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Urine drug screening on labor and delivery

  • Jennifer M. Chin
    Correspondence
    Corresponding author: Jennifer M. Chin, MD.
    Affiliations
    Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii, Honolulu, HI (Dr Chin, Ms Chen, Dr Bravo, Ms Nakashima, and Drs Kiyokawa, Karasaki, Estrada, Ghatnekar, Lee, and Bartholomew)
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  • Eileen Chen
    Affiliations
    Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii, Honolulu, HI (Dr Chin, Ms Chen, Dr Bravo, Ms Nakashima, and Drs Kiyokawa, Karasaki, Estrada, Ghatnekar, Lee, and Bartholomew)
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  • Tricia Wright
    Affiliations
    Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, CA (Dr Wright)
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  • Ricardo M. Bravo
    Affiliations
    Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii, Honolulu, HI (Dr Chin, Ms Chen, Dr Bravo, Ms Nakashima, and Drs Kiyokawa, Karasaki, Estrada, Ghatnekar, Lee, and Bartholomew)
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  • Eryn Nakashima
    Affiliations
    Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii, Honolulu, HI (Dr Chin, Ms Chen, Dr Bravo, Ms Nakashima, and Drs Kiyokawa, Karasaki, Estrada, Ghatnekar, Lee, and Bartholomew)
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  • Miki Kiyokawa
    Affiliations
    Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii, Honolulu, HI (Dr Chin, Ms Chen, Dr Bravo, Ms Nakashima, and Drs Kiyokawa, Karasaki, Estrada, Ghatnekar, Lee, and Bartholomew)
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  • Kameko Karasaki
    Affiliations
    Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii, Honolulu, HI (Dr Chin, Ms Chen, Dr Bravo, Ms Nakashima, and Drs Kiyokawa, Karasaki, Estrada, Ghatnekar, Lee, and Bartholomew)
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  • Pamela Estrada
    Affiliations
    Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii, Honolulu, HI (Dr Chin, Ms Chen, Dr Bravo, Ms Nakashima, and Drs Kiyokawa, Karasaki, Estrada, Ghatnekar, Lee, and Bartholomew)
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  • Reema Ghatnekar
    Affiliations
    Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii, Honolulu, HI (Dr Chin, Ms Chen, Dr Bravo, Ms Nakashima, and Drs Kiyokawa, Karasaki, Estrada, Ghatnekar, Lee, and Bartholomew)
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  • Men-Jean Lee
    Affiliations
    Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii, Honolulu, HI (Dr Chin, Ms Chen, Dr Bravo, Ms Nakashima, and Drs Kiyokawa, Karasaki, Estrada, Ghatnekar, Lee, and Bartholomew)
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  • Marguerite Lisa Bartholomew
    Affiliations
    Department of Obstetrics, Gynecology, and Women's Health, University of Hawaii, Honolulu, HI (Dr Chin, Ms Chen, Dr Bravo, Ms Nakashima, and Drs Kiyokawa, Karasaki, Estrada, Ghatnekar, Lee, and Bartholomew)
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Open AccessPublished:August 25, 2022DOI:https://doi.org/10.1016/j.ajogmf.2022.100733

      BACKGROUND

      Substance use including opioids, methamphetamines, benzodiazepines, and barbiturates during pregnancy is harmful for the pregnant person and the fetus. Routine screening using validated questionnaires is recommended, but often biologic sampling is done instead. There is often bias in urine drug screening on labor and delivery units.

      OBJECTIVE

      This study aimed to compare characteristics of people who did and did not receive urine drug screening during labor and delivery and to examine the relationship of maternal results to neonatal results.

      STUDY DESIGN

      This was a retrospective chart review examining all people in 2017 who delivered in the labor and delivery unit at our institution. We collected urine drug screening result information, maternal demographic data, follow-up after positive maternal tests, and neonatal test results. Individual characteristics and obstetrical outcomes were analyzed.

      RESULTS

      Of 6265 deliveries, 297 urine drug screening tests were ordered. People who were tested identified most commonly as Native Hawaiian or Pacific Islander (P<.0001). The most common indications for ordering tests were a history of substance use and insufficient prenatal care (P<.0001). People who tested positive were more likely to self-identify as White (P=.03) and have history of substance use (P<.0001). Among the positive test results, 24 (24%) were caused by a provider–ordered medication. Self-identification as Native Hawaiian or Pacific Islander was not predictive of a positive result. Of the tested people, 36% (108/297) had a positive result on preliminary testing, and 33% (98/295) on confirmatory testing.

