Caring for Pregnant Patients with Substance Use Disorder

On this page, providers will have the opportunity to learn about:

Recommended Terms and Language
Substance use disorder, other medical conditions, and personal identities can all be highly stigmatized by language that potentially shames a patient who has a particular condition or identifies a certain way. Because of this, it is vital to use language that affirms the patient’s identity and personhood and does not reduce them to a disorder.

Patient centered language (also known as person-first language) changes terminology of how patients are referenced by eliminating generalizations, assumptions, and stereotypes and by focusing on the person. This small but significant step can help reduce the stigma surrounding individuals with a substance use disorder.

Learn more about recommended language here.

How to Safely and Effectively Talk with Your Patients
Though many providers are making efforts to improve how patients with substance use disorder are treated during pregnancy, many unintentionally choose words that may shame patients for having a particular condition. It is important that we refer to our patients as a person, first. Respecting our patients is key to effective treatment. Learn more about using words that matter here.
- Instead of “Addicted Mother,” Use “Mother or Pregnant Person with a SUD”
- Instead of “Substance or Drug Abusing Mother,” Use “Mother or Pregnant Person with an OUD or a SUD”
- Instead of “Former Addicted Mother,” Use “Mother or Pregnant Person in Recovery”
- Instead of “Neonatal Abstinence Syndrome (NAS) Baby,” Use “Baby with Neonatal Opioid Withdrawal or NAS”
The Effects of Implicit Bias and Stigma

Stigma – Stigma is a perceived negative attribute that causes someone to devalue or think less of a person who has this attribute. A substance use disorder (SUD) is one of the most stigmatized disorders. This stigma is widespread and heavily written into our laws and social systems. SUD stigma can be dangerous for people with a SUD because the constant shame can cause patients to lose their self-love and cause them to accept the injustices they face. Stigma can contribute to isolation of the patient and create conditions that may lead to continued or increased substance use.

These effects are amplified when the patient with a SUD becomes pregnant. The reduction of stigma can lead to patient-provider interactions that are focused on dignity, respect, and shared decision-making about the patient’s immediate and future care plan. As a provider, you can help reduce stigma by using appropriate terms, practicing trauma-informed care, and by giving patients ample information on available treatments.

Bias – Bias is a prejudice for or against a certain group, especially in an unfair manner. Explicit bias involves knowing you hold these prejudices and act according to them regardless, while implicit bias involves making decisions based on unconscious preconceptions about groups of people. Everyone has bias, especially implicit bias. Since we are unaware of our own implicit bias, it can be hard to know when it affects how we interact and treat patients.

For treating patients with a SUD, implicit bias can cause us to act in ways and say things that can stigmatize the person with a SUD. This includes unconsciously treating patients with a SUD differently, or unconsciously speaking to patients in a manner that shames them for factors they cannot control.

Mandatory Reporting: Alabama’s Mandatory Reporting Law requires healthcare professionals to report cases of child abuse, which under the Chemical Endangerment Law includes substance use in pregnancy, to child welfare agencies. Failure to report may lead to a misdemeanor charge. This creates a dangerous barrier for pregnant people to seek help for their substance use. The involvement of healthcare providers in these punitive enforcement measures prevents a trusting relationship between patient and provider. To the extent possible, healthcare providers should avoid testing pregnant or postpartum people, as pregnancy itself does not provide a medical justification for testing. If testing does occur, it should only be done with the patient’s complete informed consent, discussed in a later section. Familiarize yourself with the guidelines for mandatory reporting and be familiar with the community resources available for the family if a report is made. When considering making a report, be aware of your own implicit and explicit biases. For information on how to navigate testing in the clinical setting, click here. For more information on mandatory reporting, click here.

Physiological Factors Associated with SUD

There are many factors that may lead to a patient developing a substance use disorder.

One important thing to acknowledge as a provider is that nobody begins using substances with the intent of becoming dependent. Neurobiology can explain the pathways associated with substance use disorder. Learn more about the physiological pathways behind neurobiological substance addiction.

