Screening
Screening Pregnancy
Learn the best practices for determining if somebody is pregnant when they get to jail.
HOW
Where can jail staff purchase disposable pregnancy tests from?
You can purchase disposable pregnancy tests in bulk from Amazon and keep them in stock.
Who should receive a pregnancy test? How should we ask them to take a pregnancy test?
The medical intake staff member should ask all females (and trans males) under the age of 55: “We recommend doing a urine pregnancy test to see if you are pregnant. This is important so that we can give you the medical care that you need. We will not test your urine for anything else. Will you give a urine sample for a pregnancy test?”
What steps should we take if the patient agrees to a pregnancy test?
If the patient agrees to test, provide privacy for them to give a urine sample. Discuss the results with them in private. Don’t make assumptions about whether this will be happy or sad news for the patient. See scripts.
What should happen next, whether positive or negative for pregnancy?
If pregnant, screen for any urgent maternal signs (especially bleeding and pain) and signs of being unwell. “Are you having any vaginal bleeding or pain in your lower abdomen?”
- If yes, consult with a medical provider (any bleeding in pregnancy can be concerning). Tell the patient you’ll refer them to a medical provider for an appointment for options counseling and routine prenatal care.
- If the test is negative or the patient declines, but the patient believes there is a chance for pregnancy, retest them in 1-2 weeks.
Screen for opioid use and alcohol/benzo use
WHY
Why should jails screen for pregnancy at intake?
Identifying a pregnant patient as soon as they enter jail will enable staff to provide appropriate medical care and pregnancy accommodations as soon as possible.
Why is a urine pregnancy test necessary for screening?
Urine pregnancy testing for all females and trans males under the age of 55 is more accurate than just asking when their last menstrual period was and only running a pregnancy test if it was more than 4 weeks ago. This is not a reliable approach, especially because many people who use substances have irregular periods.
Pregnancy tests are cheap! (<$1/test)
What additional things should jail staff consider when testing for pregnancy?
Recommend, but don’t require women to do a pregnancy test. Explain to the patient why it’s important (see How). If they decline to test, document it in the medical record and tell them that they can request a pregnancy test later.
People who have had a hysterectomy (removal of the uterus, also known as the womb) do not need a pregnancy test. If someone has had a tubal ligation (having your “tubes tied”) or is on another method of contraception, they are less likely to get pregnant, but it is still possible, so you should still offer a test to them.
- MOMCARE Initial Pregnancy & OUD Screening and Care at Jail Intake algorithm
- MOMCARE Communicating with Patients Sample Scripts
- Amazon pregnancy tests- Amazon search results for “bulk urine pregnancy tests”
- Urgent Maternal Warning Signs- information on urgent maternal warning signs to look out for and includes 1-page flyers in 14 languages. Consider posting it in the intake area.
- MOMCARE Treatment for OUD during Pregnancy and Postpartum patient education 1-pager
HOW
The best practice for screening for substance use in pregnancy is with verbal screening questionnaires. Routine urine drug screening as the way to test for substance use and determine treatment needs is not recommended.- OUD screening questionnaires in pregnancy: NIDA Quick Screen, SURP-P, S-BIRT, 4P’s Plus, CRAFT, Wayne Indirect Drug Use Screener, DAST-10. We recommend a single screening question at jail intake (adapted from the 4Ps):
“In the past year, have you used opioids? Things like heroin, fentanyl, oxycodone, methadone, or buprenorphine with or without a prescription? I am not asking to get you in trouble, but because I want to know if you could go through withdrawal.”
- See our full algorithm for steps on screening OUD and pregnancy at jail intake
- We recommend that screening be performed by a health care staff member, if possible.
- The intake staff member must assess whether the pregnant patient appears “unwell.” This includes urgent maternal warning signs. See the BJA training video (7 mins) on how to identify if someone in jail is unwell. If so, they need an immediate clinical assessment by a qualified health care provider, either onsite or offsite.
- IF THE PREGNANT PATIENT HAS USED OPIOIDS IN THE LAST 2 WEEKS, APPEARS UNWELL, OR SAYS THEY ARE IN WITHDRAWAL, FLAG FOR HIGH RISK OF WITHDRAWAL.