      CONCLUSION

      Native Hawaiians and Pacific Islanders were more likely to undergo testing, whereas White people were more likely to have a positive result. Maternal results were not reliable for predicting neonatal drug test results and vice versa. With rising rates of substance use disorders in the pregnant and reproductive-age population, standardized unbiased race-neutral guidelines for urine drug screening should be implemented using laboratory test results that include preliminary and reflex confirmatory results.

      Keywords

      Why was this study conducted?

      This study was conducted to determine if there was provider bias in ordering urine drug screening tests on our labor and delivery unit.

      Key findings

      Native Hawaiian and Pacific Islander people were tested the most; however, this was not predictive of a positive result. Less than half of people tested had a positive result. Positive tests were associated with self-identifying as White and having a history of substance use.

      What does this add to what is known?

      Without a urine drug screening policy, toxicology screening on labor and delivery is subject to implicit bias, which leads to disparities in testing. Indigenous populations are disproportionately screened, although they do not have a higher rate of positive results.
      Substance use in reproductive-age people has increased significantly in the past decade.
      • Schiff DM
      • Nielsen T
      • Terplan M
      • et al.
      Fatal and nonfatal overdose among pregnant and postpartum women in Massachusetts.
      Opioid use disorder affects up to 2% of pregnancies, and up to 20% of pregnancy-associated deaths have been attributed to opioid overdose.
      • Schiff DM
      • Nielsen T
      • Terplan M
      • et al.
      Fatal and nonfatal overdose among pregnant and postpartum women in Massachusetts.
      According to one study, 4.7% of pregnant people report using an illicit substance, defined as marijuana, cocaine, heroin, hallucinogens, inhalants, methamphetamine, or misuse of prescription psychotherapeutics in the previous month.
      • Ecker J
      • Abuhamad A
      • Hill W
      • et al.
      Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      Substance use during pregnancy can cause serious consequences to the health of both the pregnant person and neonate. For the pregnant person, substance use may result in death from overdose, high blood pressure, heart attack or failure, stroke, seizures, or coma.
      • Ecker J
      • Abuhamad A
      • Hill W
      • et al.
      Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      ,
      • Delafield R
      • Wright TE.
      Insights in public health: substance use in pregnant people inHawai.
      For the fetus and neonate, maternal substance use can result in miscarriage, placental abruption, preterm birth, low birthweight, brain injury, birth defects, developmental delay, neonatal abstinence syndrome, stillbirth, and neonatal death.
      • Ecker J
      • Abuhamad A
      • Hill W
      • et al.
      Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      Because of the potential harms of substance use during pregnancy and the opportunity for intervention, routine screening for alcohol and other substances should be done for everyone during their antepartum, peripartum, and postpartum course. The American College of Obstetricians and Gynecologists recommends universal screening for substance use regardless of age, sex, race, ethnicity, or socioeconomic status.
      Committee opinion no. 633: Alcohol abuse and other substance use disorders: ethical issues in obstetric and gynecologic practice.
      Screening should be done using validated questionnaires such as the 4P's or 4P's Plus because of their high sensitivity and negative predictive value, which are superior to biologic sampling.
      • Chasnoff IJ
      • McGourty RF
      • Bailey GW
      • et al.
      The 4P's Plus screen for substance use in pregnancy: clinical application and outcomes.
      ,
      • Schauberger CW
      • Newbury EJ
      • Colburn JM
      • Al-Hamadani M
      Prevalence of illicit drug use in pregnant women in a Wisconsin private practice setting.
      Biologic sampling carries a high rate of false-positives, provides only a small percentage of new diagnoses, does not exclude specific substance use, does not routinely test for the most commonly used substance (tobacco, caffeine, and alcohol), and is not systematically linked with support and treatment.
      • Ecker J
      • Abuhamad A
      • Hill W
      • et al.
      Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      Biologic sampling is neither mandatory nor necessary to identify those who use drugs or have substance use disorders in pregnancy.
      • Delafield R
      • Wright TE.
      Insights in public health: substance use in pregnant people inHawai.
      ,
      Committee opinion no. 633: Alcohol abuse and other substance use disorders: ethical issues in obstetric and gynecologic practice.
      At the time of data collection, there were no hospital guidelines for urine drug screening, and consequently there were no guidelines on follow-up for a positive result. Urine drug screening (UDS) tests were ordered on the basis of clinical judgment by healthcare providers. When patients are tested according to provider discretion, they may be disproportionately screened on the basis of their demographics. Therefore, we aimed to evaluate the screening practices of providers at our institution to determine if provider bias in ordering UDS tests is present in our population in the labor and delivery unit and evaluate relationships associated with positive screening tests.