A substance use disorder develops from the body’s inability to self-regulate without the substance, which causes the person to physiologically require the substance to function in their daily life. This is addiction, and it can lead to clinical and social impairment due to the patient’s dependence on the substance(s). Some individuals are predisposed to addiction due to genetics, previous trauma, and other risk factors.
Social Factors Associated with SUD
Chronic Stress Linked to Childhood Trauma:
- Adverse childhood experiences
- Stress can arise from unresolved trauma or from a current situation
Associated Stigma:
- Mental health stigma around trauma
- Lack of trauma-informed care ignores important background for SUD
Treatment Options:
- Counseling to address previous trauma can help understand a patient’s roots in SUD
Social Pressure and Use:
- People close to the patient use it to cope, patient learns that coping mechanism and uses it for themself
- Use to “get on the good side” of people who can exert power over the individual
- Parents who have SUD create potentially traumatic environments for children growing up, which can add to the child’s SUD risk when they become adults
Associated Stigma:
- It’s hard to “just say no” when there are extra factors in refusing
- Offensive terms such as “crack baby” stigmatizes children being raised in homes with individuals who have a SUD
Treatment Options:
- Counseling to address anxiety and other conditions around SUD
- Counseling to learn to improve interpersonal relationships
Prescriptions:
- Taking prescription medication in a way that doesn’t follow dosage instructions
- Taking prescription medications that aren’t prescribed to them
Associated Stigma:
- “Non-compliance” in taking medication is attributed to patients being unreliable
Treatment Options:
- Counseling to address anxiety and other conditions around SUD
- Counseling to learn to improve interpersonal relationships
- Counseling to discuss the history behind the patient’s prescription usage
Ultimately, no matter the pathway, help can be made available if the patient chooses to seek it. Treatment for SUD will vary by patient. Preliminary recommendations include counseling and addressing issues surrounding the person’s SUD.

Support Patients with SUD Using Trauma-Informed Care

Trauma-informed care is a treatment method that acknowledges a patient’s trauma and personal history while avoiding re-traumatization. The aim of trauma informed care is to understand the impact trauma has on an individual’s health and to recognize and treat symptoms caused by trauma. Providers in leadership positions should consider modifying policies and procedures for treating patients with SUD using a trauma-informed approach.

Trauma-informed care shifts the stigma of being “the problem” to a position where the patient is not entirely to blame. This is incredibly vital in treating patients with SUD as those with previous traumatic experiences have a higher likelihood of using substances. Trauma-informed care allows a provider to create rapport with a patient while supporting and including the patient in their care decisions. Trauma-informed care is not necessarily a step-by-step program, but rather a method focusing on six principles.

View Infographic
The Six Principles of Trauma-Informed Care
Safety
- Ensuring the physical and emotional safety of the patient
How to Implement:
- Create common areas like waiting rooms that are comfortable and welcoming
- Respect privacy and requests from the patient about their preferences
Examples:
- A waiting room that has calming imagery, artwork, and decorations
- Calling patients by last name only to preserve privacy
Peer Support
- Including people with shared experiences helps promote healing.
How to Implement:
- Implement peer programs and/or collaborate with peer-support specialists
Examples:
- Contract or hire peer support specialists to provide support on-site or as a part of a home visiting plan.
- Contract with an existing organization that provides peer support services
Collaboration
- Make decisions with the patient, share responsibility and power
How to Implement:
- Informed consent – gives the patient an opportunity to collaborate with a provider on a treatment plan
Examples:
- Asking patients their opinion on treatments and working to change treatment plans to suit each patient individually
Trustworthiness & Transparency
- Setting and respecting patient-provider boundaries
- Build rapport
- Recognize and disclose what you do and don’t know.
How to Implement:
- Motivational interviewing (MI)– Ask questions, tell the patient about resources, and listen to what the patient has to say
- Be honest about the expectations the patient should have.
- Effectively communicate with your patient during and in-between visits.
Examples:
- Responsively listen for patient’s concerns, worries, hopes, wishes, emotions, and opinions around treatment
- “I want to answer this to the best of my ability. Let me get more information for you.”
- “I can see why you’re worried about [X]. Let’s talk more about your options until we find one you are comfortable with.”
Empowerment, Voice, & Choice
- Prioritizing the patient’s self confidence in effectively engaging in their treatment plan
How to Implement:
- Ask the patient for consent or for their opinions, tell the patient what resources they can use to empower themselves in their treatment
- Informed consent lets the patient make the best, most informed choice for themself
Examples:

