Have that talk with your patients.

Screening for substance abuse, including alcohol, illegal drugs, and prescription medications, should be a regular part of health care. According to national data, nearly one-fourth of patients seeking routine hospital care have an active addiction. Many people go untreated for substance use disorders due to a lack of screening and diagnosis. Make the discussion about drugs and alcohol a part of routine office visits. You could help identify an addiction problem early — which could help get your patient into treatment early.

The potential for drug and alcohol abuse is everywhere — in our homes, our schools, our workplaces, and our communities. Talk with your patients. They’ll listen to you.

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How you speak with your patients matters:

  • Ask nonjudgmental, open-ended questions.
  • Start out simply: “Is it ok if I ask you some questions about drugs and alcohol?”
  • Tell patients it’s a standard part of health screening and that everyone is asked the same questions.
  • Quantify the drug or alcohol use and how it can impair judgment.
  • Be empathetic and inquisitive.
  • Be alert for signs of addiction and be prepared to refer your patient if you suspect an addiction issue. For a list of treatment resources, visit our resources section.

Signs a patient may be addicted:

  • Altered sleep habits
  • Small or pinpoint pupils
  • Dramatic weight changes
  • Frequent nosebleeds
  • Frequent colds or illness
  • Itchy skin or unexplained cuts or scabs
  • Leg cramps
  • Poor hygiene
  • Sense of desperation
  • Changes in personality or friends
  • School or work performance problems
  • Out of or in need of money
  • Nodding off or constant sleep problems
  • Paranoia
  • Secrecy

Help your patients avoid becoming addicted to opioids.

Legally prescribed opioids are a proven pipeline to prescription- and illegal-drug addiction. Nearly 80 percent of heroin users indicate they started with prescription opioids.

Medical providers are encouraged to avoid prescribing opioids as the first-line treatment for chronic pain (excluding active cancer, palliative, or end-of-life care).

Opioids can be a powerful tool if prescribed and used carefully, but should never be the first line of defense to treat chronic pain. And, the benefits of long-term opioid therapy for chronic pain are not well-supported by evidence.

Treatment of Pain and Informed-Consent Language

New Department of State regulations for the safe prescribing of opioid analgesics were published in the January 1, 2017 issue of the Delaware Register of Regulations and took effect April 1, 2017. The new regulations specify that when informed consent and a treatment agreement is required in relation to prescribing these medications.

The treatment agreement information and example informed consent form are intended to be samples only. Use of this information is not intended to fulfill a practitioner’s legal duty to obtain full and complete informed consent. Medical providers are encouraged to customize the forms and work with legal counsel prior to using the forms in their medical practice.

Consider recommending alternatives to opioids, including:

  • physical therapy
  • exercise and strength training
  • cognitive behavioral therapy
  • relaxation techniques

And use alternative medications for pain, such as:

  • non-opioid medications
  • acetaminophen
  • non-steroidal anti-inflammatory drugs (NSAIDs)
  • serotonin and norepinephrine reuptake inhibitors (SNRIs)
  • tricyclic antidepressants (TCAs) acetaminophen
  • non-steroidal anti-inflammatory drugs (NSAIDs)
  • serotonin and norepinephrine reuptake inhibitors (SNRIs)
  • tricyclic antidepressants (TCAs)

Prescribers should evaluate patients for Substance Use Disorder (SUD) risk during regular clinical visits, but especially as part of prescribing opioids.

Use the Prescription Drug Monitoring Program and be aware of the new prescribing rules by the Division of Professional Regulation.

When a patient has a chronic pain problem, set a recovery goal and develop and tailor a treatment plan. If prescribing opioids, use only those that are short-acting with the lowest dose on product labeling, and match the prescription duration to the next visit.

CDC Opioid Prescription Checklist

Information to share with your patients

Opioid Therapy Chart Download (748K)

For providers

Opioid Therapy Chart Download (373K)

Addiction Screening Tools

Asking your patients a few simple questions may help identify a substance abuse problem. Popular, proven, and easy-to-use tools that address drugs and alcohol are the CAGE and CAGE-AID Questions.


CAGE and CAGE-AID Questions

  • In the last three months, have you felt you should cut down or stop drinking or using drugs?
  • In the last three months, has anyone annoyed you or gotten on your nerves by telling you to cut down or stop drinking or using drugs?
  • In the last three months, have you felt guilty or bad about how much you drink or use drugs?
  • In the last three months, have you been waking up wanting to have an alcoholic drink or use drugs?

If you identify or suspect a problem, consider the 5 A’s of Intervention (Ask, Advise, Assess, Assist, and Arrange).

