Physicians, nurses and nurse practitioners, pharmacists, allied health care professionals, and all other clinical and non-clinical personnel who are involved in the care of pregnant and post-partum individuals who use alcohol.# Disclaimer for Health Care Providers
The recommendations in this guideline supplement represent the view of the provincial guideline supplement committee, arrived at after careful consideration of the available scientific evidence and following external expert peer review. The application of the recommendations in this document does not override the responsibility of health care professionals to make decisions that are appropriate to the needs, preferences, and values of an individual patient, in consultation with that patient and their family members or guardian(s), and, when appropriate, external experts (e.g., specialty consultation). When exercising clinical judgment in the treatment of perinatal alcohol use and alcohol use disorder, BC health care professionals are expected to take this guideline supplement fully into account while upholding their duty to adhere to the fundamental principles and values of the Canadian Medical Association Code of Ethics, especially compassion, beneficence, non-maleficence, respect for persons, justice and accountability, as well as the required standards for good clinical practice as set by the College of Physicians and Surgeons of British Columbia and any other relevant provincial regulatory body. Nothing in this guideline supplement should be interpreted in a way that would be inconsistent with compliance with those duties.

# Legal Disclaimer
While the individuals and groups involved in the production of this document have made every effort to ensure the accuracy of the information contained in this guideline supplement, please note that the information is provided "as is". The Ministry of Health (MoH), Ministry of Mental Health and Addictions (MMHA), and the BCCSU make no representation or warranty of any kind, either expressed or implied, as to the accuracy of the information or the fitness of the information for any particular use. To the fullest extent possible under applicable law, the MoH, MMHA, and BCCSU disclaim and will not be bound by any express, implied or statutory representation or warranty (including, without limitation, representations or warranties of title or non-infringement).
This guideline supplement is intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. This guideline supplement is not intended as a substitute for the advice or professional judgment of a health care professional, nor is it intended to be the only approach to the management of a clinical problem. We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.   7.1 Rooming-in and skin-to-skin contact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 7.2 Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 7.2.1 Alcohol and lactation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 7.2.2 Alcohol withdrawal pharmacotherapy and lactation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 7.2.3 AUD pharmacotherapy and lactation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 8. Child Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Appendix 1: Alcohol Use Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   2 Summary of principles of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Table 3 Comparative specifications of alcohol screening tools validated for pregnancy . . Table 4 The 5A's model for delivering alcohol use brief intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Table 5 Comparative features of pharmacotherapy options for management of alcohol withdrawal during pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Table 6 Comparison of pharmacotherapies for AUD during pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . .

# Table of Contents
Executive

# List of Tables

# Executive Summary
This document is intended to supplement the BCCSU Provincial Guideline for the Clinical Management of High-Risk Drinking and Alcohol Use Disorder (Guideline) with clinical guidance specific to pregnant and post-partum patients. While the Guideline has provided a comprehensive description of the harms of highrisk drinking and alcohol use disorder (AUD) in general adult and youth populations, it is recognized that pregnant individuals who use alcohol face an additional set of obstetrical risks. Some of the negative pregnancy outcomes associated with alcohol use during pregnancy include spontaneous abortion, intrauterine growth restriction, preterm birth, and fetal alcohol spectrum disorder.
Increased frequency of healthcare service use during pregnancy and post-partum periods present a unique opportunity for clinicians to identify and address alcohol use; however, stigma regarding substance use during pregnancy and lack of knowledge regarding appropriate screening and treatment options present barriers to early detection and treatment of alcohol use and AUD in this population.
To address this discrepancy, this guideline supplement reviews the evidence pertaining to care principles, screening and risk assessment methods, and treatment and continuing care options for pregnant individuals with high risk alcohol use and AUD. This document emphasises the need for a non-judgmental, inclusive, trauma-informed, and culturally safe approach to care that accommodates patients' individual choices and circumstances. Within this framework, the present document recommends a holistic and integrated care plan with appropriate use of the full range of available treatment options and harm reduction services. A summary of the clinical recommendations outlined in this supplement is provided in Table 1.

# Table 1 Summary of Clinical Recommendations

# Screening and Brief Intervention 1
Annual alcohol use screening for all patients of childbearing capacity should include education on Canada's Low-Risk Alcohol Drinking Guidelines and the risks of alcohol use during pregnancy.
Healthcare providers should screen pregnant and post-partum patients for alcohol use at the earliest opportunity. Screening should be repeated routinely throughout pregnancy and post-partum.
All pregnant and post-partum patients who screen positive for alcohol use should receive brief counselling intervention and advice for discontinuing alcohol use.
All pregnant and post-partum patients with AUD should be offered, or referred to, appropriate treatment interventions and support services.

# Withdrawal Management
Where possible, alcohol withdrawal management for pregnant patients should be conducted in inpatient settings where patients can receive symptom-triggered treatment with close monitoring of withdrawal symptoms. a 6 Clinicians should consider the use of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), in combination with best clinical judgement, to select the appropriate withdrawal management pharmacotherapy based on the risk of severe complications of withdrawal.
Pregnant patients who develop alcohol withdrawal symptoms should be offered pharmacotherapy for alcohol withdrawal management.
A. Either benzodiazepines or gabapentin may be offered to pregnant patients at low risk of severe complications of withdrawal (PAWSS<4).
B. Benzodiazepines are recommended for patients at high risk of severe complications of withdrawal (PAWSS>4).
All pregnant and post-partum patients who undergo withdrawal management should be connected to continuing AUD care.

# Continuing Care 9
All pregnant and post-partum patients with AUD should be offered, or referred to, psychosocial treatment interventions.
Healthcare providers should consider offering pharmacotherapy with naltrexone, acamprosate, or gabapentin to prevent relapse to alcohol use in pregnant patients with moderate to severe AUD. b

# Post-partum considerations 11
Healthcare providers should facilitate rooming in and encourage skin-to-skin contact to promote parent-neonate bonding and, in turn, improve maternal and neonatal outcomes.
Nursing parents should be strongly encouraged to discontinue alcohol use while lactating. Patients who continue using alcohol during this period should receive advice and support to reduce drinking and schedule feeding and alcohol use to ensure alcohol is eliminated from breastmilk by the time of feeding or storage of milk.
For patients who are stable on AUD pharmacotherapy (i.e., naltrexone, acamprosate, or gabapentin), decisions regarding breastfeeding c should be made on a case-by-case basis with the knowledge and involvement of the patient. The possible neonatal risks of these medications should be weighed against the well-established benefits of breastfeeding for mother and neonate.
1 Introduction

# Background
Alcohol is a known teratogen, and its use during pregnancy is associated with a wide range of negative pregnancy outcomes collectively referred to as fetal alcohol spectrum disorder (FASD), as well as spontaneous abortion and stillbirth. 1,2 According to recent Canadian estimates, FASD affects approximately 4% of the Canadian population and includes fetal growth restriction, developmental delay, neurological abnormalities, and behavioral and cognitive issues throughout life. 1,2 While a number of meta-analyses have demonstrated that the likelihood and severity of physiologic, cognitive, and behavioural sequalae of in utero alcohol exposure are dose-dependent, no consensus has emerged concerning the specific cut-off blood alcohol level below which alcohol use would be considered "low-risk" for the pregnant person and fetus. 1,3 Therefore, most jurisdictions, including Canada, strongly recommend abstinence from alcohol use during pregnancy. 4,5 Despite this unequivocal recommendation, alcohol use during pregnancy is not uncommon. According to a 2019 report by the US Centers for Disease Control and Prevention, the overall estimates of alcohol consumption and binge drinking rates among pregnant women during 2015-2017 were 11.5% and 4% respectively, marking a slight increase since the 2011-2013 period (10.2% and 3.1%, respectively). 6 Data from the 2009 Canadian Maternity Experiences Survey indicated that 62.4% of survey respondents reported drinking alcohol during the three months prior to pregnancy, and 10.5% reported that they consumed alcohol during pregnancy. 5,7 These data are likely an underestimation of the true prevalence of alcohol use in pregnancy, as the experience of stigma and fear of judgement and child apprehension can lead to significant under-reporting of alcohol use in this population. 5,8 Nevertheless, available data suggest that the prevalence of alcohol use during pregnancy is comparable to, or higher than, that of many conditions routinely screened for and addressed during prenatal care, such as cystic fibrosis, gestational diabetes, post-partum depression, and preeclampsia.  Increased frequency of healthcare service use in the prenatal period and elevated motivation for delivering a healthy baby present a unique opportunity for clinicians, particularly primary care providers, to screen pregnant patients for alcohol use and provide appropriate advice, care, and referrals to address high risk alcohol use and alcohol use disorder (AUD). 12,13 Yet, alcohol use among pregnant patients frequently goes unrecognized. The lack of clear clinical guidelines for screening, assessment, and management of alcohol use and AUD during pregnancy is a commonly cited barrier to seizing this opportunity for early detection and intervention. 3,5,9 In response to this discrepancy, a committee of experts was assembled to supplement the BCCSU, MOH, and MMHA Provincial Guideline for the Clinical Management of High Risk Drinking and Alcohol Use Disorder ("Guideline") with clinical recommendations based on a review of evidence for screening and brief intervention, withdrawal management, and continuing AUD care specifically pertaining to pregnant individuals. The following text provides a summary of research evidence from which the committee has derived the clinical recommendations and principles of care presented in this guideline supplement.

