According to the 2016 National Survey on Drug Use and Health, one in 10 people (28 million) over age 12 used an illicit drug in the past 30 days. For young adults aged 18 to 25, use ranges as high one in four for illicit drug use, one in 10 for heavy alcohol use, and two in five for binge alcohol use. Use is primarily driven by marijuana and misuse of opioid pain relievers. Of pregnant women, 6.3% used illicit drugs, 8.3% reported alcohol use, and 4.3% reported binge drinking in the last month.1
Breastfeeding is a major public health strategy because of the well-known benefits, including child spacing, and reduced rates of sudden infant death syndrome (SIDS), childhood infections, and postpartum depression. These benefits may be particularly important for families struggling with substance use. Both the American Academy of Pediatrics (AAP) and the World Health Organization (WHO) recommend exclusive feeding with breastmilk during the first 6 months of life.2,3 The Healthy People 2020 targets are 81.9% for ever breastfeeding and 60.5% for any breastfeeding in 6 months.4 In 2010, The Patient Protection and Affordable Care Act and Fair Labor Standards Act mandated that working mothers be given reasonable break time and a private place to pump that is not a bathroom for up to 1 year after childbirth.5 A woman with substance use (SU) or substance use disorder (SUD) has the same rights and desires as any other mother to receive unbiased counseling and make an informed decision about breastfeeding and is not immune to the medical and societal pressure that “breast is best,” as noted in official statements from organizations regarding breastfeeding and substance use (Table 1).
Screening for drug use
The American Academy of Pediatrics, American College of Obstetricians and Gynecologists (ACOG), and the American Society for Addiction Medicine (ASAM) recommend that all pregnant women be screened for drug use by using a validated screening questionnaire and intervention techniques to counsel abstinence and refer for treatment those who meet criteria for a SUD.6 Further, ACOG states that routine laboratory testing of biologic samples is not required.8 The validated screening questionnaires are linked with education and intervention strategies, and are superior to urine drug screening (UDS) to detect use.9 If a UDS is used, it requires informed consent and should be ordered as a preliminary test with a reflex confirmatory test. Using UDSs to triage breastfeeding has limitations and potential to stigmatize and drive women away from medical care. Substances stay in maternal urine and breastmilk for different lengths of time, assays vary, medications can cross-react, use of reflex confirmatory tests may be inconsistent, false-positives and -negatives can occur, and there may be an arbitrary potentially biased focus on certain drugs and which mothers to test. A negative UDS test does not preclude use, nor does a positive test guarantee that the breastmilk contains harmful levels of a drug.
Hospital protocols vary widely in how hospitalized newborns are triaged to receive their mother’s breastmilk. Some rely on biological testing of urine or milk at delivery. Others do not use biological testing, do not initially withhold breastmilk, and provide education and supportive intervention first before deciding about ongoing breastfeeding recommendations. The latter better supports the ethical framework put forth by ACOG to discourage breastfeeding exclusion and separation of parents from their children solely based on suspected or confirmed SUD.8
The authors report no potential conflicts of interest with regard to this article.
- 2016 National survey on Drug Use and Health: National findings. Available at: https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.pdf and https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf Accessed June 2019.
- American Academy of Pediatrics Policy Statement: Breastfeeding and the use of human milk. Pediatrics 2012; 129 (3): e827-e841.
- Word Health Organization. Breastfeeding. Available at https://www.who.int/topics/breastfeeding/en/ Accessed June 2019.
- The Surgeon General’s Call to Action to Support Breastfeeding. Table 3. Healthy People 2020 Objectives for Breastfeeding. Available at: https://www.ncbi.nlm.nih.gov/books/NBK52684/table/breastfeeding.t1/ Accessed June 2019.
- Patient Protection and Affordable Care Act 2010, Public Law 111-148. Title IV, §4207, USC HR 3590, 2010
- Ryan S, Ammerman S, O’Connor M. AAP Committee on substance use and prevention, AAP Section on Breastfeeding. Marijuana use during pregnancy and breastfeeding: Implications for neonatal and childhood outcomes. Pediatrics. 2018;142(3): e20181889.