      Materials and Methods

      We conducted a retrospective chart review of all people who delivered at our institution in the labor and delivery unit between January 1, 2017 through December 31, 2017. With the help of the Health Information Management department, we pulled information directly from the electronic health records for all people who received a UDS test in 2017 and for all people who delivered in 2017. Among those who received a UDS test, we manually confirmed the results, collected additional and missing data through chart review, and coded the information into a final spreadsheet. The data collection team consisted of obstetrics and gynecology residents and medical students, all of whom were trained in data collection by the primary researcher. Data discrepancies were resolved by the primary researcher and the principal investigator.
      Demographic data included age, race/ethnicity, county of origin, housing situation, type of insurance, route of delivery, body mass index, parity, hypertensive disease, late or insufficient prenatal care, incarceration during pregnancy, history of substance use, and gestational age at delivery. Testing information included reason for UDS test if documented, verbal consent if documented, positive results after a provider-administered medication, maternal preliminary and confirmatory results, and neonatal preliminary and confirmatory results. Preliminary results refer to rapid preliminary tests that are performed first to detect broad drug categories (eg, amphetamines or opiates). Such preliminary tests may be positive because of prescribed medications or foods and do not indicate illicit substance use. Confirmatory results refer to reflex confirmation tests that are performed for positive preliminary results. Final results of confirmatory tests take longer to receive but are more specific and accurate for detecting illicit use.
      Committee opinion no. 633: Alcohol abuse and other substance use disorders: ethical issues in obstetric and gynecologic practice.
      Because of differences in provider knowledge about specific orders in our electronic medical system, all but 2 people had UDS tests ordered with reflex confirmatory testing. Neonates were tested for substances via UDS tests, meconium tests, or both.
      Follow-up information included presence of neonatal abstinence syndrome, low birthweight, social work or child welfare service (CWS) involvement, and referral for treatment. Presence of neonatal abstinence syndrome was determined on the basis of the International Classification of Diseases, Ninth Revision, as reported in our electronic medical records. Options available for substance use treatment included resources within the Hawaii Department of Health Coordinated Access Resource Entry System such as outpatient, inpatient, and residential treatment programs. Examples of outpatient treatment programs offered by community health centers include the Waikiki Health PATH Clinic and the Waianae Coast Comprehensive Health Center.

      State of Hawaii, Department of Health Alcohol, Drug Abuse Division. About the alcohol and drug abuse division. 2022. Available at: https://health.hawaii.gov/substance-abuse/. Accessed October 25, 2020.

      This study was approved by our institutional review board.
      We determined maternal race/ethnicity by self-report in our electronic health records; the first identifier listed in the record was abstracted as the primary race/ethnicity. We specifically collected these data because previous studies have demonstrated that people of color are disproportionately affected by UDS test ordering and results.

      Amnesty International. Criminalizing pregnancy: policing pregnant people who use drugs in the USA. London, United Kingdom. Amnesty International Ltd; 2017. https://www.amnesty.org/

      We determined housing situation by self-reported or provider-reported housing instability in our electronic health records. We determined reason for ordering UDS tests and if verbal consent was documented by reviewing all history and physical and progress notes for the specific encounter. We reviewed all medications given before a positive confirmatory result to determine if a provider ordered any medications that might have inadvertently resulted in a positive UDS test.
      Late or insufficient prenatal care was defined as care provided to anyone who initially presented for prenatal care at ≥20 weeks of gestation. Preterm delivery was defined as any delivery at <37 weeks of gestation. Low birthweight was defined as any weight <2500 g. Referral for treatment was defined as referral to any substance treatment program other than tobacco cessation.
      Categorical variables were analyzed using the Pearson chi-square or Fisher exact tests, as appropriate. Continuous variables were analyzed using the Student t test or analysis of variance, as appropriate. Nominal logistic regression models were used to assess the relationship between people who received a UDS test and those who did not. Univariate analysis was performed for all other data analyses. Significance level was set at P=.05. Data were analyzed using JMP Pro 16.1.0 (JMP Statistical Discovery LLC, Cary, NC).

