Substance Use and Use Disorders in Pregnancy in Two Cultural Contexts: The United States and Afghanistan
Substance Use and Use Disorders in Pregnancy in Two Cultural Contexts: The United States and Afghanistan
- Elisabeth Johnson, Elisabeth JohnsonUniversity of North Carolina at Chapel Hill
- Abdul Subor MomandAbdul Subor MomandUniversity of North Carolina at Chapel Hill
- and Hendree E. JonesHendree E. JonesUniversity of North Carolina System
Women in all countries use substances, and for some women, such use continues during pregnancy. When substance use impairs life functioning and becomes a use disorder, regardless of the type of substance, effective treatments are available (e.g., medication to treat opioid and alcohol use disorders and behavioral approaches to treat tobacco, stimulant, and other substances). In two very different cultural contexts, the United States and Afghanistan, pregnant women face common issues when using substances and seeking and/or receiving help for problem substance use. In both countries, and around the world, many women who have substance use disorders during and after pregnancy face tremendous stigma and discrimination. Yet, similarly, in both the United States and Afghanistan, when women receive integrated medical and behavioral health care for their substance use disorder, they and their children have more optimized opportunities for healthy life outcomes.
- Sexual & Reproductive Health
It is highly unusual for women to initiate substance use when they know that they are pregnant. The more common scenario is for women using substances to become pregnant. Surveys in the United States consistently show that many women stop using substances once they are aware of their pregnancy (Substance Abuse and Mental Health Data Archive, 2012; Substance Abuse and Mental Health Services Administration, 2018a). However, some women are not able to reduce or cease use without assistance. Reduction and/or cessation of substance use is important as different types of substance use problems during pregnancy pose numerous potential adverse consequences for both the woman and her fetus.
Substance use and problem use are health issues and often occur within a complex life context of social, environmental, and internal stressors. Individuals who misuse substances often do so in response to internal and external conditions in an attempt to change how they feel. Such a desire to feel differently does not change based on pregnancy status. For some women who use substances, pregnancy can create more stress, guilt, shame, and stigma than not being pregnant. For some women using substances, pregnancy can also be an opportunity to make significant behavioral changes to benefit themselves and their child.
This article summarizes the epidemiology of types of substance use during pregnancy; screening and treatments for substance use disorders (SUDs); labor, delivery, and postpartum management; and other care considerations from two different cultural perspectives—that of the United States and Afghanistan. These two countries were selected because both have a high prevalence of substance use and both represent two extremes in terms of security, income, and infrastructure development.
Epidemiology of Substance Use
Globally, approximately 275 million people (5.6%) between the ages of 15 and 64 reported using an illicit substance such as opiates, cocaine, cannabis, amphetamines and other psychoactive agents at least once in 2016 (United Nations Office on Drugs and Crime, 2017). Of these people, 31 million exhibit the criteria of a SUD. In the United States, in 2018, one in five people (19.4% of the population) 12 years of age and older reported illicit substance use in the preceding month (Substance Abuse and Mental Health Services Administration, 2019). The most commonly used legal substances in the United States are tobacco and alcohol. Among the illicit substances used, cannabis was the most commonly reported (43.5 million people or 15.9% of the population). An estimated 10.3 million people misused opioids (9.9 million reporting pain relief misuse and 808,000 reporting heroin use). Of those surveyed, approximately 5.5 million (2.0% of the population) used cocaine, 5.1 million (1.9% of the population) misused prescription stimulants, 6.4 million (2.4% of the population) misused prescription tranquilizers, and 1.9 million used methamphetamine (Substance Abuse and Mental Health Services Administration, 2019). Overall, in the United States, men are more likely than women to use almost all types of illicit substances (Center for Behavioral Health Statistics and Quality, 2017). However, men and women often use substances differently, need different tailored treatment approaches, and can have unique obstacles to effective treatment.
Although vastly different from the United States in terms of security, income, and infrastructure development, Afghanistan is also facing significant challenges related to substance use among its population. The Afghanistan National Drug Use Survey (ANDUS) conducted in 2015 reported that one in three households has been affected by substance use, with 11% of the country’s population testing positive for an illicit substance and 7% of the population reporting actively using opioids (Morales, 2016). As in the United States, cannabis use is common in Afghanistan (approximately 5% of the population report use), but unlike in the United States, reported alcohol use is very low (approximately 0.2% of the population) due to religious laws against such use (World Health Organization, 2011). As in the United States, more men than women in Afghanistan report using substances (16.1% of men vs. 9.5% of women) (Morales, 2016). Initiation of substance use differs between men and women. Afghan women (52.2%) reported that, at first use, the substance was provided to them by a family member (e.g., husband). Women may feel pressured to use in order to maintain a relationship (Afghanistan Independent Human Right Commission, 2008).The majority of women reporting substance use are of childbearing age (Central Statistics Organization, Ministry of Public Health, & ICF International, 2016; Nikoo et al., 2015). The limited national substance use treatment resources combined with severe gender inequality results in women have limited access to substance use treatment (Momand & Jones, 2020). Therefore, there is a high probability that those reporting substance use continue to use substances during pregnancy.
Alcohol Use in Pregnancy
More American women are drinking alcohol than in previous years. From 2006 to 2010, data show that any alcohol use and binge drinking in the past 30 days among pregnant women aged 18–44 years was 7.6 and 1.4%, respectively (Centers for Disease Control and Prevention, 2012). However, from 2011 to 2013, any alcohol use and binge drinking in the past 30 days among pregnant women ages 18–44 increased to 10.2% and 3.1%, respectively (Tan, Clark, Cheal, Sniezek, & Kann, 2015). Further, compared to nonpregnant women who reported binge drinking from 2011 to 2013, pregnant women had a significantly higher frequency of binge drinking (3.1 vs. 4.6%, respectively), with self-reported alcohol use among pregnant women increasing from 1 in 13 to 1 in 10, respectively (Tan et al., 2015). Non-Hispanic white, college graduates age 35 years or older have the highest prevalence of late-pregnancy alcohol use. They are least likely to be screened for and counseled about their alcohol use (Cheng, Kettinger, Uduhiri, & Hurt, 2011). In contrast to the relatively high rates of alcohol use by women of childbearing age in the United States, Afghan women report less use due to religious tenets and more limited alcohol access (e.g., Morales, 2016).
