1. family and parenting
2. motherhood
3. pregnancy

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On April 1, 2009, AHS brought together 12 formerly separate
health entities in the province: nine geographically based health
authorities (Chinook Health, Palliser Health Region, Calgary
Health Region, David Thompson Health Region, East Central
Health, Capital Health, Aspen Regional Health, Peace Country
Health and Northern Lights Health Region) and three provincial
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(Alberta Mental Health Board), addiction (Alberta Alcohol and
Drug Abuse Commission) and cancer (Alberta Cancer Board).
Physician referrals to addiction
treatment services for women
at risk of using substances
while pregnant
A literature review of barriers
and recommendations
Physician referrals to addiction
treatment services for women
at risk of using substances
while pregnant
A literature review of barriers
and recommendations
August 2006
Alberta Alcohol and Drug Abuse Commission (AADAC)
Prepared by Jesse Jahrig and Komali Naidoo,
AADAC Research Services
Physician referrals to addiction treatment services: A literature review
AADAC | RESEARCH SERVICES
Suggested citation
Alberta Alcohol and Drug Abuse Commission. (2006). Physician referrals
to addiction treatment services for women at risk of using substances while
pregnant: A literature review of barriers and recommendations. Edmonton,
Alberta, Canada: Author.
Physician referrals to addiction treatment services: A literature review
AADAC | RESEARCH SERVICES
Table of contents
Executive Summary ..................................................................5
Introduction ................................................................................7
Background..............................................................................................7
Rates of substance use during pregnancy ........................................................7
Physician referrals ..............................................................................................8
Methods ..................................................................................................9
Literature search ................................................................................................9
Literature search process ..................................................................................9
Barriers ....................................................................................10
Before clinic visit ....................................................................................10
At-risk women ..................................................................................................11
System..............................................................................................................14
Practice ..................................................................................................15
Identification ....................................................................................................15
Intervention ......................................................................................................19
During clinic visit ....................................................................................19
Identification and intervention ..........................................................................19
Follow-up ..............................................................................................24
Recommendations ..................................................................25
1. Address risk perception and awareness of problems among
at-risk women ..............................................................................................25
2. Improve at-risk women’s perception of treatment services and
the prenatal clinic ........................................................................................27
3. Co-ordinate the referral system ..................................................................28
4. Increase at-risk women’s awareness of addiction treatment services
and the referral process ..............................................................................28
5. Standardize physician screening and referral practice................................29
6. Use suggested screening tools for tobacco and other drug use ................30
7. Provide education and training for physicians ............................................31
8. Provide financial compensation to physicians ............................................32
9. Encourage physicians to follow up with patients ........................................32
10. Provide physicians with feedback about referred patients ........................33
Conclusion ..............................................................................33
References ..............................................................................34
Table of tables
Table 1: Literature search methods: Concepts and keywords ................9
Table 2: Barriers faced by patient and physician during
the referral process ..................................................................10
Physician referrals to addiction treatment services: A literature review
AADAC | RESEARCH SERVICES
Executive Summary
Use of alcohol, tobacco and other drugs is an important concern for women
of child-bearing age, especially when it occurs during pregnancy. Substance
use during pregnancy can be harmful to the mother and can affect the child’s
physical and cognitive development. Therefore, it is imperative that pregnant
women and women of child-bearing age who are at risk of substance use
have access to help for substance use issues.
Physicians play a pivotal role in linking at-risk women1 with treatment
services for substance use. When at-risk women visit their physician,
it is vital that physicians be actively involved in the screening and referral
process for substance use during pregnancy.
This literature review was conducted to explore physician referrals of women
at risk of using substances while pregnant to addiction treatment services.
Specifically, it was intended to answer two main questions: What are some
of the main barriers to referrals? What can be done to improve the process
for all involved? Several findings were identified in the literature. A brief
summary of these follows.
Address risk perception and awareness of problem among
at-risk women
Most women are aware that alcohol use during pregnancy is harmful,
but research indicates that some women may not acknowledge the risks of
their own substance use during pregnancy. It is therefore recommended that
measures be taken to help women recognize that their substance use during
pregnancy is problematic and to raise awareness of the health risks involved.
Improve at-risk women’s perception of treatment services
and the prenatal clinic
At-risk women have criticized addiction treatment services for numerous
reasons, and it is reasonable to assume that at-risk women who hold negative
views of treatment services may be disinclined to seek help in using those
services. Therefore, it is recommended that action be taken to improve
at-risk women’s perception of treatment services and the prenatal clinic.
Co-ordinate the referral system
Ineffective and poorly co-ordinated referral networks have been reported
in the literature as a barrier to referring at-risk women to treatment services.
Consequently, it is recommended that the relevant health organizations work
toward a clearly defined referral system.
1
The term “at-risk women” in the context of this literature review refers to women of child-bearing age (15 to
54 years old) and pregnant women who use substances or are at risk of using substances during pregnancy.
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Increase awareness among at-risk women of addiction treatment
services and the referral process
The literature indicates that at-risk women are uncertain of what help is
available, where to get help and how to get help. To rectify this, appropriate
health organizations need to target at-risk women to increase awareness
about addiction treatment services and the referral process.
Standardize physician screening and referral practice
Research reveals that physicians would value clinical practice guidelines
to manage substance use issues. Thus, efforts should be made to develop
standard practice guidelines for managing substance use among at-risk
women.
Use suggested screening tools for tobacco and other drug use
Use of inappropriate screening methods to identify substance use among
women and pregnant women has been documented in the literature.
It is integral that physicians use appropriate screening tools for substance
use such as the T-ACE or TWEAK, but not use the CAGE, Alcohol Use
Disorders Identification Test (AUDIT) or Michigan Alcoholism Screening
Test (MAST), which have been criticized for being inappropriate when
dealing with this population of women.
Provide education and training for physicians
The literature indicates that physicians believe training materials on
substance issues would be useful. Proper education and training may help
physicians develop better relationships with their patients, and may help
overcome other barriers.
Provide financial compensation to physicians
Physicians may be more inclined to manage substance use issues if subsidy
or reimbursement programs are in place.
Encourage physicians to follow up with patients
Even after physicians have made referrals, it is still important that they
follow up with their patients to provide support, motivation and regular
screening.
Provide physicians with feedback about referred patients
Feedback can reinforce effective actions and allow adjustments to be made
to less effective actions. Providing feedback may also improve physicians’
view about the effectiveness of addiction treatment; this is important because
physicians will be more likely to refer to treatment services they feel are
effective.
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Physician referrals to addiction treatment services: A literature review
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Introduction
This literature review is intended to provide evidence-based information on
engaging and increasing physician referrals to addiction services. It examines
referral practices and models of service delivery provided by physicians
to at-risk women. Discussed specifically is the referral process, including
current practices as well as barriers confronted by patients and physicians
during this process. Whenever possible, references are made to articles
with national and provincial relevance.
Background
Rates of substance use during pregnancy
Three major categories of substance use will be discussed throughout this
literature review: tobacco use, alcohol use and illicit drug use. To help
contextualize this review, rates of substance use during pregnancy are
reported below. It should be noted that research indicates there may
be systematic under-reporting of substance use, especially for alcohol and
illicit drugs (Cavanagh, 1999; Gladstone, Nulman, & Koren, as cited in
Health Canada, 2000b; U.S. Department of Health and Human Services
[USDHHS], 1990). Therefore, it is plausible that actual rates of substance
use are higher than those reported in the literature.
Tobacco
Rates of tobacco use during pregnancy in Canada range from 19% to 30%
based on several national studies from 1994 to 2003 (Alberta Alcohol and
Drug Abuse Commission [AADAC], 2004; Health Canada, 2003b; Statistics
Canada, 2003). In Alberta, rates range from 23% to 33% (AADAC, 2004;
Alberta Health and Wellness, Reproductive Health Working Group, 2004;
Statistics Canada, 2003).
Alcohol
According to Canadian surveys, 14% to 25% of women across Canada
reported drinking at some point during pregnancy (AADAC, 2004;
Dzakpasu, Mery, & Trouton, 1998; Health Canada, 2003b; Public Health
Agency of Canada, 2004; Statistics Canada, 2003), and 7% to 9% reported
drinking throughout their pregnancy (Dzakpasu et al., 1998). In contrast
with these national findings, the results of a provincial report on alcohol
consumption during pregnancy (Alberta Health and Wellness, Reproductive
Health Working Group, 2004) were lower: just 4% of Alberta women
reported drinking while pregnant.
Illicit drugs
Reported prevalence of drug use during pregnancy in Canada is scarce and
varied. In studies in Vancouver, Montreal and Toronto, reported rates of drug
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use during pregnancy ranged from 4% (Ling, Albersheim, & Halstead, 1997)
to 13% (Albersheim & MacKinnon, 1993). In the Downtown Eastside of
Vancouver the rate climbed to 30% (Loock et al., as cited in Whynot, 1998).
