PRENATAL SCREENING FOR SUBSTANCE USE - March 2021 - Indiana Perinatal Quality Improvement Collaborative (IPQIC) - IN.gov
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Indiana Perinatal Quality Improvement
Collaborative (IPQIC)
Perinatal Substance Use Task Force
PRENATAL SCREENING FOR
SUBSTANCE USE
March 2021
Make Mothers and Babies Count in IndianaPrenatal Screening for Substance Use Module
The Prenatal Screening Module is the sixth module in the Perinatal Substance Use Practice
Bundle ( Labor of Love, Helping Indiana Reduce Infant Death: Health Professionals). This
new module was designed to support the continued implementation of House Enrolled Act
1007 which requires health care providers who provide maternity health care services to
use a validated and evidence based verbal screening tool to assess a substance use disorder
in pregnancy for all pregnant patients who are seen by the health care provider as early as
possible at the onset of prenatal care and throughout the pregnancy, including during the
first, second, and third trimester.
This module was developed by a multidisciplinary subgroup of the Perinatal Substance Use
Task Force with representation from obstetric, pediatric, neonatal, and addiction treatment
clinicians to assist front-line perinatal care providers to improve the quality and safety of
care provided to pregnant persons with substance use disorders. The following guidelines
are intended as a general resource for hospitals and clinicians and are not intended to
establish a standard of care or replace individual clinical judgment and medical decision
making for individual patient situations or specific healthcare environments. Module
content is designed to facilitate ease in accessibility and implementation of recent,
evidence-based practice tools, guidelines, and educational material to optimize screening
and care of this vulnerable population emphasizing a sensitive, non-judgmental, patient-
centered approach.
The core module provides tools and resources that are designed to assist the prenatal care
provider in addressing the unique needs of the pregnant patient with a substance use
disorder. The following is a list of tools that are included in this module:
• Screening algorithm:
(https://www.in.gov/laboroflove/files/Screening%20Algorithm%20Final.pdf)
• Clinical care checklist designed to support a standardized approach substance use
screening. The checklist can be imported in electronic medical records, either as a
whole or in sections, for ease of access;
https://www.in.gov/laboroflove/files/SUD%20Clinical%20Care%20Checklist%20
%20%202.22.21.pdf
• Information regarding motivational interviewing to improve communication with
the pregnant patient;
https://www.in.gov/laboroflove/files/Motivational%20Interviewing%20%20%20
Final.pdf
Make Mothers and Babies Count in Indiana• A pocket card that provides a sample script for interviewing the pregnant patient,
documentation of the conversation and appropriate billing codes for screening and
brief intervention activities;
https://www.in.gov/laboroflove/files/OB%20Provider%20Pocket%20Card%20Fin
al.pdf
• Two sample patient handouts orienting them to the prenatal risk assessment and
quality care they will be receiving, one letter for patients with known substance use
and one for the general population;
https://www.in.gov/laboroflove/files/Patient%20Orientation%20Letters%20%20
Final.pdf
• A guide to additional information that identifies counseling opportunities for the
patient and actions that should be taken by the provider;
https://www.in.gov/laboroflove/files/Recommendations%20for%20Counseling%
20%20Final.pdf
• A sample release form that identifies the key information needed to support
information sharing across service providers;
https://www.in.gov/laboroflove/files/Sample%20Release%20of%20information%
20%20Final.pdf
• A chart describing available validated and evidence -based screening tools,
including the 5Ps tool recommended by IPQIC.
https://www.in.gov/laboroflove/files/Validated%20Screening%20Tools%20Final.
pdf
https://www.in.gov/laboroflove/files/5%20Ps%20PSU%20Screening%20Tool.pdf
Additional resources for prenatal care providers and pregnant patients are posted on the
Labor of Love website.
https://www.in.gov/laboroflove/files/Provider%20and%20Patient%20Resources%20Fin
al.pdf
Screening for substance use during pregnancy is an important step toward the
implementation of a care plan that will identify appropriate resources and supports to
optimize the outcomes for both the pregnant patient and the newborn. It is also a
reimbursable activity and the billing codes are included below and on forms throughout
this module.