Alcohol is a known teratogen that can cause fetal alcohol spectrum disorder. Research has shown that, in general, pregnant women are motivated to change their drinking behavior (O’Connor & Whaley, 2007). Several studies have demonstrated that screening and brief behavioral counseling interventions with women reporting high-risk drinking reduce the incidence of alcohol-exposed pregnancies (Carson et al., 2010; O’Connor & Whaley, 2007). Women with alcohol use disorders need specialized counseling and medical support during withdrawal and stabilization, with priority access to withdrawal management and treatment. Additionally, if a woman continues to use alcohol during pregnancy, providers should discuss and encourage strategies to reduce harm and bolster healthy coping and resilience. In the United States, the American College of Obstetricians and Gynecologists (ACOG) has put forward that obstetrics and gynecology (OBGYN) providers should screen all women in order to identify those whose drinking is at a risky level, encourage healthy behaviors, provide education, and refer patients who have alcohol use disorders for professional treatment (American College of Obstetricians and Gynecologists, 2011).
With most substances, the postpartum period carries an increased risk for returning to active substance use. Providers should support women with alcohol use problems at postpartum and follow-up visits by asking women about life stresses, how they are coping, and if they need any treatment or other supports (Substance Abuse and Mental Health Services Administration, 2009). Alcohol consumption may create additional challenges in the postpartum period as it has been shown to reduce milk consumption by the infant and is associated with altered growth, sleep patterns, and psychomotor patterns in the newborn (Mennella & Garcia-Gomez, 2001; Mennella & Pepino, 2008).
In the United States, public health campaigns have helped to decrease the rates of smoking in women of childbearing age. This has led to a concomitant drop in the number of pregnant women using tobacco (Colman & Joyce, 2003). From 1990 to 2006, the rate of reported smoking during pregnancy dropped from 18.4% of women to 13.2%. Data also suggest that pregnancy may motivate women to stop smoking, with 46% of women who identified as smokers prior to pregnancy quitting just before or during their pregnancy (Colman & Joyce, 2003). Although these trends are encouraging, there are subpopulations of women in which the decrease in smoking rates has not been as dramatic. These include adolescent females, non-Hispanic white women with less education, and American Indian women (Martin et al., 2009; Tong, Jones, Dietz, D’Angelo, & Bombard, 2009). When measurements of tobacco use include vaping or electronic cigarettes, rates are actually increasing in the United States. This is concerning because vapes and electronic cigarettes are not any safer than traditional tobacco use during pregnancy (Kuehn, 2019).
In Afghanistan, the majority of women (94%) do not report tobacco use (Central Statistics Organization, Ministry of Public Health, & ICF International, 2016). However, similar to the United States, smoking rates are higher for younger Afghan women, with 8.1% of females between 13 and 15 years of age reporting tobacco use (World Health Organization, 2010). The most common tobacco products used in Afghanistan are snuff, cigarettes, water pipes, and cigars. There are limited data on the rates of smoking during pregnancy.
Smoking during pregnancy carries multiple risks for women, the developing fetus, and the neonate. Smoking has been shown to increase the risk of intrauterine growth restriction, placenta previa, placental abruption, changes in maternal thyroid function, premature rupture of membranes, low birthweight, and perinatal mortality (Castles, Adams, Melvin, Kelsch, & Boulton, 1999; McDonald et al., 2008; Spinillo et al., 1994; U.S. Department of Health and Human Services, 2004). Smoking can be directly attributed as the cause of 5–8% of preterm deliveries of low birthweight infants, 5–7% of preterm-related infant deaths, and between 23 and 34% of the cases of sudden infant death syndrome (SIDS) (Dietz et al., 2010). The risks of nicotine exposure for the fetus extend to pregnant women who report using smokeless tobacco, resulting in rates of premature birth of low birthweight infants at comparable rates to women who smoked during pregnancy (e.g., Hurt et al., 2005). It is also known that the risks associated with fetal exposure to smoking during pregnancy continue into infancy and childhood with affected children having a higher incidence of asthma, ear infections, colic, and childhood obesity (Li, Langholz, Salam, & Gilliland, 2005; Sondergaard, Henriksen, Obel, & Wisborg, 2001; von Kries, Toschke, Koletzko, & Slikker, 2002).
In the United States, cannabis sativa (marijuana) use ranges from 2% to 5% in the general population, but these numbers rise to 15%–28% among young, urban, socioeconomically disadvantaged women (e.g., El Marroun et al., 2011; Passey, Sanson-Fisher, D’Este, & Stirling, 2014; Schempf & Strobino, 2008; van Gelder et al., 2010). With a growing number of states legalizing cannabis for medicinal or recreational use, these numbers are likely to continue to increase. Many women report believing that cannabis use is relatively safe during pregnancy and they often find that it is less expensive than tobacco (Passey et al., 2014). Similar to the United States, the use of cannabis in Afghanistan is common among men (6.1%) and women (1.5%) (Morales, 2016). However, there is a scarcity of data on cannabis use among Afghan women during pregnancy.
It is challenging to identify the specific effects of cannabis on pregnancy and the developing fetus because cannabis may be mixed with other substances when consumed (van Gelder et al., 2010). Cannabis does not appear to cause structural anatomic defects in humans, but the long-term effects on growth and development have been challenging to measure because oftentimes additional psychosocial issues confound outcomes (Fergusson et al., 2002; Ostrea et al., 1997). There are insufficient data from the last two decades to determine the safety of maternal cannabis use during breastfeeding. In the absence of these data, cannabis use is discouraged by most major health-related organizations (American Academy of Pediatrics, 2012; American College of Obstetricians and Gynecologists, 2015; Reece-Stremtan & Marinelli, 2015; see Ryan, Ammerman, & O’Connor, 2018).