Ask
Ask: Screen for a potential issue.
Advise
Advise: Provide medical advice about the patient’s substance use.
Assess
Assess: Determine how willing the patient is to changing behavior.
Assist
Assist: Help the patient make a change through setting concrete goals and follow up plan.
Arrange
Arrange: refer the patient for further assessment and treatment, if appropriate, and set up follow up appointments.

Screening, Brief Intervention, and Referral for Treatment

For detailed information, training, and strategies on screening and referral, consider using Screening, Brief Intervention, and Referral to Treatment (SBIRT), is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. The SBIRT model was inspired by an Institute of Medicine recommendation that called for community-based screening for health risk behaviors, including substance use.

OB/GYN Resources

How to Educate Pregnant Patients About Substance Use

Delaware law requires medical providers to educate pregnant patients about the dangers of substance use:

DE Code, Title 24, Chapter 17, § 1769A. Required warning to pregnant women of possible effects of using alcohol, cocaine, or other narcotics.

(a) A person certified to practice medicine who treats, advises, or counsels pregnant women for matters relating to the pregnancy shall post warnings and give written and verbal warnings to all pregnant women regarding possible problems, complications, and injuries to themselves and/or to the fetus from the consumption or use of alcohol or cocaine, marijuana, heroin, and other narcotics during pregnancy.

(b) A person who treats, advises, or counsels pregnant women pursuant to subsection (a) of this section and who is certified to practice medicine may designate a licensed nurse to give the warnings required by this section.

(c) The Director of the Division of Public Health shall prescribe the form and content of the warnings required pursuant to this section.



What to Tell Your Patients

No amount of alcohol, marijuana, or other illegal drugs is safe for you or your baby. Prescription opioids should be taken exactly as prescribed, and babies may experience neonatal abstinence syndrome (NAS) after birth, which will likely need medical intervention.

From the American College of Obstetricians and Gynecologists (ACOG):

“A drug’s effects on the fetus depend on many things: how much, how often, and when during pregnancy [the drug] is used. The early stage of pregnancy is the time when main body parts of the fetus form. Using drugs during this time can cause birth defects or miscarriage. During the remaining weeks of pregnancy, drug use can interfere with the growth of the fetus and cause preterm birth or fetal death.”

(December 2013: www.acog.org/Patients/FAQs/Tobacco-Alcohol-Drugs-and-Pregnancy).

Alcohol

Alcohol is the primary cause of preventable birth defects. When a pregnant woman drinks alcohol, it reaches the baby through the placenta. While an adult liver will break down the alcohol, a baby’s liver cannot, and so the alcohol is significantly more toxic. Drinking alcohol during pregnancy can cause: damage to a baby’s organs; physical, emotional, and behavioral problems as the child develops; difficulties in learning or memory; and higher incidence of Attention Deficit Hyperactivity Disorder (ADHD).

The damage caused by drinking alcohol is well-documented and vastly underestimated.

Opioids: Legal and Illegal

Opioids are a highly addictive substance, and their use and abuse is driving the current addiction epidemic. Opioids can cause life-threatening withdrawal symptoms in babies, better known as neonatal abstinence syndrome (NAS). Symptoms include excessive crying, high-pitched cry, irritability, seizures, and gastrointestinal problems, among others. NAS requires hospitalization of the affected infant and possibly treatment with morphine or methadone to relieve symptoms. Treatment should also include nonpharmacological interventions, such as skin-to-skin contact and rooming in. Research on the long-term effects of opioid use during pregnancy is still evolving, but there is some evidence to suggest adverse behavioral and cognitive effects on children whose mother used opioids.

No patient should be counseled to immediately stop using opioids, including heroin. Suddenly stopping use could send the fetus into distress, threaten the pregnancy, and even cause miscarriage. Consistent with ACOG guidelines, physicians should discuss a broad range of treatment options, including Medication Assisted Treatment (MAT). For information on treatment programs or to learn more about MAT for pregnant women, call 1-800-652-2929 in New Castle County or 1-800-345-6785 in Kent and Sussex counties.

Cocaine and Methamphetamine (Stimulants)

Pregnant women who use cocaine are at higher risk for maternal migraines and seizures, premature membrane rupture, and placental abruption (separation of the placental lining from the uterus). Cocaine could exacerbate cardiac problems —sometimes leading to high blood pressure (hypertensive crises), spontaneous miscarriage, preterm labor, or difficult delivery.

Babies born to mothers who use cocaine during pregnancy may also have low birth weights and smaller head circumferences, and may be shorter than babies born to mothers who do not use cocaine. These newborns also show symptoms of irritability, hyperactivity, tremors, high-pitched cry, and excessive sucking at birth.

