In 2010 James J. Nocon, MD, JD, Chairman of the Indiana Prenatal Substance Abuse Commission and Director of the Prenatal Recovery Clinic At Wishard Memorial Hospital did a power point presentation titled, “Incorporating Screening for Substance use into Routine Prenatal Care”. The purpose of this excellent presentation was to, “help physicians recognize the ethical and legal duty to screen for substance use in pregnancy” and to “advocate detection and treatment of addiction during pregnancy”. While Dr. Nocon noted that screening for hypertension, diabetes and STD’s is recognized standard of care in pregnancy, he boldly claims drug use results in more fetal harm and preterm delivery than all three of these combined. We all realize the controversial emotions this subject raises, however none of us can deny the importance of protecting the unborn child as well as the mother. Currently 18 states have some form of legislation that considers illegal drug usage during pregnancy child abuse. At this time only the state of Tennessee has made it a criminal act. Prior to the government getting involved with legislating, the percentage of women who willingly self reported the use of illegal drugs was low. Due to the current environment, the self reporting percentage appears to be dropping even more. The fact still remains, if the pregnant mother is not drug tested, the physician does not know if she is using an illegal substance. All providers recommend expecting mothers refrain from alcohol and nicotine, yet statistics show among women who use both alcohol and nicotine 20.4% use marijuana and 9.5% use cocaine. In his presentation Dr. Nocon states, “Detection alone will result in 50-55% of patients using ATOD to stop using during pregnancy”.
One overused argument against universal drug screening for pregnant women is the cost of testing, however facts reveal preterm delivery accounts for the greatest amount of infant mortality, morbidity and medical costs in the first year of life. If the process of detection is, in fact, intervention as Dr. Nocon states, and it is the health care providers duty to intervene when the health of the baby could be in jeopardy, drug screening of pregnant women should also be standard in prenatal care. According to the JAMA, the rate of NAS (Neonatal Abstinence Syndrome) rose by 300 percent from 2000 through 2009. In 2012 it was published in The Study Journal of the AMA that one drug dependent baby is born every hour in the US. Yes this also included those women who used alcohol which is included in a normal screen.
Ultimately until the government legislates universal drug testing for pregnant women, the choice is still in the hands of the Ob/Gyn whether to drug screen or not, however, the unborn child does not get to choose alcohol, nicotine or other drugs if the mother is using.
Ignorance is no excuse! Sadly, this phrase is used far to frequently in the medico-legal arena when it comes to Urine Drug Testing (UDT). A provider who chooses to drug test with just a screening device, but does not send urine samples to a lab for confirmation, many times receives just enough information to get themselves in hot water. UDT, when used appropriately, accounts for the following: Improved patient adherence to their medication regiment, better provider/patient relationship and communication, alerts provider to possible drug abuse or diversion, decreases likelihood of audits and medico-legal problems and improves providers ability to monitor effective therapeutic dosages. Due to fear of over-testing or out of ignorance, some providers fail to recognize appropriate UDT includes both screening and confirmation. Screening tests were designed to give the provider immediate information on classes of drugs a patient may or may not be taking as well as some illicit drugs. The only way possible to determine what specific drug a patient is taking is to confirm the screening test. Due to the high cutoff levels, and the inability of screening devices to determine certain metabolites, many times it is impossible for a provider to know exactly what a patient is or isn’t taking. When a medical decision is made based strictly on a screen the provider is potentially putting their license and the patient’s health at risk.
To give you an example lets say you were scripting your patient oxycodone and they tested positive for oxycodone and opioids on the screening cup. Can you know for certain they didn’t take one oxycodone a few hours before the test to test positive for oxy? How do you know they aren’t taking hydrocodone and selling the oxycodone? Lets take another example. You scripted your patient Alprazolam. They screen positive for benzodiazepines so you know for a fact they are not taking their grandmothers Lorazepam and selling the Alprazolam on the street, right? Sure you do. Finally, what about the patient your staff and you think is a liar and drug abuser because their negative test is below the screening cutoff for the prescription you give them. How do you know they didn’t run out several days before which confirmation would verify due to the level of the metabolites present in their urine? The fact is, you don’t.
You get it. The bottom line is if you do drug screening, the medical community standard of care is to confirm at least the positive and inconsistent findings.
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