Substance Use During Pregnancy: Essential Resources and Key Points for Healthcare Providers

Substance use during pregnancy is a significant and growing public health concern worldwide. Research indicates a rising prevalence of substance use among pregnant individuals, including alcohol, tobacco, cannabis, opioids, and other substances. Women account for approximately 40% of the global substance-using population, with the highest risk during their reproductive years, particularly between ages 18 and 29. In the U.S., 5.9% of pregnant women report using illicit drugs, 8.5% consume alcohol, and 15.9% smoke cigarettes. Additionally, up to 50% of pregnant women who use substances engage in polysubstance use. The impact of substance use during pregnancy extends beyond the individual, with societal costs in the U.S. alone estimated at $510.8 billion annually.

The effects of substance use pose serious risks to both maternal and fetal health. For the fetus, exposure can result in complications such as neonatal abstinence syndrome (NAS)—particularly associated with opioid use—along with developmental delays, cognitive and behavioral challenges, low birth weight, and preterm birth. For mothers, substance use increases the likelihood of complications such as preeclampsia, infections, poor nutrition, and co-occurring mental health conditions like depression or anxiety.

Stigma surrounding substance use during pregnancy often prevents individuals from seeking prenatal care or addiction treatment, while limited access to comprehensive, tailored care further compounds the issue. To address these challenges, it is critical to implement integrated treatment programs, expand access to prenatal care, promote early intervention strategies, and reduce the stigma associated with substance use during pregnancy.

The Comprehensive Addiction and Recovery Act (CARA) of 2016 introduced federal requirements under the Child Abuse Prevention and Treatment Act (CAPTA) to address the impact of substance abuse on infants, children, and families. In Nevada, the CARA Plan of Care was launched in 2018 to ensure that infants affected by substance exposure receive appropriate care and services, while also supporting their families in maintaining safety and well-being. The key elements of the Comprehensive Addiction and Recovery Act (CARA) and the Plan of Care are outlined below:

Purpose of CARA: CARA aims to protect infants affected by prenatal substance exposure and support their families without taking punitive action against mothers. The focus is on identifying and addressing health, development, and safety needs through collaborative planning.

When is a CARA Plan of Care Required? A CARA Plan of Care is required when a healthcare provider identifies an infant as substance-affected due to exposure to legal or illegal substances, withdrawal symptoms, or Fetal Alcohol Spectrum Disorder (FASD). Substance-affected infants include those exposed to maternal substance use disorder, whether treated (e.g., medication-assisted treatment) or untreated.

Definition of Substance-Affected Infants: Substance-affected infants are those exposed to maternal substance use (legal or illegal) during pregnancy. This includes infants who are experiencing or are likely to experience withdrawal symptoms or those displaying symptoms of FASD.

Development of the Plan: The CARA Plan is developed before hospital discharge and is tailored to the family’s needs. Healthcare providers, including nursing staff, OB/GYNs, and social workers, work collaboratively with parents to identify necessary services. These services may include:

Prenatal and postpartum care
Substance use treatment
Parenting support
Housing, food, and transportation assistance
Developmental screenings and early intervention

Legal and Procedural Notes: Both legal substances (e.g., marijuana, prescribed medications) and illegal substances are considered in CARA Plans. Determining whether an infant is substance-affected is based on clinical judgment and specific criteria.

Voluntary Participation: While mothers can decline participation in the CARA Plan, mandated CPS notifications still apply.

Hospital Responsibilities: Positive toxicology reports are not required to create a CARA Plan. The plan must be completed before discharge and shared with the caregiver and CPS, if applicable.