Marijuana

Marijuana use should not be viewed as a safe alternative to other drugs. Contrary to reports, marijuana can be addictive. ACOG and American Academy of Pediatrics (AAP) state that marijuana cannot be used safely during pregnancy. There is research to suggest that using marijuana during pregnancy can cause impaired neurodevelopment in fetuses, as well as low birth weight and problems in behavior and cognition in childhood. While more research must be done, ACOG states that the adverse effects of smoking marijuana to mother and fetus are well-documented.

Tobacco

While this information focuses on alcohol, illegal substances, and prescription drug abuse, the negative impact of tobacco use on birth outcomes is also well-documented. If a patient indicates that she smokes, consider referrals to the Delaware Quitline for free cessation resources and tools — at QuitNow.net/Delaware or by calling 1-866-409-1858.


How to Screen Pregnant Patients for Substance Use Disorder and Alcohol Use

ACOG recommends universal screening with brief intervention and treatment referrals for cannabinoids, alcohol, club drugs, dissociative drugs, hallucinogens, opioids, stimulants, tobacco, and other compounds such as anabolic steroids and inhalants.

You have an important role in educating women about the dangers of substance abuse during pregnancy, screening women for substance use disorder, and referring those with a potential substance use disorder. The goal is to help the mother and her baby.

Any pregnant woman who is on opioids — legal or illegal — should not cease her use immediately, because there could be significant risks to the fetus. Conversion to MAT is preferred for women seeking to discontinue use of illegal or legal opioids during pregnancy.

To learn more about MAT treatment locations for pregnant women, visit the Substance Abuse and Mental Health Services Administration (SAMHSA) website at www.samhsa.gov, or call 1-800-652-2929 in New Castle County and 1-800-345-6785 in Kent and Sussex counties.

Pregnant women cannot be penalized under the law for substance use during pregnancy. Medical providers do not have a legal requirement or obligation to report substance use in pregnant women or to perform testing to confirm suspected use. In fact, it is outside of child protective services’ legal authority to take a report of a mother’s behavior while she is pregnant.

General Screening Recommendations

STEP ONE: START THE CONVERSATION

Following the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model, start the conversation in a reassuring and compassionate manner. For example, you could say, “Can I ask you about drug or alcohol use? This information is important to working with you to have a healthy pregnancy.” Be reassuring. Be clear that the information will not be used against the patient or impact her ability to keep custody of the child. Emphasize the importance of your commitment to help her have a healthy pregnancy.

STEP TWO: DO THE SCREENING

Use the screening tool that works best for your practice and your population. The next page includes three validated screening tools that can be used easily in a health care setting. All seek to identify potential issues that would require further dialogue with the patient and referrals to treatment providers for continued assessment. These screening tools are in the public domain and are recognized by SAMHSA.

General Screening Tools

“Screening” means using a validated screening tool to ask questions aimed at understanding the patient’s potential substance use. There are several validated screening tools for pregnant women, including 4P’s, T-ACE, and CRAFFT for adolescents and young adults.

THE 4 P’S (for substance abuse):

  • Have you ever used drugs or alcohol during Pregnancy?
  • Have you had a problem with drugs or alcohol in the Past?
  • Does your Partner have a problem with drugs or alcohol?
  • Do you consider one of your Parents to be an addict or alcoholic?

Scoring: Any “yes” should be used to trigger further discussion about drug or alcohol use. Any woman who answers “yes” to two or more questions should be referred for further assessment.

Source: Adapted from Ewing H Medical Director, Born Free Project, Contra Costa County, 111 Allen Street, Martinez, CA. Phone: 510-646-1165.

THE 4 P’S (for substance abuse):

ACOG recommends the T-ACE screening tool for alcohol, specifically developed for use with pregnant women. Ask patients four questions:

  1. (T) Tolerance: How many drinks does it take to make you high?
  2. (A) Have people Annoyed you by criticizing your drinking?
  3. (C) Have you ever felt that you should Cut back on your drinking?
  4. (E) Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

Scoring: Any woman who answers the first question with “Three or more drinks” receives two points. Each “yes” to the additional three questions scores one point. A score of two or more is considered a positive screen, and the woman should be referred for further assessment.

Source: Sokol RJ, Martier SS, Ager JW. 1989. The T-ACE questions: Practical prenatal detection of risk drinking, American Journal of Obstetrics and Gynecology 160 (4).

CRAFFT — SUBSTANCE ABUSE SCREENING FOR ADOLESCENTS AND YOUNG ADULTS

  1. Have you ever ridden in a CAR driven by someone (including yourself) who was high or had been using drugs or alcohol?
  2. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
  3. Do you ever use alcohol or drugs while you are ALONE?
  4. Do you ever FORGET things you did while using drugs or alcohol?
  5. Do your FAMILY or FRIENDS ever tell you that you should cut back on your drinking or drug use?
  6. Have you ever gotten into TROUBLE while you were using alcohol or drugs?