SBIRT Billing Codes:
• Commercial Insurance/Medicaid:
o CPT 99408: Alcohol and/or substance abuse structured screening and brief
intervention services; 15 to 30min
Make Mothers and Babies Count in Indianao CPT 99409: Alcohol and/or substance abuse structured screening and brief
intervention services greater than 30min
• Medicaid:
o H0049: Alcohol and/or drug screening
o H0050: Alcohol and/or drug service, brief intervention, per 15 minutes
Make Mothers and Babies Count in IndianaPrenatal Screening for Substance Use
Proceed with
routine prenatal Periodic screening
Verbal Screen
care with in each trimester
Negative
discussion of as needed
needed resources
Verbal
Initial Prenatal Substance Use
Visit Screen
Completed
If history of Counsel on MAT
opiates or and arrange for
heroin use.. referral
With consent,
Discuss Policy
UDS ordered Counsel on
Verbal Screen regarding
to confirm referral for
Positive additional
substance(s) treatment
testing If history of
used
alcohol or
benzodiazepine
use, counsel for
risks of
Counsel on risks and link withdrawal
to behavioral health,
social work, and insurance
for linkages to services
and supportsMCH MOMS Helpline: Disclaimer:
1-844-MCH-MOMS This document is a tool and is not all
encompassing of pregnancy SUD care.
MCHMOMSHelpline@isdh.in.gov
SUD Clinical Care Checklist
Checklist Element Date Comments
Antepartum Care
Complete verbal substance use screen
Consider UDS for review and discuss institutional drug testing plan and policies
Review Prescription Drug Monitoring Programs (PDMP)/INspect
Counsel on MAT for opioid use disorder and arrange appropriate referrals
Counsel and link to behavioral health counseling /recovery support services
Social worker, nurse case manager, or navigator consult who will link patient to care and follow up
Obtain recommended lab testing-
• HIV / Hep B / Hep C (if positive viral load & genotype)
• Serum Creatinine/ Hepatic Function Panel
Discuss naloxone as a lifesaving strategy and prescribe for patient / family
Neonatology/Pediatric consult provided, discuss NAS, engaging mom in non-pharmacologic care of
opioid exposed newborn, and plan of safe care.
DCS Reporting system reviewed, discuss safe discharge plan for mom/baby
Screen for alcohol/tobacco/non-prescribed drugs and provide cessation counseling
Screen for co-morbidities (ie: mental health & intimate partner violence)
Consent for obstetric team to communicate with MAT treatment providers
Consider anesthesia consult to discuss pain control, L&D and postpartum
Third Trimester
Repeat recommended labs (HIV/HbsAg/Gc/CT/RPR)
Ultrasound (Fluid/Growth)
Urine toxicology with confirmation (consent required), and review policy
Review safe discharge care plan, DCS process, identify ongoing MAT prescribing in postpartum
Postpartum discharge planning
Patient Education: OUD/NAS, participating in non-pharmacologic care of the opioid exposed newborn, including
breastfeeding, and rooming in.