Ask permission to discuss topics, using open and closed questions
- “I know you were very hurt and upset when [X], how do you feel about discussing [Y]?”
- “How can I help you with ___?”
- “What would you like to do next?”
Share resources and information with the patient
- “VitAL has an app that can help you find counselors; would you be interested?”
- “We just talked about the options you have. What questions do you have that will help you make your decision?”
Cultural, Gender, & Historical Issues
- Biases, stereotypes, and historical trauma are recognized and addressed.
- Awareness and proper management of bias is essential.
How to Implement:
- Approach every patient with compassion.
- Assume each patient is trying their best and wants the best for their wellbeing.
- Exercise cultural humility when working with all patients.
Examples:
- Routinely engage in implicit bias training.
- Do not make assumptions based off race, socioeconomic status, or any other stereotypes.
- When possible, offer culturally responsive services.
Before a patient agrees to treatment, it is important for them to be informed about the risks, benefits, and alternatives of that specific treatment. This is known as informed consent. As a healthcare provider, it is your responsibility to ensure that all patient waivers have been signed after thoroughly explaining the benefits, risks, and procedures included in the treatment plan. Ensuring the patient has all the information and resources needed to make an informed decision can empower them, while also giving them the ability to make the best decision for them and their body.

Motivational Interviewing is a tool that can assist providers in navigating difficult conversations. This can be particularly useful when addressing stigmatized topics and chronic conditions, such as SUDs. This tool encourages the provider to ask questions and then listen to the response while also focusing on identifying the patient’s goals. When using motivational interviewing, healthcare providers should ask questions (permission to discuss certain topics, open-ended questions, and closed-ended questions), tell the patient about resources and information to educate the patient about their choices, and listen to what the patient has to say.

Treatment Options

Assessing and testing for substance use during pregnancy presents practical challenges in the clinical care setting, however, there are positive and effective ways to support and serve pregnant patients with SUD.

Effective Screening

Effective screening can allow providers to identify patients at risk of SUDs or those who may be engaging in risky behaviors consistent with an alcohol or substance use disorder. Patients are more likely to disclose substance use if they have a trusting relationship with a care provider who is trauma sensitive. Pregnant populations are also the most likely to be screened for substance use given the potential health risks to the pregnant person and the fetus. Screening helps you determine the next steps you can take to get your patient the treatment they need. Visit this link to learn more about the screening process for pregnant patients.
Counseling

For most SUDs and other chronic conditions, counseling or therapy is recommended to address the personal, psychosocial factors associated with a patient’s addiction. Counseling is meant to explore the underlying complexities of the patient’s SUD, including prior trauma, chronic stress, and other factors. This mode of treatment helps patients recognize and understand the effects of their lived experiences on their SUD and can help them develop coping mechanisms to work toward sobriety. Some counselors or therapists even specialize in serving pregnant populations. You can find treatment centers through the Connect Alabama App at this link.
Medication Assisted Detox Treatment

To address the physiological effects of SUD, patients may also need to begin the process of medication assisted detox treatment. This involves weaning the patient off the substance(s) that is/are threatening to the health of the pregnant person and/or their fetus. Medication assisted detox treatment allows the patient’s body to reduce the physiologic drive for the substance(s). This mitigates the risks associated with suddenly stopping substance use during pregnancy, which can include seizures or other life-threatening conditions.
Comprehensive Treatment