As for Alberta, the Reproductive Health Working Group (2004) found that
just 2% of women provincewide reported drug use during pregnancy. Again,
these numbers may be subject to under-reporting.
Physician referrals
At-risk women entering motherhood have been identified as having
an enhanced motivation to make positive changes for themselves and their
unborn child, including decreasing or ceasing substance use (Albersheim,
1992; Beckett, 1995; British Columbia Ministry of Health Services, as cited
in AADAC, 2004; Bruce and Williams, 1994; Dow-Clarke, MacCalder,
& Hessel, 1994; Finkelstein, 1994; Gomez, 1997; Little & Streissguth,
1978). In Canada, 70% of women reported that they would stop using
alcohol if they became pregnant, and 42% who were currently pregnant
said they would stop using alcohol (Environics Research Group, 2002).
This opportunity might be optimized by increasing physician identification
of clients through a screening process, as well as by increasing physician
referrals to treatment services. However, the frequency with which
physicians screen and refer at-risk women to substance use treatment
services is reported as low in the literature (Best Start, 2005; Donovan, 1991;
Health Canada, 2003a; Miner, Holtan, Braddock, Cooper, & Kloehn, 1996;
Howell, Heiser, & Harrington, 1999; Nanson, Bolaria, Snyder, Morse, &
Weiner, 1995; Nevin, Parshuram, Nulman, Koren, & Einarson, 2002).
The large majority of research on maternal substance use suggests much
room for improvement in terms of screening and referral practices.
To improve the frequency with which physicians refer at-risk women
to appropriate treatment, it is necessary to examine the referral process,
identify those involved in the referral process, and assess the barriers
to referral. As such, it is useful to address the referral process in three
different stages: what happens before, during and after a visit to the
physician. When possible, it is also beneficial to examine these three
stages from the perspective of at-risk women, physicians, and other
health organizations that provide service to similar clients. Accordingly, the
organization of the literature reviewed reflects these stages and perspectives.
Refer to Table 1 for a brief summary of the barriers faced by patients and
physicians during the different stages of the referral process; this summary
highlights the main themes that emerged from the literature review.
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Table 1: Barriers faced by patient and physician during the referral process
Before clinic visit
· patient denial of problem
· patient denial of risks involved with substance use during
pregnancy
· patient denial of the need for professional help
· patient’s lack of awareness of where and how to get help
· patient places low priority on getting help
· poorly co-ordinated referral system
· inadequate physician practice in screening and referring
patients
During clinic visit
· patient does not answer physician’s screening questions
honestly or openly
· physician discomfort dealing with substance issues
· lack of proper education and training for physicians
· lack of financial compensation for physicians
· physician perception of addiction treatment efficacy
Follow-up
· lack of patient follow-through after receiving a referral
· lack of physician follow-up with referred clients
Methods
Literature search
The literature search was intended to find evidence-based information
about barriers to referrals made by physicians to at-risk women. As such,
evidence-based material connecting these categories was pursued. When
necessary, the scope of the literature search expanded to substance use
among the general population to fill in gaps where there was a lack
of research specific to women and pregnancy.
In addition to focusing on referrals, physicians and women, the literature
search was used to locate information about health policy, practice and
recommendations. As mentioned, this literature review was intended
to provide evidence-based information that is provincially and nationally
relevant; therefore, provincial and national information was searched initially
and international studies were searched subsequently.
Literature search process
Concepts and keywords
The following concepts and keywords were searched in the literature in
combination with other concepts and keywords. The list of keywords
is not inclusive.
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Table 2: Literature search methods: Concepts and keywords
Concept
Keywords (not inclusive)
client or patient perspective and awareness, motivation, barriers, prevalence, attitude,
role in substance use issues
characteristics, service needs, women, female, maternal,
pregnancy, prenatal, at risk, perinatal, primary care
physician perspective and role
in substance use issues
training, education, preparation, instruments, methods,
tools, screen, diagnose, detect, identify, intervene, barriers,
prevalence, best practice & actual practice, attitude, type of
referral, practices, on-site counsellor, facilitators, follow-up,
referral effectiveness, attitude, relationship with clients,
counsellors, treatment services, physician, doctor, practitioner,
clinic
referrals
counsel, advise, refer, management, recommend,
support, guidance, intervention, treatment services
substance use
substance, drugs, cocaine, crystal meth, heroin, street drugs,
marijuana, cannabis, pot, opiates, alcohol, drink, alcoholism,
tobacco, smoke, cigarettes, addiction
Databases
The literature was searched using the following databases: PsycINFO,
Medline, ERIC, MasterFILE Premier, Psychology and Behavioral
Sciences Collection. Other Internet databases, institute websites, relevant
organizational sources, government sources, and Google were also searched.
These sources were searched for articles, papers, dissertations, book
chapters, and manuals. The literature search was restricted to publications
occurring between 1995 and 2006. Useful references cited in the literature
originally reviewed were also acquired and subsequently reviewed.
As a result, some of these research articles date back to before 1995.
The literature search yielded hundreds of articles, about 175 of which are
cited in this literature review. The final allocation of literature spanned from
1972 to 2006. The majority of the literature cited was published after 1995.
Barriers
Before clinic visit
Perhaps the most obvious barrier to a physician referral is that it cannot
take place unless the prospective patient sees a physician. Many pregnant
substance users do not seek prenatal care at all (Hankin, McCaul, &
Heussner, 2000; Kelly et al., 1999; Melnikow, Alemagno, Rottman, &
Zyzanski, 1991; Pagnini & Rechman, 2000) or if they do, it may be late
in their pregnancy, when negative health effects to the mother and fetus
may already have occurred (Armstrong, as cited in Masotti, Szala-Meneok,
Selby, Ranford, & Koughnett, 2003; Astley, Bailey, Talbot, & Clarren, 2000;
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Brady, Bisscher, Feder, & Burns, 2003; Hankin et al., 2000; Kelly et al.,
1999; Klein & Zahnd, 1997; Roberts & Nanson, 2000; Tait, 2000). Brady
et al. (2003) found that 17% of women did not receive prenatal care until
their third trimester, or did not receive any prenatal care at all. Additionally,
the more substances are used, the less likely prenatal services are to be used
(Brady et al., 2003; Hankin et al., 2000).
There are a variety of barriers that can prevent any interaction between
physicians and at-risk women, and it is often the potential patient who
must overcome the majority of these barriers. These barriers include denial
that there is a problem, denial of the risks involved (Poole & Isaac, 2001;
Tait, 2000; Testa & Reifman, 1996), denial of the need for professional help
(Hughes, Epstein, Andrasik, Neff, & Thompson, 1982; Klein & Zahnd,
1997; Poole & Isaac, 2001), lack of awareness of where and how to get help
(Allen, 1994; Currie, 2001; Grant, 1997; McElaney, as cited in Morse, 2000;
Tait, 2000), and negative attitudes and perspectives about treatment services
and the prenatal clinic (Beckman & Amaro, 1986; Currie, 2001; Deville and
Kopelman, 1998; Finkelstein, Kennedy, Thomas, & Kearns, 1997; Poole
& Isaac, 2001; Tait, 2000). In addition, getting help for substance use issues
may be a low priority because of competing life priorities at-risk women
face (Brady et al., 2003; Milligan et al., 2002). A poorly co-ordinated
referral system can also hamper referrals (Donovan, 1991; Miner et al.,
1996). Understanding the barriers that prevent at-risk women from visiting
a physician is important because these barriers result in a decreased
opportunity for referrals to be made.
At-risk women
Risk perception and awareness of problem
Although most women are aware that alcohol use during pregnancy can cause
lifelong disabilities in a child (University of Alberta, Population Research
Laboratory, 2004), research still shows that some women may not acknowledge that their own substance use during pregnancy is problematic (Poole &
Isaac, 2001; Tait, 2000; Testa & Reifman, 1996). In 2001, Poole and Isaac
conducted a study in British Columbia that sampled substance-using mothers
in treatment from across the province in an attempt to identify barriers to
seeking treatment. Seventeen per cent of the mothers interviewed were
pregnant at the time of the study. The results revealed that 43% of mothers
and pregnant women who were using substances felt their substance use was
not a problem. In another study, Testa and Reifman (1996) found that at-risk
women who drank during pregnancy, but still had a healthy child, held a
decreased perception of the risks involved. Similarly, in a Manitoba study
in which pregnant substance users were interviewed, one respondent reported,
...my mother drank with all of us and all of us are healthy. I thought, ah,
it’s just BS what they say about alcohol... And so I never thought it could
really harm a baby. (Tait, 2000)
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In another Canadian survey, the researchers found that women who
consumed more alcohol were more likely to think it was safe to drink
while pregnant (Environics Research Group, 2002).