The impact of the opioid epidemic in the United States has been well documented. The increasing number of childbearing-age women regularly using opioids combined with a high rate of unintended pregnancy has led to increased exposure during pregnancy. Between 1999 and 2014, the United Sates experienced a fourfold increase in the rate of opioid use disorder (OUD) at delivery hospitalization (Haight et al., 2018). This is consistent with trends during 1999 to 2013 reporting the increased national incidence of neonatal abstinence syndrome (NAS), the clinical diagnosis made when an infant experiences withdrawal symptoms secondary to in utero opioid exposure (Patrick, Davis, Lehmann, & Cooper, 2015).
With the increase in the number of pregnant women diagnosed with OUD, more pregnant women have been seeking treatment services for OUD. Between 1992 and 2012, while the overall proportion of women admitted for substance use treatment remained stable at 4%, the admissions of pregnant women who reported prescription opioid use increased from 2 to 28% (Martin et al., 2015). Throughout the United States, pregnant women with OUD face unique barriers including inadequate insurance and the underutilization of medication-assisted treatment (Hand, Short, & Abatemarco, 2017). Other barriers include fear of losing child custody, not wanting to be away from children/partner during treatment, concern about stigma/privacy, and lack of child care and transportation (Frazer et al., 2019). Like women in Afghanistan, mental health issues are common and urgent (e.g., 24% of U.S. women in treatment for OUD report lifetime suicide attempts) (Eggleston et al., 2009).
Opioids are the most common substance used in Afghanistan. One study found that 83.21% of women reporting a SUD had a primary diagnosis of OUD (Afghanistan Independent Human Right Commission, 2008). Another study found that of women in treatment for SUDs, 72% reported opium or heroin use in the month before treatment (Abadi et al., 2012). Women who enter treatment in Afghanistan face incredible discrimination and stigma and suffer multiple human rights violations and mental health issues due to their circumstances. For example, among a sample of women, the majority of whom were in treatment for OUD, 91% reported social functioning challenges, 50% reported recent human rights violations, 41% reported suicide ideation, and 27% reported having attempted suicide at least once a month prior to entering treatment (Abadi et al., 2012). SUD treatment for women in Afghanistan is relatively new and although the country is progressing in providing treatment, specialized treatment for women as well as for pregnant women is still a challenge. The available data show that, on average, among those receiving comprehensive SUD, women, as compared to men, showed greater reductions in substance use and crime and greater social functioning (Abadi et al., 2015).
In the United States, between 4% and 5% of the general population report the use of benzodiazepines (Olfson, King, & Schoenbaum, 2015). Compared to men, women are twice as likely to be prescribed benzodiazepines (Olfson et al., 2015; Thangathural, Roby, & Roffey, 2010). With increasing benzodiazepine-prescribing prevalence, the rates of misuse have also risen. Between 2.3 and 18% of people in the United States report misusing benzodiazepines for nonmedical reasons at some point in their lifetime (Becker, Fiellin, & Desai, 2007; Simoni-Wastila, Ritter, & Strickle, 2004).
It has been estimated that up to 15% of pregnant women in the United States have a diagnosis of anxiety disorder with or without comorbid depression (Dennis, Falah-Hassani, & Shiri, 2017; Falah-Hassani, Shiri, & Denn, 2017). For severe anxiety disorders, benzodiazepines may be used for both their anxiolytic and sedative effects and their rate of use in pregnancy ranges from 1 to 4% (Hanley & Mintzes, 2014; Lacroix et al., 2009; Riska, Skurtveit, Furu, Engeland, & Handal, 2014).
In Afghanistan, a higher number of women than men report using benzodiazepines and other sedatives for nonmedical purposes. Women are more likely to report taking substances orally while men report a preference for smoking (United Nations Office on Drugs and Crime, 2014). The increased number of women reporting use may, in part, be because in Afghanistan, taking substances by mouth usually signifies that the substances are being used for a medical purpose. Thus, women can reduce the stigma that is associated with substance use.
Although benzodiazepines have the potential to interfere with the brain maturation of the developing fetus, there is not definitive evidence that their use in pregnancy has long-term adverse effects on the development of young children (Lupattelli et al., 2019). A systematic review conducted by the National Institute for Health and Care Excellence (2020), which included nine observational studies with more than a million subjects, suggested that benzodiazepines are not associated with an increased risk of congenital malformation. Earlier research had shown similar results (Eros, Czeizel, Rockenbauer, Sorensen, & Olsen., 2002; Koren, Pastuszak, & It, 1998). Additionally, benzodiazepine use does appear to be associated with other pregnancy complications, including an increased risk of miscarriage, preterm birth, and low birthweight (National Institute for Health Care Excellence, 2020; Wikner, Stiller, Bergman, Asker, & Källén, 2007). It is known that benzodiazepine use during pregnancy that is proximal to delivery can contribute to neonatal withdrawal symptoms, including apnea, hypothermia, hyperreflexia, irritability, tremor, and diarrhea (Newport, Fernandez, Juric, & Stowe, 2009).
Cocaine and Other Stimulants
The 2017 National Survey on Drug Use and Health found that 8,000 women (0.4%) in the United States reported using cocaine in the previous month. This is an increase from 2,000 (0.1%) in 2016 (Substance Abuse and Mental Health Services Administration, 2018b). Cocaine is a substance that readily crosses the placenta as well as the fetal blood–brain barrier. It is thought that vasoconstriction is the primary mechanism causing fetal and/or placental damage (Plessinger & Woods, 1993). A systematic review and meta-analysis of 31 studies that evaluated the relationship between maternal cocaine exposure and adverse perinatal outcomes found that cocaine use significantly increases the risk of preterm birth, low birthweight, delivery of an infant who is small for gestational age, and placental abruption (Bandstra et al., 2004; Gouin, Murphy, Shah, & Knowledge Synthesis Group, 2011).