# Objectives and scope of the guideline supplement
This guideline supplement primarily focuses on the identification, assessment, and clinical management of high-risk alcohol use and AUD in pregnant and post-partum individuals. To support transition from prenatal care to post-partum care for this population, the committee has also provided a review of available evidence on the implications of alcohol use, AUD, and AUD treatment on immediate post-partum care and breastfeeding.
This supplement is intended to serve as a companion document to the Guideline which provides a comprehensive review of the evidence on high risk-alcohol use and AUD treatment, clinical recommendations, and a general framework of care for the treatment of AUD; readers are encouraged to also refer to the Guideline for broadly applicable guidance in this area.
The objectives of this document are to address barriers to routine screening for the early identification of alcohol use and AUD among pregnant patients and to promote the uptake of evidence-based prevention, risk reduction, and treatment interventions appropriate for pregnant patients within primary care and other clinical settings.
Specifically, these guidelines aim to:
- Describe the principles of care and general considerations for screening, diagnosis, and management of high-risk drinking and AUD for pregnant and post-partum patients.
- Review specific strategies for alcohol use screening and brief intervention for pregnant patients.
- Recommend a clinical pathway for alcohol withdrawal management, whereby appropriate withdrawal risk and severity assessment facilitates tailored treatment selection and symptom-triggered approach that minimizes harm to the patient and fetus.
- Review and recommend pharmacotherapeutic and psychosocial alcohol withdrawal management options that are safe and suitable for the pregnant patient and the fetus.
- Review and recommend strategies for continuing AUD care with demonstrated maternal and fetal safety, including use of pharmacotherapy, psychosocial treatment interventions, and community-based treatment and support geared towards this population.
- Provide an overview of relevant care and safety considerations for patients with AUD and alcohol-exposed infants in the immediate post-partum period.
- Provide guidance on the potential impact of alcohol consumption and the safety considerations of alcohol withdrawal and AUD pharmacotherapy on lactation and breastfeeding.

# Guideline development process
Between January 2017 and November 2018, the guideline committee for the pregnancy supplement to the Provincial Guideline for the Clinical Management of High-Risk Drinking and Alcohol Use Disorder conferred through email, teleconferences, and three face-to-face meetings. At the first committee meeting, the purpose, scope, and outline of the guideline were provisionally approved by committee consensus in accordance with the AGREE-II reporting checklist for development of clinical practice guidelines.
From May 2019 to January 2020, guidance committee members conferred over email and teleconference, and held two in-person meetings to review and approve evidence summaries prepared by the medical writer and draft guideline contents and recommendations.

# Development and approval of recommendations
The recommendations for the pregnancy supplement were developed in reference to the broadly applicable recommendations of the Guideline, which were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool to develop and score recommendations. In view of limited volume and low quality of evidence focused on pregnant patients, recommendations specific to pregnant and postpartum populations were developed through committee consensus after rigorous review and discussion of prepared evidence summaries. In addition to the safety and efficacy data pertaining to both pregnant and non-pregnant populations, a range of factors, such as clinician, patient, and policy makers' values and preferences, costs, risk-benefit ratios, and feasibility were considered in the process of recommendation development.
The draft supplement and recommendations were compiled and circulated to the full committee to provide feedback on contents and recommendations. The committee was given four weeks to submit written feedback on the draft supplement. Feedback was collated and incorporated into a revised draft which was then circulated to the committee for additional feedback. Further feedback was collated and incorporated into a second revised draft for external review

# External review
The draft guideline supplement was circulated for review and comment to relevant experts and stakeholders as identified by the committee. Feedback from the external reviewers was reviewed and incorporated into the final draft of the supplement and external reviewers approved this draft. The final draft was then circulated to the committee for final approval.

# Principles of Care
As outlined in detail in the Guideline, healthcare providers are encouraged to observe a set of overarching principles of care that inform a collaborative, equitable, and effective therapeutic relationship with patients and, where appropriate, families affected by high-risk alcohol use and AUD. These principles enable clinicians and care teams to meet the healthcare needs of patients within a patient-centred framework and along an integrated continuum of addiction care. This section highlights a number of care principles and practices with particular practical relevance to the care of pregnant and post-partum individuals who use alcohol. Table 2 provides a summary of the key care principles described in this section.

# Respect for the autonomy, agency, and individuality of patients
As with all patients, pregnant individuals who use alcohol should be empowered to take an active role in decisions concerning their own health and well-being; this includes making informed decisions concerning the fetus. While patients should be provided with clinical recommendations to improve pregnancy outcomes, clinicians' concern for the health of the fetus should not override the patient's individual preferences and values. 4 Securing the patient's informed consent prior to implementing clinical decisions, and non-judgemental and informative dialogue are among the key aspects of respectful and effective care.

# Privacy and consent
Assuring patients of the confidentiality of the information they disclose helps establish a trusting and open therapeutic relationship. Care providers should inform patients of the relevant aspects of their duty to report and emphasize that there is no legal obligation to report substance use and risks to the fetus during the course of pregnancy to Child Protection Services (see the Child Protection section). This is an important detail to include in the initial discussion as, according to numerous studies, the fear of intervention by child welfare services and losing custody of a child is a major barrier to seeking treatment for pregnant people who use substances. 14,15 Respect for the privacy of patients extends to the involvement of family members or other support resources in their care. While a patient's family and social circle can have a key role in supporting the patient's care, healthcare providers should avoid assuming that involving a family member is always in the best interest of every patient.

# Information sharing and education
Continuous education and sharing of relevant information with patients are the cornerstones of collaborative and empowering care. Lack of knowledge about available treatment options and their implications for the health of the patient and the fetus may act as a barrier to accessing substance use care and engaging in treatment. 16 Thus, it is imperative that clinicians discuss the risks and benefits of available clinical care options for the patient and fetus, and provide referrals to educational and support resources that enhance patients' self-efficacy and independence in improving their health. 16 For example, clinicians should combine alcohol screening for pregnant patients and patients of childbearing capacity with a conversation regarding the risks of alcohol use during pregnancy and post-partum using the recommendations of Canada's Low Risk Alcohol Drinking Guidelines for this population. 5 

# Gender-inclusive and non-judgemental language
While the majority of pregnant people identify as women, some pregnant people, including those who are transgender, transsexual, nonbinary, genderqueer, gender neutral, agender, Two-Spirit, and gender nonconforming (also collectively referred to as "trans" individuals) do not identify as women. Historically, clinical interventions for alcohol use during pregnancy have been designed and evaluated with insufficient awareness or understanding of the diversity of pregnant patients in terms of gender and reproductive intentions. 17 A 2018 commentary on gender-inclusive alcohol interventions for pregnant people argues that the assumption that all pregnant people are women creates gaps in services for people who are both trans and pregnant. 17 For many pregnant patients, the prospect of parenthood is an important source of motivation for positive change. However, care approaches and discourses that do not take into account gender diversity among pregnant people may render alcohol use interventions inapplicable, inaccessible, ineffective, and potentially harmful for pregnant patients who do not identify as women or do not intend to assume the role of mother (e.g., surrogates, patients who choose adoption, expecting parents who do not identify as "mothers"). It should be noted that normative pressures are cited as risk factors for problematic substance use among trans individuals, as they may lead to feelings of guilt, isolation, and inadequacy that, in turn, increase the risk for excessive alcohol consumption and reluctance to access care. 17,18 Clinicians should respect the identities of patients by using appropriate terminology and pronouns according to each individual's identity and preference. 19 In cases where clinicians require clarity, it is appropriate to ask the patient regarding pronouns and terminology that corresponds with their identity. Where possible and appropriate, care providers should also accommodate the gender identities and reproductive intentions of their patients in care plans and offer to connect patients with support resources. These measures have a significant role in ensuring the engagement and retention of trans patients in care.