These misperceptions about substance use during pregnancy are partially
caused by a combination of misinformation provided by unreliable sources
and a lack of information provided by credible sources such as health
professionals (Tough, Clarke, Hicks, & Clarren, 2005; Baric & MacArthur,
1977). A 2005 Canadian study showed that 69% of family physicians felt
that misinformation about the safety of drug use during pregnancy prevented
women from seeking treatment (Tough et al., 2005).
Self-perceived need for professional help
Many women do realize that their own maternal substance use has adverse
effects on the baby; however, this does not necessarily mean they will seek
professional help. Studies show that some mothers feel they can handle the
problem on their own and do not require professional help (Hughes et al.,
1982; Klein & Zahnd, 1997; Poole & Isaac, 2001). For example, Poole and
Isaac (2001) found that 62% of at-risk women in B.C. believed they could
cut down drinking on their own. The literature suggests that women who do
not think they need help may be less likely to contact a physician for help
with their substance use.
Attitudes and perspectives about treatment services
Presumably, the likelihood that at-risk women will consult a physician for
a referral to substance treatment may be influenced by their attitudes towards
treatment. At-risk women who hold negative attitudes about treatment may
avoid seeking services for the purpose of receiving a referral, including
physician services.
In the literature, at-risk women have criticized treatment services because of a
lack of appropriate programs for women only, a lack of programs for parental
services and parental training, a lack of child-care services, long waiting
lists, distant services accompanied by a lack of transportation, and a limited
number of referral services in rural regions (Tait, 2000; Currie, 2001; Dore
& Doris, 1997). More personal barriers to treatment include fear of having
their child apprehended by social services; feelings of denial, guilt and shame;
a sense of stigma and lack of confidentiality; social costs; and opposition
from family and friends (Beckman, 1994; Beckman & Amaro, 1986; Poole &
Isaac, 2001; Tait, 2000). These barriers are found in any geographic location,
but are exacerbated in smaller urban and rural communities (Currie, 2001;
Finkelstein et al., 1997; Poole & Isaac, 2001). Additionally, at-risk mothers
may be reluctant to enter treatment because of a lack of culturally sensitive
programming (Currie, 2001; Lundquist & Jackson, as cited in Stockburger,
2003). The literature suggests that at-risk women who hold negative views
of treatment services may be less likely to seek help in gaining access
to these services, including help obtained through their physician.
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Attitudes and perspectives about the prenatal clinic
There is limited research on barriers related to attitudes and perspectives
about the prenatal clinic, yet it is plausible that the majority of the barriers
regarding attitudes and perspectives about treatment will apply when visiting
a health professional. The available research corroborates this notion. Studies
show that the threat of legal intervention, primarily child apprehension, is a
barrier for at-risk women to seek prenatal care (Jessup, Humphreys, Brindis,
& Lee, 2003; Moss, 1991; Sullivan, 1990; Tait, 2000). Additionally, women
of child-bearing age who were using substances have reported avoiding
prenatal visits because they feared their care provider would discover their
drug use (Milligan et al., 2002). Moreover, substance-using mothers have
reported that prenatal clinics have treated them poorly, and that as a result
they have refrained from prenatal visits (Milligan et al., 2002). In a U.S.
focus group study conducted by Milligan et al. (2002), one participant said,
When providers find out you use drugs, they treat you bad, i.e., like
an addict. [They] put you on the table like you’re a piece of meat....
Addicts, being addicts, underprivileged, and you done been through
the ringer and you’re trying to get your life back on perspective and
they treat you like a bunch of crap.
Similarly, Canadian Aboriginal women have reported experiencing poor
treatment when using health services. Specifically, Aboriginal women have
reported being subjected to cultural insensitivity and racism (Stout, Kipling,
& Stout, 2001). Disrespectful treatment could cause women to become
disinclined to revisit for care (Benoit, Carrol, & Chaudhry, 2003).
Awareness of services and how to access them
I just didn’t realize how the system worked. There’s no real paper stating
that this is the way you go about getting treatment.
—an at-risk woman (Poole & Isaac, 2001)
Once at-risk women resolve to get help, it is critical that they be aware
of available help and how to reach it; however, this is not always the case
(Allen, 1994; Currie, 2001; Grant, 1997; McElaney, as cited in Morse, 2000;
Roberts & Nanson, 2001; Tait, 2000). Women have reported wanting help
but not knowing where or how to get it (McElaney, as cited in Morse, 2000).
In Poole and Isaac’s 2001 study, over half of the at-risk B.C. women sampled
reported not knowing what help was available. It may also be the case that
at-risk women may not understand how to obtain a referral (Tait, 2000).
The gravity of being unaware of where and how to receive help is illustrated
by a quote from an interviewee in Tait’s Manitoba study of substance-using
mothers:
Realizing I’m an alcoholic, I have a drinking problem, and trying to
understand that I’m an alcoholic... I really didn’t know who to talk to
about it. That was when I was still pregnant with my last daughter.
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It can be inferred from the findings above that women who are unaware
of how or where to get help may be less likely to seek a physician’s help.
Prenatal care within the context of other determinants of health
Women who use substances may often face many other problems, such
as a drug lifestyle, abusive relationship, employment issues, depression,
lack of child care, poverty and homelessness (Brady et al., 2003; Milligan
et al., 2002). Many of these problems fall under the Public Health Agency
of Canada’s (2003) key determinants of health, such as income and social
status, social support networks, employment and working conditions,
and social environments. Considering this, it might be assumed that these
problems may interfere with or take precedence over the pursuit of prenatal
care. Milligan et al. (2002) found that in focus groups with women of childbearing age who had substance use problems, many women identified their
lifestyle as a barrier to seeking prenatal care. One participant’s response
reflects the low priority of prenatal care in the context of other problems:
Do you think that I’m going to look at my watch and say, “It’s nine
o’clock everybody, so put down the [crack] pipe so I can go to my
prenatal care appointment”? (Milligan et al., 2002)
System
Lack of a standardized referral system
Although any referral to treatment services is positive no matter the source,
a poorly co-ordinated referral system will not foster referrals. The literature
indicates that a structured and integrated referral system is not common in
actual practice. One reason for this is that there are numerous providers
of referral for substance use treatment (e.g., mental health services, social
services, health organizations, community support groups, emergency
rooms, child protective services, family and parenting programs, religious
institutions, pharmacists, women’s shelters and crisis centres, as well as
physicians), which makes establishing and co-ordinating a referral process
difficult. In fact, certain at-risk women are more likely to receive a referral
from sources other than their physician. For instance, research has shown
that women who use substances also tend to suffer depression, anxiety and
post-traumatic stress disorders. Women suffering from these disorders are
more likely to seek help at a general mental health centre, and may follow
a different path to treatment (Schober & Annis, 1996; Weisner, Greenfield,
& Room, 1995). One study also indicated that women are more likely
than men to rely on referrals from family or friends as opposed to family
physicians (Grant, 1997). Ultimately, this research implies that a standard
and co-ordinated referral process does not exist in most communities.
Ineffective and poorly co-ordinated referral networks have been reported
as a barrier to referring at-risk women to treatment services (Donovan, 1991;
Miner et al., 1996).
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Practice
Studies indicate that the general population who abuse alcohol seldom go
to treatment services directly, and often seek guidance from their physician
(Jones & Helrich, as cited in Boyd, 1985; Murphey, as cited in Boyd, 1985).
This accentuates the important role of physicians to detect whether their
at-risk patients use substances and, if so, to appropriately refer them. During
a typical visit to a clinic, substance use must first be identified, and then
a referral can be made. Because positive identification commonly leads
to some type of intervention (which, among other things, includes a referral),
identification is integral to the referral process. The following is an overview
of some identification and referral practices.
Identification
Three common ways to screen for substance use are biochemical testing,
clinical interviews, and use of screening tools (i.e., standardized
questionnaires).
Biochemical tests
Biochemical tests can be effective to determine substance use. There are
many biological markers for substance use, which can be identified by
testing urine toxicology, carbohydrate-deficient transferrin, gamma-glutamyl
transpeptidase, blood alcohol levels, alcohol metabolites, enzyme levels, mean
corpuscular volume, altered proteins, etc. (Allen, Litten, Fertig, & illanaukee,
2000; Bearer et al., 1999; Glantz & Woods, 1991; Stratton, Howe, &
Battaglia, 1996). However, there is debate in the medical community
regarding the ability of biochemical tests and biological markers
to distinguish one-time or occasional use versus long-term addiction
(Goldsmith, as cited in Wheeler, 1993; Moss, 1989; U.S. Preventive Services
Task Force, 1989). Furthermore, some laboratory tests have been criticized
for limited sensitivity and susceptibility to contamination (Taylor, Zaichkin,
& Bailey, 2002; Conigrave, Saunders, & Whitfield, 1995; Schellenberg,
Benard, Le Goff, Bourdin, & Weill, 1989). For instance, a 1994 technical
bulletin by the American College of Obstetricians and Gynecologists (as cited
in Taylor et al., 2002) reported that urine toxicology testing has a limited
ability to detect substance use; consequently, ACOG does not recommend
the use of universal toxicology screening as standard practice to detect
substance use in pregnant women.