- If screened positive for opioid use in the last year, proceed to the “INITIAL CARE STEPS” for details of what to do, when to transport to the hospital, how to start methadone/buprenorphine in pregnancy, and how to manage withdrawal symptoms in pregnancy while awaiting MOUD (also referred to as MAT) dosing.
- Proceed to screening for alcohol, benzo, and other substance use in pregnancy.
WHY
- Jails must adequately and efficiently screen for opioid use to identify pregnant individuals who are at risk of withdrawal and who need MOUD. This will help avoid withdrawal symptoms and get them treatment in a timely fashion.
- Screening for opioid use in pregnancy is important because withdrawal symptoms may be mislabeled as pregnancy symptoms (i.e. vomiting)
- Screening for opioid use in pregnancy should be done with questions, NOT with urine or blood samples. This is in line with national guidance. Urine drug tests can give false positives, are expensive, and can take time for results to come back—which can cause delays in starting MOUD or recognizing withdrawal. Urine drug tests in pregnancy can cause problems for patients when it comes to ensuring child custody.
KEEP IN MIND
- Remember, a drug test is not a parenting test. If someone screens positive, this does not mean they cannot parent, but they should be referred for services. And, being in jail while pregnant doesn’t mean they are a bad parent.
- Any pregnant patient appearing unwell must receive IMMEDIATE medical attention.
- Pregnant patients who use substances are worried about the health of their babies and are afraid to seek help due to judgment and possible loss of custodial rights.
- If your jail requires urine drug testing of pregnant patients, you must obtain the patient’s consent to do so.
- Jail staff should also screen for:
- Alcohol or Benzo use. See “Alcohol and Benzo Screening and Withdrawal Management in Pregnancy”
- Other substance use. See “Screening for Other Substance Use in Pregnancy
- Review the urgent maternal warning signs and educational materials on being pregnant/postpartum with OUD with patients. Educate your patients about these symptoms so they are aware while in jail and in the community.
HOW
See our full algorithm for the questions and steps on screening OUD and pregnancy at jail intake (also posted below)
What does the person doing the initial medical intake need to know when screening a pregnant person for opioid use?
Even before asking a patient about opioid use, the person doing their initial medical intake should determine if they appear “unwell.” If they are unwell, then they need an immediate clinical assessment by a qualified healthcare professional.
“Unwell” means that someone has observed signs and symptoms that are obvious to a layperson that they are physically or psychologically sick, including signs of self-reported intoxication or substance withdrawal (see BJA Withdrawal Management Guidelines, p. 5, for more about “unwell”). For a pregnant patient, this also includes signs or symptoms of urgent maternal warning signs, like bleeding, pelvic pain, severe headache, contractions, and other symptoms.
See the BJA training video (7 mins) on how to identify if someone in jail is unwell.
Additional signs of being unwell during pregnancy could include that they look dehydrated, they are actively vomiting or have a fast heart rate. In pregnancy, this could also include vaginal bleeding, contractions, abdominal pain, shortness of breath, decreased fetal movement, and fever.
How should I screen pregnant patients for opioid use?
Several OUD screening questionnaires have been validated in pregnancy—NIDA Quick Screen, SURP-P, S-BIRT, 4P’s Plus, CRAFT, Wayne Indirect Drug Use Screener, DAST-10. We recommend a single screening question (adapted from the 4Ps). (See the algorithm below, “In the past year…”)
These screenings should be done ideally by health care staff who can then appropriately counsel and refer patients who screen positive. But if your jail does not have 24/7 health care staff and someone else does intakes, we have guidance for them on MOMCARE.
Screening for opioid use during pregnancy is designed to ensure pregnant patients in jail have access to treatment when needed, not to apply formal diagnoses. Formal diagnostic criteria that define “opioid use disorder should not be used in pregnancy.
IF THE PATIENT HAS USED OPIOIDS IN THE LAST 2 WEEKS, APPEARS UNWELL, OR SAYS THEY ARE IN WITHDRAWAL, FLAG FOR HIGH RISK OF WITHDRAWAL.
Why shouldn’t urine drug tests be used for pregnant patients?