      Results

      Between January 1, 2017 and December 31, 2017, among 6265 births, 281 UDS tests were ordered for 297 (5%) pregnant people who presented to labor and delivery. People who were tested were significantly younger than those who were untested (27 vs 29 years; P<.001). Tested people were more likely to self-identify as Native Hawaiian or Pacific Islander and have a history of substance use, insufficient prenatal care, or housing instability compared with people who were not tested (Pearson chi-square and Fisher exact tests; P<.0001) (Table 1). Among those tested, there was a higher rate of adverse obstetrical outcomes, including preterm delivery, low birthweight, neonatal abstinence syndrome, gestational hypertension, and preeclampsia compared with those who were not tested (Pearson chi-square and Fisher exact tests; P<.0001) (Table 2). Significantly more tested people received a social work consultation (85% vs 20%; P<.001).
      Table 1Characteristics of people with and without urine drug screening tests
      Chin. Urine drug screening. Am J Obstet Gynecol MFM 2022.
      CharacteristicPeople with UDS N=281People without UDS N=5984P valuea
      Age (y)27.4 (6.4)29.6 (6.1)<.0001
      Native Hawaiian/Pacific Islander173 (58)1750 (30)<.0001
      Multiparity189 (67.3)3612 (60.4).06
      History of substance use147 (52.3)308 (5.2)<.0001
      Insufficient prenatal care4 (1.4)4 (0.1)<.0001
      Housing instability30 (10.7)28 (0.5)<.0001
      CHTN3 (1.1)21 (0.4).12
      Prisoner1 (0.4)0<.0001
      Data are mean (standard deviation) or number (percentage) unless otherwise specified.
      CHTN, chronic hypertension; UDS, urine drug screening.
      aP values calculated with the Pearson chi-square test, Fisher exact test, or analysis of variance, as appropriate.
      Table 2Obstetrical outcomes of people with and without urine drug screening tests
      Chin. Urine drug screening. Am J Obstet Gynecol MFM 2022.
      Obstetrical outcomePeople with UDS N=281People without UDS N=5984P valuea
      Preterm delivery47 (16.7)306 (5.1)<.0001
      Low birthweight74 (26.3)761 (12.7)<.0001
      Neonatal abstinence syndrome5 (1.8)4 (0.1)<.0001
      Gestational hypertension80 (28.5)962 (16.1)<.0001
      Preeclampsia44 (15.7)361 (6)<.0001
      Delivery route
      Vaginal delivery203 (72.2)4458 (74.5).03
      Cesarean delivery75 (26.7)1518 (25.4).03
      Social work consult240 (85.4)1180 (19.7)<.001
      Data are number (percentage) unless otherwise specified.
      UDS, urine drug screening.
      aP values calculated with the Pearson chi-square test, Fisher exact test, or analysis of variance, as appropriate.
      The indications for ordering maternal UDS tests are shown in Table 3. The most common reason for ordering a UDS test was for a reported history of substance use (n=147, 52%). Confirmatory testing results were positive in 52 (35%) of such cases. The second most common reason for ordering a UDS test was insufficient prenatal care (n=47, 16%), with confirmatory results positive in 13 (28%) of such cases. Reason for ordering UDS test was not documented in 91 (31%) of UDS tests ordered. Among all UDS tests ordered, 104 (35%) had verbal consent documented.
      Table 3Reason for ordering urine drug screening tests and confirmatory positive result
      Chin. Urine drug screening. Am J Obstet Gynecol MFM 2022.
      Reason for orderingN (%) N=281Confirmatory positive result N (%)a
      History of substance use147 (52.3)52 (35)
      Not documented91 (32.4)30 (33)
      Insufficient prenatal care47 (16.7)13 (28)
      Unexplained elevated blood pressure7 (2.5)1 (14)
      Housing instability2 (1)1 (50)
      Other2 (1)1 (50)
      Behavior/signs of intoxication1 (<1)1 (100)
      aPercentage is out of those tested for that particular reason.
      Among those tested, factors predictive of a positive result included self-identifying as White or experiencing housing instability, and having a history of substance use (P<.0001). These factors are shown in Table 4. Other variables such as insufficient prenatal care and identifying as Native Hawaiian or Pacific Islander were not predictive of a positive result, despite these being common reasons for ordering UDS tests. People with a positive result were more likely to experience preterm delivery, low birthweight, and cesarean delivery (Pearson chi-square; P<.05) (Table 5).