Clinician interview/self-report
The clinician interview is an informal screening method in which the issue
of substance use is broached by either physician or patient and discussed
without using formal screening or testing (Hicks, Sauve, Lyon, Clarke,
& Tough, 2003). Physicians quite often discuss alcohol use with pregnant
women, and this may or may not be followed up with the use of a screening
tool (Tough et al., 2005). Notably, the clinician interview relies heavily upon
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the accuracy of patients’ self-report to informal questioning (Hicks et al.,
2003). Unfortunately, in an informal setting, self-reported alcohol and other
drug use during pregnancy is highly variable, and often results in underreporting (Chang et al., 1998; Chasnoff, 1989; Finkelstein, 1993). Despite
this unreliability, this self-report method is still a practice for detection of
substance use during pregnancy. A study of metropolitan Toronto physicians
(Nevin et al., 2002) showed that 66% relied on their patients’ self-report in
order to detect alcohol use during pregnancy. Furthermore, research suggests
that less than a quarter of substance-using women voluntarily report their use
(Corse, McHugh, & Gordon, 1995). In review, the literature suggests that
a reliance on informal self-report may in some cases be an unreliable method
for substance use detection, considering how seldom substance-using women
voluntarily raise the issue or honestly answer informal questions.
Screening tools
Since the clinical interview may be inadequate, physicians may adopt a more
formal approach for detecting substance use, an approach that incorporates
formal screening tools. These tools can be administered by the physician
or self-administered by the patient. Although screening tools still rely on
self-report, a formalized self-report encourages more honest responses;
research has shown that use of formal screening tools and protocol results
in many times the number of occurrences of substance use detection than
does the use of no screening tools or protocol (Chasnoff, 1989; Cyr &
Wartman, as cited in Saitz et al., 2002). Moreover, screening tools have
been proposed as superior to both the clinician interview and biochemical
testing in detecting excessive alcohol use (Bernadt et al., as cited in Chang,
1997; Chasnoff, 1989). Therefore, screening tools are often recommended
as an effective practice to detect substance use, particularly for alcohol and
other drug use.
There are a number of screening tools for alcohol, tobacco and other drugs.
(For a comprehensive review of various screening tools, refer to Center
for Substance Abuse Prevention [CSAP], 1993.) Specific tools for detecting
tobacco or illicit drug use were seldom used in the studies cited in this literature review. However, screening tools for alcohol were used in many studies.
Commonly used alcohol questionnaires to gauge alcohol use among at-risk
women include the Michigan Alcoholism Screening Test (MAST) (Selzer,
Vinokur, & van Rooijen, 1975), the Alcohol Use Disorders Identification
Test (AUDIT) (Babor, De La Fuente, Saunders, & Grant, 1989), and
the CAGE (Ewing, 1984). However, these tools were designed to detect
alcoholism in men and are not considered effective to detect alcoholism in
women, let alone alcohol use during pregnancy (CSAP, 1993; Chang, 2001;
Goldberg, Mullen, Ries, Psaty, & Ruch, 1991). Thus, identification of at-risk
women can be compromised by use of ineffective screening tools.
More sensitive tools exist, such as the TWEAK and T-ACE (Chang, 2001;
Russell, 1994). The TWEAK is viewed as one of the most accurate and
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sensitive tools to detect risk drinking during pregnancy (CSAP, 1993).
The TWEAK is reported as brief, easy to administer, and simple to score
(CSAP, 1993). On the other hand, it has been criticized for not being
sensitive enough to target moderate problem drinkers or at-risk patients
(CSAP, 1993; Sokol, Delaney-Black, & Nordstrom, 2003). Another tool that
is used is the T-ACE (Sokol, Martier, & Ager, 1989), which was designed
to detect at-risk drinking among pregnant patients. Like the TWEAK, T-ACE
is reported as quick, easy to administer, and easy to score (CSAP, 1993).
It has been praised for bypassing the denial syndrome frequently experienced
by alcohol users, but has been criticized for not identifying moderate
drinkers (CSAP, 1993).
Despite the claimed sensitivity of these tools, they are not always used.
For instance, Nevin et al. (2002) found that 34% of physicians used
the inappropriate CAGE tool to screen for alcohol use during pregnancy,
and that no physicians reported using the TWEAK. Tough et al. (2005) found
that 74% of family physicians used a screening tool for alcohol with their
prenatal patients. However, 87% of those physicians who used a screening
tool reported using the CAGE and only 23% reported using the T-ACE.
(Some physicians used more than one tool.) A survey conducted by the
American College of Obstetricians and Gynecologists (Hollander, 2002)
found that only 23% of physicians used a standardized screening tool;
the exact tool was not specified.
Physician reasons for screening
A U.S. study (Zellman et al., 1999) examined the reasons physicians
responded to suspected prenatal substance use. According to the study,
physicians most often acted on suspicions in order to help the patient,
to protect the fetus and prevent fetal problems, and to cease their patients’
substance use. About half of the physicians felt that legal requirements and
workplace policy were also important reasons for a response. Less than
a quarter reported fear of a lawsuit as an important reason for responding
to suspected substance use.
Screening protocol
Research among the general population (not just at-risk women) shows that
physicians may fail to recognize substance abuse (Buchsbaum, Buchanan,
Poses, Schnoll, & Lawton, 1992; Cleary et al., 1988; Coulehan, ZettlerSegal, Block, McClelland, & Schulberg, 1987; Institute for Health Policy,
as cited in Saitz et al., 2002; Isaacson, Butler, Zacharek, & Tzelepis, 1994;
Kamerow, as cited in Saitz et al., 2002; Saitz, Mulvey, Plough, & Samet,
1997). In one study, 42% of patients reported that their physicians were
unaware of their substance use (Saitz et al., 1997). Furthermore, physicians
are less likely to diagnose or take an alcohol history from women than from
men (Awad & Wattis, as cited in Chang, 1997; Beckman & Amaro, 1986;
Shapiro et al., 1984). As for at-risk women, there is a paucity of research
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describing physician detection rates of substance use. However, there are
numerous protocol- and practice-related barriers that may hinder identification of substance use among at-risk women; as Zellman et al. (1999, p. 29)
state, “substance use in pregnancy is a frequently missed diagnosis.”
It has been suggested that physicians do not appropriately or routinely
screen all at-risk women (including pregnant women), and often only
screen patients who they suspect or are fairly certain are using substances
(Best Start, 2005; Donovan, 1991; Health Canada, 2003a; Hollander, 2002;
Howell et al., 1999; Miner et al., 1996; Nanson et al., 1995; Nevin et al.,
2002). A survey conducted by Health Canada (2003a) showed that less than
50% of health care providers discussed risks of alcohol use during pregnancy
with their at-risk female patients. Similar rates have been found in the United
States (Fleming, as cited in Enoch & Goldman, 2002; Hollander, 2002).
Hollander (2002) reported on a 1998 U.S. study, which indicated that just
50% of physicians offered advice about alcohol use to all pregnant women,
36% of physicians did so only when they knew or suspected alcohol use
was an issue, and 13% of physicians offered prenatal advice to women
who had a history of substance use. It should also be noted that in this
study, 97% physicians stated they obtained information about alcohol use
from their obstetric patients. Although the methods for doing so included
physicians asking women if they drink (48%), and having a non-physician
staff member ask the patient about alcohol use (41%), 19% of physicians
obtained information by having the patient answer an alcohol-related
question on a form that patients complete. Only 23% of physicians reported
using a standardized screening tool.
Further barriers related to protocol include the following:
· Physicians may not take an active role in detecting substance use
because there is a lack of policy and procedures defining the role
physicians play in systematically identifying substance-using women
(Li, Olsen, Kvigne, & Welty, 1999; U. S. Government Accounting
Office, as cited in Zellman, Jacobson, DuPlessis, & DiMatteo, 1992).
· Physicians may be less likely to screen if they do not perceive
a screening instrument as validated and if there is a lack of clear,
science-based guidelines (Miner et al., 1996).
· Some physicians believe substance use is not prevalent among their
patients; for instance, Donovan (1991) found that some New Jersey
physicians denied that fetal alcohol syndrome occurred in their
practices.
· Physicians who inquire about alcohol use seldom probe with
follow-up questions (Miner et al., 1996).
Given these barriers, it is plausible that insufficient practice and protocol
may lead to significant rates of undetected substance use among women
who are pregnant or of child-bearing age.
