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Approaching Substance Use in Pregnancy: Giving Brief Intervention a Chance

      Substance use among women of reproductive age continues to be a concern. Women account for 40% of the substance-using population.
      • Stinson FS
      • Grant BF
      • Dawson DA
      • et al.
      Comorbidity between DSM-IV alcohol and specific drug use disorders in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions.
      Substance use, in particular substance use disorder, affects the health of women and their families. Because the gap between the number of men and women using substances is closing, being aware of substance use in women is of increasing importance.
      • Steingrimsson S
      • Carlsen HK
      • Sigfusson S
      The changing gender gap in substance use disorder: a total population-based study of psychiatric in-patients.
      Screening for alcohol use in women of reproductive age serves as a reminder of the teratogenic effect of alcohol in pregnancy and identifies women affected by alcohol use disorder. The Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines on alcohol use in pregnancy were published in 2010 and updated in 2017.
      • Carson G
      • Cox LV
      • Crane J
      • et al.
      No. 245 - Alcohol use and pregnancy consensus clinical guidelines.
      The focus of the 2017 document was screening—specifically, creating a nonjudgmental screening process.
      • Carson G
      • Cox LV
      • Crane J
      • et al.
      No. 245 - Alcohol use and pregnancy consensus clinical guidelines.
      Valid screening tools continue to be used for screening for alcohol use and are documented in the 2020 guidelines. Provincial and territorial prenatal forms have embedded screening questions for alcohol use. However, feedback from users of the 2017 guidelines suggested that providers were looking for additional guidance related to treatment, especially treatment during pregnancy. Further advice about providing care in settings in which specialized addiction treatment services are available or in which women were reluctant to seek services was also requested. After screening, providers asked, “What next?” The 2020 guidelines have been designed to start to answer this question.
      • Graves L
      • Carson G
      • Poole N
      • et al.
      Guideline No. 405: Screening and Counselling for Alcohol Consumption During Pregnancy.
      Alcohol is a known teratogen. Screening and treating alcohol use in pregnancy benefits both the infant and the mother. Pregnancy is a time of transition, marked by change. Women are often motivated to make changes for their own health and for the health of their pregnancy. Using Prochaska's model, pregnancy provides an opportunity to move from a precontemplation phase to action. Between single-question screening for alcohol use and pharmacological treatment of alcohol use disorder rests a model of care: screening, brief intervention, and referral for treatment (SBIRT). SBIRT has been demonstrated to be an effective intervention for women with alcohol use disorder. Evidence supports SBIRT's use as cost-effective and suitable for a variety of settings in the presence of concerns related to alcohol use.
      • Graves L
      • Carson G
      • Poole N
      • et al.
      Guideline No. 405: Screening and Counselling for Alcohol Consumption During Pregnancy.
      Brief interventions are the cornerstone of SBIRT. The most commonly used brief intervention is motivational interviewing, but harm reduction is also commonly used.
      • Graves L
      • Carson G
      • Poole N
      • et al.
      Guideline No. 405: Screening and Counselling for Alcohol Consumption During Pregnancy.
      Providers need to feel empowered to use brief interventions in various clinical settings. Brief interventions can be perceived as complex, time-consuming, or challenging. In fact, brief interventions are indeed brief. Gains have been seen with interventions completed in less than 5 minutes. A brief intervention can be a single session or can consist of multiple sessions; greater success has been noted with multiple sessions.
      • Angus C
      • Latimer N
      • Preston L
      • et al.
      What are the implications for policy makers? A systematic review of the cost-effectiveness of screening and brief interventions for alcohol misuse in primary care.
      Motivational interviewing focuses on collaborative goal-setting with a focus on personal reasons for change.
      • Miller WR
      • Rollnick S.
      Motivational inteviewing: helping people change.
      It is as effective as usual advice-giving and uses the same amount of time.
      • Miller WR
      • Rollnick S.
      Motivational inteviewing: helping people change.
      The simplicity of brief interventions such as motivational interviewing lies in the fact that many current conversations between provider and patient can be reframed to become brief interventions. The AAA model uses three steps that can reframe aspects of a patient encounter to include a brief intervention after a positive response to an alcohol screen.
      • Graves L
      • Carson G
      • Poole N
      • et al.
      Guideline No. 405: Screening and Counselling for Alcohol Consumption During Pregnancy.
      The first “A” is to raise “awareness” while assessing readiness for change. For women with low-risk drinking, this can be as straightforward as a reminder of the teratogenic impact of alcohol. For women engaging in high-risk alcohol use behaviours, it can be more detailed. The second “A” of AAA is providing “advice” geared to the stage of change identified, which varies for those at differing risk levels. Finally, the third “A” is “assistance” to make needed change. This can include a wide variety of behaviours connected by the common theme of goal-setting.
      • Graves L
      • Carson G
      • Poole N
      • et al.
      Guideline No. 405: Screening and Counselling for Alcohol Consumption During Pregnancy.
      Given the simplicity of brief interventions using the AAA model, brief intervention should accompany each screening opportunity. Adding harm reduction approaches to motivational interviewing allows a celebration of small gains, such as a decision to cut down on alcohol use or attend a counselling session or support group meeting. As health care providers, we often look for the large changes, but benchmarking success through the harm reduction lens shifts the focus to the strengths of patients themselves.
      The new guidelines on alcohol use in pregnancy support providers in delivering brief interventions using their preferred method. The guidelines should empower providers to screen all women of reproductive age and to consider embracing the simplicity of brief interventions using the AAA model. The new guidelines provide more detailed treatment options, including links to available resources and medication that can be used to treat alcohol use disorder. These new additions should allow providers to engage more fully in “what's next.”

      REFERENCES

        • Stinson FS
        • Grant BF
        • Dawson DA
        • et al.
        Comorbidity between DSM-IV alcohol and specific drug use disorders in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions.
        Drug Alcohol Depend. 2005; 80: 105-116
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        • Carlsen HK
        • Sigfusson S
        The changing gender gap in substance use disorder: a total population-based study of psychiatric in-patients.
        Addiction. 2012; 107: 1957-1962
        • Carson G
        • Cox LV
        • Crane J
        • et al.
        No. 245 - Alcohol use and pregnancy consensus clinical guidelines.
        J Obstet Gynaecol Can. 2017; 39
        • Graves L
        • Carson G
        • Poole N
        • et al.
        Guideline No. 405: Screening and Counselling for Alcohol Consumption During Pregnancy.
        J Obstet Gynaecol Can. 2020; 42: 1162-1177
        • Angus C
        • Latimer N
        • Preston L
        • et al.
        What are the implications for policy makers? A systematic review of the cost-effectiveness of screening and brief interventions for alcohol misuse in primary care.
        Front Psychiatry. 2014; 5: 114
        • Miller WR
        • Rollnick S.
        Motivational inteviewing: helping people change.
        3rd ed. Guilford Press, New York2012

      Linked Article

      • Aborder la consommation de substances psychoactives pendant la grossesse : adopter l'intervention brève
        Journal of Obstetrics and Gynaecology Canada Vol. 42Issue 9
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          La consommation de substances psychoactives chez les femmes en âge de procréer demeure préoccupante. Les femmes représentent 40 % de la population consommant des substances psychoactives1. La consommation de substances psychoactives, en particulier les troubles de consommation, nuit à la santé des femmes et à leurs familles. Comme l’écart entre le nombre d'hommes et de femmes qui consomment des substances psychoactives diminue, il est de plus en plus important de savoir reconnaître cette consommation chez les femmes2.
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