non-pharmacologic-treatment-protocol-9-20.pdf (in.gov)
Comprehensive contraceptive counseling provided and documented
https://www.in.gov/laboroflove/files/20_Breastfeeding%20Traffic%20light.pdf
During Delivery Admission
Social work consult, peds/neonatology consult, (consider) anesthesia consult
Verify appointments for support services (MAT/BH / Recovery Services)
Confirm Hep C, HIV, Hep B screening completed
Discuss naloxone as a lifesaving strategy and prescribe for patient / family
Provide patient education & support for non-pharmacologic care of newborn
non-pharmacologic-treatment-protocol-9-20.pdf (in.gov)
Review plan of safe care including discharge plans for mom/infant
infant-discharge-planning-10-20.pdf
Schedule early postpartum follow-up visit (within 2 weeks pp)
Provide contraception or confirm contraception plan
20_Contraception chart (in.gov)
SBIRT Billing Codes: Adapted from: Illinois Perinatal Quality
Commercial Insurance/Medicaid: Collaborative, 2019, https://ilpqc.org
CPT 99408: Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30min
CPT 99409: Alcohol and/or substance abuse structured screening and brief intervention services greater than 30min
Medicaid:
H0049: Alcohol and/or drug screening
H0050: Alcohol and/or drug service, brief intervention, per 15 minutesMOTIVATIONAL INTERVIEWING
Motivational Interviewing is an “empathic, person-centered counseling approach that
prepares people for change by helping them resolve ambivalence, enhance intrinsic
motivation, and build confidence to change.” (Kraybill and Morrison, 2007) In addition to
motivational interviewing, it is also useful to gage the stages of behavioral change. There
are six stages of change (Prochaska & Velicer, 1997):
1. Precontemplation (includes denial of a problem)
2. Contemplation (includes ambivalence about change)
3. Preparation (includes becoming informed about goal)
4. Action (includes behaviors toward a goal)
5. Maintenance (includes avoiding temptation, continuing behavior toward goal)
6. Relapse (includes disappointment, frustration, feelings of failure)
Motivational interviewing can be helpful in understanding how one is feeling about change
and encouraging them to move from one stage to the next.
There are 5 principles of Motivational Interviewing (MI):
1. Express empathy through reflective listening.
2. Develop discrepancy between goals and their behavior.
3. Avoid argument and direct confrontation.
4. Adjust to resistance rather than opposing it directly.
5. Support self-efficacy and optimism.
The basic techniques of MI include: open questions, affirmation, reflective
listening, and summary reflections (OARS).
OARS: Open Questions
Open questions invite others to “tell their story” in their own words without leading them
in a specific direction. The goal of open ended questions is to better understand the
patient’s perspective.
• Help me understand ?
• How would you like things to be different?
• What are the good things about and what are the less good things about it?
• What do you think you will lose if you give up ?
• What have you tried before to make a change?
• Are you ready to make a change? On a scale from 1-10 (10 being very ready and 1
not ready at all), how ready are you to make any kind of change in use of _? That is
PRENATAL SUBSTANCE USE MODULE 1MOTIVATIONAL INTERVIEWING
great! Why did you choose that number?
• What do you want to do next?
Affirmations are statements and gestures that recognize strengths and acknowledge
behaviors that lead in the direction of positive change, no matter how big or small.
Affirmations build confidence in one’s ability to change. To be effective, affirmations must
be genuine and congruent.
• I appreciate that you are willing to meet with me today.
• You are clearly a very resourceful person.
• You handled yourself really well in that situation.
• That’s a good suggestion.
• I’ve enjoyed talking with you today.
Reflective Listening
Reflective listening is the pathway for engaging others in relationships, building trust, and
supporting motivation to change. Reflective listening appears easy, but it takes hard work
and skill to do well. It is vital to learn to think reflectively. This is a way of thinking that
accompanies good reflective listening. It includes interest in what the person has to say
and respect for the person’s inner wisdom.
• It sounds like you might be feeling…
• You might be wondering if…
• Repeating or rephrasing: Listener repeats or substitutes synonyms or phrases,
and stays close to what the speaker has said
• Paraphrasing: Listener makes a restatement in which the speaker’s meaning is
inferred
• Reflection of feeling: Listener emphasizes the emotional aspects of
communication through feeling statements. This is the deepest form of
listening.
Summaries
Summaries are applications of reflective listening. They can be used throughout a
conversation but are particularly helpful at transition points, for example, after the person
has spoken about a particular topic, has recounted a personal experience, or when the
encounter is nearing an end. Summarizing helps to ensure that there is clear
communication between the speaker and listener.
PRENATAL SUBSTANCE USE MODULE 2MOTIVATIONAL INTERVIEWING
Structure of Summaries
1) Begin with a statement indicating you are making a summary.
• Let me see if I understand …
• It sounds like …
• You have given me a lot of important information today, I want to be sure I got it all…
2) Give special attention to ambivalence.
• On the one hand, …, on the other hand…
3) Use empathic statements to support ambivalence.
• Feeling torn between _ and _ can be very difficult.