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Intervention
Physicians’ responsibilities are not typically limited to identifying substance
use; they often intervene to provide counsel or offer referrals to their
patients. Physicians may provide counsel to women by encouraging them
to stop on their own, advising them to delay pregnancy or supplying
written information about substance use during pregnancy (Handmaker &
Wilbourne, 2001; May, 1995; Roberts & Nanson, 2000). Physicians may
also provide a referral to substance treatment services, or to other services
such as community support organizations, social services and mental health
programs (Handmaker & Wilbourne, 2001; May, 1995; Roberts & Nanson,
2000).
Whether or not a physician chooses to intervene with a referral or another
type of intervention will affect overall referral rates. One study indicates
that referrals may not be physicians’ first choice for intervention (Hollander,
2002). The American College of Obstetricians and Gynecologists conducted
a survey in 1998 and found that upon a positive screen for alcohol use, most
physicians chose to discuss the adverse effects of prenatal alcohol use with
women who were moderate drinkers (three to 13 drinks per week) and heavy
drinkers (14 or more drinks per week). Notably, 86% of physicians discussed
the effects with moderate drinkers, and 97% with heavy drinkers. In the
same study, 83% of physicians dealing with moderate drinkers and 92% of
physicians dealing with heavy drinkers said they would discourage patients
from drinking during pregnancy. Seventy-nine per cent of physicians would
tell moderate drinkers and 88% of physicians would tell heavy drinkers to
discontinue alcohol use while pregnant. However, just 21% of physicians
referred at-risk women who were moderate drinkers to treatment services,
and 61% of physicians referred heavy drinkers (Hollander, 2002).
During clinic visit
In review, identification and intervention practices are key factors in the
referral process. Apart from physician practice, further factors affecting
the referral outcome come into play during the patient’s visit to their
physician. The following is an exploration of some of the common
influences and barriers facing the patient, physician and overall system
that affect the identification of at-risk women and the referral process.
Identification and intervention
Substance use identification and referral barriers are often intertwined.
These barriers include patients’ honesty and willingness to facilitate
a referral (Sloan, Gay, Snyder, & Bales, 1992; Tait, 2000); physicians’
comfort levels (Beich, Gannik, & Malterud, 2002; Donovan, 1991;
Spandorfer, Israel, & Turner, 1999; Zellman et al., 1999); fear of patients’
reaction (Donovan, 1991; Miner et al., 1996; Svikis et al., 1997); capability,
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education, and training (Aira, Kuahanen, Larivaara, & Rautio, 2003;
Donovan, 1991; Fucito, Gomes, Murnion, & Haber, 2003; Herbert & Bass,
1997; Li et al., 1999; Miner et al., 1996); time constraints (Aira et al., 2003;
Cornuz, Ghali, Carlantonio, Pecoud, & Paccaud, 2000; Donovan, 1991;
Kaner, Heather, McAvoy, Lock, & Gilvarry, 1999; Li et al., 1999; Miner
et al., 1996; Richmond & Anderson, 1994; Rush, Ellis, Crowe, & Powell,
1994; Spandorfer et al., 1999; Zellman et al., 1992); financial compensation
(Hollander, 2002; Roche & Richard, 1991; Zellman et al., 1992); physician
satisfaction (Miner, Giner, Lacalle, Franco, & Belasco, 1990; Saitz et al.,
2002; Sansone, 2000); and perceived effectiveness of treatment services (Aira
et al., 2003; Kaner et al., 1999; Laudet & White, 2005; Miner et al., 1996).
Patient self-report
Q: Did the doctor ask you about your [substance] use?
A: Well they did ask me but I lied to them. I’m not going to tell them
because Child and Family Services would have got called.
(quoted from Tait, 2000)
As mentioned earlier, one barrier to identification during a clinical interview
or completion of a screening tool is that self-report depends largely on
the at-risk woman to honestly answer questions about substance use.
However, women who use substances (especially those who use during
pregnancy) may be unwilling to divulge information regarding their
substance use, particularly alcohol and other drug use, because they may be
in denial; feel guilt; fear shame, stigma and judgment; or fear consequences
such as child apprehension or legal intervention (Finkelstein, 1994; Howell
et al., 1998; Jacobson, Chiodo, Sokol, & Jacobson, 2002; Moss, 1991;
Roberts & Nanson, 2000; Sloan et al., 1992; Sullivan, 1990; Tait, 2000).
Interestingly, physicians who consistently find their patients responding
dishonestly may decrease their screening practices for substance use
(Donovan, 1991; Li et al., 1999). Moreover, some physicians place the
responsibility for recovery primarily on the patient, and emphasize that
it is the patient who must take the initiative. Roche, Guray and Saunders
(1991) conducted interviews with physicians about their views on alcohol
and other drug problems among the general public. Roche et al. reported
that physicians did not feel it was their responsibility to initiate the recovery
process; as one physician stated,
The only role for the doctor in substance abuse is where people want
to do something about it anyway.
Another physician interviewed in the same study felt that help would
go for naught because the physician cannot change the patient’s lifestyle:
I assume alcohol is in the background of all problems in my area but
you can’t change their [patients’] lifestyle, so you forget about it.
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Poorly phrased questions exacerbate these barriers and can cause patients
to become more reticent (Corse et al., 1995; Morse, 2000). That is, if health
providers phrase their interview questions or comments negatively (such as,
“Now that you’re pregnant, just don’t drink,” “You don’t drink or use drugs,
do you?” or “You know you shouldn’t do that when you’re pregnant”), it
may inadvertently hinder open discussion and inhibit voluntary self-report
(Corse et al., 1995; Morse, 2000).
Physician discomfort and perceived patient reaction
Like patients, physicians may feel discomfort when the issue of substance
use emerges (Beich et al., 2002; Donovan, 1991; Spandorfer et al., 1999).
This is more apparent for issues of alcohol or illicit drug use than for tobacco
use (Jones-Webb, McKiver, Pirie, & Miner, 1999; Miner et al., 1996).
Physicians may experience discomfort because screening interferes with
establishing and maintaining a relationship, it imposes an unwelcome
judgment role, and it entails intrusive questioning (Beich et al., 2002;
Spandorfer et al., 1999). In addition, physicians may be uncomfortable
raising the issue because they do not want to offend their patients (Donovan,
1991). Zellman et al. (1999) suggest that this discomfort causes physicians
to avoid such issues. A physician interviewed by Roche et al. (1991) stated,
Confronting or scaring them [patients] makes them feel worse about
themselves.
In terms of patient reaction, physicians perceive at-risk women to be reluctant to consent to the administration of a screening tool, and have reported
that patient unwillingness is a barrier to screening for substance use (Li et
al., 1999). Several studies have shown that physicians who are uncertain
about how to approach or deal with at-risk women fear that inquiring about
substance abuse during pregnancy may deter and drive women away from
prenatal care (Donovan, 1991; Miner et al., 1996; Svikis et al., 1997).
Physician education and training
...to get through the undergraduate course, and pass the exams. You’re
not thinking about the wider social issues and you don’t appreciate
the problems of alcoholism and managing patients, until you’ve got
your own practice.
–an interviewed physician (Roche et al., 1991)
A lack of relevant education and training is often cited in the literature as
reasons that physicians do not identify substance use, particularly alcohol
and illicit drug use, in the general population as well as in at-risk women
(Aira et al., 2003; Beckman, 1994; Donovan, 1991; Fucito et al., 2003;
Herbert & Bass, 1997; Li et al., 1999; Miner et al., 1996). Some physicians
may simply be unaware of safe drinking levels (Fucito et al., 2003; Howell
et al., 1996; Roche & Richard, 1991). For instance, a Minnesota study
showed that physicians were uncertain of the risks associated with different
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degrees of alcohol use, were unaware of the scope of the problem, were
uncertain of the best time to screen during pregnancy, and did not know
the optimal medical recommendation (Miner et al., 1996). Further,
in a Cincinnati study, some obstetricians believed that drinking was
acceptable in the third trimester (Kenner, 1998). Physicians may also
lack confidence in obtaining accurate information, and are consequently
reluctant to screen for substance use (Miner et al., 1996). Other research
suggests that physicians may be capable of diagnosing substance use,
but lack proper training to handle the issue with their patients; that is,
capable physicians may fear their inquiries will open a “Pandora’s box”
of issues they are unprepared to manage (Durand, 1994; Li et al., 1999;
Rosett & Weiner, 1981).
