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From: Exposure to Psychotropic Medications and Other Substances during Pregnancy and Lactation: A Handbook for Health Care Providers

Screening and assessment are often spoken of as one process. While they often overlap, there are significant differences between the two. Screening uses simple, brief procedures, often no more than a list of standard questions, to determine whether a person is likely to have a substance use problem. If a problem is likely, assessment uses more in-depth and ongoing processes to identify substance-related disorders.

Screening can be done by phone or face-to-face. The screening method can be tailored to clients’ needs and to the needs of the health care setting. Other considerations include using questions that are appropriate for the age, culture and literacy level of a client.

Screening for alcohol, tobacco, illegal drug and psychotropic medication use should be undertaken with all pregnant women and, for planned pregnancies, can begin during a preconception visit. As part of the overall health examination, women should be asked about their use of psychotropic medication and other drugs during each trimester, and again after delivery. Asking screening questions can lead to an open discussion about alcohol, tobacco and other drug use. In talking with women about problematic medication and substance use during pregnancy, health care providers can determine appropriate interventions in a timely fashion, which may help improve both the mother’s and the baby’s health outcomes.

Screening questions, rather than drug toxicology tests alone, continue to be the most effective method for detecting those at risk for alcohol or other drug problems.1 Toxicology tests are based on detecting particular drug concentrations at a certain point in time, and so may miss substance use if the test does not coincide with a drug’s detection period. To engage women in addiction treatment, it is ideal that screening for those at risk of substance use problems be based on self-report. During screening, a provider follows general questions with more specific ones, which are chosen depending upon the woman’s responses.

A variety of screening questionnaires have been developed to detect substance use in pregnancy. They are brief, easily administered and readily incorporated into routine prenatal care.

Prevalence studies have found that the following characteristics are usually present in women at higher risk of substance use during pregnancy:2,3

  • polysubstance abuse (i.e., concurrent abuse of more than one psychotropic medication and/or illegal substance)
  • low socio-economic status
  • less formal education
  • stressful life events
  • lack of a supportive social network (e.g., being without a caring and helpful partner or living with a partner or household member who uses drugs)
  • history of mental health disorders (e.g., mood, anxiety or eating disorders)
  • history of physical or sexual abuse
  • family history of substance abuse
  • lack of adequate prenatal care.

However, women who are older and have higher socio-economic status and higher levels of education have also been found to have higher rates of alcohol use in pregnancy, and so are a special population to be considered.4 This is one of the reasons why universal screening is so important.

General screening questions

Screening tools can help identify women who are at risk for problematic substance use and who may need more in-depth assessment by a primary care provider such as a family physician or nurse practitioner, or a health care specialist such as an obstetrician, a psychiatrist or an addiction medicine professional.1 Ideally, screening questions are introduced as a normal part of any visit with a health care provider; the rationale for such a discussion can be explained within the context of the woman’s overall health status.

Building trust and rapport with the woman is critical to screening for problematic substance use,1,2 as is a non-judgmental approach to both negative substance use disclosures (i.e., that a woman is not using) and positive substance use disclosures (i.e., that a woman is using). A woman may deny any drug use when asked the first time but, depending on the quality of the client-provider relationship and the way that she was initially asked about her substance use, may acknowledge use on subsequent questioning.

Health care providers are advised to encourage dialogue with a woman by initially asking open-ended questions, which can feel less intrusive, about less sensitive areas (e.g., medications) before proceeding to questions related to illegal drugs. Then the focus can shift to areas where a woman has reported problematic substance use.

The questions below, which have been adapted from multiple toolkits, are examples of ways to approach the subject of substance use with pregnant and breastfeeding women. Health care providers need to ask questions sensitively but directly.

The majority of research on physician performance in the area of substance use—which has largely focused on alcohol problems—suggests that “physicians perform poorly in screening and counselling patients with alcohol problems. . . . Physicians commonly report that lack of knowledge and training is a barrier to their detection and management of substance use”5 (pp. 1–2). Clinicians may be uncomfortable asking questions about an area where they lack clinical expertise. A health care provider who is not comfortable asking questions about substance use needs to learn to, or find support to, increase his or her comfort level, because these questions are an important part of providing overall health care. Providers can phrase the questions in their own words to fit their own comfort level; the more often they ask these questions, the more comfortable they will become with them. In addition, it is important for providers to be aware of community resources and agencies so they can refer women for the support and information they need.

Screening questions about psychotropic drug use

“Do you use any prescription medications to help with mental health symptoms, such as mood and anxiety symptoms?”

If the woman answers “yes”:

  • Ask about the source of the medication and how the woman is using it (e.g., ask: “Did your doctor write you a prescription for this medication, or did you get it from another place?” If it is a prescribed medication, ask: “Are you following the directions on the prescription or using the medication differently?”)
  • Ask about the pattern (amount and frequency) of medication use (e.g., ask: “How much are you taking and how often are you taking it?”)
  • Assess the stage of change (see Figure 2) the woman may be at with respect to problematic psychotropic drug use (e.g., ask: “How do you feel about making a change in your medication use?”)