4) Depending on the response of the client to your summary statement, it may lead
naturally to planning for change.
• How can I be most helpful to you on this journey?
• What would you like to work on first?
• What would you like to see happening going forward?
• Where should we go from here?
Websites:
Motivationalinterviewing.org
https://www.uptodate.com/contents/motivational-interviewing-for-substance-use-
disorders
https://americanaddictioncenters.org/therapy-treatment/motivational-interviewing
https://www.theraplatform.com/blog/339/motivational-interviewing-for-substance-
abuse
https://store.samhsa.gov/product/TIP-35-Enhancing-Motivation-for-Change-in-
Substance-Use-Disorder-Treatment/PEP19-02-01-003
https://www.samhsa.gov/homelessness-programs-resources/hpr-
resources/motivational-interviewing-recovery
PRENATAL SUBSTANCE USE MODULE 3Brief Interview & Referral for Substance Use Disorder Script
Raise • Thank you for answering my questions. From what I understand from your
1 Subject screening, you are using X. Is it OK if we talk more about X and your
pregnancy?
• Help me understand, through your eyes, what connection (if any) do you see
between your use of X and this pregnancy?
• People use drugs for many reasons: what do you like most/least about using X
2 Provide • Sometimes patient’s who give similar answers are continuing to use drugs and
Feedback alcohol during their pregnancies.
(including patient
• I have some information on risks of substance use in pregnancy. Would you
education handouts) mind if I shared them with you? Share education handouts.
• Because of those risks, I recommend avoiding drugs and alcohol use during
pregnancy.
• For pregnant patients using opioids regularly, medication assisted therapy,
such as methadone or buprenorphine, is recommended during pregnancy and
after to improve outcomes for both mom and baby.
3 • What are your thoughts about the information I just shared?
Investigate
Readiness • Do you have any concerns?
• On a scale of 1-10, with 10 very ready and 1 not ready, how ready are you to
(Use readiness ruler)
make any kind of changes in your use of X. You marked ___. That’s great.
• Why did you choose ___ and not a lower number like a 1 or 2?
4 Create • What are some steps you could take to reduce the things you don’t like about
Action Plan using that you shared with me earlier like___ ? Restate answers the patient
(Provide a warm
shared earlier.
handoff) • What steps can you take today to reach your goal of having a healthy pregnancy
and healthy baby?
• Those are great ideas! Is it OK for me to write down the steps/plan you just
shared with me? What exactly should I write?
• I have additional resources and people that patients often find helpful, would
you like to meet with them? Discuss options, schedule consults, make referrals
to MAT/ BH counseling/recovery services. Introduce SW.
• Thank you for talking with me. Can we schedule a date to check in again to F/U?
Substance Feedback
SMOKING ALCOHOL MARIJUANA
Smoking cigarettes There is no known safe The potential risks of
during pregnancy amount of alcohol during Marijuana use during
may cause: pregnancy. Alcohol use pregnancy & while
during pregnancy may cause: breastfeeding are not well
•Miscarriage understood.
•Pre-term birth • Miscarriage Marijuana use may:
•Low birth weight • Newborn death • Disrupt normal brain
• Fetal Alcohol development
•Babies born with low birth Spectrum Disorder (FASD) • Concentrate or build-up in
weight can have more health breast milk
and learning problems Babies born with FASD have low birth Use of marijuana in any form is
•Babies exposed to cigarette weight, physical defects, not recommended during
smoke are at increased risk of developmental delay and intellectual pregnancy or while
SIDS/crib death disabilities breastfeeding
Adapted from: Illinois Perinatal Quality Collaborative, 2019, https://ilpqc.orgDocumenting and Billing Guidance
Documentation should include time spent counseling along with details of the
interaction including:
❑ Face-to-face interaction with the patient
❑ Assessed readiness for change
❑ Advised the patient about risks
❑ Recommended MAT treatment / Behavioral health
counseling/ recovery services for the patient
❑ Referrals made to link patient to care
Sample Documentation:
Screen positive → with SUD
“I met with ________ to discuss her positive (ie. 5P’s/NIDA) screening. We discussed the risks of
alcohol and substance use during pregnancy and explored options for supporting abstinence
from alcohol and illicit drugs. We reviewed patient information describing hospital policies on
prenatal substance use and reporting requirements. We discussed that SUD is a chronic
disease with treatment available. We discussed benefits of MAT including improved pregnancy
outcomes and maternal risk reduction. Referral to MAT, behavioral health counseling/recovery
services, behavioral health and social work follow up was offered. She accepted/declined
________. Education materials on SUD/NAS were provided with referral for prenatal pediatric
consult on NAS. SUD clinical care check list was included in patient chart. Time spent in
counseling was (30 min) minutes).”
