Your doctor wants to talk to you about substance use in pregnancy

Don’t be surprised if your OB-GYN wants to talk to you about your substance use. You’ve heard about the dangers of drinking while pregnant and seen the scary warnings about smoking’s effects on a fetus on cigarette packages, but with the legalization of marijuana and the growing opioid crisis, experts think it’s time to turn all those warnings into a bigger conversation.

The Society of Obstetricians and Gynaecologists of Canada (SOGC) have released new guidelines on substance use in pregnancy, recommending that healthcare providers ask all pregnant women about their past and current alcohol, nicotine and illicit and prescribed drug use. It’s an important conversation to have, because at least 11 percent of Canadian women report smoking or drinking when pregnant, while two percent are estimated to use marijuana and one percent take opioids.

While drug testing could give doctors a quick answer, the SOGC discourages universal screening and says a woman’s consent should be required for any drug testing. Instead, “Using open-ended, non-judgmental questioning is more likely to elicit disclosure of perinatal substance use,” say the guidelines. The SOGC’s recommendations seek to start the discussion so that OB-GYNs can counsel women on the effects of substance use—before, during and after pregnancy—and assist them in seeking help through harm-reduction strategies.

Of course, all of that starts with the doctor and mom-to-be having a trusting conversation. To do that, “comfort and confidence need to be built on both sides,” says Jennifer Blake, chief executive officer at the SOGC. Understandably, Blake says that many women may be hesitant to speak with their doctors about substance use because they are afraid of being judged or even reported to Children’s Aid Society.

According to the SOGC, the earlier the conversation starts, the better. Their recommendations suggest doctors periodically discuss substance use with all women of child-bearing age. “Sixty-one percent of Canadian women report having had an unplanned pregnancy,” says Blake. “And when you’re using substances, there’s an increased risk of unplanned pregnancy. The time to start thinking about your substance use is before you even start thinking about getting pregnant.”

The effects on a growing baby vary widely from substance to substance. Marijuana use, for example, has been shown to cause cognitive impairments in babies when used during pregnancy—though those impacts haven’t been studied as well as the brain effects that are associated with fetal alcohol spectrum disorder. “Right now, as there’s discussion around the impact of impending legalization, we think it’s really important to be very clear that making cannabis legal doesn’t make it safe in pregnancy,” says Blake.

Withdrawal symptoms are also unique to each drug. “Cannabis doesn’t have the same withdrawal symptoms as, say, an opioid,” says Jocelynn Cook, chief scientific officer for the SOGC. “But for people who are using it for medical indications, they would have to have a discussion with their physician as to what their alternatives are to manage their symptoms.”

For cigarettes, the SOGC recommends counselling as a first resort to help quit, and, if that doesn’t work, nicotine replacement as a second resort. Opioid users are counselled to start opioid replacement therapies with drugs such as methadone or buprenorphine because of the dangerous effects of withdrawal and the high risk of relapse.

When doctors start these conversations with women, they can help connect them to the treatment resources they need. “I hope that [the] will encourage women to know that if they are using substances, we will still be there to help them provide the best possible environment for their baby, to support them in harm-reduction strategies and to understand that it’s not always easy,” says Blake.

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