While we DO NOT recommend urine drug tests, if your facility requires this, you must obtain verbal consent from the patient. Qualified health care professionals must therefore tell patients about this and get their consent before doing a drug test; they can decline. This way the patient understands that you are not judging her, but just telling her the legal requirements. Note that jail staff are not mandated reporters, but results obtained in the jail could be used in a report from the birthing hospital. Consider a language like this:
“Do you give your permission for us to run a urine drug test? The test results will allow your healthcare team to understand what substances you and your baby were exposed to in order to provide the highest quality of care to you and your baby. A provider will discuss the results with you and offer suggestions for your care. You have the right to decline a drug test. If you choose not to be tested, there will not be a delay in your care, but it may delay the treatment of substance use disorder, which could increase the risk of harm to you and your baby. A risk of a test is that results may be communicated to child welfare agencies.”
What should jail staff do next if a pregnant patient screens positive for opioids?
After screening for opioid use, jail staff should assess for withdrawal and create a plan to provide MOUD.
Screen for other substances. Many people also use benzodiazepines (e.g. Valium, Ativan, etc.) and/or alcohol. Withdrawal from these substances in pregnancy is also physically dangerous and requires specific medical management.
See MOMCARE Communicating with Patients Sample Scripts for guidance on screening language and how to counsel pregnant patients about opioid use and treatment.
WHY
Why is screening for opioid use at jail intake important?
To identify pregnant patients at risk of opioid withdrawal who need specialized, time-sensitive care, like methadone/buprenorphine or transport off-site.
Identifying pregnant patients with OUD can help avoid the risks of withdrawal for the fetus and pregnant patient and can get them into ongoing treatment.
How might screening in pregnancy be unique from screening non-pregnant individuals for opioid use?
Certain symptoms like vomiting are common in pregnancy and early withdrawal, which can make the two conditions difficult to distinguish.
Following national guidelines, we recommend screening for opioid use in pregnancy with questions and NOT with urine drug tests or blood samples. Urine tests are not always accurate, their results can be delayed, and their use can discourage pregnant patients from engaging in care, often because they are afraid their babies will be taken away by Child Protective Services.
That being said, we know that many jails have protocols that require urine drug tests for all patients before starting MOUD. If so, you must get verbal consent from the pregnant patient for a urine drug test. See sample language
- MOMCARE Initial Pregnancy & OUD Screening and Care at Jail Intake algorithm
- MOMCARE Communicating with Patients Sample Scripts
- MOMCARE Treatment for OUD during Pregnancy and Postpartum patient education 1-pager
- Urgent Maternal Warning Signs– information on urgent maternal warning signs to look out for and includes 1-page flyers in 14 languages.
- Use the MOMCARE Recognizing Urgent Maternal Warning Signs in Custody 1-pager to educate jail staff on what to look out for
- NIH substance screening tools table with links to various screening tools, including ones we recommend, NIDA Quick Screen, SURP-P, and 4P’s Plus categorized by substance type, patient age, and tool administration.
- Best Practices for Prenatal Substance Use Screening- PowerPoint on best practices for pre-natal substance use screening.
- BJA Guidelines for Managing Substance Withdrawal in Jails- Newly developed toolkit on substance withdrawal management instructions and care guidance (including opioids) for Local Government Officials, Jail Administrators, Correctional Officers, and Health Care Professionals.
- DSM-5 Criteria for Diagnosis of Opioid Use Disorder-This is a fillable checklist of the diagnostic criteria for opioid use disorder, along with a designation for mild, moderate, and severe symptoms depending on the number of boxes checked.
- American College of Obstetricians and Gynecologists OUD in Pregnancy– Screening and clinical care guidance.
Alcohol and Benzo Screening and Withdrawal Management in Pregnancy
It is beyond the scope of MOMCARE at this time to provide extensive guidance about non-opioid substance use in pregnancy. However, if a pregnant individual is using alcohol or benzodiazepines, special care must be taken to avoid dangerous complications for the patient and fetus.
HOW
Not everyone who uses alcohol or benzos will develop withdrawal, but because of the risk anyone reporting recent use (7 days) must be assessed for withdrawal symptoms.
How should jail staff assess alcohol use in pregnancy?