Screen positive → with risk factors
The patient was screened for substance use / opioid use using the (ie 5P’s/ NIDA/integrated
health screen) screening tool on ________ date. The score was ________ . A brief intervention
was conducted, information on risks of substance use and pregnancy was provided. Follow up
includes: ________ .
Insert Clinical Care Checklist & obtain recommended lab testing:
❑ HCV antibody ❑ HIV ❑ Hepatitis B
Billing Codes:
CPT 99408: Alcohol and/or substance abuse structured screening and brief intervention services;
15 to 30min
CPT 99409: Alcohol and/or substance (structured screening and brief intervention services; greater
than 30min
H0049: Alcohol and/or drug screening
H0050: Alcohol and/or drug service, brief intervention, per 15 min
Indiana Department of Health 1-844-MCH-MOMS
MCH MOMS Helpline www.mchindiana.comSAMPLE PATIENT ORIENTATION LETTER FOR SUBSTANCE USE SCREENING
Congratulations!
Anticipating your birth experience is an exciting time, but sometimes it can also feel overwhelming.
We are here to be a resource for you and your baby and to support you through your pregnancy.
An important part of prenatal care is identifying any risks that might exist for you, your pregnancy,
or for your baby after birth. These might include medical conditions such as diabetes, asthma,
depression or other issues that might make it hard to take care of yourself.
Substance use is one concern that could affect the care of you and your baby. Therefore, we ask all
of our patients about the use of tobacco, alcohol, or drugs at the first prenatal visit, in the second
trimester, and again in the third trimester.
Here are some facts you may not know about substance use during pregnancy:
• Smoking cigarettes and other forms of tobacco may decrease the flow of blood and oxygen
to the placenta, causing low birth weight and preterm birth
• Alcohol may cause birth defects and problems with brain development
• Other drugs, like opioids, heroin, or oxycodone, cause symptoms of withdrawal in newborn
• Marijuana may cause problems with learning and behavior
• Drug and alcohol use may affect your ability to care for your newborn baby
If you are experiencing challenges with substance use, this is the ideal time for us to connect you to
treatment services and available community resources. We can be the extra hand you need to help
guide you through your journey to recovery and optimal health through your pregnancy. Research
shows that the earlier you can begin treatment for substance use, the healthier you and your baby
can be during and after pregnancy. We will always provide accurate and honest information you
can trust. Thank you for including us in your pregnancy story and allowing us to partner with you.
The Indiana Department of Health has specialists to help pregnant patients with important
resources to promote healthy families at the MCH Moms Helpline – 1-844-MCH-MOMS (1-844-624-
6667l).
2-1-1 or (866) 211-9966 is a free and confidential service available 24 hours a days, 7 days a week,
to help find any local resources you may need.
Are you ready to stop smoking? This FREE service is available to Indiana residents that make the
call. Simply call 1-800-QUIT-NOW( 1-800-784-8669) or visit QuitNowIndiana.com.SAMPLE PATIENT LETTER WHEN IDENTIFIED POSITIVE VERBAL OR URINE SCREEN
Anticipating your birth experience is an exciting time, but sometimes it can also feel overwhelming.
We are here as a resource for you and your baby and to support you through your pregnancy. An
important part of prenatal care is identifying any risks that might exist for you, your pregnancy, or
for your baby after birth. These might include medical conditions such as diabetes, asthma,
depression or other issues that might make it hard to take care of yourself.