There are a considerable number of physicians who feel unprepared to deal
with alcohol and other drug use. In a Canadian study, just 55% of physicians
and 41% of pediatricians reported feeling prepared to manage pregnant
women who use alcohol (Tough et al., 2005). Interestingly, physicians who
are younger and who have graduated more recently may be better equipped
to handle such problems (Hollander, 2002; Roche & Richard, 1991; Roche et
al., 1991; Fucito et al., 2003). A U.S. survey showed that 27% of physicians
felt medical school did not adequately prepare them to assess alcohol use
among pregnant women, 35% thought their training was adequate, and the
remainder (38%) felt their training was very good or outstanding. The study
also showed that physicians who felt better about their training were those
who graduated after 1989; the level of satisfaction dropped drastically for
earlier graduates. Compared with those who graduated after 1989, those
who graduated before 1973 were 40% less likely to feel very prepared to
determine alcohol use, 80% less likely to use a screening tool, and generally
offered less advice to women who used alcohol during pregnancy. Physicians
who graduated before 1973 were 10 times more likely to feel they received
inadequate medical school training (Hollander, 2002).
Financial compensation
Lack of financial compensation as a barrier to treating substance-using
patients has been documented in the literature on both the general public
and at-risk women (Roche et al., 1991). In a study conducted by Roche et
al., one physician stated,
[It is] not financially rewarding to counsel because patients who are
waiting will go elsewhere.
Likewise, for at-risk women, research indicates that one disincentive
for physicians to engage in the identification and intervention process
is that they may not be reimbursed for their time spent (Zellman et al.,
1992). Hollander (2002) found that a lack of insurance reimbursement was
a barrier to providing screening services, more so among physicians who
graduated from medical school before 1973 than among those who graduated
after 1989.
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Physician time constraints
It is well reported in the literature that lack of time is a barrier physicians
face when dealing with substance use, whether it be in the general population or in at-risk women (Aira et al., 2003; Cornuz et al., 2000; Donovan,
1991; Kaner et al., 1999; Li et al., 1999; Miner et al., 1996; Richmond &
Anderson, 1994; Rush et al., 1994; Spandorfer et al., 1999; Zellman et al.,
1992). In a study involving Canadian physicians (Tough et al., 2005),
59% reported not having enough time to talk to women about alcohol before
they are pregnant. Physicians’ response that time is a limitation to identifying
substance use certainly has merit (U.S. Preventive Services Task Force,
1996), but a researcher in this field suggests that this response may only
be taken at face value because physicians take the time to deal with other
similar preventive health issues, such as diabetes or follow-up of high blood
pressure (Aira et al., 2003).
Physician satisfaction and perception of addiction treatment efficacy
Satisfaction is important to consider because it influences physician
motivation to identify and treat addictions (Sansone, 2000). Specifically,
physicians who gain less satisfaction from caring for patients may have
a reduced intrinsic motivation to identify and provide intervention to their
patients with addictions (Sansone, 2000). Thus, it is not surprising that physicians who are more satisfied with their efforts are more likely to diagnose
patients with alcohol problems (Miner et al., 1990). However, Saitz et al.
(2002) found that physicians were significantly less likely to experience
satisfaction from caring for patients with alcohol or other drug problems
than from caring for those with hypertension. Considering this research,
it is plausible that dealing with patients who use alcohol or other drugs
yields less satisfaction for physicians, and that physicians may therefore be
less motivated to identify and treat addictions.
In studies involving the general population, physicians have reported
being more likely to refer patients to treatment services if those services
have proven effective in the past (Kaner et al., 1999). Correspondingly,
physicians who doubt the availability and effectiveness of a program will
refrain from referring at-risk women to it (Miner et al., 1996). Unfortunately,
some physicians believe their intervention efforts have little impact on their
patients and view treatment services as ineffective (Aira et al., 2003; Laudet
& White, 2005; Richmond & Anderson, 1994; Roche et al., 1991). Studies
indicate that physicians have low expectations for the effectiveness of
treatment services, especially those that emphasize “powerlessness”
(giving up control) and spirituality (Aira et al., 2003; Laudet & White,
2005; Roche et al., 1991).
Despite some physicians’ belief that their screening and intervention efforts
have little or no impact, there is an abundance of research suggesting that
physician intervention does in fact protect against substance use during
pregnancy (Boyd, 1985; Cunningham, Sobell, Sobell, Agrawal, & Toneatto,
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1993; Ershoff, Mullen, & Quinn, 1989; Jones-Webb et al., 1999; Manwell,
Fleming, Mundt, Stauggacher, & Barry, 2000; Minor & Van Dort, 1982;
Rosenblatt, 1989; Secker-Walker, Solomon, Flynn, & Skelly, 1995; Windsor
et al., 1985). Moreover, treatment services have proven effective in reducing
and eliminating substance use among at-risk women (Beschner, Reed, &
Mondanaro, 1981; Bien, Miller, & Tonigan ,1993; Finnegan, 1979;
Mondanaro, 1987).
In studies involving the general population, it has been suggested that
physicians hold the misperception that treatment services are ineffective
because physicians commonly receive feedback from clients who relapse
or end up in acute emergency situations (Aira et al., 2003). Presumably,
this type of feedback may lead physicians to believe that their counselling
efforts or the treatment services were not effective. It is not surprising,
then, that physicians report that caring for patients with alcohol and other
drug problems yields less satisfaction than caring for patients with other
problems such as hypertension or depression (Saitz et al., 2002). In review,
the literature suggests that lower physician satisfaction may result in less
substance use intervention and treatment referrals for at-risk women.
Notably, experiencing repeated failure and little success may result in
physicians reducing not only their intervention practices, but also their
identification practices (Li et al., 1999).
Follow-up
Patient follow-through
Even after a physician has made a referral, this does not necessarily translate
into a patient entering treatment. One study showed that among the general
population of patients who screened positively for substance use and who
received a referral from their physician, only 2% to 11% accepted a referral,
and of these, approximately 67% actually kept their appointments (Goldberg
et al., 1991). The researchers concluded that less than 5% of positively
screened patients ever followed through on the referral. There are many
reasons for this, some of which have been discussed earlier in this literature
review as barriers with regard to at-risk women’s attitudes about treatment
services.
Women who are more likely to accept treatment when it is offered usually
suffer more severe substance use problems, have undergone treatment in
the past, have partners who use alcohol, and have experienced physical
and/or sexual abuse during pregnancy (Messer, Clark, & Martin, 1996).
Physician follow-up
There is little literature on physician follow-up with pregnant substance
users. One study indicated that after identifying tobacco use in an initial
prenatal visit, physicians only provided counsel for 21% of the return visits
made by pregnant patients, despite the fact that the guidelines for these
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physicians recommended questioning and counsel on all return visits
(Moran, Thorndike, Armstrong, & Rigotti, 2003).
Recommendations
The following recommendations address the information and barriers
presented in this literature review. Though the specific purpose of these recommendations is to improve physician referral rates to addiction treatment
services, they may be beneficial in areas beyond referrals. Therefore, when
appropriate, the reader is referred to sources of more detailed information
that is relevant, but beyond the scope of this recommendations section.
Implementing these recommendations will vary extensively in terms
of the source of delivery, the method of delivery, the demographics of
the target population (e.g., culture), relevant policy and regulations, and
so forth. It is also recognized that for every challenge, there typically exist
several solutions. Therefore, it is not practical to list all imaginable service
delivery scenarios in this document. Rather, the purpose of these recommendations is to provide a launching point for stakeholders by addressing
the barriers raised in the literature review. It is essential that stakeholders
take the initiative in developing innovative and successful strategies to
address issues concerning referrals of at-risk women.
When considering how these recommendations will be delivered to at-risk
women, it is important to emphasize an approach that promotes a safe
and welcoming environment, that is respectful and non-judgmental, that
is tailored to at-risk women, that is culturally relevant, and that delivers
a consistent message. These characteristics are all key underpinnings
necessary to arrive at a successful outcome (Leslie & Roberts, 1991;
Working Group for FAS, 1999a; 1999b; 1999c).
1. Address risk perception and awareness of problem among
at-risk women
Despite high awareness of the harmful consequences of alcohol use during
pregnancy (University of Alberta, 2004), women may not recognize that their
own substance use during pregnancy is problematic (Poole & Isaac, 2001;
Tait, 2000; Testa & Reifman, 1996). This may result in fewer women seeking
help or receiving a referral. Therefore, measures should be taken to increase
the number of women who acknowledge their own substance use during
pregnancy as hazardous. For example, at-risk women could be provided
with resources that help them to identify and discuss their own risks of
substance use during pregnancy.
It has also been found that certain groups of women (e.g., those who consume
higher amounts of alcohol) may be less aware of the harm of substance use
during pregnancy (Environics Research Group, 2002). Therefore, it may also
be useful to focus relevant awareness and educational campaigns on at-risk
women.
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An effort that combines the aforementioned goals may improve the likelihood that at-risk women will seek help. In turn, this may potentially increase
the number of physician referrals to treatment services. The content of such
an effort to promote acknowledgement and awareness should
· illustrate the health consequences to the mother
· facilitate self-acknowledgement among at-risk women about the risks
of their own use. This could be done by disseminating relevant
resources (i.e., materials that incorporate the T-ACE or TWEAK).
