Using While Pregnant

A Life-Changing Knock


By Meheret Mekonnen, MS

The fear of having a newborn taken away—this is a reality for many women who test positive for substances on a urine drug screen during pregnancy. The stigma and complications of substance use disorders are associated with insufficient prenatal care, inadequate nutrition, chronic medical conditions, and domestic violence.¹

Prenatal substance use and neonatal substance exposure have become pressing public health concerns. It is estimated that more than 4.4% of pregnant women in the United States use 1 or more substances during pregnancy.² Opioid use among pregnant women and cases of neonatal abstinence syndrome have risen alarmingly, with a 131% increase in opioid-related diagnoses during delivery hospitalizations from 2010 to 2017.² Each year, approximately 800,000 of the 4.3 million neonates born in the United States are exposed to illicit substances in utero.³ These statistics, along with countless patient testimonials, highlight the critical need for health care professionals to implement screening, brief intervention, and referral to treatment as part of routine care.

One of the many challenges clinicians and institutions face is how to effectively screen pregnant patients. Many facilities still rely on unstandardized substance use screening, often in the form of urine toxicology testing. However, urine drug screens have demonstrated poor positive predictive value and reveal significant disparities in outcomes.⁴ Historically, unstandardized screening and disclosure practices have been shaped by provider bias, particularly against single women with poor psychological, financial, or social functioning; women with delivery complications; Black women; and those receiving care in public health settings.⁵

Leading organizations—including the World Health Organization (WHO), the US Preventive Services Task Force (USPSTF), the Substance Abuse and Mental Health Services Administration (SAMHSA), and the American College of Obstetricians and Gynecologists (ACOG)—strongly recommend standardizing substance use screening as part of comprehensive obstetric care.⁶ Validated screening tools such as the 5Ps (Parents, Peers, Partner, Pregnancy, Past) offer a structured approach to assessing alcohol and substance use during pregnancy.⁷

Critics of universal verbal screening cite concerns about patient honesty, staff burden, and time constraints. Yet, successful models demonstrate that integration into existing clinic workflows, engagement of multidisciplinary stakeholders, and support from institutional leadership can facilitate adoption and acceptance.⁸

More work is needed to address disparities in substance use screening and the broader public health challenge of prenatal substance exposure. However, universal verbal screening is a meaningful step toward building patient trust, mitigating provider bias, and promoting equity in prenatal care.⁹

References

1. Wendell AD. Overview and epidemiology of substance abuse in pregnancy. Clin Obstet Gynecol. 2013;56(1):91–96. Available from: https://journals.lww.com/clinicalobgyn/FullText/2013/03000/Overview_and_Epidemiology_of_Substance_Abuse_in.15.aspx

2. Hirai AH, Ko JY, Owens PL, Stocks C, Patrick SW. Neonatal abstinence syndrome and maternal opioid-related diagnoses in the US, 2010–2017. JAMA. 2021;325(2):146–147.

3. Joseph R, Brady E, Hudson ME, Moran MM. Perinatal substance exposure and long-term outcomes in children: a literature review. 2020.

4. Chin JM, Chen E, Wright T, Bravo RM, Nakashima E, Kiyokawa M, et al. Urine drug screening on labor and delivery. Am J Obstet Gynecol MFM. 2022;4(6):100733. doi:10.1016/j.ajogmf.2022.100733

5. Madora M, Wetzler S, Jose A, Bernstein PS. Pregnant and postpartum people with substance use disorders: understanding the obstetrical care provider’s roles and responsibilities. Matern Child Health J. 2022;26(7):1409–1414.

6. Whittaker A. Guidelines for the identification and management of substance use and substance use disorders in pregnancy. By World Health Organization. Geneva, Switzerland: WHO Press; 2014. Drug Alcohol Rev. 2015;34(3):340–341.

7. Hostage JC, Brock J, Craig W, Sepulveda D. Integrating screening, brief intervention and referral to treatment for substance abuse into prenatal care [3L]. Obstet Gynecol. 2018;131:129S–130S.

8. Chasnoff IJ, Wells AM, McGourty RF, Bailey LK. Validation of the 4P’s Plus© screen for substance use in pregnancy. J Perinatol. 2007;27(12):744–748.

9. Ulrich M, Memmo EP, Cruz A, Heinz A, Iverson RE. Implementation of a universal screening process for substance use in pregnancy. Obstet Gynecol. 2021;137(4):695–701.