      Table 4Predictors of positive urine drug screening result
      Chin. Urine drug screening. Am J Obstet Gynecol MFM 2022.
      CharacteristicChi-squareP valuea
      Housing instability19.41<.001
      History of substance use262.25<.001
      History of tobacco use12.63<.001
      Insufficient prenatal care0.18.67
      aNominal regression analysis was performed to determine which factors predicted a positive urine drug screening result. Race and ethnicity were not included in the nominal regression model because of several small subpopulation groups with 0 frequencies.
      Table 5Urine drug screening result by demographic and obstetrical outcome
      Chin. Urine drug screening. Am J Obstet Gynecol MFM 2022.
      Demographic/obstetrical outcomeUDS positiveUDS negativeP valuea
      White21 (22.3)20 (10.7).03
      History of substance use52 (55.3)95 (50.8)<.0001
      Preterm delivery22 (23.4)25 (13.4).04
      Low birthweight34 (36.2)40 (21.4).01
      Neonatal abstinence syndrome3 (3.2)2 (1.1).22
      Gestational hypertension29 (30.9)51 (27.3).53
      Preeclampsia16 (17)28 (15).66
      Delivery route
       Vaginal delivery58 (61.7)145 (77.5).02
       Cesarean delivery34 (36.2)41 (21.9).02
      Data are number (percentage) unless otherwise specified.
      UDS, urine drug screening.
      aP values calculated with the Pearson chi-square test, Fisher exact test, or analysis of variance, as appropriate.
      Preliminary results were positive in 108 (38%) of people, and confirmatory results were positive in 98 (35%) of people. The most common substance identified in the UDS test was methamphetamine (n=46, 47%) followed by amphetamine (n=45, 46%) and 11-nor-9-carboxy-THC (n=27, 28%). In 24 (24%) of confirmatory positive tests, medications ordered by the provider caused the positive result, including morphine, alprazolam, butalbital, oxycodone, buprenorphine, and hydromorphone. Confirmatory results were negative in 6 (6%) of all positive maternal UDS tests, all of which preliminarily resulted as benzodiazepine. However, 2 (2%) of the positive preliminary results were not sent for confirmatory testing because automatic reflexing to such testing requires a specific order in our hospital system. These tests preliminarily resulted positive for amphetamine and barbiturate.
      After a positive maternal UDS test, 97 (90%) of people received a social work consultation, 76 (70%) were referred to CWS, and 64 (59%) were referred to substance treatment. However, 33 (11%) people were already in a substance treatment program.
      Neonatal screening was ordered according to provider discretion. All neonatal screening was reflexed to confirmatory testing. Out of all neonatal UDS confirmatory positive results, 39 (70%) were positive and 10 (18%) were negative, with 7 (13%) having an insufficient sample for confirmatory testing, most of which were preliminarily positive for cannabinoids.
      Out of all neonatal meconium confirmatory positive results, 40 (83%) were positive and 3 (6%) were negative, with 5 (10%) having an insufficient sample for confirmatory testing. Out of 201 maternal results with a corresponding neonatal result, the positive predictive value of maternal to neonatal result was 77%, and the negative predictive value of neonatal to maternal result was 5%.

      Discussion

      Principal findings

      Our study shows that the maternal UDS test ordered on labor and delivery has a low positive predictive value for detecting substance use. Most pregnant people who received UDS tests identified as Native Hawaiian or Pacific Islander, and had a history of substance use, insufficient prenatal care, or housing instability. Identifying as Native Hawaiian or Pacific Islander and having insufficient prenatal care were not predictive of a positive test result, whereas identifying as White had a higher association with a positive UDS result. Over half of tested people were referred to a substance treatment program. We found poor association between maternal and neonatal results and vice versa.