· debunk myths about substance use during pregnancy (e.g., emphasize
that even if a woman has had a healthy baby despite using substances
during pregnancy, drinking during a future pregnancy still poses
significant health risks)
· be delivered by a credible source, such as a physician
Delivery of the above messages need not be the sole responsibility
of the physician; it could occur through various community agencies,
venues and initiatives. A popular method to raise public awareness is
a media campaign. A Health Canada study (Environics Research Group,
2002) involved a nationwide survey of 907 women and 300 men. One part
of the survey gauged recall of advertisements addressing alcohol use during
pregnancy. Fifty-two per cent of women recalled ads about alcohol use
during pregnancy. Women most often recalled seeing information or ads
about alcohol use during pregnancy on television (56%), at a doctor’s
office/hospital/clinic (27%), in magazines (26%), on the radio (11%) and
on posters (10%). In addition, women were asked for their opinion on
the effectiveness of different ways to inform them about the risks of drinking
during pregnancy. Women felt that television advertising (74%), sending
information to doctors and health-care professionals (70%), and posters in
waiting rooms and clinics (62%) were all very effective methods to inform
them about the health risks of alcohol use during pregnancy; these were
followed by ads in buses, subways or bus shelters (44%), and posters or
brochures in pharmacies (42%). Women were more likely than men to
favour these methods.
Other methods to publicize information include utilizing a community
task force or committee; offering courses, seminars and luncheons; having
guest speakers at community events, and conducting lectures. (For more on
dissemination strategies, see Canadian Health Services Research Foundation,
2004; Harmsworth & Turpin, 2000; Lomas, 1997). Whatever the method
of dissemination, there are a few key points that should be followed:
· It should have a message that is laid out in plain language.
· It should be widely accessible.
· It should target areas where at-risk women can be reached.
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2. Improve at-risk women’s perception of treatment services and
the prenatal clinic
Women who hold negative views of treatment services or of the prenatal
clinic may be hesitant to seek referrals for such service. It is therefore
recommended that providers of addiction treatment services take
the initiative to enhance their reputation among at-risk women. There
are several key steps in doing so:
· Treatment service providers and prenatal clinics garner input
about how they are perceived by relevant communities and how
these communities envision their role.
· Treatment service providers and prenatal clinics assess and resolve
common criticisms of their service delivery (e.g., legal intervention,
child apprehension) and programs (e.g., culturally inappropriate).
· Treatment service providers and prenatal clinics revamp their image
as appropriate. For instance, treatment service providers may consider
rephrasing or renaming programs so they have less social stigma tied
to them. This notion has met with success before; a program involving
Native American populations in the United States was able to increase
the rate of accepted referrals for alcohol use to 56%. This high rate of
acceptance was attributed to the phrasing of the referred program as
a prevention program rather than a social work or alcohol program
(LeMaster & Connell, 1994; Masis & May, 1991).
· Treatment service providers and prenatal clinics bolster their revamped
image in the target community.
One example of how addiction treatment services in particular could
improve their reputation requires proving the effectiveness of treatment
to at-risk women as well as to physicians. At-risk women may be more likely
to seek addiction treatment services if they are convinced of its effectiveness.
It has been reported that over 60% of at-risk women believe they can cut
back drinking on their own (Poole & Isaac, 2001). However, this is highly
unsuccessful. At-risk women must be made aware that self-administered
treatment or no treatment at all results in considerably less success than
treatment provided by an addiction treatment service provider (Brown,
2001; Miller, Walters, & Bennett, 2001; Prendergast, Podus, Chang, &
Urada, 2002; Winters, Stinchfield, Opland, Weller, & Latimer, 2000). Also,
physicians have reported reluctance in referring their at-risk patients to
addiction treatment services because of uncertainty that the treatment is
effective (Miner et al., 1996). On the other hand, Kaner et al. (1999) found
that physicians were more likely to make a referral if the referred service
had been proven effective. Therefore, convincing physicians of treatment
effectiveness is also important in order to improve referrals.
In order to convince at-risk women and physicians that professional
treatment is effective, treatment services need to be evaluated and,
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if necessary, improved. When a program is deemed effective, this message
needs to be circulated throughout communities, with emphasis in the
communities where at-risk women and physicians can be reached.
3. Co-ordinate the referral system
Physicians report a poorly co-ordinated referral system as a barrier to providing referrals (Donovan, 1991; Miner et al., 1996). A 2005 study of Canadian
physicians and pediatricians showed that 73% of physicians and 48% of
pediatricians felt referral resources for women of child-bearing age with
alcohol problems were very helpful (Tough et al., 2005). The study also
showed that 67% of physicians and 54% of pediatricians felt that a registry
of FAS/FAE specialists available for consultation would be very helpful.
This indicates that physicians do find referral systems useful. If well-defined
referral systems were readily available, physicians would likely be more
inclined to use them.
Some at-risk women may be more likely to seek help at places other than
a medical clinic, such as a general mental health centre (Schober & Annis,
1996; Weisner et al., 1995). It is therefore important that a continuum
of care be in place to ensure that women who seek help receive effective and
efficient care. To this end, health organizations, agencies and governments
should take it upon themselves to bridge gaps and promote relationships
with one another. Once relationships and partnerships have been established,
these groups can define effective referral processes, transfer knowledge and
educate each other about the best ways to manage and help at-risk women.
In turn, this could facilitate a seamless flow among services provided by
different health organizations.
4. Increase at-risk women’s awareness of addiction treatment
services and the referral process
The literature indicates that at-risk women are unsure of what help
is available, and where and how to get help (Allen, 1994; Currie, 2001;
Grant, 1997; Howell et al., 1996; McElaney, 1991; Poole & Isaac, 2001;
Roche & Richard, 1991; Tait, 2000). To remedy this, health organizations
(particularly addictions treatment providers and medical clinics) should
develop a presence in areas that are frequented by at-risk women.
Determining these areas may require some research into the different
demographics and characteristics of at-risk women. Some areas may include
social organizations, health communities, schools, income assistance offices,
neighbourhood and friendship centres, and relevant government ministries.
Once areas have been identified, treatment service providers need to broadcast information about their services and the processes required to receive
those services, specifically outlining the referral process (which should be
well defined and straightforward). Research suggests using a community task
force to advocate such messages (Working Group for FAS, 1999a; 1999b;
1999c). Outreach efforts to at-risk women have also been recommended
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in the literature (Howell et al., 1999; Namyniuk, Brems, & Carson, 1997;
other dissemination strategies can be reviewed in Canadian Health Services
Research Foundation, 2004; Harmsworth & Turpin, 2000; Lomas, 1997).
5. Standardize physician screening and referral practice
Tough et al. (2005) report that 60% of Canadian physicians and 67% of
Canadian pediatricians would value clinical practice guidelines related
to fetal alcohol syndrome (FAS). The Alberta Medical Association and
Health Canada have published best practice guidelines for preventing
FAS, which includes formal screening guidelines for at-risk women. These
guidelines may be used as a source to develop standard practice guidelines
for managing substance use among at-risk women as well as among
the general public. (For complete guidelines, see Working Group for
FAS, 1999a; 1999b; 1999c; Roberts & Nanson, 2001.) Moreover, guideline
development could be proposed to appropriate health agencies, specifically
the Alberta Medical Association, the College of Physicians and Surgeons
of Alberta, and the Royal College of Physicians and Surgeons of Canada.
Because of the large numbers of at-risk women and the potential
consequences of substance use during pregnancy, it is often recommended
and warranted that routine screening for all women of child-bearing age be
conducted using effective screening tools (Health Canada, 2000b; Legge,
Roberts, & Butler, 2000; Morse, 2000; Working Group for FAS, 1999b;
1999c). Combining multiple methods of screening (biological, clinician
interview/self-report, and proven screening tools) would likely prove
the most successful method to detect substance use.
Contrary to the notion that physician identification and intervention
is of little consequence, it should be viewed as an optimal opportunity
to make a positive impact on the life of an at-risk woman and her child.
There are numerous reasons it is important for physicians to routinely
screen and, if necessary, refer at-risk patients:
· Patients may be reluctant to self-report or voluntarily discuss
substance use, and a screening tool should yield more honest answers.
· Routine screening may help the physician develop rapport with
the patient, which may encourage an open atmosphere; in turn, this
may increase referral rates. In fact, physicians have indicated that
their patients have responded positively to their intervention because
the patients felt the inquiry stemmed from genuine concern for their
health and well-being (Beich et al., 2002).
· Early identification and treatment can have a major impact on
the health of the fetus. For pregnant women who are using substances
but are unaware of their pregnancy, or for women who are using
substances and likely to become pregnant, early identification of
a substance problem can prevent health problems in the fetus.