# Awareness of social determinants of health
Healthcare providers should view and address alcohol use and AUD during pregnancy within the broader context of social determinants of health. Social determinants of health are defined as "the economic and social conditions that shape the health of individuals, communities, and jurisdictions as a whole. " 20 The distribution of resources and opportunities that a society makes available to its members (e.g., food, income, housing, education, and healthcare) is affected by a range of factors including socioeconomic class; gender; sexual orientation; race and ethnicity; refugee, migrant or immigrant status; and disability status. 21,22 The intersection of multiple factors (e.g., gender, race, sexual orientation) informs each individual's social identity and, access to resources, and, in turn, health outcomes. 23 People who belong to marginalized groups experience the most significant barriers to accessing resources, and, thus, have the poorest health outcomes. 21 Cited determinants of high-risk drinking and AUD include negative childhood experiences; 24 lower socioeconomic status; 25 living in poorer neighbourhoods; 26 and being a member of a racial, ethnic, gender, or sexual orientation minority. 27 In addition, race, history of physical abuse, general health status, and, to a lesser extent, education have been identified as some of the social determinants of alcohol use during pregnancy. 28 Lack of awareness of the complexity of socioeconomic factors contributing to alcohol use among pregnant individuals may lead to further marginalization of this population, and may impede access to adequate care.
In addition to having a basic understanding of how the unequal distribution of opportunity and resources in the Canadian society impacts the health of individuals, clinicians and care teams should endeavour to identify and remove barriers to accessing care. Clinicians should also aim to address disparities that may exist in the social determinants of health by offering to connect patients to resources that help meet their social and survival needs (e.g., housing, food/nutrition, child care, financial assistance).

# Trauma-and violence-informed care
Alcohol use disorder has been associated with a high lifetime prevalence of trauma including physical and sexual abuse, and pregnancy is a period of particular vulnerability for individuals who have experienced trauma. 29,30 It is also noteworthy that pregnant individuals are at an increased risk of intimate partner violence, particularly in the case of unplanned pregnancies. 31,32 Clinicians involved in the care of pregnant patients with AUD should be familiar with the principles of trauma-informed practice (e.g., trauma awareness; safety and trustworthiness; choice, collaboration and connection; strengths-based approaches and skill building). The provincial Trauma-informed Practice (TIP) Guide may be a useful resource when working with this patient population. 33 Healthcare providers serving this population should also be equipped to identify and respond to gender-based violence; to this end, the Provincial Health Services Authority (PHSA) offers a brief online course series entitled "Gender-Based Violence: We All Can Help Improving the Health Sector's Response", which may serve as a helpful resource.

# Integrated medical management
Care for pregnant individuals with AUD should reach beyond a strictly substance-focused approach in order to improve long-term outcomes for the patient and fetus. As the standard of care for the management of any complex or chronic medical condition, thorough medical management should be provided to pregnant patients with AUD. In this context, medical management is defined as informal medically-focused counselling that includes, but is not limited to, conducting health and mental wellness checks; offering non-judgmental support and advice; assessing motivation and exploring ideas for change; developing a holistic treatment plan; promoting alternative strategies for managing stress; and providing appropriate referrals to health and social services with the consent and input of the patient. Clinicians should also ascertain patients' housing, food/nutrition, and security needs and make necessary referrals to address them, with the consent and input of the patient. 29,30

# Harm reduction during pregnancy and post-partum
Harm reduction is commonly defined as policies, programs, and practices aimed at minimizing the negative impact of substance use on the individual and the society without necessarily stopping or reducing substance use. 34,35 In essence, a harm reduction-oriented approach seeks to meet patients "where they are at" and supports any step or behaviour that enhances the health and safety of patients and their communities. This fundamental framework of care requires particular attention in the context of pregnancy, given that recommended AUD interventions for pregnant patients are mainly aimed at abstinence.
While recognizing that discontinuing alcohol use is the only means of fully eliminating alcohol-related risks to the patient and the fetus, this supplement strongly emphasises that the provision of comprehensive and continued care should never be contingent on a pregnant patient's willingness to discontinue alcohol use. Clinicians providing care for pregnant or lactating individuals who continue drinking alcohol should adopt appropriate harm reduction strategies such as promoting safer alcohol use (e.g., reduced drinking, refraining from drinking and driving, discontinuing non-beverage alcohol use) and providing referrals to resources that address social determinants of health (e.g., housing, nutrition, legal services, financial assistance, child care). 35,36 Harm reduction measures have been shown to contribute to reduced drinking, improved nutrition, and improved overall health outcomes for the patient and fetus. 35,36 For additional information on evidence-based harm reduction strategies geared towards pregnant patients who use substances, see Harm Reduction and Pregnancy: Community-based Approaches to Prenatal Substance Use in Western Canada. 3
Clinicians should incorporate the principles of trauma-and violence-informed care in the care and clinical management of pregnant and post-partum patients who use alcohol and those with AUD.
Alcohol use and AUD in pregnant patients should be managed within the framework of comprehensive medical care and support, including routine and ongoing medical, mental health, and psychosocial assessments.
Provision of comprehensive and continued care should never be contingent on a pregnant patient's willingness to discontinue alcohol use. Clinicians providing care for pregnant individuals who continue drinking alcohol should adopt appropriate harm reduction strategies.
3 Screening and Brief Intervention

# Considerations for alcohol screening during pregnancy
Regular substance use screening is widely recommended for patients who are or may become pregnant, in order to identify risk and prevent or minimize harm to the patient and the fetus. 4,5,11 Substance use screening should be included in the first prenatal assessment, or at the first available opportunity, and conducted routinely throughout pregnancy and post-partum and when clinically relevant and necessary. 37 Research has suggested that patient self-reports are a reasonably reliable measure of alcohol use during pregnancy; however, clinicians should be sensitive to factors that may deter patients from providing accurate responses to screening questions, such as stigma and fear of child apprehension. 38,39,40 To address these concerns, it is crucial to establish comfort and trust by securing the patient's informed consent prior to screening, and to assure them of confidentiality and other rights in accordance with the standards of medical practice. 41,42 It is also helpful to mention that all patients are periodically asked about substance use as a standard of primary care provision. Some guidelines recommend that care providers ask pregnant individuals about alcohol consumption at every visit as patients are more likely to disclose alcohol use after a therapeutic relationship has been established. 41 Additionally continuous documentation of alcohol use patterns in pregnant patients with AUD is instrumental to the early identification and management of FASD. 5 

# Initiating a dialogue about alcohol use and pregnancy
Screening and assessment for all patients of childbearing capacity should be combined with education about Canada's Low-Risk Alcohol Drinking Guidelines 3 , which recommends abstinence from alcohol use during pregnancy and outlines low-risk drinking limits for adults. In addition to raising awareness of these guidelines, introducing the topic of alcohol use in a general and conversational manner can also help build rapport and facilitate a natural transition to questions regarding personal alcohol use. For example, alcohol screening can be initiated by asking: "Have you heard about Canada's Low-Risk Alcohol Drinking Guidelines? I talk to all my patients about these guidelines. They contain important information about safer alcohol use that everyone should know. It also offers recommendations for people who are or may become pregnant. "
Where appropriate, clinicians should also discuss effective contraceptive methods and how to access them with patients of childbearing capacity. This is in consideration of the persistently high prevalence of unplanned pregnancies in Canada. 8,43 Contraceptive counselling services and supplies should also be offered to patients who are currently pregnant in order to reduce the likelihood of a subsequent unplanned pregnancy as short intervals between pregnancies may disrupt ongoing treatment and amplify potential risks to recovery and long-term health. 44,45 3.3 A simplified screening method to address time constraints Despite the well-established utility of regular alcohol screening for early detection of alcohol use and AUD, and the secondary prevention or minimization of harm to the patient and fetus, many pregnant patients are not screened for alcohol use. 5,11 Time constraints are frequently cited as a key barrier to adequate screening; primary care clinicians often report being overwhelmed by the number of conditions for which they are required to screen pregnant patients. The duration of the average primary care visit is often insufficient to accommodate a thorough screening process which ideally involves an introductory conversation about the maternal and fetal risks of alcohol use. 5,11 To counteract this barrier, a simplified and stepped alcohol screening process is recommended for pregnant patients, involving a single alcohol screening question (SASQ) to identify alcohol use in pregnant individuals. Patients who screen positive should be offered brief intervention and further assessment with validated screening and/or a diagnostic interview using the DSM-5 criteria for AUD. 5 See Appendix 1 for an instructive overview of alcohol use screening for pregnant patients.
A recommended screening method in the general population, the SASQ is typically constructed in reference to low-risk drinking limits in order to determine if, and how frequently, the patient's alcohol consumption has exceeded these limits. For example, an adult patient would screen negative for high-risk alcohol use if their response to the following question was "zero" or "never":
"In the past year, how often have you consumed more than 3 drinks (for adult women) or 4 drinks (for adult men) on any one occasion?"
In the context of pregnancy, the SASQ may be modified to identify any alcohol use in accordance with the Low-Risk Alcohol Drinking Guideline recommendation for this population:
"Do you sometimes drink beer, wine, or other alcoholic drinks?" 46 An affirmative response indicates the need for brief intervention and further assessment.
Studies have found that the sensitivity of the SASQ ranges from 60-90%,  and systematic reviews involving non-pregnant patient populations have validated this option for clinical settings where time and patient interactions are limited, notwithstanding its slightly lower sensitivity than structured screening instruments for the detection of high-risk drinking behaviours. 51,52 Although the SASQ has not been explicitly validated for screening pregnant patients, it has been recommended as the first step in alcohol use screening in this population by the Society of Obstetricians and Gynaecologists of Canada 5 and the U.S. Preventive Health Services Task Force on account of its brevity and sufficient sensitivity and specificity. 53 Another advantage of the SASQ is that it can be integrated into an informative conversation without disrupting the flow of the appointment.