      Results

      Although history of substance use and insufficient, late, or no prenatal care are often considered as reasons to order a UDS test, multiple studies have shown that this approach discriminates against non-White people on public insurance because of lack of access to early prenatal care.

      Amnesty International. Criminalizing pregnancy: policing pregnant people who use drugs in the USA. London, United Kingdom. Amnesty International Ltd; 2017. https://www.amnesty.org/

      Consequences of a positive UDS result are heightened for pregnant and postpartum people, particularly among people of color. Black people are 1.5 times more likely to be tested than non-Black people, and Black people who test positive are 10 times more likely to be reported to CWS.

      Amnesty International. Criminalizing pregnancy: policing pregnant people who use drugs in the USA. London, United Kingdom. Amnesty International Ltd; 2017. https://www.amnesty.org/

      This is especially problematic given the possibility of false-positive results, particularly if confirmatory testing is not universally used. Most of the UDS tests ordered for non-White persons in our study returned negative on confirmatory testing.
      Many UDS tests were ordered without a documented reason for ordering or verbal consent. This highlights the importance of obtaining verbal or written consent, unless performed in emergency situations. The Substance Abuse and Mental Health Services Administration recommends written consent when performing UDS tests on pregnant people because of the severe consequences of a positive result.

      Klaman SL, Isaacs K, Leopold A, Perpich J, Hayashi S, Vender J, Campopiano M, Jones HE. Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance. J Addict Med. 2017 May/Jun;11(3):178–190

      Consent should include reason for testing, clear explanation of confidentiality, types of drugs being tested, and potential consequences of a positive test. A significant number of people had a positive UDS test as a result of a medication ordered by their provider, which was confirmed by reviewing each inpatient medication record.
      Six percent of preliminary positive maternal results were found to be negative on confirmatory testing. All neonatal testing, including UDS tests and meconium drug screening, were systematically reflexed to confirmatory testing. This highlights the importance of confirmatory testing on maternal samples to minimize the social stigmatization of having a positive UDS result. One of the major concerns of maternal opioid use during pregnancy is the development of neonatal abstinence syndrome; however, we found a low rate among all mothers who received UDS tests, which was also true among mothers who did not receive UDS tests. This was reflective of the low rate of opioid use in our population.

      Clinical implications

      Validated questionnaires are superior to UDS tests for identifying substance use in pregnancy.
      • Chasnoff IJ
      • McGourty RF
      • Bailey GW
      • et al.
      The 4P's Plus screen for substance use in pregnancy: clinical application and outcomes.
      ,
      • Schauberger CW
      • Newbury EJ
      • Colburn JM
      • Al-Hamadani M
      Prevalence of illicit drug use in pregnant women in a Wisconsin private practice setting.
      A negative UDS result does not preclude use because some substances, such as the most common and harmful substances, tobacco and alcohol, are not detected on all assays. People with substance use disorder can strategically time visits to provide negative samples to prevent reports to CWS, whereas those with a positive UDS result often are not referred for appropriate treatment. Positive biologic test results may particularly harm families when an individual is stigmatized and labeled as a “drug user.”
      Committee opinion no. 633: Alcohol abuse and other substance use disorders: ethical issues in obstetric and gynecologic practice.
      There are 23 states plus the District of Columbia that define substance use during pregnancy as child abuse, which, along with knowledge of potential CWS involvement, may ultimately decrease adherence to prenatal care because of fear of these ramifications.

      Guttmacher Institute. Substance use during pregnancy. 2020. Available at:https://www.guttmacher.org/state-policy/explore/substance-use-during-pregnancy. Accessed October 25, 2020.

      ,
      • Terplan M
      • Minkoff H.
      Neonatal abstinence syndrome and ethical approaches to the identification of pregnant women who use drugs.
      There are at least 2 states, Alabama and Tennessee, that have passed laws criminalizing people who use drugs during pregnancy, regardless of knowledge, gestational age, or intent of pregnancy.