The prevalence of methamphetamine use during pregnancy is estimated to range from 0.7% to 4.8% in highly areas of concentrated use (Arria et al., 2006; Derauf et al., 2007). Worldwide, use also continues to grow (United Nations Office on Drugs and Crime, 2017). In Afghanistan, it was found that 0.5% of adults (0.9% men and 0.1% women) tested positive for amphetamines (Morales, 2016). Among women in treatment for SUDs in Afghanistan, 22% reported using methamphetamines in the month before treatment (Abadi et al., 2012). Methamphetamine exposure during pregnancy has been associated with perinatal morbidity and mortality. Similar to cocaine, methamphetamine exposure is associated with an increased risk of fetal growth restriction, gestational hypertension, placental abruption, and preterm birth (Gorman, Orme, Nguyen, Kent, & Caughey, 2014; Nguyen et al., 2010).
The World Health Organization (WHO) and ACOG recommend early and universal screening for alcohol and/or substance use that prompts a brief behavioral intervention and, if warranted, a referral for treatment (Committee on Obstetric Practice, 2017; World Health Organization, 2014). This recommendation is driven by the acknowledgement that patients typically do not spontaneously disclose alcohol and/or substance use (Committee on Obstetric Practice, 2017). It has also been found that substance use is often underreported, even among women who have regular urine toxicology screens (Garg et al., 2016).
Universal verbal screening should be completed using validated questionnaires and conversations with patients. Urine toxicology is not an effective screening methodology because a positive test result is not diagnostic of either the presence or the severity of a substance use disorder (American College of Obstetrics and Gynecology, 2015). While there are screening instruments for alcohol use disorder in pregnancy, there is no consensus on a single screening instrument for other prenatal SUDs (DeVido, Bogunovic, & Weiss, 2015). There are several available screening instruments with evidence for use in pregnancy. These include the Substance Use Risk Profile-Pregnancy (SURP-P) (Yonkers et al., 2010), the Wayne Indirect Drug User Screen (WIDUS) (Ondersma et al., 2012), a five-item screener with questions related to car, relax, alone, forget, friends, and trouble (CRAFFT) (Chang et al., 2011) and the 5Ps (parents, peers, partner, pregnancy, past) (Kennedy, Finkelstein, Hutchins, & Maho, 2004). Ondersma and colleagues compared each of these screening instruments with the National Institute on Drug Abuse (NIDA) Quick Screen (Ondersma et al., 2019). Of note, the Quick Screen has not been validated among pregnant women but has shown efficacy with other populations. The authors found that no one tool demonstrated consistent performance better than another tool. Thus, until a single, superior-performing tool is available, a variety of brief, validated tools can be used.
Substance use disorders can be classified as mild, moderate, or severe (American Psychiatric Association, 2013). The level of care needed by pregnant women with SUDs is determined by a variety of factors, including the availability of services, a woman’s willingness to seek care, the type of substance used, the severity of use, and the potential implications for perinatal outcomes (American Society of Addiction Medicine, 2017). For pregnant women with OUD, existing guidelines recommend treatment with either methadone or buprenorphine, as these medications may mitigate the significant risks to the mother and fetus from illicit substance use and recurring withdrawal (American College of Obstetrics and Gynecology, 2012; Substance Abuse and Mental Health Services Administration, 2018a; World Health Organization, 2014). Stimulants, cocaine, and cannabis do not have the benefit of medication as an adjunctive therapy.
The early identification and referral of pregnant women with SUDs to treatment is critical (Tuten, Fitzsimons, Hochheimer, Jones, & Chisolm, 2018). For pregnant women with a diagnosis of a SUD, the most dramatic improvement in perinatal outcomes is achieved when prenatal care is combined with substance use treatment including medication-assisted treatment. The benefits of an integrated model of care (see Table 1 for examples) have been demonstrated and include increased prenatal visit attendance, increased length of gestation, and decreased length of hospitalization for newborns (Committee on Healthcare for Underserved Women, American Society of Addiction Medicine, & American College of Obstetricians and Gynecologists, 2017). These models improve patient satisfaction and participation in care and ultimately reduce costs for the healthcare system (Committee on Healthcare for Underserved Women, American Society of Addiction Medicine, & American College of Obstetricians and Gynecologists, 2017).
Table 1. Examples of Model Substance Use Disorder Treatment Programs in the United States
Child and Recovering Mothers (CHARM) (Meyer et al., 2012)
To improve access to medication-assisted treatment for pregnant women by combining these services with prenatal care
Improved perinatal outcomes
Women begin treatment at an earlier gestational age
Improved birthweight, reduced treatment for neonatal abstinence syndrome More women who were able to parent their newborns
Comprehensive care coordination
Provide medication-assisted treatment
Kaiser Permanente Northern California (Goler et al., 2008)
To improve access to medication-assisted treatment for pregnant women by combining these services with prenatal care
Improved prenatal care
Decreased preterm rate low birthweight, and decreased incidence of placental abruption
Placement of a licensed substance abuse expert and program specialist in the OB/GYN department
Universal screening of women for substance use
Educating all providers and patients about the effects of substances, alcohol and tobacco use in pregnancy
Pregnant women treatment program in Toronto, Montreal, and Vancouver (Ordean et al., 2015)
To incorporate comprehensive addiction and obstetric care at a single-access site
Reduced substance use
Lower incidence of obstetrical complications
Less pharmacological treatment of neonatal abstinence syndrome
Promoting maternal–newborn contact
Rooming-in and breastfeeding to decrease the severity of neonatal abstinence syndrome and the need for pharmacological treatment of neonatal abstinence syndrome
Dartmouth-Hitchcock Medical Center Perinatal Addiction Program (Goodman, 2015)
To address the numerous barriers that women face to obtaining treatment for substance use disorder
Improved coordination of care
Increased satisfaction among both pregnant women and providers
Improved prenatal visit attendance
Increased patient satisfaction
The program brings together multiple services in one place at one time
UNC Horizons Program (Jones et al., 2015)
To overcome numerous barriers that pregnant and parenting women face to obtaining treatment for substance use disorder and improve substance treatment and child outcomes
Birth outcomes better than that national average
Over 70% of completers being employed o
Over 90% of completes with positive child protective services outcomes
Continuum of services from residential for mothers and children
Outpatient individual and group counseling
OB/GYN, psychiatry services, maternal child therapy, peer support, case management, and child care
In the general population of pregnant Afghan women, only 18% report attending the recommended four or more prenatal visits (Central Statistics Organization, Ministry of Public Health, & ICF International, 2016). In the postpartum period, 40% of women and 9% of newborns receive recommended postnatal health checkups within two days of delivery. There is not any specific survey data available about pregnancy management for women with SUDs. Given that many affected women live in poverty, their access to prenatal care may be limited. Additionally, medication-assisted treatment with methadone or buprenorphine for OUD is not common practice in Afghanistan. Pregnant women with an OUD are most commonly offered symptomatic treatment with management for withdrawal symptoms.