# Additional validated screening tools for pregnant patients
Studies involving pregnant participants support the effectiveness of a range of screening tools validated for the general population, such as the AUDIT, AUDIT-C, CAGE, and CRAFFT methods. 4,46 Additionally there are a number of screening tools specifically developed for detecting high-risk drinking and AUD among pregnant patients, including the T-ACE, and TWEAK tools. This guideline supplement presents AUDIT, AUDIT-C, TWEAK, and T-ACE, commonly recommended screening tools which have been validated for use during pregnancy. (See Appendix 1)
Table 3 provides a comparative overview of pregnancy-validated tools in terms of selectivity, specificity, time and expertise required, and other factors informing usefulness. Refer to the Guideline for screening tools not presented in this document. 

# Diagnosis of AUD
Pregnant patients who screen positive for alcohol use during pregnancy should undergo further assessment to confirm or exclude AUD. As with the non-pregnant population, this assessment may be conducted through a structured interview using the DSM-5 criteria for the diagnosis and severity of AUD. Confirmation or exclusion of an AUD largely determines subsequent steps in the treatment pathway. Appendix 1 presents the diagnostic criteria for AUD.
While all pregnant individuals who screen positive for alcohol use should receive brief counselling intervention and routine follow-ups (see next section, Brief intervention), brief intervention alone is not effective for individuals with AUD. 4,55 Patients who are diagnosed with an AUD should be offered evidencebased treatment for AUD. (See Withdrawal Management and Continuing Care Sections for an overview of evidence-based interventions)

# Brief intervention
Brief intervention is a time-limited single-session counselling dialogue that typically follows a positive screen for alcohol use during pregnancy. The aim of this intervention is to assess, strengthen, and mobilize patients' motivation for change in order to help them reduce or discontinue alcohol use. There are a number of different approaches and models for delivering brief intervention for alcohol use in primary care settings, but most are variations of motivational interviewing (MI), a psychosocial intervention which empowers patients to make positive behavioural changes. 5,56 Key components of brief intervention are exploring and discussing motivations for or against reducing alcohol use, identifying barriers and facilitators to change and available treatment and supports, assisting the patient to set goals, and providing non-judgmental encouragement and support. Brief intervention also serves as an opportunity to offer referrals to community-based resources or supports. An advantage of brief intervention is that it can be easily implemented by a range of health care providers including physicians, nurse practitioners, nurses and other allied health professionals who may not have specialized training in addiction medicine.
As with the non-pregnant population, brief intervention is widely recommended for pregnant patients and supported by a number of clinical trials. A 2009 systematic review (n=4 studies; 715 participants) of randomized controlled trials (RCTs) examining the effectiveness of psychosocial treatment interventions found that brief psychosocial or educational interventions may motivate pregnant patients to reduce or discontinue alcohol use, although the authors found the data insufficient for performing a meta-analysis. 57 A number of individual studies have reported significant results in favor of BIs in this population. For example, in a randomized study comparing brief intervention (n=162) to assessment only, O'Conner and Whaley (2007) reported that pregnant individuals in the brief intervention treatment group were 5 times more likely than participants in the control group to report that they abstained from alcohol use throughout pregnancy. The infant mortality rate in the brief intervention group was 3 times lower than the rate in the control group, and newborns from the brief intervention group had greater birth length and weight than control subjects. 58 A practical example of brief intervention that has been well studied in primary care and used for various specific populations is the 5As (Ask, Advise, Assess, Assist, and Arrange) model for behavioural change. 59 Ease of recall, brevity, and adaptability are practice-relevant strengths of this approach. This model is presented in Table 4. Appendix 2 provides general instructions for conducting brief intervention with a trauma-informed approach.
It should be noted that, while guidelines endorse a range of validated brief intervention methods, research has shown that simply asking patients in a detailed manner about the extent of their alcohol use, discussing potential risks, and offering brief non-judgmental advice may help raise awareness about their actual levels of alcohol consumption and modify behavior. 53,60 Table 4 The 5A's Model for Delivering Alcohol Use Brief Intervention 61,62 (modified for pregnancy)

# Ask
Screen pregnant patients in a conversational and non-judgmental manner with awareness of the stigma affecting this population. Acknowledge the patient's existing knowledge about the risks of alcohol use during pregnancy and any changes they have already made to mitigate this risk.

# Advise
In a clear and personalized manner, inform patients of the risks of alcohol use during pregnancy and postpartum and advise them to discontinue alcohol use during this period.

# Assess
Assess and record patients' readiness to discontinue or reduce alcohol use at this time.
At this stage, it is advised to conduct a diagnostic interview to confirm/exclude AUD, as brief intervention alone is not effective for individuals with AUD.

# Assist
Work with the patient to develop a treatment plan that accommodates their level of readiness and motivation. Offer supportive counselling and advice, provide a menu of options for treatment and referrals to community resources.
Arrange Schedule follow-up contact, preferably within a week of the intended "change date".
4 Withdrawal Management

# Overview
Alcohol withdrawal occurs with the sudden cessation or significant reduction of alcohol use after a period of chronic heavy alcohol consumption. These symptoms are believed to result from the hyperactivity of glutamate, the main excitatory neurotransmitter of the central nervous system (CNS), upon the sudden reduction in the blood alcohol level. 3,63,64 In normal conditions, the brain maintains a balance between the effects of GABA, a major inhibitory neurotransmitter, and glutamate. Alcohol disrupts this balance by increasing the inhibitory effect of GABA and suppressing the excitatory effects of glutamate. Chronic alcohol consumption causes the CNS to compensate for the inhibitory effects of alcohol by upregulating glutamate transmission in order to restore neurochemical equilibrium. When suddenly unopposed by the inhibitory effects of alcohol, the upregulated excitatory system results in overall CNS hyperactivity, which manifests as a range of withdrawal symptoms in up to 50% of individuals with long-term alcohol dependence. 3,63,64 Common alcohol withdrawal symptoms include tachycardia, pyrexia, tremor, nausea, vomiting, and sweating, which may also be accompanied by psychological distress in the form of anxiety, agitation, and sleep disturbance or insomnia. Symptoms of alcohol withdrawal typically begin 6-24 hours after the last intake of alcohol and reach peak intensity at 24-48 hours, with resolution of symptoms within 5-7 days. 65 Additionally, a small percentage of symptomatic patients may experience severe complications of withdrawal consisting of tonic-clonic seizures and delirium tremens which are life-threatening if left untreated.  The data available on the specific effects of acute withdrawal on the pregnant patient are sparse; however, some have extrapolated that pregnant individuals may be particularly vulnerable to the withdrawal symptoms listed above due to their well-documented increased susceptibility to physiological and environmental stress. 3, Acute maternal alcohol withdrawal may, in turn, lead to a host of adverse effects on the fetus including fetal distress, placental abruption, preterm labour, and fetal demise. 3 In view of the added risks of alcohol withdrawal during pregnancy, it is recommended that, where possible, pregnant patients with AUD undergo withdrawal management in inpatient settings where patients can receive symptom-triggered treatment with close monitoring of withdrawal symptoms and fetal health. 3,4,9 It should also be noted that available studies on withdrawal management for this specific population have been conducted in inpatient settings. However, if inpatient withdrawal management is not an option due to patient preference or lack of timely access to available beds, outpatient treatment with close monitoring may be offered to pregnant patients who otherwise meet the criteria for this setting (e.g., low risk of severe complications of withdrawal, family or community-based support, ability to attend medical visits, absence of other conditions requiring inpatient care). For instructions on outpatient withdrawal management, see Appendix 3, Patient Criteria and Considerations for Outpatient Alcohol Withdrawal Management.
It should be emphasised that withdrawal management alone does not constitute treatment for AUD. Studies report high post-withdrawal relapse rates and suggest that sustained abstinence and reductions in alcohol use are unlikely without provision of continuing AUD care. 73,74 Patients should be connected to continuing care following the completion of withdrawal management. See the Continuing Care section in this supplement for an overview of evidence-based treatment interventions. This section provides a review of the efficacy and safety of clinical withdrawal assessment and management options with a focus on fetal and neonatal outcomes.
Refer to Section 3 of the Guideline for a comprehensive review of all common withdrawal management treatment options for the general population of patients with AUD.

