance and the need to obtain the substance affects the individual’s brain and behaviour, often leading to harmful consequences. Symptoms can range from mild to severe. A person’s ability to function in their day-to-day life may be impacted.
Common substances of abuse include:
- Stimulants like cocaine, methamphetamine
- Sedatives, hypnotics, and anxiolytics (medicines for anxiety such as tranquilizers)
- Opioid painkillers, such as codeine and oxycodone, heroin
- PCP, LSD, and other hallucinogens
- Inhalants, such as paint thinners and glue
New drugs of abuse to be aware of include:
- Purple Heroin
- Grey Death
- Smurf Dope
Substance use disorders in the perinatal period
In addition to the general risks of alcohol use and illicit substance use, substance use can lead to following complications during pregnancy:
- Abruptio placentae
- Fetal death
- Intraamniotic infection
- Fetal growth restriction
- Fetal passage of meconium
- Premature labor and delivery
- Premature rupture of membranes
- Placental insufficiency
- Postpartum hemorrhage
- Septic thrombophlebitis
Little is known about how substances can impact an infant when a mother is breastfeeding and using illicit substances. Research has suggested the following:
- Marijuana usage may cause delayed motor development at 1 year.
- Alcohol may reduce milk ejection and may disrupt the infant’s sleep cycle.
- Nicotine from cigarettes enters breast milk and may impact development. Second-hand smoke also places infants at greater risk of SIDS.
- Methadone, and opiates may lead to sedation and respiratory depression in the nursing infant.
Which patients are at greater risk?
Obstetric patients that are at greater risk of a SUD:
- Late initiation into prenatal care or multiple missed prenatal visits.
- Personal diagnosis of a mental health disorder or family history of substance use disorders.
- A sudden change in behaviour, such as somnolence, intoxication, agitation, aggression, disoriented or erratic behaviour. Patients using substances may also exhibit symptoms of depression, including sleep disturbance, weight loss, and loss of interest in eating.
- High-risk sexual behaviour or history of sexually transmitted infections.
- Unstable home environment or relationship problems, including having a partner who has a substance use disorder.
- Past obstetric history of unexplained adverse events, such as abruptio placentae.
- Children not living with the mother or involved with child protection agencies.
- History of medical problems frequently associated with drug use disorders .
- Poor dentition.
- Encounters with law enforcement agencies because of violence or trauma, theft, or other issues (e.g., exchanging sexual acts for drugs).
Comorbid mental disorders
About half of individuals who experience a SUD during their lives will also experience a co-occurring mental disorder and vice versa. Among the more commonly seen diagnoses in patients with SUD are:
- Depressive disorders
- Bipolar disorder
- Anxiety disorders
- Post-traumatic stress disorder
- Eating disorders
- Attention deficit hyperactivity disorder
PEACE for Moms recommends universal screening for substance use disorders for all pregnant patients. All those identified with unhealthy use of alcohol or other substances should receive an intervention. Those who manage to abstain during pregnancy may have a return of their substance usage during the postpartum.
Screening tools can be handed to the patient in the waiting room or sent to the patient with their admission package.
You can open the discussion by asking questions about alcohol, illegal drugs, and prescription drug use.
- “Do you sometimes drink beer, wine, or other alcoholic beverages?”
- “How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?”
Diagnosis and assessment
When the possibility of an SUD has been established through screening, history, or one or more clinical findings, the patient should undergo a comprehensive assessment to determine:
- The pattern of use – Ask about the frequency of drug use, length of the most recent pattern of use, and time of last use. It may be helpful to ask about where, when, and with whom drugs are most often used.
- Route of administration – Oral, intranasal, subcutaneous injection (“skin popping”), or intravenous. If the patient has ever used a needle to inject drugs, ask about shared needles.
- Quantity used – For each substance, ask about the quantity used (ie, quantity of powder, unit of sale from a dealer). Terms used for drug units vary regionally, and it is helpful to be familiar with local drug slang and to ask for explanations of unfamiliar terms. The amount of money spent on a daily, weekly, or monthly basis for drugs may also be used to quantify drug use. However, information about the quantity of drug use is not helpful in determining if an individual has a use disorder and may not be accurately reported.
- Additional symptoms – Ask about the presence of tolerance and withdrawal symptoms specific to each substance used.
- Prior substance use treatment – Ask about participation in self-help programs such as Narcotics Anonymous (NA), prior detoxification or addiction treatment, and abstinence periods. What has been helpful in the past and what has been tried? How long was the longest period of abstinence or maintenance treatment without using illicit drugs?
- Comorbid psychiatric and medical conditions.
- The patient’s perception of their condition and readiness to change.
- Possible barriers and facilitators to reducing substance use.
It is not the intent of PEACE for Moms to turn its obstetric and primary care colleagues into substance abuse counsellors. If you are concerned a patient may be suffering from an SUD, please reach out to us to help you find services for your patients.
Treatment for substance use needs to be tailored to an individual’s specific combination of disorders and symptoms. The person’s age, the misused substance, the amount of substance used, the length of time it has been used, comorbid psychiatric diagnoses and psychosocial circumstances must all be considered when developing a treatment plan for the patient. Treatment may include attendance at a substance abuse treatment program, self-help programs like NA or AA, and psychotherapy. Pharmacotherapy may be used to detox the patient, or deter the further usage of drugs of abuse.