Medications Used for the Treatment of SUDs
There are effective medications to treat alcohol, tobacco, and OUD in adults. As of the early 21st century, there are no available medications to treat cannabis, cocaine, or methamphetamine use disorders.
Alcohol Use Disorder
In the United States, the Food and Drug Administration (FDA) approved three medications for the treatment of alcohol use disorders: acamprosate, disulfiram, and naltrexone. There are limited data on the safety of these medications during pregnancy. Therefore, it is recommended that when deciding whether to use a medication to assist in the treatment of alcohol use disorder in a pregnant woman, the risks posed by the use of alcohol must be carefully weighed against the risks of these medications (DeVido et al., 2015). In Afghanistan, reported alcohol use is low. Thus, treatments for this disorder are not a focus.
Acamprosate reduces alcohol withdrawal symptoms by normalizing the brain systems that are disrupted by chronic alcohol consumption. It is believed that this primarily involves the modulation of glutamate neurotransmission. This modulation may lessen postacute withdrawal symptoms and help to maintain sobriety (Rösner et al., 2010). Animal studies suggest possible teratogenic effects of acamprosate. However, there are no human trial data to support this assertion (DeVido et al., 2015).
Disulfiram works for the treatment of alcohol use disorder by inhibiting an enzyme involved in the metabolism of alcohol. The inhibition causes an unpleasant reaction if alcohol is consumed after taking the medication (Niederhofer & Staffen, 2003). There is limited evidence that suggests that the use of disulfiram in the first trimester may increase the risk of limb reduction anomalies and other fetal malformations (Helmbrecht & Hoskins, 1993; Nora, Nora, & Blu, 1977). It is important to note that these data are not consistent (DeVido et al., 2015). An additional concern is that the disulfiram–alcohol reaction can result in severe acute autonomic instability, including hypertension. The severity of this reaction can also be considered an increased risk to both the pregnant woman and her fetus. However, no studies have assessed the magnitude of this risk (DeVido et al., 2015).
Naltrexone is a mu-opioid receptor antagonist. It has been shown to decrease the risk of heavy drinking by decreasing alcohol-induced euphoria (Rösner et al., 2010). The medication is available in both oral tablets and long-acting injectable preparations. There are no published studies on the safety or efficacy of either formulation of naltrexone for use in the treatment of alcohol use disorder in pregnant women. Naltrexone’s other indication is in the treatment of OUDs.
Nicotine Use Disorder
The U.S. Preventive Task Force (USPTF) has decided that there is not sufficient evidence to recommend that providers advise medications to assist with smoking cessation efforts for pregnant women (U.S. Preventive Task Force, 2015). Providers should ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco (U.S. Preventive Task Force, 2015).
Endorsed by the WHO and the United States, the standard of care for pregnant women diagnosed with OUD includes opioid agonist treatment with either buprenorphine or methadone (Substance Abuse and Mental Health Services Administration, 2018a; World Health Organization, 2014). Early research in the field, as well as a Cochrane review of studies comparing the efficacy of the two medications, has not identified one medication as superior to the other (Jones et al., 2010; Jones, O’Grady, Malfi, & Tuten, 2008; Substance Abuse and Mental Health Services Administration, 2018a). In Afghanistan, methadone is highly limited and buprenorphine is not yet available.
Methadone is a full mu-opioid agonist and, in the United States, only administered in federally accredited opioid treatment programs, where patients receive their daily dose under direct observation. Full access to treatment hinges upon geographic availability of services. It is estimated that 88.6% of large rural counties across the county lack a sufficient number of opioid treatment programs (Dick et al., 2015). Additional barriers include access to reliable transportation and the ability to take the time needed to travel to the treatment clinic. In Afghanistan, the use of methadone has remained in a pilot phase for decades and is restricted to men at risk for HIV/AIDS (Ruiseñor-Escudero et al., 2015).
For pregnant women with an OUD, the use of methadone in conjunction with a comprehensive program of behavioral health services has been associated with a reduction in pregnancy complications, higher birthweights, decreased fetal mortality, and increased adherence to prenatal care (Jones et al., 2010). Women with OUD who have had previous treatment success with the use of methadone but have had an inadequate response to buprenorphine may benefit from the increased structure of daily dosing and may be good candidates for methadone use during pregnancy (Jones et al., 2014b). The aims of pharmacotherapy with methadone are to alleviate withdrawal symptoms and reduce cravings (Boyars & Guille, 2018; Klaman et al., 2017). Women who make the choice to take methadone during pregnancy should be counseled that, to date, research has not shown that methadone can cause an increase in birth defects (Committee on Obstetrics, 2017) and appears to have a minimal long-term impact on neurodevelopment impact (American Society of Addiction Medicine, 2015).
Buprenorphine is a partial mu-opioid receptor agonist and is available in both office-based treatment settings and through opioid treatment programs in the United States. It is not available in Afghanistan to treat OUD. Healthcare providers (physicians, nurse practitioners, physician assistants, certified nurse midwives) who want to provide this option for their patients must complete a training program and obtain the appropriate waiver from the Drug Enforcement Administration. Although the number of prescribers in the United States has increased, many areas of the country, particularly rural ones, lack access to a waivered provider (Andrilla, Coulthard, & Larson, 2017). An additional challenge is the recommendation that patients who receive buprenorphine attend a minimum of once-a-month counseling sessions. This recommendation is challenging to fulfill considering that there is a lack of OUD providers and certified substance use disorder counselors in the United States (Jones et al., 2015).