# Assessment

# The Prediction of Alcohol Withdrawal Severity Scale (PAWSS)
The Prediction of Alcohol Withdrawal Severity Scale (PAWSS) is a validated score-based tool for estimating the risk of developing severe complications of withdrawal (i.e., seizures and delirium tremens), which facilitates the selection of appropriate withdrawal management interventions. 75 The PAWSS incorporates the evidence-based risk factors of developing severe complications of withdrawal into a 10-item cumulative scale with a maximum score of 10, wherein a score of <4 indicates low risk and a score of 4 denotes high risk for severe complications of withdrawal. 75 While this tool has not yet been validated specifically for use in pregnant patients, its accuracy and usefulness in inpatient settings was validated in a 2018 systematic review of 14 studies (n=71,295) evaluating single and composite measures of severe withdrawal risk. 76 The authors demonstrated that composite scales that measured multiple signs and symptoms were more useful in predicting an individual's risk than individual signs or symptoms. Of these composite scales, the PAWSS was found to have the highest sensitivity (93%, ) in assessing the risk of severe complications of withdrawal. 76 Recommended preliminary assessment for alcohol withdrawal in non-pregnant populations involves the administration of the PAWSS tool in order to select the appropriate treatment setting based on their risk of developing severe complications of withdrawal. 75,76 Given the recommendation that all pregnant patients requiring withdrawal management undergo treatment in an inpatient setting, assessment for the purpose of selecting the treatment setting may not be indicated in this population unless strong patient preference or scarcity of beds prompts risk assessment for outpatient treatment. However, the PAWSS is also a useful means of selecting the appropriate withdrawal management pharmacotherapy, as non-benzodiazepine withdrawal management medications may not be appropriate for individuals at high risk of experiencing severe complications of alcohol withdrawal. 9 As such, this supplement recommends that clinicians consider the use of this tool to help select between gabapentin and benzodiazepines for withdrawal management in pregnant patients.
For more information see Pharmacotherapies for withdrawal management. If clinicians elect to administer the PAWSS tool to inform medication selection, its result should be combined with additional clinical assessment and observation.9 The PAWSS tool and corresponding instructions will be produced in Appendix 3.B.

# Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)
The CIWA-Ar is considered the gold standard for assessing withdrawal symptom severity in a range of clinical care settings for the general patient population, with demonstrated inter-rater reliability and validity. 77 This tool is commonly used to determine and adjust symptom-triggered dosing schedules. Studies have shown that using the CIWA-Ar in this context minimizes both under-and over-medicating patients while mitigating the risk of severe symptoms. 78,79 The CIWA-Ar involves the assessment of 10 individual symptoms and signs of alcohol withdrawal including anxiety and agitation; auditory, visual, and tactile disturbances; tremor; sweating; nausea; headache; and clouding of sensorium, which are assigned a numerical score based on objective and subjective measures of severity. A score <15 indicates mild withdrawal symptoms while scores 15 and 20 are indicative of moderate and severe withdrawal symptoms respectively. 77 Due to the wide recognition of the CIWA-Ar scale, the terms "mild", "moderate", and "severe" withdrawal used in this supplement are defined according to these numerical scores.
Although the CIWA-Ar has not been validated for pregnant patients, its use is common for alcohol withdrawal symptom assessment during pregnancy and has been described in a case report. 80 The authors reported the utility of this tool in devising a symptom-triggered withdrawal management regimen and minimizing the exposure of the patient and fetus to potentially harmful medications.80 Clinicians using this tool for withdrawal symptom severity assessment should be mindful that some of the CIWA-Ar criteria (e.g., nausea and headache) overlap with common symptoms of pregnancy. Thus, CIWA-Ar results should be interpreted with clinical judgment and in communication with the patient to distinguish between pregnancy and withdrawal symptoms. 80 The CIWA-Ar tool and corresponding instructions are presented in Appendix 3.B.

# Management of negligible to mild withdrawal symptoms
In consideration of the significant risks of acute withdrawal to the patient and fetus, all pregnant patients diagnosed with AUD should be offered medication for withdrawal management. However, patients with mild AUD may experience negligible withdrawal symptoms and may prefer to receive supportive therapy and continuing care without pharmacological detoxification.
There is a lack of consistent guidance regarding the non-pharmacological management of mild withdrawal symptoms among non-pregnant and pregnant patients alike. Many practice guidelines pertaining to the general population recommend provision of supportive care alone until withdrawal symptoms subside (e.g., supportive environment; close monitoring with the involvement family where possible; adequate nutrition and hydration; encouragement and positive reinforcement; referrals to psychosocial treatment interventions and communitybased support resources). 8,81 If not contraindicated, over-the-counter pain relievers, anti-emetics, and antidiarrheal medications approved for use during pregnancy and lactation may also be prescribed for management of mild symptoms. This is based on early studies involving non-pregnant populations that found supportive care was sufficient for approximately 75% of patients with no psychiatric or medical comorbidities. 82,83 Clinical experience suggests that pregnant patients are more likely than other populations to opt for nonpharmacological treatment options due to heightened motivation to minimize possible risks of pharmacotherapy to the fetus. 84,85 While patient preference and motivation are among the predictors of treatment success and key factors in treatment selection, patients should be clearly informed of the risks of maternal withdrawal symptoms, and offered frequent monitoring and reassessment.

# Pharmacotherapies for withdrawal management
Common pharmacotherapies for alcohol withdrawal in non-pregnant patients consist of benzodiazepines; anticonvulsants including carbamazepine, gabapentin, and valproic acid; and alpha-2 adrenergic agonists. There is a dearth of research and evidence-based guidance pertaining to pharmacotherapeutic withdrawal management in pregnant individuals. This is partly due to the ethical concerns restricting clinical investigation in this population, particularly given the suggested risk of teratogenicity associated with a number of common withdrawal management medications in animal studies. 9 A 2009 Cochrane review of pharmacotherapies found no randomized or quasi-randomized studies of pharmacologic interventions for pregnant participants enrolled in alcohol treatment programs and concluded that considerably more research was needed to assess the safety of available treatments in this population. 86 As reviewed below, the limited research on the safety of pharmacological options for withdrawal management during pregnancy has been focused almost exclusively on benzodiazepines. However, in response to emerging evidence in support of gabapentin for this indication, this supplement also provides a brief overview of the safety and efficacy of this medication. Considered as an aggregate, the literature summarized in this section suggests that the harms of acute alcohol withdrawal surpass the potential risks associated with its pharmacological treatment with these agents. See Table 5 below for a comparative overview of the clinically relevant characteristics of benzodiazepines and gabapentin. Appendix 3.C provides general prescribing information and sample dosing protocols for the medications reviewed in this section.
Refer to the Guideline for a comprehensive review of evidence concerning all evidence-based pharmacotherapies for alcohol withdrawal in the general population.