Screen for alcohol use. There are many questionnaires, such as the TACE. We recommend the Alcohol Quantity and Drinking Frequency Questions from NIAA:
- “In a typical week, how many drinks do you have that contain alcohol?” If more than 7 drinks, POSITIVE SCREEN.
- “In the past 3 months, how many times have you had more than 3 alcoholic drinks on any one occasion?” If more than once, POSITIVE SCREEN.
- If screened positive, ask when their last drink was. If within the last 7 days, at RISK FOR WITHDRAWAL.
How should jail staff assess Benzo use during pregnancy?
Screen for Benzo use.
- “Do you take any sedatives or benzos that are not prescribed by a doctor?” If YES, ask how much and when the last use was. If they use it daily or almost daily and have used it within the past 7 days, at RISK FOR WITHDRAWAL.
- If the patient is prescribed benzodiazepines for medical indication, then they should be continued on this as with any other medication.
What should jail staff do if a pregnant patient screens positive for alcohol or Benzo use?
In most cases, we recommend TRANSPORT TO HOSPITAL for pregnant patients at risk for alcohol and/or benzo withdrawal for assessment and initial management.
If your jail is properly staffed with people with training and experience managing alcohol and benzo withdrawal in pregnant patients, including recognition of when patients need to be referred and staffing to do frequent withdrawal assessments and dosing of benzo taper, then some patients who do not appear unwell may be able to stay on site. See the BJA training video (7 mins) on how to identify if someone in jail is unwell.
- All patients who are pregnant and appear unwell or have urgent maternal warning signs
should be transferred to the hospital, regardless of jail staffing - Benzodiazepine taper is the preferred medication treatment for pregnant patients with alcohol or benzo withdrawal.
How should jail staff assess alcohol and Benzo withdrawal symptoms?
Score withdrawal symptoms using a validated tool:
- Alcohol: CIWA-Ar Scale (Clinical Institute Withdrawal Assessment of Alcohol Scale)
- Benzos: CIWA-B Scale
- Patients should be scored every 10-15 minutes if severe symptoms, or every 4-6 hours if mild symptoms.
- Treat symptoms (usually scores>10) with an established benzodiazepine taper protocol (see Resources)
What other services should pregnant patients who use alcohol and Benzos be connected to?
Connect patients to behavioral health treatment, recovery groups, and other support services, support groups (including mutual aid groups). Counsel patients on the risks to the fetal physical and intellectual development of alcohol use in pregnancy.
WHY
How common is alcohol use in pregnancy?
Alcohol use in pregnancy is more common than people think. The CDC reports that 14% of pregnant individuals report current drinking and 5% report binge drinking.
Alcohol exposure in pregnancy is a leading cause of preventable intellectual disability and birth defects in the U.S. Here is more information on the risks of moderate and heavy drinking in pregnancy.
What are benzodiazepines?
Benzodiazepines or “benzos” are medications that relieve anxiety, muscle spasms, and seizures, and can also cause sedation. While they can be prescribed, many people misuse prescribed or non-prescribed benzos. Some examples are Valium, Xanax, Ativan, and Klonopin.
Why is it important to screen for alcohol and Benzos use in pregnancy?
Withdrawal from alcohol or benzos, if not properly treated, can be deadly and lead to maternal and fetal complications in pregnancy.
Treating alcohol and benzo withdrawal symptoms with medications and connecting them to recovery resources is essential for the health of the mother and fetus.
- MOMCARE Communicating with Patients Sample Scripts
- Urgent Maternal Warning Signs- information on urgent maternal warning signs to look out for and includes 1-page flyers in 14 languages
- Use the MOMCARE Recognizing Urgent Maternal Warning Signs in Custody 1-pager to educate jail staff on what to look out for
- Alcohol withdrawal scoring scale, CIWA-Ar Scale
- Benzo withdrawal scoring scale, CIWA-Benzo scale
- Comprehensive guidelines from the American Society of Addiction Medicine on Alcohol Withdrawal Management
- BJA Guidelines for Managing Substance Withdrawal in Jails- Newly developed toolkit on substance withdrawal management instructions and care guidance (including opioids) for Local Government Officials, Jail Administrators, Correctional Officers, and Health Care Professionals.