Scoring: Two or more positive items indicate the need for further assessment.

Source: Center for Adolescent Substance Abuse Research, Children’s Hospital of Boston. The CRAFFT screening interview. Boston (MA) CeASAR; 2009.

STEP THREE: EDUCATE THE PATIENT AND PROVIDE REFERRALS

If the screening tool does not identify a potential problem:

State law requires all medical providers serving pregnant women to counsel them on the dangers of alcohol, marijuana, and other drug use during pregnancy. Recommend that they cease use of all drugs, except opioids, which require special considerations and may need to involve MAT.

If the screening tool does identify a risk for substance use disorder:

  • Be clear that you understand the mother wants to be as healthy as possible for her baby and herself, and that she can reduce the health risk to both of them by stopping her use of alcohol and drugs. If eligible, connect her with a care coordinator through her medical insurance.
  • Discuss possible strategies for her to stop — individual or group counseling, 12-step program, or substance-use-disorder treatment. If she is struggling with opioid addiction, MAT should be discussed.
  • Advise women to visit HelpIsHereDE.com or call 1-800-652-2929 in New Castle County and 1-800-345-6785 in Kent and Sussex counties to learn more about services for pregnant women.

MEDICATION ASSISTED TREATMENT

MAT is an important part of the treatment plan for pregnant women, and has shown improved outcomes. According to ACOG, “The rationale for medication-assisted treatment during pregnancy is to prevent complications from illicit opioid use and narcotic withdrawal; encourage prenatal care and drug treatment; reduce criminal activity; and avoid risks to the patient associated with a drug culture.”

The two main medications involved in MAT for pregnant women are methadone and buprenorphine (without Naloxone). The decision regarding the most appropriate medication should be made jointly with the MAT provider, the obstetrician, and the woman.

Dangers of Substance Use During Pregnancy

Opioid Therapy Chart Download (117K)

Screening Pregnant Patients

Opioid Therapy Chart Download (493K)

Remind Patients

not to use alcohol or illegal drugs during pregnancy, and take prescription medications exactly as prescribed.

Most people know that using illegal drugs, including marijuana and heroin, is not safe for the fetus during pregnancy, but many do not know that alcohol is just as, or even more dangerous. Remind your patients that drinking alcohol and using illegal drugs while pregnant harms their baby, and that prescription drugs should be taken exactly as prescribed.

For information and referrals for pregnant women needing treatment in partnership with medical services, call:

  • New Castle County: 800-652-2929
  • Kent and Sussex counties: 800-354-6785
  • Resources

General Screening Tools and Recommendations

The American College of Obstetricians and Gynecologists (ACOG) recommends universal screening for alcohol and opioids, and that providers ask pregnant women about their marijuana use. If they are using, you should urge them to stop because of the risk of permanent damage to the baby.

There are several validated screening tools for pregnant women, including DAST and MAST (Kemper 1993), and CRAFFT (Chang 2011) for pregnant adolescents. Another tool to consider is 4P’s Plus (Chasnoff 1999).

Alcohol Dangers and Screening Tools

Alcohol is the number one cause of preventable birth defects in this country. Drinking alcohol during pregnancy greatly increases the chances that the fetus will develop a fetal alcohol spectrum disorder (FASD). According to the Centers for Disease Control and Prevention, up to one in 20 school children have FSAD.

Signs and symptoms of the various FASDs range from mild to severe, and include a combination of physical, emotional, behavioral, and learning problems. Prenatal alcohol exposure is a frequent cause of structural or functional effects on the brain, heart, bones and spine, kidneys, vision, and hearing. It's also associated with a higher incidence of attention-deficit/hyperactivity disorder and specific learning disabilities, such as difficulties with mathematics and language, information processing, memory, and problem solving.

The American College of Obstetricians and Gynecologists recommends the T-ACE screening tool, specifically developed for use with pregnant women.


Ask patients four questions:

  • (T) Tolerance: How many drinks does it take to make you high?
  • (A) Have people annoyed you by criticizing your drinking?
  • (C) Have you ever felt you ought to cut down on your drinking?
  • (E) eye opener: Have you ever had a drink the first thing in the morning to steady your nerves or get rid of a hangover?

Any drinking during pregnancy requires education and intervention. Inform patients that any alcohol during pregnancy can harm their fetus, and offer resources to address drinking.

Additional Resources

For further health provider resources on fetal alcohol and counseling patients, visit CDC.gov .

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