# Benzodiazepines
Benzodiazepines have the most substantial history and supportive evidence in alcohol withdrawal management for pregnant and non-pregnant populations. 4,87 Numerous systematic reviews have established the superior efficacy of this class of medications in suppressing alcohol withdrawal symptoms and preventing withdrawal seizures and delirium tremens. 4, Early case-control studies on the use of benzodiazepines in pregnancy suggested that these medications may be associated with increased risk of fetal malformations. 3,80 However, a number of more recent cohort studies found no increased risk of congenital malformations, cardiac defects, or neurobehavioural problems among children born to people who used benzodiazepines during pregnancy in comparison to the general population. 3,91,92 A 2011 systematic review and meta-analysis including nine case-control and cohort studies also examined the correlation between maternal benzodiazepine use and major fetal malformation. 93 The authors also concluded that, in sum, benzodiazepines did not appear to increase teratogenic risk (OR, 1.07 ), although the case-control studies demonstrated an increased risk of cleft lip. 93 Currently, the use of benzodiazepines during pregnancy holds a category D designation by the US Food and Drug Administration (FDA), which denotes evidence of risk to human fetuses with prolonged use. 9 This categorization is attributed to evidence suggesting an increased risk of cleft lip.9 However, it is important to note that the duration of alcohol withdrawal management is typically 5-7 days, which does not constitute prolonged use. Additionally, the majority of studies concerning the fetal safety of benzodiazepine treatment in pregnancy do not account for the purpose, duration, and dose of maternal benzodiazepine use. 3 One case-control study examining the fetal outcomes of short-term (generally 3 weeks) diazepam treatment during pregnancy found that short-term exposure to this medication presented no detectable teratogenic risk to the fetus. 94 Additional considerations for benzodiazepine use during the final trimester of pregnancy include "floppy infant syndrome" and neonatal benzodiazepine withdrawal. Floppy infant syndrome is characterized by a constellation of treatable symptoms such as mild sedation, hypotonia, reluctance to suck, apneic spells, and cyanosis that can persist for hours to months after birth.3 Neonatal benzodiazepine withdrawal symptoms may include hypertonia, hyperreflexia, restlessness, irritability, abnormal sleep patterns, inconsolable crying, tremors or jerking of the extremities, bradycardia, cyanosis, suckling difficulties, apnea, diarrhea, and vomiting. 3,95 While there is no conclusive data regarding the specific type of benzodiazepine that would prevent the development of these symptoms, some reports suggest that short acting benzodiazepines (e.g., lorazepam) may be preferable in the third trimester for minimizing the duration and severity of neonatal benzodiazepine withdrawal. 80,95 Overall, considering the well-established risks of untreated withdrawal, the literature suggests that potential benefits of benzodiazepine use for the treatment of acute alcohol withdrawal outweigh its risks, particularly in the case of severe AUD where the prevention of seizures and delirium tremens is a key consideration. In reference to these findings, the 2014 World Health Organization guidelines recommend management with a benzodiazepine, titrated to the severity of withdrawal. 4

# Gabapentin
The effectiveness of gabapentin for alcohol withdrawal management in non-pregnant patients at low risk of developing seizures and delirium tremens is demonstrated by a growing evidence base. To date, results from two RCTs (n=126) indicate that gabapentin (at total doses of 1200mg/day) is as effective as benzodiazepines for the outpatient management of mild to moderate alcohol withdrawal symptoms, and may yield additional benefits in terms of improved daytime alertness, sleep quality, anxiety, and mood. 96,97 With respect to safety for use during pregnancy, gabapentin is listed as a category C drug by the FDA; there is no evidence suggesting that this medication is teratogenic in humans, though some dose-dependent adverse effects to the fetus have been observed in animal studies. 9,98 Recent evidence suggests that the use of this medication for withdrawal management during pregnancy is safe. 9,45 Clinicians should be mindful that this medication is not suitable for preventing severe complications of withdrawal (i.e., seizures and delirium tremens). Therefore, it is recommended to assess the patient's risk of severe complications of withdrawal using the PAWSS tool prior to selecting between benzodiazepines and gabapentin.

# Caution regarding other agents
Alternative options for the management of alcohol withdrawal in the non-pregnant population include other anticonvulsants (i.e., carbamazepine, valproic acid) and alpha-adrenergic agonists including clonidine (See Guideline Chapter 4). However, due to the lack of sufficient supporting evidence, and reported risk of teratogenicity, these agents should not be considered for pregnant patients unless acute withdrawal constitutes a life-threatening emergency and the use of recommended options is contraindicated. 9 Safety for use during pregnancy 9 FDA category D:
- Evidence of cleft lip and "floppy infant syndrome" in human studies
- Potential benefits may outweigh risks FDA category C:
- No adequate human studies
- Possible risk extrapolated from animal models include preterm birth, low birth weight, and neonatal withdrawal symptoms
- Potential benefits may outweigh risks

# Efficacy
Superior efficacy for suppression of withdrawal symptoms compared to placebo and other active treatments. 90 Superior efficacy for prevention of seizures compared to placebo and active treatments.  Emerging data (2 RCTs) showing equal efficacy to benzodiazepines in suppressing mild to moderate withdrawal.
May be superior for treatment of insomnia and anxiety symptoms. 96,97 Insufficient evidence for prevention of seizures or delirium tremens. Less common side effects include changes in skin colour, nausea, headache, blurred vision, tremors, hypotension, GI disturbances. Memory loss may also occur.
Higher doses may cause ataxia, slurred speech and drowsiness.
Favourable side effect profile in comparison to other anticonvulsants.

# Safety for breastfeeding
Sedation and poor weight gain in infants have been rarely reported. Short acting agents (e.g., lorazepam, oxazepam) may be preferable. Overall, deemed compatible with breastfeeding by WHO and ACGC. 4,101 Small number of case reports reported no adverse neonatal effects. Infants should be monitored for drowsiness, adequate weight gain, and developmental milestones, especially in younger, exclusively breastfed infants. 102 Other considerations
Potential for non-medical use, diversion, and dependence.
Potential for drug-drug interactions leading to excess sedation, impaired psychomotor and cognitive functioning.
Potential for non-medical use, diversion, and dependence.
Toxicity profile parallels that of alcohol.
Easy to transition from withdrawal management to long-term relapse prevention.
- Note: This information is directly adapted from the product monographs of these medications. The fact that benzodiazepines are excreted into human milk was cited as a reason for caution during breastfeeding. See Section 7.2.2 for a summary of evidence supporting the compatibility of these medications with breastfeeding.
5 Continuing Care

# Pharmacotherapy
There are no clinical trials evaluating the possible options for the pharmacological management of AUD during pregnancy. The meagre existing literature on this topic is extrapolated from animal studies and evidence pertaining to non-pregnant populations. A recent practice guideline by the American Psychiatric Association recommends against pharmacotherapeutic interventions for AUD during pregnancy, except for the management of alcohol withdrawal. 9,45 This is due to the risk of teratogenicity associated with many evidencebased AUD medications. In line with available guidelines, all patients with AUD should be offered evidencebased psychosocial treatment interventions and supports for AUD. However, the risks of pharmacotherapy to the fetus should be weighed against risk of relapse to alcohol use in the case of pregnant patients with moderate to severe AUD.
Naltrexone and acamprosate are considered first-line AUD treatment agents for non-pregnant patients. This section provides an overview of the safety and efficacy of these treatments for pregnant individuals in reference to available literature. Gabapentin is also reviewed as a potential alternative option for this population. Overall, it is suggested that the benefits of preventing relapse outweigh the risk of possible effects of these agents on the fetus. 9 See Table 6 below for a comparative summary of the characteristics of these medications. Sample dosing protocols and PharmaCare coverage information are provided in Appendix 4. Additionally, please refer to the Guideline for a comprehensive review of all evidence-based AUD pharmacotherapies for the general population.