Numerous studies have demonstrated the safety of buprenorphine in pregnancy. Early research by Jones and colleagues compared maternal and fetal outcomes of women on either methadone or buprenorphine. The authors found no significant differences in maternal outcomes. Although the proportions of babies having neonatal opioid withdrawal (also known as neonatal abstinence syndrome) were not statistically different, the amount of medication needed to treat an infant prenatally exposed to buprenorphine was significantly less than the amount needed to treat prenatally methadone-exposed infants (Jones et al., 2010).
Women who have had a previous positive response to treatment with buprenorphine, have access to a buprenorphine prescriber, and have had an inadequate response to methadone may all be good candidates for treatment with buprenorphine (Jones et al., 2014a, 2014b). An additional consideration is the feasibility of a woman continuing to access buprenorphine treatment in the postpartum period. Historically, it was recommended that pregnant women be offered buprenorphine monotherapy because of theoretical concerns about the fetus related to withdrawal from the naloxone component of the combination product. Available data do not support this concern and both medications should be available as options for treatment (Nguyen et al., 2018; Substance Abuse and Mental Health Services Administration, 2018a).
The initiation of buprenorphine treatment requires that a patient be in moderate withdrawal prior to starting the medication. This reduces the risk of acute opioid withdrawal. Women need to avoid using short-acting opioids for 12–24 hours and long-acting opioids for 36 to 48 hours prior to induction. Withdrawal should be assessed using a validated opioid withdrawal scale (Substance Abuse and Mental Health Services Administration, 2018a).
Naltrexone, an opioid antagonist, has been approved for the treatment of OUD. Available data are not sufficient for this treatment for its initiation during pregnancy to be recommended. No specific adverse pregnancy outcomes appear linked to the use of naltrexone in pregnancy (Jones et al., 2013). More research is needed to establish the safety and efficacy of naltrexone so that pregnant women are able to access the full range of medications used for the treatment of OUD.
Assisted Opioid Withdrawal
Like the WHO (2014), the United States, had several major professional societies, including ACOG and ASAM, endorse opioid agonist pharmacotherapy with either methadone or buprenorphine as the treatment of choice for pregnant women with OUDs. They discourage the use of assisted opioid withdrawal (Committee on Healthcare for Underserved Women, American Society of Addiction Medicine, & American College of Obstetricians and Gynecologists, 2017; World Health Organization, 2014).
In a systematic review of available literature, the evidence does not support detoxification as a recommended treatment option for OUD/SUD (Terplan et al., 2018). The reviewers found that the complete evaluation of detoxification as a viable alternative was limited by high rates of maternal return to substance use, low detoxification completion rates, and limited data on the effects of detoxification on maternal and neonatal outcomes after birth. The evidence found in the 2018 review does not suggest that there is an increased risk of fetal demise. However, the authors note that loss of follow-up was an important limitation. It has been asserted that women and children need to be followed for at least one year after delivery in order to properly assess the true effects of substance use for both populations (O’Donnell et al., 2015; Simkiss, Stallard, & Thorogood, 2013).
It is important that women with opioid and other SUDs have access to the full spectrum of treatment options. More research is needed to determine if there is a subset of the population of pregnant women with OUDs for whom detoxification would be beneficial. Additional evidence would allow for the development of comprehensive guidelines that support optimal treatment without increasing morbidity and mortality for both mother and fetus?
Labor and Delivery Management
The management of labor and delivery for women with SUDs does not significantly differ from normal care (Gopman, 2014). As with most pregnancies, continuous fetal monitoring may be considered if there are concerns about the ability of the fetus to tolerate labor. Baseline fetal heart rate may be lower in women treated with methadone. This is particularly true two to three hours after they take their methadone dose. This effect is not as prominent in women who take buprenorphine (Salisbury et al., 2012).
Women who are receiving medication-assisted treatment for OUD should remain on their daily dose of medication throughout their labor and delivery (Substance Abuse and Mental Health Services Administration, 2018a). For women who present for the first time in labor and with no previous prenatal care, it is important to understand that acute withdrawal may occur during the labor process. If appropriate, methadone or buprenorphine may be initiated to prevent withdrawal symptoms (Gopman, 2014). Full opioid agonists are not contraindicated for pain management, and, as with any patient, the potential for oversedation should be monitored. Mixed opioid agonist–antagonists such as nalbuphine, butorphanol, and pentazocine should be avoided as they can precipitate withdrawal in opioid-dependent patients (Gopman, 2014). The Society for Maternal-Fetal Medicine recommends that if pharmacological pain management is desired, women with OUD should be encouraged to receive neuraxial analgesia with an epidural or combined spinal epidural as soon as they report contractions to be uncomfortable (Substance Abuse and Mental Health Services Administration, 2018a). Inhaled nitrous oxide may be less effective for women with opioid dependence and may increase the risk of oversedation (Substance Abuse and Mental Health Services Administration, 2018a). Women who plan to undergo a scheduled Caesarean delivery should be instructed to continue their opioid replacement therapy, including on the day of delivery (Gopman, 2014).
In Afghanistan, less than half (48%) of births are delivered in healthcare facilities. Home deliveries are more common in rural and less resourced communities, with 77% of women in poor households delivering at home (Central Statistics Organization, Ministry of Public Health, & ICF International, 2016). Girls marry early, sometimes before the age of 18, and have an average fertility rate of 5.3 children. They have less access to pre- and postnatal care and face mortality rates of 1.291 maternal deaths per 100,000 live births (Central Statistics Organization, Ministry of Public Health, & ICF International, 2016). More research is needed to fully characterize, respond to, and manage the needs of pregnant women with OUD in Afghanistan.
Pain management in the postpartum period is an important consideration for all women, but it is particularly true for women with SUDs. The use of oral opioids after a vaginal or Caesarean delivery can be problematic because of the risk of exposure to medications with addictive potential. These medications are also associated with side effects including nausea, dizziness, lethargy, sedation, and constipation (Substance Abuse and Mental Health Services Administration, 2018a). There is growing support for opioid medications to be used as a rescue rather than a first-line treatment, with that position being reserved for nonpharmacological approaches and nonopioid analgesics.