Substance use is one concern that could affect the care of you and your baby. When patients are
pregnant and using substances like pain pills, marijuana, cocaine, methamphetamines, heroin,
tobacco, or alcohol, we know that getting help is extremely important. Decreasing drug and alcohol
use in pregnancy will increase the chances of having a healthier pregnancy and baby.
It’s best when health care providers and patients work together to create a plan for the patient to
stop using drugs and alcohol. Depending on the circumstances, the plan may include the following:
• Finding a safe living environment
• Starting medications
• Peer recovery support/services
• Seeing a mental health specialist
• Going to community recovery support meetings (12 Step, Smart Recovery, Celebrate
Recovery etc.)
• Counseling
In addition to regular prenatal visits, patients with substance use disorders may need additional
care while pregnant. The ultimate goal is to set every patient up for success in life and in parenting
their baby. We know this can be scary to talk about, and there can be a fear that your baby will be
“taken” from you. Our commitment to you is that we will always work with you to establish a
supportive team to develop a plan of safe care for you and your baby.
Research shows us that the earlier a pregnant patient begins treatment for substance use disorder,
the better the environment is for the baby to thrive and grow. Babies who are exposed to drugs or
alcohol during pregnancy can experience withdrawal symptoms, heart or brain abnormalities,
physical defects, learning disabilities, cognitive or behavioral problems, growth restriction, or even
death. However, our goal is to partner together for a safe pregnancy and a healthy outcome for you
and your baby. We look forward to walking with you through your pregnancy journey.
The Indiana Department of Health has specialists to help pregnant patients with important
resources to promote healthy families at the MCH Moms Helpline – 1-844-MCH-MOMS (1-844-624-
6667l).
2-1-1 or (866) 211-9966 is a free and confidential service available 24 hours a days, 7 days a week,
to help find any local resources you may need.
Are you ready to stop smoking? This FREE service is available to Indiana residents that make the
call. Simply call 1-800-QUIT-NOW (1-800-784-8669) or visit QuitNowIndiana.com.RECOMMENDATIONS FOR COUNSELING PREGNANT PATIENT
Patient Does Not Want to Stop Using:
For the Patient: Patient has the freedom to make For the Provider:
her choices. Educate the patient on: • Supply patient with naloxone prescription
• Reduce IV use, discuss snorting instead of with refills, goal is at least two doses.
injecting, goal is zero IV use. • Give them a 24 hour a day access to care if
• Buy from the same supplier every time, possible but may be rare in rural
hoping for consistent dosing. communities.
• Make sure someone knows where they are • Safety planning till services can be
and when they are expected back. established.
• Encourage routine OB care. • Approach every interaction with patient
• Use with a sober partner who can call 911 if with an open mind towards recovery.
needed. • Seek mentorship from others with
• Obtain naloxone from pharmacy for experience treating patients with perinatal
emergency use. Store in safe place and substance use disorders.
inform another adult. • Peer recovery coach/specialist referrals,
• Talk to case manager weekly. virtual when needed.
• Encourage no needle sharing and seek • Obtain ROI’s to communicate with other
sterilized needles. providers.
• Utilize needle exchange and ask providers
for script.
Patient wants to obtain sobriety
• Counsel on choice of Medication Assisted Treatment (MAT).
• Refer to MAT provider for rapid access to recovery services and if possible, have a warm handoff.
• Address barriers to treatment.
• Seek assistance from insurance case managers.
• Link patient to OB provider: Flexibility with no shows, late arrivals, and scheduling
• Supply patient with naloxone prescription with refills, goal is at least two doses.
• Help patient establish behavioral health services.
• Consider higher levels of care with relapses:
o MAT only -> therapy with MAT -> IOP with MAT -> inpatient with MAT
• Consider safety planning needed until services can be established.
• Refer to peer recovery specialist referrals, Virtual when needed.
• Expand mentorships for program experienced in PSUD to consult with offices less experienced.
• DCS - verify rules and regulations.
• Unless concerned about your own safety, be open with the patient about need for DCS referrals.