      Amnesty International. Criminalizing pregnancy: policing pregnant people who use drugs in the USA. London, United Kingdom. Amnesty International Ltd; 2017. https://www.amnesty.org/

      An example is Tennessee's Fetal Assault Law that was passed in 2014, which for the first time allowed prosecution of pregnant people for their pregnancy outcomes. Under this law, people could be prosecuted if their child was born addicted or harmed by illegal use of narcotics during the pregnancy. Fortunately, the Tennessee General Assembly observed that people avoided prenatal care because of fear of legal ramifications due to this law; therefore, this was allowed to sunset in 2016.

      American Civil Liberties Union of Tennessee. Tennessee's fetal assault law impact flyers. 2020. Available at: https://www.aclu-tn.org/tennessees-fetal-assault-law-impact-flyers/. Accessed October 25, 2020.

      ,

      Ballotpedia. Sunset provision. 2020. Available at: https://ballotpedia.org/Sunset_provision. Accessed November 8, 2020.

      Our results demonstrate that ordering UDS tests according to clinician discretion leads to disproportionately higher screening in stigmatized groups, which can perpetuate interpersonal and institutional racism. This higher screening can also further health disparities by delaying care. It is recognized that the use of illicit substances, particularly stimulants, is contraindicated while breastfeeding. However, confirmatory results often do not result until after discharge or after maternal care has already been altered by preliminary results. The neonatal benefits of breast milk may not be received, and bonding may be reduced on the basis of false-positive preliminary results. Postpartum persons who do require treatment for substance use may be shamed, prohibited, or discouraged from providing breast milk to their infants, including starting the process of pumping and dumping while seeking treatment. Positive UDS results for methamphetamine can also affect maternal care for hypertension in pregnancy. Some practitioners have incorrectly insisted that active methamphetamine is a contraindication to prescribing the commonly used beta-blocker labetalol. However, according to a systematic review in 2015, for methamphetamine-related tachycardia and hypertension that does not respond to sedation, labetalol is actually the preferred treatment because of its beta- and alpha-blocking ability and the added advantage of being lipophilic, thus penetrating the blood–brain barrier and decreasing agitation.
      • Richards JR
      • Albertson TE
      • Derlet RW
      • Lange RA
      • Olson KR
      • Horowitz BZ.
      Treatment of toxicity from amphetamines, related derivatives, and analogues: a systematic clinical review.
      ,

      Richards JR, Laurin EG. Methamphetamine Toxicity. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430895/

      Thus, maternity patients with severe hypertension and a false-positive preliminary UDS test showing methamphetamine may have appropriate treatment withheld in their care.
      The current UDS test performed at our institution does not test for alcohol, tobacco, or synthetic and semisynthetic opioids, which may be more prevalent in the community and more harmful to pregnancy. Thus, our current UDS test may not be helpful for both pediatricians and obstetricians because of the limited substances tested and the short interval during which common substances are detectable in the urine (eg, 48–72 hours for methamphetamine and cocaine).
      Education about the limitations and consequences of UDS testing, appropriate care pathways, and safe medications to treat maternal symptoms would be beneficial for all labor and delivery staff and peripartum healthcare providers. In addition, the incorporation of validated questionnaires as standard practice into electronic health record templates would be beneficial to ensure proper utilization.

      Research implications

      These findings were presented to our institution, and an evidence-based UDS testing policy was implemented as a result. Future research is needed to determine if this policy has decreased biased screening, improved the positive predictive value of the test, and improved care of our pregnant patients. Other institutions with UDS testing policies also need to examine the effects and changes to patient care that have resulted after implementation of these policies.

      Strengths and limitations

      The strengths of our study include a unique, underrepresented, indigenous population that differs from contiguous US cohorts, and comparison with neonatal biologic samples. Limitations of our study include being conducted at a single institution, which limits our generalizability, and ascertainment bias owing to the retrospective nature of our data collection. For example, some of our data points, such as reason for ordering UDS tests, were not documented regularly and thus may have been a confounder when we analyzed these results. However, despite these limitations, similar biases against minority racial/ethnic groups to those reported in the contiguous United States were observed in our population of indigenous people.

      Conclusions

      When used on labor and delivery, UDS tests have a poor positive predictive value for identifying substance use. Traditional indications for ordering UDS tests, such as insufficient prenatal care, do not reliably predict substance use and may perpetuate racial and social discrimination. More research is needed to elucidate medical indications for UDS tests that are not stigmatizing and are associated with improved perinatal outcomes.

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