# Naltrexone
Naltrexone is a mu-opioid receptor antagonist shown to block euphoria associated with alcohol consumption. 103 It is hypothesized to work by diminishing the rewarding effect of alcohol in the brain following its consumption, as well as reducing cravings for alcohol in some individuals. 103 This blunting effect on neural reward pathways is consistent with research findings that naltrexone is particularly effective in preventing a return to heavy or ongoing drinking. 104 Naltrexone has a well-established evidence base for safety and efficacy in the treatment of AUD among non-pregnant populations. 105 Notably, a 2010 meta-analysis including 50 RCTs (n=7793 participants) reported that 17% fewer participants treated with naltrexone engaged in heavy drinking, and had 4% fewer drinking days per month when compared to the placebo group. 104 Participants treated with naltrexone also showed a greater reduction in heavy drinking days (-3.25%) and the amount of alcohol consumed (-10.83g) compared to the placebo group. 104 The FDA has classified naltrexone as a category C medication for use during pregnancy, meaning that there are no adequate human studies on the effects of naltrexone on the fetus, while animal studies have demonstrated mild adverse effects on the fetus. 3,9 Animal studies on in utero exposure to naltrexone have found that this medication crossed the placenta and was associated with reduced sensitivity of the offspring to morphine, and possibly with early fetal loss and increased birth weight. 9 However, limited evidence pertaining to the use of naltrexone for the treatment of opioid use disorder has demonstrated no adverse effects on pregnancy outcomes, although the long-term developmental effects of in utero exposure to this medication are not known. 106,107

# Acamprosate
Acamprosate is believed to restore the balance between glutamate-mediated excitation and GABA-mediated inhibition of neural activity, and reduce general neuronal hyperexcitability. 103 Together, these modify responses to alcohol-related cognitive cues. 103 Acamprosate has been used for the treatment of AUD for several decades in Europe prior to its approval in North America, and has an established evidence base for safety and efficacy in non-pregnant populations.  A 2010 meta-analysis including 24 RCTs (n=6915) reported that acamprosate reduced the risk of return to any drinking by 14% and increased the cumulative duration of abstinence by 11 days compared to placebo. 111 In addition, the authors found that the treatment effects of acamprosate persisted at 3-12 months after treatment discontinuation. 111 Acamprosate is classified as a category C medication. Until recently, human data on the impact of in utero exposure to acamprosate was limited to one observational personal communication reporting one case of cleft lip among 18 pregnancies, while animal studies show dose-related defects in offspring including retinal dysplasia, iris malformation, hydronephrosis, and increased rate of stillbirth. 9,114 However, more comprehensive supportive evidence was presented by a 2019 population-based retroactive cohort study from New South Wales, Australia, comparing maternal and neonatal health outcomes of acamprosate-exposed pregnancies (n=54) to those of untreated alcohol-exposed (alcohol comparison group; n=162) and non-exposed (community comparison group; n=162) pregnancies. 115 Authors reported that rates of hospital admissions during pregnancy and 42 days post-partum in acamprosate-treated individuals were not significantly different from the community comparison group (adjusted rate ratio  = 0.85, 95% CI = 0.65-1.11), but were significantly lower compared with the alcohol comparison group (adjusted RR = 1.26, 95% CI = 1.00-1.60).115 Acamprosateexposed neonates were not significantly different from the alcohol comparison group or the community comparison group in terms of birth weight, proportion of small-for-gestational-age neonates, or incidence of congenital abnormalities (including FASD). 115 It should also be noted that this study only included individuals who were exposed to acamprosate for more than 30 days during pregnancy in the case group, so that the results would be applicable to patients receiving pharmacotherapy for continuing AUD care. Available data suggests that the benefits associated with the use of this medication during pregnancy may outweigh the risks of continued alcohol consumption during this period. 9,114,115

# Gabapentin
Emerging evidence for the efficacy of gabapentin in preventing relapse in non-pregnant populations is derived primarily from three placebo-controlled clinical trials. Two RCTs comparing 7-day gabapentin treatment to placebo found that gabapentin was more effective in reducing alcohol craving, the number of drinks per day, and percentage of heavy drinking days, and increasing the number of days abstinent. 116,117 Most recently, a 12-week trial of 150 participants in an outpatient setting demonstrated that gabapentin significantly improved rates of cumulative abstinence (estimated number needed to treat  of 8) and heavy drinking (estimated NNT of 5), with no difference in adverse events compared to placebo. 118 A distinctive advantage of gabapentin is that it has been found effective for outpatient withdrawal management in patients at low risk of developing severe complications of withdrawal (PAWSS<4), and patients who complete withdrawal using this medication may have the option to continue its use beyond the acute withdrawal period as part of a long-term treatment strategy without the risk of disruption to care. 119 In terms of safety for use during pregnancy, gabapentin is a category C medication which indicates evidence of risk to the fetus in animal studies. Available animal models reveal a higher risk of embryotoxicity during organogenesis, but this is purported to occur at supratherapeutic doses that would not typically be seen in humans. 120 In a limited 2013 prospective cohort study with pregnant participants, no fetal malformations were observed, but the authors reported a possible association with preterm birth and low birth weight. 121 Clinicians considering gabapentin for pregnant patients should be mindful of the risk of non-medical use and dependence associated with this medication.  It is also important to note that concurrent use of alcohol, opioids, or other CNS depressants with higher doses of gabapentin increases the risk of respiratory depression, profound sedation, syncope, and death. 100 While available evidence suggests that these risks are significantly lower than those associated with untreated AUD,  clinicians should arrange frequent follow-ups and monitor patients for non-medical use, dependence, diversion, and concurrent alcohol or opioid use. Particular attention is advisable in the case of patients who are prescribed multiple medications for concurrent conditions. 123 Gabapentin withdrawal has also been reported in a number of infants born to patients who used gabapentin; this condition is treatable, though it may require admission to the neonatal intensive care unit. 9,130

# Caution regarding other agents
The use of other AUD medications, such as topiramate and disulfiram, during pregnancy is not recommended.
A preliminary report on 203 prospectively followed pregnancies exposed to topiramate found a high rate of major congenital malformations among neonates. 131 Similarly, sparse evidence associates maternal disulfiram use with fetal limb reduction. 132 There is no evidence-based guidance regarding patients who are stable on one of these medications prior to becoming pregnant. In these cases, clinicians should carefully consider the risks and benefits of transitioning patients to alternative treatment options in communication with an addiction specialist and the patient. 45 Where possible, transitioning the patient to safer pharmacotherapies (i.e., naltrexone, acamprosate, or gabapentin) or psychosocial treatment interventions and supports may be appropriate. Additionally, patients of childbearing capacity who are prescribed one of these medications should be informed of possible risks in the event of pregnancy and advised of the importance of contraception in the course of treatment. Higher doses may cause ataxia, slurred speech, or drowsiness.
Favourable side effect profile in comparison to other anticonvulsants.

# Concurrent alcohol use
Safe to start while patients are using alcohol, but may be more effective and side effects minimized if started following completion of withdrawal.
Safe to start while patients are using alcohol, but may be more effective if started following completion of withdrawal management.
Higher than therapeutic dose and use concurrent with alcohol increases the risk of respiratory depression, profound sedation, syncope, and death.

# Breastfeeding
Minimally excreted into breast milk. Limited case studies show no adverse neonatal effects. 135,136 Not a barrier to breastfeeding.
No adequate human studies.
Deemed "probably safe" in pharmacokinetic investigations. 45,137 Small number of case reports reported no adverse neonatal effects.
Infants should be monitored for drowsiness, adequate weight gain, and developmental milestones, especially in younger, exclusively breastfed infants. 102 - This information is directly adapted from the product monographs of these medications, where lack of sufficient data pertaining to pregnancy and lactation was cited as cause for caution. Section 7.2.3 for a review of available information on the safety of AUD pharmacotherapy for breastfeeding.

# Psychosocial treatment interventions
Validated psychosocial treatment interventions for AUD in pregnancy do not differ from those offered to the general population. There is modest RCT evidence supporting the effectiveness of cognitive behavioural therapy (CBT), motivational interviewing (MI), and contingency management during pregnancy. 3 A 2009 Cochrane review of psychological and educational interventions for reducing alcohol use in pregnancy (4 RCTs, n=715) concluded that there was insufficient data on the effectiveness of these interventions for reducing alcohol consumption or supporting abstinence. 57 However, the authors cited inconsistent results, small sample sizes, high risk of bias, and heterogeneity in intervention types and outcomes assessed across trials as confounding factors hindering evidence synthesis. The authors also acknowledged that the existing literature supports the usefulness of these psychosocial interventions in increasing abstinence from alcohol use and reducing alcohol consumption among pregnant individuals. 57 Accordingly, most clinical practice guidelines recommend that all pregnant individuals with AUD be offered psychosocial treatment interventions to support abstinence or reduced alcohol consumption. 138 It is important to note that MI, CBT, and CM are well-studied in the context of substance use disorders among the general populations, and have a significant track record of use in a wide range of settings and patient populations. 139,140 For a comprehensive review of evidence on the efficacy of these interventions, see the corresponding sections of the Guideline. See Appendix 5 for an instructive overview of MI.