Mandated Reporting and CPS Involvement: Mandated reporting and Child Protective Services (CPS) involvement are essential in addressing substance exposure in infants. When an infant is identified as substance-affected, CPS must be notified. However, prenatal substance exposure does not automatically constitute maltreatment, and not all notifications result in CPS involvement. The CARA Plan of Care, which focuses on providing resources and support rather than enforcement, is separate from CPS reports. CPS involvement is based on additional risk factors, such as immediate safety concerns, the mother’s engagement in care, or prior CPS reports. For healthcare providers, it is important to note that the CARA Plan is required even if CPS assumes custody of the infant. Hospitals must complete the CARA Plan before discharge and submit it to the Nevada Department of Public and Behavioral Health (DPBH) within 24 hours of discharge.

The CARA Plan of Care in Nevada is a vital tool for addressing the needs of substance-affected infants and their families. It ensures collaboration between healthcare providers, families, and community resources while distinguishing between support-focused care and mandated reporting requirements. Providers play a crucial role in developing these plans to promote infant safety, family stability, and long-term well-being. For additional resources and to find referral sources in Nevada, visit Nevada’s Department of Public and Behavioral Health website.

The Nevada Perinatal Health Initiative recently shared the below selection of resources that may be of interest to you. Several focus on information related to cannabis use during pregnancy.

ASTHO Newsletter: Substance Misuse and Overdose Prevention

This newsletter provides updates and legislative trends regarding harm reduction, care, and regulation. Please note that while this article states overdose deaths have decreased nationwide, this trend does not apply to Nevada.

Marijuana and Pregnancy Infographic

This infographic from ACOG outlines the possible effects of marijuana use during pregnancy on both the fetus and the pregnant individual.

Marijuana and Pregnancy FAQ

This webpage from ACOG provides answers to frequently asked questions about marijuana use during pregnancy.

Article on Cannabis Use Early in Pregnancy

Published by the Society for Maternal-Fetal Medicine, this article discusses findings from a study on the increased risk of poor pregnancy outcomes associated with cannabis use early in pregnancy.

Marijuana Risks During Pregnancy

This webpage from SAMHSA highlights the health effects of marijuana use during pregnancy.

Cannabis and Pregnancy

This webpage from the CDC provides an overview of the potential health effects of cannabis use during pregnancy and breastfeeding.

Using Cannabis, Including CBD, When Pregnant or Breastfeeding

This article from the FDA explains key considerations regarding the use of cannabis, including CBD, during pregnancy and breastfeeding.

Healthcare providers are essential in addressing perinatal substance use by educating patients about the risks associated with substance use during pregnancy, screening for and offering evidence-based interventions for substance use and co-occurring mental health conditions, and collaborating with multidisciplinary teams to provide holistic care for both mothers and their infants. By understanding these trends and their implications, providers are better equipped to mitigate risks and foster healthier outcomes for mothers and their children. Additionally, healthcare providers can support families by connecting them to appropriate resources, ensuring a comprehensive approach to treatment and prevention throughout the perinatal period.

References

Centers for Disease Control and Prevention. (2024). Substance use during pregnancy. https://www.cdc.gov/maternal-infant-health/pregnancy-substance-abuse/index.html

Chang, G. (2020). Maternal substance use: Consequences, identification, and interventions. Alcohol Research, 40(2), 06. https://doi.org/10.35946/arcr.v40.2.06. PMID: 32612898; PMCID: PMC7304408.

Nevada Department of Health and Human Services, Division of Public and Behavioral Health. (n.d.). Perinatal substance use treatment network. https://dpbh.nv.gov/Programs/ClinicalSAPTA/Womens_Substance_Use_Prevention_and_Treatment/Women_s_Substance_Use_Prevention_and_Treatment/

OpenAI. (2024). ChatGPT (Version 4) [AI language model]. Assisted in generating ideas and editing content for improved flow in the blog post on substance use in pregnancy. Retrieved January 22, 2024, from https://chat.openai.com

Rodriguez, J. J., & Smith, V. C. (2019). Epidemiology of perinatal substance use: Exploring trends in maternal substance use. Seminars in Fetal and Neonatal Medicine, 24(2), 86–89. https://doi.org/10.1016/j.siny.2019.01.006