Screening questions about alcohol use3

“How much alcohol do you drink?”

If the woman indicates that she drinks alcohol:

  • Ask about the pattern (amount and frequency) of use, and about any binge drinking—heavy episodic drinking, during which a person consumes five or more standard drinks on one occasion (e.g., ask: “In a typical week, on how many days do you drink? On those days, how many drinks would you usually have?”)
  • Assess the stage of change the woman may be at with respect to alcohol use  (e.g., ask: “How do you feel about stopping drinking?”)

    (These questions can be followed by the T-ACE or TWEAK questionnaires, to detect at-risk drinking.)

If the woman indicates that she does not drink alcohol:

  • Determine any prenatal exposure to alcohol during the early part of the pregnancy (e.g., ask: “Before you knew that you were pregnant, did you drink alcohol?”)

Screening questions about tobacco use6,7

“Do you smoke?”

If the woman answers “yes”:

  • Ask about the pattern (amount and duration) of tobacco use (e.g., ask: “How much do you smoke and how long have you smoked?”)
  • Assess the stage of change the woman may be at with respect to smoking cessation (e.g., ask: “How do you feel about quitting smoking?”)

If the woman answers “no”:

  • Screen for second-hand smoke exposure (e.g., ask: “Does anyone smoke around you or your children?”)

Screening questions about illegal drug use

“Have you ever used cannabis, cocaine or any other recreational drugs?”

If the woman answers “yes”:

  • Enquire about the kind of drug (e.g., ask: “What drug(s) do you use currently?”)
  • Ask about the pattern (amount and frequency) of illegal drug use (e.g., ask: “How much are you using and how often?”)
  • Assess the stage of change the woman may be at with respect to illegal drug use (e.g., ask: “How do you feel about stopping your use of illegal drugs?”)

If the woman answers “no”:

  • Determine any history of illegal drug use before the pregnancy (e.g., ask: “Have you used illegal drugs in the past?”)
  • Ask about any drug use during an earlier part of this pregnancy (e.g., ask: “Have you ever used illegal drugs during this pregnancy?”)
  • Screen for exposure to drugs in the woman’s/child’s environment (e.g., ask: “Does anyone use illegal drugs around you or your child?”)

Figure 2: Stages of change

Adapted from Prochaska, J.O. & DiClemente, C.C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 19 (3), 276–288.

Screening questionnaires

The Antenatal Psychosocial Health Assessment (ALPHA) form, the T-ACE and the TWEAK have been developed and validated for use with pregnant women.8-12 These instruments (discussed below) are easily incorporated into a provider-client interview. Both the T-ACE and TWEAK have been shown to be highly sensitive in the detection of periconceptional risk drinking. A positive screen indicates the need for further assessment of alcohol use by the pregnant woman. (Risk drinking during pregnancy is defined as the level of maternal alcohol consumption associated with adverse outcomes [i.e., one ounce or more of absolute alcohol per day, the equivalent of two or more drinks per day, or 14 or more drinks per week].)

Antenatal Psychosocial Health Assessment form

To ensure that psychosocial assessment becomes a routine part of prenatal care, the University of Toronto’s Faculty of Medicine developed the ALPHA form after a comprehensive literature review.12 This guide addresses four categories of factors:

  • family factors (e.g., social support, stressful life events, relationship with partner)
  • maternal factors (e.g., prenatal care, prenatal education, feelings toward pregnancy, relationship with parents during childhood, self-esteem, history of mental health problems, depression in current pregnancy)
  • substance use (e.g., alcohol and other drug abuse, partner’s substance use)
  • family violence (e.g., experiencing or witnessing physical, emotional or sexual abuse; experience of and thoughts about child discipline).

Problems identified in these areas have been associated with poor postpartum outcomes such as child and woman abuse, couple dysfunction, postpartum depression and increased infant physical illness.

The substance use section of the form enquires about alcohol and other drug use during pregnancy through a series of general screening questions, followed by the CAGE questionnaire below.

Two versions of the alpha form are available: a provider-completed form and a patient self-report. (Links to English and French versions of the ALPHA forms can be accessed at


The CAGE screening questionnaire is incorporated into the ALPHA form as a screen for problematic alcohol use.13 However, this tool is adaptable to asking about other drug use as well.

C Cut down Have you ever felt you should cut down on your drinking?
A Annoyed Have people annoyed you by criticizing your drinking?
G Guilty Have you felt guilty about your drinking?
E Eye-opener Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

Scoring: Each yes response equals a score of 1. A total score of 1 may indicate the need for further discussion. A total score of 2 or greater is clinically significant, suggesting a current or past alcohol problem and, therefore, warranting a more in-depth assessment.