• https://www.overdoselifeline.org/2020-indiana-naloxone-request/
• Mentorship/peer recovery information: www.indianarecoverynetwork.org there is a ‘connect with
a peer’ button on the front. Can use that anywhere in Indiana. Can also call 2-1-1 and press 6.
• https://in211.communityos.org/RELEASE OF INFORMATION FORM
Patient Name: Date of Birth (MM/DD/YYYY)
Street Address: City: State: Zip Code:
Daytime Phone (with area code): Cell Phone (with area code): Message Phone (with area code)
My information can be released to the following individuals/organizations:
My Primary Care doctor (enter first and last name) My Specialist (enter first and last name and specialty)
My Obstetrician (enter first and last name) My insurance company (name)
My Specialist (enter first and last name and specialty) Other:
I allow the following information to be used or released on my behalf:
Check only one box
All my information. This can include health, diagnosis, claims, doctors and other health care providers
and financial information (billing and banking). This does not include sensitive information unless it is
approved below.
OR
Only limited information may be released (check all boxes that apply)
Benefits and Doctor and hospital Referral
Coverage Eligibility & enrollment Treatment
Billing Financial Dental
Claims and payment Medical records Vision
Diagnosis Pre-certification and pre- Pharmacy
authorization (for Other:
treatment approvals)
I also approve the release of the following types of sensitive information:
All sensitive information
OR
Just information about topics checked below:
Abortion Genetic Mental Health
Abuse (sexual/physical/mental) Testing Sexually transmitted illness
Substance Use Disorder 1,2 HIV or AIDS Other:
Maternity
1 Specify time period of records to be disclosed:
Description of records that may be disclosed:
2 I understand that my substance use and/or Mental Health records are protected under Federal and State
confidentiality laws and regulations and cannot be disclosed without my written consent unless otherwise
provided for in the laws and regulations. I also understand that I may revoke/cancel this approval at any
time.VALIDATED SCREENING TOOLS*
Primary
Name Description Links
Population
Parents, Peers, Partner, Screening tool that detects tobacco, Pregnant 5 Ps PSU Screening Tool.pdf
Pregnancy, and Past alcohol, and drug use, as well as domestic women
(The 5Ps) violence among pregnant women and
women of reproductive age.
Recommended by IPQIC Focus: Drug, alcohol, and tobacco use
NIDA Quick Screen Screening tools that detect alcohol, Adults The NIDA Quick Screen | NIDA
______________________ tobacco, and drug use; tools can be used including Archives (drugabuse.gov)
Alcohol, Smoking and sequentially based on the individual’s pregnant
substance involvement score. women NIDA Drug Screening Tool
Substance Involvement
(drugabuse.gov)
Screening Test Focus: Drug, alcohol, and tobacco use
(NIDA-Modified ASSIST)
Recommended by ACOG
Car, Relax, Alone, Forget, Screening tool that identifies alcohol, Women 26 CRAFFT
Friends, Trouble drug use and substance-related driving years or
(CRAFFT) risk among adolescents and young adults. younger
Focus: Drug and alcohol use; driving risk
Recommended by ACOG
Parents, Partners, Past and Screening tool developed to detect dug, Pregnant About the 4P's Plus — NTI
Pregnancy alcohol, and tobacco use among pregnant women Upstream
(The 4Ps) women and women of childbearing age.
The 4Ps Plus includes additional
questions about depression and domestic
violence.