Pain after a vaginal delivery varies from woman to woman but is reported generally to range from mild to moderate (e.g., Komatsu, Carvalho, & Flood, 2017). For the majority of U.S. women who have a Caesarean delivery, opioids are the most common pain management strategy with an estimated 85% of women filling an opioid prescription after discharge (Bateman et al., 2017). For opioid-naïve women and particularly those with other SUDs, it is estimated that 1 in 300 women exposed to opioids will go on to use them chronically for up to a year after delivery (Bateman et al., 2016). In many countries outside the United States, opioids are rarely used for post-Caesarean pain management (Wong & Girard, 2018).
Women with SUDs, particularly OUD, may face additional challenges after a vaginal or Caesarean delivery. Opioid-dependent patients may have lower pain thresholds and are more likely to experience opioid-induced hyperalgesia (Mitra & Sinatra, 2004). Appropriate and sufficient pain management is critical, as failure to receive such pain management may place women at increased risk for return to substance use. Given that approximately 66% of women in Afghanistan deliver at home without a skilled birth attendant, pain management is not documented. Such a statistic may reflect the fact that women in Afghanistan need a man’s permission to go to the hospital for any treatment (Perrott, 2017).
Preventing Return to Substance Use
For women with SUDs, pregnancy is often a protective factor. Maternal concerns about exposure of the fetus can be a strong incentive for abstinence. Once delivery occurs, the loss of this protection can contribute to an increased risk for return to substance use. It has been noted that women are at a particularly high risk of overdose and death in the first year postdelivery (Schiff et al., 2018). Additionally, new mothers are confronted with increased stressors from sleep deprivation, hormonal changes, relationship dynamics, the demands of parenting, changes in access to care, and concerns about the loss of child custody. There is evidence that women with SUDs also are at increased risk for the development of postpartum mood disorders (Holbrook & Kaltenbach, 2012). This risk may also contribute to an increased risk for a return to substance use (Chapman & Wu, 2013).
During the postpartum period, it is critical that women and providers are aware of the risks for women with SUDs. Close follow-up, including an early visit at one to two weeks postpartum for a mood check, is recommended (Gopman, 2014). At this visit, a formal screening for postpartum mood disorders, such as the Edinburgh Postnatal Depression Scale, should be administered. Additionally, healthcare providers should inquire about potential increases in cravings or possible return to substance use.
Healthcare Management, Postpartum and Beyond
Multiple healthcare issues may arise in the postpartum period. For all women, becoming postpartum means both a change in the frequency of their interaction with the healthcare system as well as with clinicians providing care. It is important that any initiation of treatment and the establishment of healthy behaviors continues to be encouraged. Transition to primary care is a critical part of this process. A successful transition of care is best achieved with an active connection between the obstetric provider and the primary care provider. All women need contraceptive counseling, provided within the framework of reproductive justice, with the goal of empowering women to achieve their desired pregnancy spacing and family size free from the judgment of their ability to parent.
Women living in communities with fewer resources face additional challenges in the postpartum period. The WHO recommends that all women who do not deliver in a healthcare facility receive a postpartum health checkup within the first 24 hours of delivery. In Afghanistan, data have shown that 40% of new mothers received a postpartum checkup in first two days after delivery, while 56% did not have any postpartum healthcare visits (Central Statistics Organization, Ministry of Public Health, & ICF International, 2016). There are no available data that specifically address these issues among Afghan women with SUDs. However, with poverty, stigma, and other social factors, postpartum care for this population can be expected to be less than for women without SUDs.
Babies born to women with SUDs are often at risk for multiple health and developmental challenges and deserve to benefit from breastfeeding. The Academy of Breastfeeding Medicine (ABM) recommends that a plan be made with each woman during her pregnancy through patient-centered discussions. Discussions should include the consequences of a return to substance use and how to safely bottle-feed should the mother choose to do so, or if breastfeeding becomes contraindicated (Reece-Stremtan & Marinelli, 2015). Of note, the only true contraindication for breastfeeding is infants with classic galactosemia (galactose 1-phosphate uridyltransferase deficiency) (American Academy of Pediatrics, 2012). For mothers in the United States, having human immunodeficiency virus (HIV) is a breastfeeding contraindication. In developing countries, such as Afghanistan, where mortality is increased in nonbreastfeeding infants from a combination of malnutrition and infectious diseases, breastfeeding may outweigh the risk of HIV infection from human milk.
The WHO asserts that mothers with SUDs should be encouraged to breastfeed unless the risks outweigh the benefits. In addition to the consequences of a return to substance use and possible substance exposure, the WHO directs that a risk assessment should include HIV status, the availability and safety of breast milk substitutes, access to clean water, and the age of the baby (World Health Organization, 2014). Contrary to some community beliefs, women who are maintained on methadone or buprenorphine may safely breastfeed regardless of their medication dose (Reece-Stremtan & Marinelli, 2015). ABM and WHO also recognize that, ideally, a woman who chooses to breastfeed will have been engaged in substance use treatment prenatally, and new mothers need to be educated about the risks associated with any substances that may be sedating to a newborn.
Infants prenatally exposed to substances in utero have an increased risk of experiencing withdrawal symptoms. The cluster of symptoms including severe irritability, difficulty feeding, respiratory problems, and seizures is referred to as NAS. Given that prenatal exposure to opioids is necessary but not sufficient to result in NAS, and there is wide variability in how NAS is identified, assessed, and treated, this article uses the term “neonatal withdrawal.” In the United States, neonatal withdrawal symptoms are most often cited as being related to maternal use of opioids; however, babies may also experience withdrawal symptoms from prenatal exposure to nicotine as well as other psychoactive substance (Jones & Kraft, 2019).
When specifically examining neonatal withdrawal from opioids in the United States, there have been an increasing number of cases reported with withdrawal estimated to affect 6 infants per 1,000 live births (Patrick et al., 2015, 2016). In countries outside the United States, such as Afghanistan, there is less information about the impact of withdrawal on neonates. While there are no available data on neonatal withdrawal in Afghanistan, with a reported 9.5% of women using opioids it can be assumed that the condition occurs and there is a need for maternal and child organizations to address it (Marcellus, 2019).