Behind the Curtain: What Really Happens After You Submit a Paper to a Journal

By Sarina Schrager, MD, MS, 
Family Medicine editor-in-chief

Many people express confusion about the process of submitting a paper to a journal, receiving peer reviews, and ultimately getting published. This post attempts to answer your questions. Editors do not want their activity to be opaque. We want everyone to know what really happens when you submit a paper. The team at Family Medicine may do things a little differently than other journals, but the major steps will be the same.

You hit “submit”, then what? Once you submit your paper into the electronic portal (we use ScholarOne) the paper will be evaluated by our editorial assistant. S/he will determine if your paper conforms to our author instructions (please read before submitting) for formatting and whether you have IRB approval, if needed. The assistant will unsubmit your paper if it is too long, has too many references, or if the references are not in the proper format.

First review by the editor in chief: At Family Medicine, I read each submitted paper carefully before assigning it to an associate editor. I will occasionally reject a paper at this stage if it is not in scope for our journal (ie, we do not publish clinical papers) or if I think it is in the wrong category. For example, papers describing educational studies in one residency or one medical school fit in our Brief Report category, but probably not in Original Research. I will send those papers back to the authors if they are submitted in the Original Research category and ask the author(s) to shorten them. Another common mistake I often see is papers submitted as a narrative essay when they are really a commentary or an editorial. Narratives are personal stories about an experience you have with patient care, teaching, or your career.

Assigning papers to the associate editors: We have a team of fabulous associate editors at
Family Medicine. Papers that are both in scope and of interest our readers go on to the next step. I assign these papers to one of our associate editors who carefully reads the paper again, and either advises me they don’t think the paper is appropriate for our journal, or, more commonly, sends the paper for peer review.

Requesting peer reviewers: We have hundreds of peer reviewers who volunteer their time and expertise to help us publish the best papers we can. The associate editors aim to get 2-3 reviewers to evaluate each paper before sending it back to me with a recommendation. The associate editor sends requests to 4-6 people. Sometimes these invited reviewers don’t respond, and sometimes they respond but decline the invitation. It will occasionally require upwards of 10 invitations to find the 2-3 reviewers needed for a thorough review of each paper. We give all peer reviewers 3 weeks to return the review. Sometimes a
paper will be caught in this step for a few months. Family Medicine designates 4 potential
outcomes for a paper after peer review: accept (it’s very unusual to accept after initial peer review),
minor revision, major revision, and reject.

Revisions: The vast majority of authors will be asked to revise their paper. This is a good thing.
It means that the editorial team believes that the paper will be an important addition to the literature when revised. We expect authors to respond to every reviewer comment and explain how they addressed each comment. After the revised manuscript is submitted, I will review it again and then send back to the associate editor. In some cases, if there were many revisions, the associate editor will send the revision back to the reviewers to assure that all comments were addressed. After those reviews come back, the associate editor indicates an outcome. It is not unusual for a paper to be revised a second (and occasionally a third) time. It is important for authors to remember at this point that these further reviews are designed to improve your paper.

Recommendations for publication: Even great papers can be improved, and this is always the goal of peer review. Our peer reviewers and our associate editors provide feedback to authors to help make
their papers better. A minor revision decision signifies that a paper needs only small changes before it is appropriate to publish. A major revision decision signifies that the peer reviewers and the associate editor like the paper and think it has potential to be a meaningful addition to the scholarly literature, but has some weaknesses. We do not ask people to revise a paper if we do not think it will be interesting to our readers and contribute to the literature. Those papers are denied further review.

Acceptance: Once the associate editor believes that the authors have addressed all revision
requests, they send it to me with a recommendation for publication: Yay! Our production
team has worked hard to decrease the time from acceptance to online publication. You may expect your paper to be published online about 6 weeks after you get your acceptance notice. It will be available on the journal’s ‘Recently Published’ page before being assigned to a monthly issue. As you can see, there are a lot of steps in the process! However, they all aim to support authors through optimizing their paper’s impact.

