Screening OUD

Learn the best way to assess if a pregnant person uses opioids.

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Key Points

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:
  • 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. 

Deeper Dive

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

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