Current Trends Statewide Prevalence of Illicit Drug Use by Pregnant Women -- Rhode Island

The effects of illicit drug use by women during the perinatal period--including inadequate prenatal care, premature labor, low birthweight infants, and other adverse pregnancy outcomes (1-9)--have been given high priority by the Rhode Island Department of Health (RIDH) and other maternal and child health leaders in Rhode Island. In 1989, the RIDH, the state medical society, and the state college of obstetricians and gynecologists conducted a statewide survey of illicit drug use in pregnant women to aid in the development of programs to reduce drug abuse during pregnancy.

The survey measured the prevalence of illicit drug use among women admitted in active labor to the regional perinatal center and to seven other maternity hospitals in the state. For 17-day periods in October and November 1989, each hospital provided aliquots of routinely collected urine specimens to the RIDH for testing. Names were not provided in an effort to protect patient confidentiality. Labor and delivery nurses recorded race, age, parity, insurance status, town or city of residence, and hospital of delivery for each patient.

Each urine specimen was tested by enzyme-multiplied immunoassays for cocaine metabolites, opiates, marijuana, and amphetamines. Toxicology screen cutoffs were: cocaine, 300 ng divided by L; amphetamines, 1000 ng divided by L; opiates, 300 ng divided by L; and cannabinoids, 100 ng divided by L.* Positive results were confirmed with thin-layer chromatography for cocaine (150 ng divided by L), opiates (200 ng divided by L), and cannabinoids (50 ng divided by L); gas chromatography was used to confirm positive results for amphetamines (50 ng divided by L). Whether the opiate use was illicit or by prescription could not be determined.

During the study period, 713 birth certificates were filed in the state. Specimens and data were obtained from 465 (65.2%) women in active labor during the same period. A urine sample was not obtained from other patients admitted during that period because the patient did not have to void, delivery was imminent, or labor and delivery staff did not collect the specimen. However, based on a comparison using birth certificate data, characteristics of tested and untested women were similar except for age of mother. Women aged less than 25 years were more likely to be included in the sample than were women aged greater than or equal to 25 years.

Specimens for 35 (7.5%) of the 465 women were positive for at least one drug (Table 1). Women with public insurance coverage were four times more likely to be positive (16.1%) than were women with private insurance (4.1%) (p less than 0.0001, Fisher's exact test).

Cocaine was detected more commonly in women who were other than white (8.2%; p less than 0.0001), used public insurance (8.9%; p less than 0.0001), were classified as living in poverty (6.8%; p less than 0.0001), had one or more children (4.2%; p less than 0.01), and delivered at the regional perinatal center (3.9%; p less than 0.01). Women who were using public insurance were also more likely to be positive for marijuana (5.6%; p less than 0.01). Reported by: WH Hollinshead, MD, JF Griffin, MPH, HD Scott, MD, ME Burke, MSN, Office of Data and Evaluation, Div of Family Health, Rhode Island Dept of Health; DR Coustan, MD, Rhode Island Medical Society; TA Vest, MD, American College of Obstetricians and Gynecologists--Rhode Island Section.

Editorial Note

Editorial Note: The Rhode Island survey represents one approach to estimating the prevalence of illicit drug use in a population subgroup. Most previous studies have sampled high-risk inner-city populations, which are less representative of the general population (10-12); in these studies, overall rates of illicit drug use have ranged from 6% to 11%.

The Rhode Island sample was representative of all births occurring in the state during the study period. The protocol was simple and produced a more complete measure of the prevalence of drug use at delivery than has been available by other means. These rates are probably underestimated, however, because they reflect drug use only within 48 hours of labor and delivery and because only a limited number of drugs were assessed.

These data identify and suggest patterns of drug use that warrant clinical and preventive attention. The findings in this study have been used in Rhode Island for public health program planning and evaluation. The study has provided estimates of the number of pregnant women who are in need of drug counseling and treatment in Rhode Island. The findings also have provided baseline evaluation data to measure the effectiveness of new program interventions aimed at reducing illicit drug use by pregnant women.

References

1. Weston D, Ivans B, Zuckerman B, Jones C, Lopez R. Drug

exposed babies: research and clinical issues. Zero to Three Bulletin of National Center for Clinical Infant Programs 1989;9(5):1-7.

2. Chasnoff I, Burns W, Schnoll S, Burns K. Cocaine use in pregnancy. N Engl J Med 1985; 313:666-9.

3. Chervkuri R, Minkoff H, Feldman J, Parekh A, Glass L. A cohort study of alkaloidal cocaine ("crack") in pregnancy. Obstet Gynecol 1988;72:147-51.

4. MacGregor S, Keith L, Chasnoff I, et al. Cocaine use during pregnancy: adverse perinatal outcome. Am J Obstet Gynecol 1987;157:686-90.

5. Little B, Snell L, Kelin V, Gilstrap L. Cocaine abuse during pregnancy: maternal and fetal implications. Obstet Gynecol 1989;73:157-60.

6. Chouteau M, Namerow P, Leppert P. The effect of cocaine abuse on birth weight and gestational age. Obstet Gynecol 1988;72:351-4.

7. Zuckerman B, Frank DA, Hingson R, et al. Effects of maternal marijuana and cocaine use on fetal growth. N Engl J Med 1989;320:762-8.

8. CDC. Urogenital anomalies in the offspring of women using cocaine during early pregnancy--Atlanta, 1968-1980. MMWR 1989;38:536,541-2.

9. CDC. Congenital syphilis--New York City, 1986-1988. MMWR 1989;38:825-9. 10. Neerhof M, MacGregor S, Retzky S, Sullivan T. Cocaine abuse during pregnancy: peripartum prevalence and perinatal outcome. Am J Obstet Gynecol 1989;161:633-8. 11. Frank D, Zuckerman BS, Amaro H, et al. Cocaine use during pregnancy: prevalence and correlates. Pediatrics 1988;82:888-95. 12. Osterloh J, Lee B. Urine drug screening in mothers and newborns. Am J Dis Child 1989;143:791-3. *Amphetamines, opiates, and cannabinoids can be detected in the urine at the stated cutoffs 2-3 days after use; cannabinoid metabolites can be detected at this cutoff for several days longer in chronic users. Cocaine is likely to be detected for 1-2 days.

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