Best practices for treatment consist of a comprehensive treatment approach that combines medication with counseling and other behavioral therapies. Previously known as medication assisted treatment (MAT), this comprehensive approach’s name should be adapted for the specific substance use disorder, such as “medications for opioid use disorder”. We will refer to the general form as “medications for SUD”. This adds specificity and clarity to terminology around treatment, while acknowledging that medications for SUD do not play a temporary role in treatment. Much like antidepressants or antipsychotics, they are a critical tool within treatment for SUDs. Pharmaceutical therapies are designed to safely moderate the physiological factors associated with substance use while preventing a potentially dangerous high. This is a more holistic approach to addressing SUD, conceptualizing SUD as a chronic condition, and recognizing the complex intra and interpersonal factors associated with this health behavior.
Treatment Facilities

SUD treatment services can be offered in a facility, in a patient’s home, or in one’s community. Pregnant people with SUD are a priority population for these services in Alabama. In-patient services are offered in a facility where the patient lives while they receive treatment for SUD. There are many different in-patient programs that vary in duration from brief to long-term. The state of Alabama has Special Women’s Programs that provide in-patient treatment services that can accommodate both the mother and infant. Out-patient services can be offered in a clinic, in a patient’s home, or in a community setting. A comprehensive approach to SUD treatment can also include skills training, and other services that can be offered in the outpatient setting as patients continue to live in their own home and/or community while receiving treatment.

These treatment facilities, including Special Women’s Programs, are categorized into levels by the American Society of Addiction Medicine (ASAM). These levels are defined as:

Level 0.5: Early Intervention Treatment

Level 1: Outpatient Treatment

Level 2: Intensive Outpatient/Partial Hospitalization

Level 3: Residential/Inpatient Treatment

Level 4: Medically Managed Intensive Inpatient Treatment

Counseling, medication assisted detox treatment, and/or other treatments for SUD may be initiated. Many facilities offer additional services, such as family counseling, HIV services, and financial planning classes. These additional services can support patients with a SUD or a history of SUD in addressing other factors in their life that affect their ability to maintain sobriety.

For more information on SBIRT, counseling access, medication assisted detox treatment, comprehensive treatment approaches, in-patient and out-patient services, and additional SUD treatment services, please see https://vitalalabama.com/resources/find-help/connect-alabama/ to get information on additional support services available in Alabama.

Facilities Infographic

Policies Affecting Care in Alabama

When a pregnant patient actively seeks medical help for substance use, they may be worried about negative responses such as the involvement of the Department of Human Resources, losing custody of their child/ren, and/or potential imprisonment. Laws regarding substance use during pregnancy vary by state and range from supportive to punitive. In Alabama, it is considered a felony when an individual is actively using substances and has a child or children living in their place of residence. Currently, the legal definition of “child” in this policy was expanded to include “fetus”, creating conditions in which a pregnant person could be prosecuted for substance use during pregnancy. Healthcare providers know that patients have the right to refuse testing at any time and for any reason, and that they should not be tested without their consent.
Alabama’s Chemical Endangerment Law
Substance use during pregnancy could be a felony if a pregnant individual is using substances and/or has a child/ren living with them. This felony carries up to a 10-year prison sentence for child abuse.

This law can negatively affect the patient on at least three levels:
Systemic
- The meaning of the word child legally includes fetus.
- The enforcement of this law varied by county.
Medical
- Penalizing pregnant people for substance use makes care less accessible.
- Fear of reporting creates life-threatening barriers to care.
Individual
- Long-term negative consequences (i.e., employment, housing, finances) of a criminal record disproportionately affect marginalized communities.
- Trauma associated with arrests, incarceration, detentions in hospitals, protracted court involvement, civil child welfare investigations, family separation, and termination of parental rights.