(35) Consent First: Reviewing A Urine Drug Screening Protocol on Labor and Delivery

Background & Introduction: Perinatal substance use has been increasing in the last decade, with significant impact on maternal and neonatal outcomes. According to a 2018 national survey on drug use, 5.4% of pregnant women reported illicit drug use. In the last 5 years, several studies have shown a profound increase in drug overdose mortality for pregnant people. Universal screening for substance use in pregnancy is strongly recommended. The American College of Obstetricians and Gynecologists recommends screening via a validated questionnaire (i.e. the four Ps) over biologic sampling (i.e. urine drug screening). Despite this, urine drug testing remains common as the primary screening tool in emergency, triage, and labor & delivery settings, and is often performed without patient consent or awareness of the consequence. Arguments against primary biologic sampling include their high false positive rate and the potential for biases, with associated stigma and potential legal consequences that often target ethnic and racial minorities. A prior study at our institution demonstrated racial/ethnic biases in the rate of urine drug screening without increased detection or correlation with neonatal drug screens. In 2021 our hospital implemented a formal Urine Drug Screening protocol. The aim of our study was to evaluate our protocol’s impact.

Methods: In January 2021, a new urine drug screen (UDS) protocol was implemented at our institution. This included a mandatory written consent form, documentation of a testing indication, and an electronic UDS order which requires completion of the consent protocol to run the urine sample. Physicians and nurses on labor and delivery were trained on the protocol and on obtaining consent for UDS. We then conducted a retrospective chart review of all pregnant people at our institution who were admitted to the labor and delivery unit and received a UDS from January 2021 through October 2022. Data was extracted from the electronic health record for each delivering patient that received a UDS. We then confirmed UDS results and collected additional data through manual chart review. Data extracted included maternal demographics, obstetric outcomes, indication for UDS, type of consent (written or verbal), accessibility of the signed consent form in patient charts, and maternal preliminary and confirmatory urine toxicology test (aka confirmatory test) results. Descriptive statistics were performed. Finally, we compared the post-implementation data to pre-implementation, which was previously published by Chin et al.

Results: We identified 102 patients that received a UDS during our study period of 22 months, which was a large decline compared to the 281 patients tested during the pre-implementation period of 12 months. Sixty-one (60%) patients had documented verbal or written consent, which is increased from 35% pre-implementation. However, only 32 (31%) had completed the intended written consent protocol, with similar rates in 2021 and 2022. The racial/ethnic proportions of UDS patients were similar pre- and post-implementation: Native Hawaiian and/or Pacific Islander patients made up most of the patients screened (62% pre vs 67% post) but continued to have a low positive confirmatory test rate (37%) compared to patients who identified as white (79%), consistent with pre-implementation. The overall positivity rate of confirmatory testing was similarly stable, at 35% pre-implementation and 32% post-implementation. Current or history of marijuana use alone was the documented indication for 16 (15%) patients, but only one patient had a confirmed positive urine test. In comparison, current or history of methamphetamine use was the indication for 35 patients (34%), with 11 patients having positive confirmation testing. Limited prenatal care was the indication for three patients and hospital policy of breastfeeding was the indication for two patients, none of whom had a positive confirmation test. Only four patients (4%) had unclear or unknown indications for UDS, compared to 32% pre-implementation. Eighty-nine patients (87%) had a social work consult, but only 34 of those patients had a confirmed positive result.

Conclusion & Discussion: Since the implementation of a UDS consent protocol at our institution, we saw a significant decrease in frequency of testing and improvement in documented indication, suggesting that providers are more intentional regarding when testing to collect UDS. Patients are more likely to be consented verbally at minimum, and many patients signed written consents. There was less use of insufficient prenatal care, a poor predictor of positive urine toxicology, as indication for testing. Positive substance use history use was previously noted as a good predictor of positive urine toxicology, but was inconsistent in our review: current or prior marijuana use alone was almost never associated with a positive confirmatory test, whereas methamphetamine use was frequently associated with a positive confirmatory test. Finally, Native Hawaiian/Pacific Islanders continue to be screened at a high frequency but with a lower confirmed positivity rate, compared to white patients. Findings suggest that our current protocol has not improved the discriminatory screening of Native Hawaiians/Pacific Islanders. More anti-discrimination training is needed, and our UDS policy should be improved to minimize discriminatory UDS (i.e. screening for history of marijuana use alone), that may result in unnecessary social work involvement and stigma for patients.

References: American College of Obstetricians and Gynecologists. (2015). Committee opinion no. 633: alcohol abuse and other substance use disorders: ethical issues in obstetric and gynecologic practice. Obstetrics and gynecology, 125(6), 1529-1537.

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Chin, J. M., Chen, E., Wright, T., Bravo, R. M., Nakashima, E., Kiyokawa, M., ... & Bartholomew, M. L. (2022). Urine drug screening on labor and delivery. American Journal of Obstetrics & Gynecology MFM, 4(6), 100733.

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