Focus: Drug, alcohol, and tobacco use
Tolerance, Four-item screening tool that identifies Pregnant The T-ACE questions: practical
Anger/annoyance, Cut risk-drinking in pregnant women. Women prenatal detection of risk-drinking
Down, Eye-opener Focus: Alcohol use - PubMed (nih.gov)
(T-ACE)
t-ace_alcohol_screen.pdf (va.gov)
Tolerance, Worried, Eye- Five-item instrument that screens for risk Pregnant TWEAK (nih.gov)
opener, Amnesia, Cut Down drinking among obstetric patients. women
(TWEAK) Focus: Alcohol use
Alcohol Use Disorders 10-item questionnaire that screens for Adults Alcohol Use Disorders
Identification Test alcohol consumption and alcohol-related including Identification Test (AUDIT)
(AUDIT) problems. pregnant (nih.gov)
Focus: Alcohol use women
Alcohol Use Disorders
Identification Test (AUDIT)
(drugabuse.gov)
Drug Abuse Screening Test Self-administered instrument that Adults and Instrument: Drug Abuse
(DAST) detects substance use or substance use older youth Screening Test (DAST-10) | NIDA
disorders CTN Common Data Elements
Focus: Drug Use
DAST-10 (drugabuse.gov)
*Screening, Brief Intervention, and Referral to Treatment (SBIRT) for
ONCE THE PREGNANT PATIENT IS SCREENED, REFER BACK TO Pregnant and Postpartum Women, October 2020 Issue Brief,
THE PRENATAL SCREENING ALGORITHM Association of Maternal and Child Health Programs /National
Association of State Alcohol and Drug Abuse DirectorsPROVIDER AND PATIENT RESOURCES
Provider ACOG position on screening
materials https://www.acog.org/clinical/clinical-guidance/committee-
opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-
pregnancy
Provider Screening for Social Determinants of Health
materials The Accountable Health Communities (AHC) Health- Related Social Needs
(HRSN) Screening Tool is used to screen for unmet HRSNs like
homelessness, hunger and exposure to violence which if addressed can lead
to undoing harm to their heath. The provider can use the results from the
screening tool to inform patient’s treatment plan and make referrals to
community services. Additional languages available.
https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf
Provider Mood disorder screening tool
materials Edinburgh Postnatal Depression Scale
https://med.stanford.edu/content/dam/sm/ppc/documents/DBP/EDPS_te
xt_added.pdf
Provider Training materials - Stigma education
materials Link to Know the Facts
https://www.in.gov/recovery/know-the-facts/
(IL and NY have examples also)
Provider DMHA link to treatment centers
materials https://www.in.gov/fssa/dmha/files/CMHC_Outpatient_Mental_Health_Serv
ice_Locations.pdf
Provider DMHA link to behavioral health
materials https://www.in.gov/fssa/addiction/
Provider Referral info to community services
materials https://in211.communityos.org/
Aunt Bertha https://www.findhelp.org
Provider Links to rest of the PSU Practice Bundle
material https://www.in.gov/laboroflove/208.htm
DCS letter for patients
https://www.in.gov/laboroflove/files/DCS%20Patient%20Handout.pdf
Breastfeeding & Substance Use guidance
https://www.in.gov/laboroflove/files/breastfeeding-and-substance-use-
final.pdf
Breastfeeding & Substance Use Traffic light
https://www.in.gov/laboroflove/files/20_Breastfeeding%20Traffic%20light
.pdf
Breastfeeding & Substance Use Traffic light (Spanish)
https://www.in.gov/laboroflove/files/20_Breastfeeding%20Traffic%20light
_Spanish.pdf
PRENATAL SCREENING FOR SUBSTANCE USE 1PROVIDER AND PATIENT RESOURCES
Patient material MAT education
https://www.samhsa.gov/medication-assisted-treatment. The SAMHSA
website has the most comprehensive information as well as lists of where to
obtain MAT.
Patient material Naloxone Counseling Where to get Naloxone (specific to Indiana) :
https://optin.in.gov/
Patient material Alcohol use and withdrawal education
Alcohol and Women
Rethinking Drinking
CDC resources
5 Things You Should Know about Drinking Alcohol during Pregnancy
Alcohol Use in Pregnancy
An Alcohol-Free Pregnancy is the Best Choice for Your Baby
A lot of these can be ordered for free on the CDC website.
Patient material Substance use and withdrawal education
Pregnancy and Opioid Pain Medications
Preventing An Opioid Overdose
Patient material Smoking Cessation
Tobacco, Alcohol, Drugs, and Pregnancy
Smoking During Pregnancy
Pregnant? Don't Smoke!
Quitting While Pregnant (government resource)
How Quitting Can Be Different for Women
PRENATAL SCREENING FOR SUBSTANCE USE 2You can also read