A Life in Family Medicine: Steven Lin, MD: A Journey to the STFM Presidency

The Power of Community in Family Medicine

For incoming STFM President Steven Lin, MD, STFM is more than an organization—it’s a home. “Going to an STFM conference with colleagues and friends from all over the world is like going back home for Thanksgiving!” he says. “That cozy feeling of purpose and belonging is what makes STFM and its community of members so indispensable, especially during times of challenge.” Coming from an institution that lacked a strong primary care culture, he found a sense of belonging in STFM’s network of educators and clinicians. This deep connection is why he is so committed to strengthening and expanding STFM’s role in supporting family medicine educators. “Our vision is to be the indispensable academic home for every family medicine educator” he added.

A Passion for Social Justice and Medicine

Before pursuing medicine, Dr Lin was enamored with music and musical theater. “My childhood dream was to become a symphony conductor or a Broadway musical director. By the time I graduated high school, I had learned how to play multiple instruments and earned a piano performance degree from the London College of Music.” As it turned out, fate had other plans. “It was during college that I became interested in health disparities and social determinants of health,” he says. “I dedicated much of my free time to volunteering at halfway homes in underserved communities to better understand the needs and struggles of vulnerable populations. In medical school, I committed my energies to the study and advocacy of immigrant health and addressing structural determinants,” he continued. “So naturally, I was led to pursue primary care and family medicine.”

Leadership and Lessons for the Future

“When I was younger, I never aspired to be a leader… My greatest fear was not knowing what to say or do.” However, leadership eventually found Dr Lin. “If I could travel back in time to my past self, I would impart this sage advice from Maya Angelou, renowned poet and civil rights activist: ‘People will forget what you said, people will forget what you did, but people will never forget how you made them feel.’” This perspective continues to shape his leadership philosophy, reminding him that empathy and impact matter more than perfection. “I have the same itch that drives many of my colleagues in family medicine: that deeply human urge to do something meaningful, something lasting, something that touches the lives of others, in the relatively short time we have on the planet. That, and a lot of coffee,” he said.

Finding Balance Beyond Work

When not advocating for family medicine education, Dr Lin enjoys binge-watching K-dramas and baking competitions on Netflix. He is also an avid fan of Disney, Marvel, Star Wars, Final Fantasy, and Harry Potter. “Oh, in case you’re wondering, I’m supposed to be a Gryffindor,” he quipped. And music still holds a special place in his life—especially when playing piano with his 7-year-old daughter. He stressed, “She is way more musically talented than I ever was!”  In fact, Dr Lin takes great pride in his titles of dad and husband. “I can’t think of anything else in life that is more crushingly difficult yet so endlessly fulfilling.”

A Message for Future Family Medicine Leaders

For medical students and residents embarking on their careers, Dr Lin offers a piece of advice: “Whatever it was that drew you to family medicine—whether it was a story, a cause, a loved one, a patient, a mentor—find a way to capture that memory. Write a letter to your future self, create a time capsule, or share your journey with those who can help remind you why you chose this noble path.”

The Challenges and Opportunities Ahead

As he prepares to step into his role as STFM President, Dr Lin is aware of the hurdles facing family medicine today. “There has never been a more challenging time to be a family medicine clinician, scholar, or educator. Global socio-political-economic unrest, the greed-driven corporatization of healthcare, the disruptive pace of artificial intelligence advancement, and a deepening crisis of human and planetary health all add to a practice and teaching environment that is increasingly complex. Now, more than ever, we need Family Medicine to be the countervailing force for a healthier world,” he emphasized.

When asked for his advice for young medical students and residents, he encourages future family medicine practitioners and educators to remember what drew them to the field in the first place. “Write a letter to your future self. Put photos in a time capsule. Share your personal journey with family and friends so they can help you remember why you walk this noble path,” he recommends. “The crippling forces of the modern medical-industrial complex can weigh you down sometimes. Whatever it was that drew you to family medicine—a story, a cause, a loved one, a patient, a mentor—find a way to capture that memory so that you can always go back to it when times get tough.”

Looking Forward

With a deep commitment to the future of family medicine, Dr Lin is ready to lead STFM into a new chapter. His vision is clear: to foster community, advocate for primary care, and support practitioners and educators in their vital work. “STFM members are on the frontlines, being the change that we so desperately need,” he says. “I’m proud to stand alongside each and every one of our members in this fight, and I look forward to finding new ways to support and empower our amazing community of family medicine heroes.”

Prior to being sworn in as president of the STFM Board of Directors, Dr Lin served as member-at-large on the STFM Board of Directors, the chair of the Artificial Intelligence in Medical Education Task Force, and the chair of the Telemedicine Curriculum Task Force.