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· Physicians are one of the best sources of information for at-risk
women, especially because at-risk women value their physician’s
counsel (Boyd, 1985; Cunningham et al., 1993; Ershoff et al., 1989;
Jones-Webb et al., 1999; Manwell et al., 2000; Minor & Van Dort,
1982; Rosenblatt, 1989; Secker-Walker et al., 1995; Windsor et al.,
1985). If physicians convey that substance use during pregnancy
is an issue worthy of attention, it may be more likely that at-risk
women will take positive action. Even pregnant women who do not
disclose alcohol use to their physician still heed the advice given
(Rosett et al., as cited in Working Group for FAS, 1999c).
· At-risk women may be reluctant to be identified as substance users and
reluctant to receive referrals for treatment; thus, consistent screening
and referral efforts may eventually reach intractable women who were
not initially identified, as well as motivate others who were previously
referred but have not yet utilized the service.
6. Use suggested screening tools for tobacco and other drug use
The TWEAK and the T-ACE were described earlier in this literature review
as effective and recommended screening tools for alcohol use among
at-risk women (Chang, 1997; Chang et al., 1998). However, in the articles
reviewed, there were few incidences where physicians chose to use a formal
screening tool to identify tobacco or other drug use. Nevertheless, tools have
been developed to screen for alcohol, tobacco and other drug use during
the prenatal and pregnant periods. Two of these tools are the Hospital
Screening Questionnaire (HSQ) (CSAP, 1993) and the Pregnancy
Information Program (PIP) (Lapham, Kring, & Skipper, 1991).
The HSQ is an extensively used questionnaire that is advantageous
because it assesses patients’ alcohol, tobacco and other drug usage over
time (pre-pregnancy, during pregnancy, and in the perinatal period). One
drawback of the HSQ is the high quantity of questions; however, it has
been suggested that the questionnaire could be modified to fit a more timesensitive environment (CSAP, 1993). The second screening tool, the PIP,
is a patient-interactive computer program that follows a self-administered
questionnaire format. The PIP provides risk assessment data for dietary
habits; alcohol, tobacco and other drug use; psychosocial stressors; and
social support. The program was designed specifically for pregnant and
postpartum women. The program has been used successfully in clinical
settings to screen women of different cultures for substance use (CSAP,
1993; Lapham et al., 1991). A screening tool’s cultural sensitivity is important, especially in light of the findings of Horn, Wanberg and Foster (1990),
which demonstrated marked cultural differences in responses to their screening instrument (CSAP, 1993). The Maternal Substance Use Assessment
Methods Reference Manual (CSAP, 1993) reports that patients preferred
the PIP to a written questionnaire; that there were high concurrence rates
with urine testing; and that compared with the written questionnaire,
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the program detected similar rates of tobacco use, but significantly higher
rates of alcohol and other drug use (Allen & Skinner, 1987; CSAP, 1993;
Lapham et al., 1991; Lapham, Henley, & Kleyboecker, 1993). In support
of this latter finding, some research indicates that computer-delivered
self-assessments yield more valid responses than face-to-face administrations
(CSAP, 1993; Russell et al., 1996). One reported drawback to the use of
the PIP is the purchasing cost of the program (CSAP, 1993).
The HSQ and the PIP are two of many tools that may be used to screen
for use of substances other than just alcohol. (For a complete review
of screening tools, please see CSAP, 1993 and Wild, Hodgins, Thygesen,
Cooper, & Curtis, 2004). Whatever the tool chosen, it is important
to determine the tool’s effectiveness and sensitivity within the population
of at-risk women. It is also critical that physicians receive training to use
the tool and recognize the value and benefit of using it. Proven success with
evidence-based tools and subsequent dissemination of the results are both
key to the uptake of such practices in the clinical and the health community.
7. Provide education and training for physicians
Physicians have expressed a need and desire for relevant educational
information on substance use during pregnancy (Miner et al., 1996).
Tough et al. (2005) found that 49% of Canadian family physicians and
45% of Canadian pediatricians felt that literature on the impact of alcohol
use during pregnancy was very helpful. In the same study, 50% of physicians
and 54% of pediatricians reported feeling that materials or training on
FAS/FAE were very helpful, and 34% of physicians and 17% of pediatricians
reported feeling that training on addictions counselling was very helpful.
Proper education and training may help physicians develop better relationships with their patients and help overcome barriers such as discomfort,
fear of patient reaction, and lack of confidence to manage such cases.
Among many things, educational efforts should inform physicians about
the prevalence of substance use during pregnancy; emphasize the importance
of screening, referral and early engagement (for more details see Pepler,
Motz, Moore, & Leslie, n.d.); and promote collaboration within the general
community and the health community. Perhaps the most important focus
of any education or training effort is on effective physician communication
with the patient. As mentioned, a non-judgmental, respectful, consistent and
culturally sensitive message is fundamental to any approach; this seems
especially central in the case of the physician-patient relationship. Research
has shown that effective physician communication with the patient can ameliorate tension and confrontation (Boyd, 1985). Patients are also more
motivated to follow their physician’s advice if there exists a supportive
relationship (Boyd, 1985).
Several educational and training resources directed at physicians that
incorporate the above elements are available, and could be drawn from
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to develop educational efforts aimed at preventing substance use during
pregnancy. Current resources include courses offered by Continued Medical
Education (CME), which is recognized as an authority in ongoing physician
education. For example, the Doctors and Tobacco Reduction in Pregnant
Women project (Barrett, 2005) has recommended that an online or face-toface CME course be offered to physicians in the Red Deer region to help
reduce tobacco use. Another resource stems from the Tobacco Reduction
and Assessment project, which has developed a training manual targeted at
physicians managing tobacco dependence with their patients. Educational
efforts may also involve providing physicians with training in motivational
interviewing techniques (Miller & Rollnick, 2002; Miller, Zweben,
DiClemente, & Rychtarik, 1994) as well as educating physicians about
the transtheoretical model of behaviour change, also known as the stages
of change model (Prochaska, DiClemente, Velicer, Ginpil, & Norcross,
1985; Prochaska & Goldstein, 1991; Prochaska & Velicer, 1997).
8. Provide financial compensation to physicians
It has been suggested that adequate reimbursement protocol would improve
identification and intervention rates (Green, Eriksen, & Schor, 1988).
Physicians need to be made aware of government subsidy programs that
allocate reimbursement funding for specific tasks such as managing at-risk
women. As well, subsidy and reimbursement programs should be established
if they do not exist. In doing so, government bodies concerned with the issue
of pregnancy and substance use need to be made aware of the lower costs
and greater benefits of funding preventative medicine as opposed to spending on lifelong treatment. Gortmaker (1981) reported that funds spent on
prenatal care reduce by two to three times the future costs of supporting
babies who were exposed to substances during gestation, as well as their
families. However, this study was based on the U.S. health system, so
caution must be taken in generalizing this to Canada. Nevertheless, subsidy
or reimbursement programs for physician management of at-risk women
may be a viable option for funding in the area of preventative medicine.
9. Encourage physicians to follow up with patients
It is recommended that physicians follow up with their patients frequently,
even during periods between pregnancies, for several reasons:
· Even though a woman may not screen positive one time, it does not
mean she will not screen positive the next.
· One screening may not be enough to elicit honest self-report, and
consistent screening may be necessary before an at-risk women feels
comfortable enough to respond openly. Similarly, one referral may
not be enough to motivate an at-risk woman to enter treatment; several
referrals may be necessary.
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· Because high-risk mothers may be least likely to get care early in
pregnancy, it is of particular importance to screen them whenever
possible, even during periods before or after pregnancy (Masotti
et al., 2003).
· Follow-up is vital in developing rapport and establishing continuity
of care, both of which may increase the likelihood that an at-risk
woman will seek physician direction for substance use.
10. Provide physicians with feedback about referred patients
Whether at-risk women receive a referral and do not seek treatment services,
or whether they seek treatment services and successfully cease substance
use, it is critical that physicians receive feedback about the outcomes of their
efforts. This will reinforce actions that result in positive outcomes while
allowing physicians to adjust actions that have not met with success. At the
same time, however, if physicians do not receive feedback, they must trust
that their efforts have a positive impact. For instance, pregnant women who
do not divulge their substance use to their physician will still heed advice
their physician provides (Rosett et al., as cited in Working Group for FAS,
1999c). Providing physicians with feedback may also improve their view
about the effectiveness of addiction treatment, which is important because
physicians are more likely to refer to treatment services they feel are
effective (Kaner et al., 1999).
Conclusion
This literature review has explored the referral practices and models
of service delivery provided by physicians to at-risk women. Identified
specifically were some of the barriers confronted by the patient and
physician during the referral process; current practices have also been
examined. Recommendations have been made to provide direction in
resolving the barriers identified. These recommendations are intended
as a launching point for stakeholders, who are encouraged to carefully
consider the barriers and develop subsequent strategies to improve
physician referrals of at-risk women to addiction treatment services.
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