- ACOG Patient information regarding alcohol use in pregnancy- details the risk of using alcohol in pregnancy
- Alcohol Consumption and Binge Drinking During Pregnancy Among Adults Aged 18–49 Years — United States, 2018–2020 (CDC, Morbidity & Mortality Weekly Report)
Screening for other Substance Use in Pregnancy
It is beyond the scope of MOMCARE to provide extensive guidance about non-opioid substance use in pregnancy. However, we provide some basic things to know.
HOW
When should screening for other substance use in pregnancy occur?
Screening for other substance use (non-opioids/alcohol/benzos) in pregnancy should occur either at intake or the full initial health assessment visit. Because there is not a dangerous withdrawal syndrome with these other substances, it is okay to defer screening to the full assessment.
How should jail staff screen for other substance use in pregnancy?
As with screening for opioid use, we do NOT recommend using urine drug tests. Screening should be with validated verbal screens.
As with screening for OUD in pregnancy, there are several validated screening questionnaires. NIDA Quick Screen, SURP-P, S-BIRT, 4P’s Plus, CRAFT, Wayne Indirect Drug Use Screener, DAST-10. Here is an adapted, simple question you can ask:
- “In the past year, have you used any of the following substances? Marijuana, cocaine, methamphetamines, hallucinogens (e.g. LSD, acid, mushrooms, Special K, or ecstasy), prescription stimulants (e.g. Ritalin or Adderal), sedatives/sleeping pills? I’m not asking to get you in trouble, but because it’s important for your health and your baby’s health to know.”
There are many, many screening questionnaires to screen for tobacco use. Here is one option:
- When you are not in jail, what describes your current tobacco use (cigarettes, vaping, e-cigarettes)? Smoke every day, a few times a week, less than that, I quit in the last year, never smoked.
What should be done if a pregnant patient screens positive for other substance use?
Refer them for recovery support services and behavioral treatment. You can discuss the risks of substance use during pregnancy, and why it’s important to be in recovery, but avoid language that blames them for harming the fetus. Use a compassionate approach as you refer them to services, acknowledging that recovery is a long and difficult process.
What should be done if a pregnant patient screens positive for tobacco or nicotine use?
Discuss the risks of tobacco and nicotine use in pregnancy. Refer the patient for behavioral smoking cessation programs as you would for non-pregnant patients, either in jail or upon return to the community. Nicotine replacement (e.g. gum, patch) may be appropriate for some pregnant patients. See this guidance from the American College of Ob/Gyn’s (ACOG) for more information about treatment.
WHY
Why is it important to screen pregnant patients for other substances?
Many pregnant people who use opioids use other substances as well—alcohol, benzos, methamphetamines, cocaine, marijuana, tobacco, and others.
While only opioids, alcohol, and benzos have a treatable withdrawal syndrome when someone stops using them, other substance use in pregnancy can cause maternal or fetal complications. For example:
- Smoking in pregnancy is associated with miscarriage, preterm birth, low birth weight, and, after birth, sudden infant death syndrome (SIDS), and other medical problems during childhood.
- Cocaine and methamphetamine use in pregnancy can cause similar problems, and can also lead to preterm birth, hemorrhage, and fetal or maternal death.
Screening for other substance use can identify people who would benefit from treatment resources and other social supports as they prepare to parent.
- MOMCARE Communicating with Patients Sample Scripts
- Urgent Maternal Warning Signs– information on urgent maternal warning signs to look out for and includes 1-page flyers in 14 languages
- Use the MOMCARE Recognizing Urgent Maternal Warning Signs in Custody 1-pager to educate jail staff on what to look out for
- BJA Guidelines for Managing Substance Withdrawal in Jails- Newly developed toolkit on substance withdrawal management instructions and care guidance (including opioids) for Local Government Officials, Jail Administrators, Correctional Officers, and Health Care Professionals.
- Best Practices for Prenatal Substance Use Screening– Powerpoint with information on screening for substance use in pregnancy, including multiple screening tools
- FAQs on tobacco, alcohol, and drug use in pregnancy from the American College of Ob/Gyn’s. It is patient-facing, but much of the material is helpful for jail staff to learn key counseling points too.
- ACOG guidance on tobacco screening and cessation in pregnancy.