- Centers for Disease Control and Prevention. Contraindications to breastfeeding or feeding expressed breast milk to infants. Available at: https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/contraindications-to-breastfeeding.html Accessed August 16, 2019.
- ACOG Committee Opinion No. 633. Alcohol and other substances use disorders: Ethical Issues in obstetric and gynecologic practice. June 2015, reaffirmed 2018.
- Klawans M, Northrup T, Villarreal Y, et al. A comparison of common practices for identifying substance use during pregnancy in obstetric clinics. Birth. 2019;00:1-7.
- American Society of Addiction Medicine Consensus Statement. Appropriate use of drug testing in clinical addiction medicine, 2017. Available at: http://bit.ly/DrugTestingDownload Accessed August 16, 2019.
- Amnesty International. Criminalizing pregnancy: policing pregnant women using drugs in the USA 2017. Available at: http://advocatesforpregnantwomen.org/blog/Pregnancy%20Criminalization%20Report%2019%20May%20Final.pdf Accessed August 16, 2019.
- Goel N, Beasley D, Rajkumar V, et al. Perinatal outcome of illicit substance use in pregnancy-Comparative and contemporary socio-clinical profile in the UK. Eur J Pediatr 2011;170:199-205.
- Yonke N, Maston R, Weitzen S, et al. Breastfeeding intention compared with breastfeeding postpartum among women receiving medication-assisted treatment. J Hum Lact. 2019;35 (1):71-79.
- England L, Brenner R, Bhaskar B, et al. Breastfeeding practices in a cohort of inner city women: the role of contraindications. BMC Public Health. 2003:3:28.
- Rutherford HJ, Williams SK, Moy S, et al. Disruption of maternal parenting circuitry by addictive process: rewiring of reward and stress systems. Front Psychiatry. 2011;2:37.
- Wright T. Opioid use disorders during pregnancy. 1st ed. Jansson LM, Patrick S. Breastfeeding and the substance exposed dyad. Cambridge UK: Cambridge University Press; 2018. 133 p.
- Reece-Stremtan S, Marinelli K, and The Academy of Breastfeeding Medicine. ABM Protocol #21. Guidelines for breastfeeding and substance use or substance use disorder, Revised 2015. Breastfeed Med. 2015;10(3):135-141/.
- Drugs & lactation database (Lactmed) NLM Available at https://toxnet.nlm.nih.gov/ Accessed August 16, 2019.
- Wojnar-Horton RE, Kristensen JH, Yapp P et al. Methadone distribution and excretion into breast milk of clients in a methadone maintenance program. Br J Clin Pharmacol. 2001;52:681-685.
- Jasson LM, Choo R, Velez ML et al. Methadone maintenance and long-term lactation. Breastfeed Med. 2008;3:34-37.
- Jasson LM, Choo R, Velez ML et al. Methadone maintenance and breastfeeding in the neonatal period. Pediatrics. 2008;121:106-114.
- Ilett KF, Hackett LP, Gower S, et al. Estimated dose exposure of the neonate to buprenorphine and its metabolite norbuprenorphine via breastmilk during maternal buprenorphine substitution treatment. Breastfeed Med. 2012;7:269-274.
- O’Connor AB, Collett A, Alto WA et al. Breastfeeding rates and the relationship between breastfeeding and neonatal abstinence syndrome in women maintained on buprenorphine during pregnancy. J Midwifery Womens Health. 2013;58:383-388.
- Dean L. Codeine Therapy and CYP2D6 Genotype. 2012 Sep 20 [Updated 2017 Mar 16]. In: Pratt V, McLeod H, Rubinstein W, et al., editors. Medical Genetics Summaries [Internet]. Bethesda (MD): National Center for Biotechnology Information (US); 2012. Available at: https://www.ncbi.nlm.nih.gov/books/NBK100662/ Accessed August 16, 2019.
- Friguls B, Joya X, Garcia-Algar O et al. A comprehensive review of assay methods to determine drugs in breastmilk and the safety of breastfeeding when taking drugs. Anal Bioanal Chem. 2010;379:1157-1179.
- Anderson P. Drugs of abuse during breastfeeding. Breastfeed Med. 2018;13(6):405-407.