Historically, babies who are at risk for or show symptoms of going through neonatal withdrawal have been managed with a combination of pharmacological and nonpharmacological strategies (Patrick et al., 2015, 2016). This management has most often occurred in the context of the neonatal intensive care unit. However, a growing body of research has emphasized a more collaborative approach to care, including keeping the infant with the mother whenever possible, skin-to-skin placement, swaddling, and limited stimulation (Atwood et al., 2016; Holmes et al., 2016; MacMillan et al., 2018; Patrick et al., 2016).
The most commonly used tool used to evaluate infants who are experiencing neonatal withdrawal symptoms is the Finnegan Neonatal Abstinence Scoring System (FNASS), often referred to as the “Finnegan Scale” for its creator Loretta Finnegan (Finnegan, Connaughton, Kron, & Emich, 1975). Although it continues to be widely used in the United States, the FNASS faces challenges with internal consistency and rigorous validation (Jones et al., 2016). Some U.S. healthcare systems have started to explore other approaches to the management of neonatal withdrawal symptoms in newborns (Holmes et al., 2016; MacMillan et al., 2018). One such alternative is known as “Eat, Sleep, Console.” This method relies upon a structured assessment of infant feeding, sleep duration between feedings, and the ability to be consoled (Grossman, Lipshaw, Osborn, & Berkwitt, 2018). One study utilizing this approach in conjunction with as-small-as-needed doses of morphine, demonstrated a marked reduction in postnatal opioid exposure without short-term adverse consequences for the newborn (Blount, Painter, Freeman, Grossman, & Sutton, 2019).
In 2016, the U.S. government passed the Comprehensive Addiction and Recovery Act. This act built upon the 2010 Child Abuse and Prevention Treatment Act and required states to create safe plans of care for children affected by maternal substance use that also address the treatment needs of the families and caregivers (Substance Abuse and Mental Health Services Administration, 2016). States were mandated to develop a monitoring system to determine if and how local entities were providing referrals for necessary services. Instead of creating standard federal guidelines, states were directed to define substance exposure and whether notifying child protective services of prenatal exposure constitutes a report of child abuse or neglect. This decision has resulted in numerous inconsistencies in policies from state to state, which has given rise to differing approaches to identifying pregnant women who are in need of treatment (Substance Abuse and Mental Health Services Administration, 2016). These inconsistencies have had major implications for family systems particularly during the critical early time of maternal–child attachment.
The United States is not alone in the criminalization of substance use; however, approaches to consequences vary. In Afghanistan, the country’s counternarcotic law classifies substance use as a crime. However, if a person with a SUD pursues treatment, the individual can avoid prosecution (Special Inspector General for Afghanistan Reconstruction, 2018). It is important to note, however, that Afghanistan law does not specifically address substance use during pregnancy.
Stigma and Other Barriers to Treatment
Pregnant women with SUDs face numerous barriers in both the United States and Afghanistan. As a group, pregnant women with a SUD often experience multiple psychosocial challenges including stigma, social and legal consequences of substance use, food insecurity, chronic medical conditions, psychiatric disorders, poverty, lack of adequate housing, trauma exposure, intimate partner violence, and too few treatment centers to access care (Abadi et al., 2012; Jones et al., 2015).
Although there is an increasing acceptance of the chronic disease model for SUDs, people with SUDs are more highly stigmatized than people with other chronic health conditions (Corrigan, Kuwabara, & O’Shaughnessy, 2009). Stigma carries with it numerous negative consequences including poor physical health, avoidance of healthcare services, and an increase in risky behaviors (Brener, von Hippel, von Hippel, Resnick, & Treloar, 2010; Brewer, 2006). Pregnant women with SUDs are one of the most highly stigmatized/discriminated against populations in the United States. Much of the general population, including healthcare providers, operate on the assumption that pregnancy should be protective and that women have personal control over their substance use. Using this line of reasoning, it is the women themselves who are to blame for adverse perinatal outcomes (Livingston, Milne, Fang, & Amari, 2012). Such negative perceptions of women with SUDs are found in both the United States and Afghanistan, can lead to suboptimal care, and, thus unwittingly, cause women not to disclose their diagnoses to their healthcare providers (Ahern, Stuber, & Galea, 2007).
Commonly used pregnancy benchmarks include the number of prenatal visits attended, length of gestation, and overall health measures, such as pregnancy-related weight gain. Successful prenatal care for women with SUDs is also measured through the evaluation of birth outcomes including birthweight, head circumference, Apgar scores, the need for pharmacological treatment for neonatal withdrawal, and length of hospital stay. Although these measures are helpful, they do not represent the complete picture. It has been asserted that clinical care considerations and measurements of success should instead focus upon the mother—infant dyad, rather than each one in isolation (Klaman et al., 2017). This dyadic approach could include such measures as maternal—fetal attachment during pregnancy, rates of breastfeeding, skin-to-skin contact, rooming-in during the immediate postnatal period, and amount of perceived support from others by the mother.
Substance use and use disorders occur as a part of a complex life circumstance for women in all countries. The contrast between the United States and Afghanistan is illustrative of the differing international landscape of resources and access to care. This summary shows that SUDs can be treated during pregnancy, and long-term recovery is most possible when comprehensive services are provided well into the parenting period. For pregnant women with SUDs, evidence has demonstrated that facilitating access to integrated, trauma-informed prenatal care has the potential to create a positive impact on long-term family outcomes. Outside the United States, and particularly in countries with fewer economic resources, there is scarcity of data on this important topic. It has been shown that women using substances often consider pregnancy a time for making healthy behavioral changes. There is need for additional research and training of staff to provide evidence-based substance use treatment to pregnant and postpregnant women nationally and internationally. Additionally, all national and international maternal and child health and social organizations need to recognize and respond to this subpopulation of women and children in need of help and hope. The benefits for mothers and their children are significant and may create the foundation for improved social and health outcomes for future generations.
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