The T-ACE questionnaire has been extensively validated in different obstetrical populations.8,9 It has been shown to be effective as a self-administered screening tool and a one-minute screen used by practitioners as part of routine care. T-ACE has a sensitivity* of 70 per cent and  a specificity of 85 per cent.

T Tolerance How many drinks does it take for you to feel high?
A Annoyed Have people annoyed you by criticizing your drinking?
C Cut down Have you ever felt you should cut down on your drinking?
E Eye-opener Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

Scoring: Any woman who answers the tolerance question by indicating that she needs more than two drinks is scored 2 points. Each yes response to the additional three questions receives a score of 1. A score of 2 or more indicates risk of a drinking problem, and the woman should be considered for further assessment.

*Correct identification of people who meet the criteria for a particular diagnosis or problem.

†Correct identification of people who do not meet the criteria for a particular diagnosis or problem.


The TWEAK questionnaire has also been shown to be effective at detecting risk drinking among pregnant women.10,11 This questionnaire has no advantages over T-ACE but is an alternative method for screening for alcohol use. TWEAK has a sensitivity of 79 per cent and a specificity of 83 per cent.

T Tolerance How many drinks does it take for you to feel high?
W Worries Do family members or friends ever worry or complain about your drinking?
E Eye-opener Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?
A Annoyed Have people annoyed you by criticizing your drinking?
K K/Cut down Have you ever felt that you should cut down on your drinking?

Scoring: A woman receives 2 points on the tolerance question if she reports that she needs three or more drinks to feel the effect of alcohol. A positive response to the worry question scores 2 points. A positive response to each of the last three questions scores 1 point each. A total score of 2 or more indicates that the woman is a risk drinker and requires further assessment.


  1. Morse, B., Gehshan, S. & Hutchins, E. (1997). Screening for Substance Abuse during Pregnancy: Improving Care, Improving Health. Arlington, VA: National Center for Education in Maternal and Child Health.
  2. Gavin, K. (2003). The Help Guide for Professionals Working with Women Who Use Substances. Edmonton: Alberta Alcohol and Drug Abuse Commission.
  3. Best Start. (2002). Supporting Change: Preventing and Addressing Alcohol Use in Pregnancy. Toronto: Ontario Prevention Clearing House.
  4. Dzakpasu, S., Mery, L.S. & Trouton, K. (1998). Canadian Perinatal Surveillance System: Alcohol and Pregnancy. Ottawa: Health Canada.
  5. Kahan, M., Midmer, D., Wilson, L. & Borsoi, D. (2007). Medical students’ knowledge about alcohol and drug problems: Results of the Medical Council of Canada Examination. Substance Abuse: Journal of the Association for Medical Education and Research in Substance Abuse, 27 (4), 1–7.
  6. Greaves, L., Cormier, R., Devries, K., Bottorff, J., Johnson, J., Kirkland, S. et al. (2003). Expecting to Quit: A Best Practices Review of Smoking Cessation Interventions for Pregnant and Postpartum Girls and Women. Vancouver: British Columbia Centre of Excellence for Women’s Health. Available:  pubs/tobac-tabac/expecting-grossesse/index_e.html. Accessed July 13, 2007.
  7. Pregnets. (2005). Smoking Cessation during Pregnancy. Available: Accessed July 13, 2007.
  8. Sokol, R.J., Martier, S.S. & Ager, J.W. (1989). The T-ACE questions: Practical prenatal detection of risk drinking. American Journal of Obstetrics and Gynecology, 160 (4), 863–870.
  9. Russell, M., Martier, S.S., Sokol, R.J., Mudar, P., Jacobson, S. & Jacobson, J. (1996). Detecting risk drinking during pregnancy: A comparison of four screening questionnaires. American Journal of Public Health, 86 (10), 1435–1439.
  10. Russell, M. (1994). New assessment tools for risk drinking during pregnancy: T-ACE, TWEAK, and others. Alcohol Health and Research World, 18 (1), 55–61.
  11. Chang, G., Wilkins-Haug, L., Berman, S. & Goetz, M.A. (1999). The TWEAK: Application in a prenatal setting. Journal of Studies on Alcohol, 60 (3), 306–309.
  12. Midmer, D., Biringer, A., Carroll, J.C., Reid, A.J., Wilson, L., Stewart, D. et al. (1996). A Reference Guide for Providers: The ALPHA Form—Antenatal Psychosocial Health Assessment Form. (2nd ed.). Toronto: University of Toronto.
  13. Mayfield, D., McLeod, G. & Hall, P. (1974). The CAGE questionnaire: Validation of a new alcoholism screening instrument. American Journal of Psychiatry, 131 (10), 1121–1123.

Exposure to Psychotropic Medications and Other Substances during Pregnancy and Lactation: A Handbook for Health Care Providers

General issues and background

Psychotropic medications and other substances: Properties, effects and recommendations


Index of drugs

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