Mandatory Drug-Testing in Pregnancy: Lesson learned.
I don’t know if you missed it but I did until tonight. We don’t have this in Canada but there have been some US states that have been doing so for the past while. You may find the following link very interesting that explains the positions of each state in regards to drug use in pregnancy. The intentions were good to protect the unborn child but the consequences to mother’s who tested positive were of great concern. While testing of mothers for drug use has been done off and on for years what made this different was that the confirmation of drug use was deemed to be a criminal offense with the results handed over to the police.
As this article from March 4th indicates the practice has been ongoing in Tennessee for at least a year and a pilot project was planned for Indiana this year. According to the article the situation in Tennessee came with some significant risk to the mother if found to have a positive screen.
“Lawmakers in Tennessee last year increased drug screenings of expectant mothers and passed a law allowing prosecutors to charge a woman with aggravated assault against her unborn baby if she was caught using illicit drugs. The penalty is up to 15 years in prison.”
The law may seem harsh and in my eyes is but it came in response to the tidal wave of drug addiction and neonatal withdrawal in the US as was identified in the article from the NEJM in 2015 entitled Increasing Incidence of the Neonatal Abstinence Syndrome in U.S. Neonatal ICUs. The impact on neonatal ICUs in the US can be seen in the following graphs which demonstrate not only the phenomenal rise in the incidence of the problem but in the second graph the gradually prolonging length of stay that these patients face. Aside from the societal issues these families face and the problems their infants experience, the swelling volume of patients NICUs have to contend with are quite simply overwhelming resources with time. Although I reside in Canada, it is the trend shown that likely motivated some states to adopt such a draconian approach to these mother-infant dyads.
There are so many questions that would arise from such an approach.
- What if a mother refuses testing as is the option in Indiana. Would Child and Family services be called simply on the suspicion?
- What if a mother received prescription opioids for chronic back pain or used an old prescription in the days before she was tested after a fall to ease her pain?
- Then there is the Sharapova situation where a mother could conceivably take a medication that she is unaware is on a list of “banned substances”. What about Naturopathic or herbal supplements that might test positive?
- Then what about false positive tests?
The ramifications of any of the above situations on the family unit could be devastating. Interestingly this year the courts in Indiana passed a law that prevents health care providers from releasing the results of such toxicology screens to police without a court order so indeed there would need to be suspicion. In the end though is it right?
Tennessee Sings a New Tune
As surprised as I was to hear about the situation in Tennessee just now I was equally surprised to come across a U.S. Supreme Court ruling handed down March 21st, 2001 that has ruled that subjecting mothers to such testing in hospitals is unconstitutional. This may disclose my ignorance of US law but I would have thought if the US Supreme Court says you cannot do something the states would follow along but at least in Tennessee that was not the case…until now.
March 23rd the law in Tennessee is changing as the state has chosen not to renew the legislation after a two year trial period saw about 100 women arrested. For more information on this decision see Assault Charges for Pregnant Drug Users Set to Stop in Tennessee.
Where do we possibly go from here?
I found this whole storyline shocking but I am taking some solace in knowing that this was a very limited experiment in one state. Neonatal abstinence is a problem and a big one at that. Criminalizing mothers though is not an effective solution and to me the solution to this problem will need to involve a preventative approach rather than one of punishment. A first step in the right direction will be to stem the tide of liberal use of prescription opioids in pregnancy as was suggested in the BMJ news release in January of this year. In the end if we as medical practitioners are freely prescribing such medications to the mothers we care for perhaps we should look in the mirror when pointing fingers to determine fault. So many of the mothers and the infants we care for may well be victims of a medical establishment that has not done enough to prevent the problem.
While screening women presenting to the hospital in labour or their newborns for that matter may seem like a wise choice, the request to procure a sample remains just that. It is a request and in collecting consent is needed. This was the advice at least I was given by the Canadian Medical Protective Association. It does create an interesting situation though in the mother who refuses to have her or her baby submit a urine specimen. Should we assume that a woman who refuses testing is in fact using an illicit substance or is she merely choosing to not have a wasted test when she knows that she is not using anything? How do we as practitioners view this decision and do we jump to a verdict of guilt immediately? I suspect the answer is that most of us would assume so especially if we are using a targeted screening approach in which we are only approaching those mothers who we suspect are using.
The secondary question becomes the “so what”? What I mean by this is how will our management change if we know or don’t know? If we suspect use and the baby is demonstrating signs of withdrawal abstinence scoring will start. If the source of the symptoms are unknown would we not just treat with phenobarbital to cover the possibility that there is more than one drug at play here? I used to be on the side of the argument that felt we had to know and therefore pushed for such screening but in the end will it really change our management? Not really.
This past month the American College of Obstetricians and Gynecologists (ACOG) issued a committee opinion on opioid use in pregnancy. The important points to share with you are the following and I would agree with each.
- Screening for substance use should be part of comprehensive obstetric care and should be done at the first prenatal visit in partnership with the pregnant woman. Screening based only on factors, such as poor adherence to prenatal care or prior adverse pregnancy outcome, can lead to missed cases, and may add to stereotyping and stigma. Therefore, it is essential that screening be universal
- Urine drug testing has also been used to detect or confirm suspected substance use, but should be performed only with the patient’s consent and in compliance with state laws.
- Breastfeeding should be encouraged in women who are stable on their opioid agonists, who are not using illicit drugs, and who have no other contraindications, such as human immunodeficiency virus (HIV) infection. Women should be counseled about the need to suspend breastfeeding in the event of a relapse.
The issue of consent seems to be firmly in place based on this position and as I mention above I think that is a good thing. The question of breastfeeding comes up frequently and it is good to see ACOG take a clear view on this as I have often thought that the benefits of the same plus the administration of small quantities of the drug in the milk may have a double benefit in reducing symptoms.