# Considerations for Bed-Based Treatment Facilities
Although the evidence supporting the efficacy of bed-based treatment facilities e for substance use disorder is relatively limited, guidelines pertaining to pregnant individuals cite residential settings as potentially beneficial for patients who require more intensive medical care and support to improve health and pregnancy outcomes. 120,141 These facilities may also be appropriate for patients with comorbidities and complex medical and psychosocial needs, as well as those who have unstable housing and social circumstances. Decisions regarding the selection of this treatment setting should be made in collaboration with, and with the consent of, the patient.
The following factors should be considered when selecting a treatment facility for pregnant patients:
- Capacity to provide pharmacological treatment for AUD as directed by the patient's prescriber
- Capacity to provide wraparound medical and psychosocial support for concurrent conditions as well as AUD
- Access to comprehensive specialist pregnancy and prenatal care
- If applicable, access to post-partum and neonatal care, as well as onsite accommodation or visitation provision for patient's child(ren) and family. 142 Keeping parents and children together should be among primary considerations when selecting a treatment setting for this population.
Effective discharge planning is also crucial to ensure positive long-term bed-based treatment outcomes. 143,144 The treatment facility should communicate with outpatient care providers and relevant community-based services to ensure the continuation of care and support after discharge. It may be necessary to intensify support and monitoring during transition between settings as patients are particularly vulnerable to relapse to alcohol use in these periods. Every effort should be made to ensure patient's access to safe and stable housing prior to discharge. 142 Several systematic reviews have concluded that there is insufficient research evidence to recommend an optimal screening/rescreening interval for alcohol use in adults and youth. 127 In the absence of robust evidence, most public health agencies, including the Canadian Task Force on Preventive Health Care 139 and the Canadian Paediatric Society, 140,141 recommend screening adults and youth on an annual basis. This is for reasons of convenience -alcohol screening can be combined with other components of a routine medical exam or preventive health screening -and to detect changes, as an individual's alcohol use can shift from low-to high-risk over a one-year period. In line with this, a U.S. study found that use of annual substance use screening intervals identifies a modest number of incident cases of high-risk use in adult primary care patients. 142 Of 1014 patients who initially screened negative for high-risk alcohol or drug use, 34 (3.4%) screened positive for high-risk use when screened again one year later, with the majority (23/34) meeting criteria for high-risk alcohol use. 142
e Also referred to as "residential treatment" or "inpatient treatment" facilities in the literature.
7 Post-partum Considerations

# Rooming-in and skin-to-skin contact
Rooming-in and skin-to-skin contact during the immediate post-partum period is associated with healthy parent-infant bonding leading to improved long-term developmental outcomes, higher likelihood of breastfeeding, improved access to integrated care and initial childcare education in a family-centered setting, and reduction of maternal and neonatal distress and alcohol withdrawal symptoms. 4,145,146 Skin-to-skin contact and gentle rocking of the infant in a quiet environment are also widely recommended interventions for management of neonatal withdrawal symptoms. 4,136 Thus, in line with standards of care pertaining to the general populations, healthcare facilities providing obstetric care should have a rooming-in protocol in place whereby the monitoring and treatment of patients with AUD and their infants can take place without interrupting nursing and parent-infant contact.

# Breastfeeding
Breastfeeding f is consistently recommended in guidelines pertaining to neonatal care, including care for infants born to parents in treatment for substance use disorders. 4 This is in view of a robust evidence base demonstrating that breastfeeding is the ideal means of supporting the healthy growth and development of a child while promoting parent-infant bonding and reducing maternal stress. 4 In the case of nursing parents who use alcohol or are receiving pharmacotherapy for AUD, the risks and benefits of breastfeeding should be considered on an individual basis. This section provides a brief overview of the pharmacokinetics of alcohol and AUD pharmacotherapies (i.e., naltrexone, acamprosate, and gabapentin) during lactation and discusses neonatal and developmental safety concerns associated with the maternal use of these agents while breastfeeding.

# Alcohol and lactation
Available research on the effects of maternal alcohol use during lactation on the neonate is limited and contradictory. While there is some evidence suggesting that occasional drinking while breastfeeding does not have significant adverse effects on nursing infants, there is insufficient investigation and lack of consensus regarding the long-term consequences of heavy maternal alcohol use during breastfeeding. Alcohol is transferred into breast milk; the alcohol concentration in breast milk is known to resemble that in maternal blood, and the amount of alcohol transferred to nursing infants during feeding is approximately 5 to 6% of the weight-adjusted dose consumed by the nursing parent. 147,148 Thus, some studies have suggested that, even in the case of binge drinking, the infants may not be subjected to clinically relevant amounts of alcohol 148,149 while others associate heavy maternal alcohol use during lactation with decreased rate of infant growth and psychomotor development. 149,150 A systematic review of 11 studies (n=36) investigating alcohol's effect on nursing neonates found that infants breastfed by mothers who had consumed alcohol prior to feeding temporarily ingested 20% less milk, arguably as a result of reduced milk ejection reflex. 148 Temporary sedation and changes in sleeping patterns in the neonate have also been documented. 4,148 In view of these effects and the lack of conclusive evidence on the possibility of long-term developmental risk, most guidelines strongly recommend that breastfeeding mothers refrain from consuming alcohol during lactation. 4,147 However, many guidelines also emphasise that alcohol use is not necessarily a contraindication to breastfeeding. For example, the World Health Organization lists alcohol use among maternal conditions during which breastfeeding may still continue based on a case-by-case analysis of benefits and risks. 151 Breastfeeding patients who continue consuming alcohol should be strongly advised to reduce drinking and provided with education to schedule breastfeeding and alcohol use to ensure alcohol is eliminated from breastmilk at the time of feeding or storage of breastmilk. In the case of moderate drinking (i.e., 1-2 standard drinks in a day), guidelines generally recommend waiting 2-2.5 hours after drinking to store breastmilk or breastfeed. 4 However, the time required for the elimination of alcohol is dependent on the amount of alcohol consumed; alcohol appears to be eliminated from breastmilk more slowly in the case of daily heavy alcohol use (i.e., more than two standard drinks per day), and there is a decrease in the length of time that mothers can breastfeed their infants, resulting in significant risk. 152 Therefore, the risk of breastfeeding may outweigh its benefits in the case of chronic heavy maternal alcohol use.
See Appendix 6 for a sample patient information handout of alcohol use and safer nursing practices.

# Alcohol withdrawal pharmacotherapy and lactation
Benzodiazepines: All major classes of benzodiazepines are known to be excreted into human milk in varying but generally low concentrations. 95 Limited evidence characterises possible adverse effects of neonatal exposure to benzodiazepines through human milk as lethargy, sedation, and reduced sucking ability which may lead to poor weight gain. 95, However, available literature suggests that these adverse effects are rare and mild.  For example, in a 2012 retrospective cohort study (n=124) examining the neonatal impact of maternal benzodiazepine use during lactation, adverse outcomes-namely sedation-were observed in two (1.6%) infants, both of whom were breastfed by participants who used benzodiazepines in conjunction with other CNS depressants. 154 Similarly, a 2014 review of 16 studies on the impact of neonatal benzodiazepine exposure found rare reports of sedation, predominantly associated with longer-acting benzodiazepines (e.g., diazepam, clonazepam). 155 The authors emphasize the absence of serious negative effects among infants exposed to relatively short acting drugs and suggest that lorazepam and oxazepam may be among preferable agents for breastfeeding patients.
There findings are in line with guidelines by the WHO and the American College of Obstetricians and Gynecologists which deem benzodiazepines compatible with breastfeeding unless the infant's ability to metabolize the medication is impaired. 4,101 Gabapentin: The safety of gabapentin for breastfeeding has been investigated by a small number of case reports involving a range of doses and durations of treatment, and no significant adverse effects were reported. 102,156 Limited information indicates that maternal doses of gabapentin up to 2.1g daily produce relatively low levels in infant serum. 102 Accordingly, an expert consensus guideline indicates that gabapentin is an acceptable medication during lactation. 102 However, the authors advise to monitor the infant for drowsiness, adequate weight gain, and developmental milestones, especially in younger, exclusively breastfed infants. 102 

# AUD pharmacotherapy and lactation
There are no controlled studies and limited human data on the safety of maternal use of naltrexone, acamprosate, and gabapentin during breastfeeding. On account of this lack of evidence, careful assessment of benefits and risks, fully informed patient consent, and close monitoring of the infant is advised when considering these medications for nursing parents.
Naltrexone: Limited data indicate that naltrexone is minimally excreted into human milk. A case study cited by the Drugs and Lactation Database involves two 1.5-month-old infants breastfed by individuals who were receiving 50mg of oral naltrexone daily during pregnancy and lactation. 135,136 The authors reported no naltrexone-related adverse effects in the infants. Accordingly, while the Health Canada-approved product monograph for naltrexone recommends caution with regards to the use of this medication by nursing parents, 133 the benefits of breastfeeding may outweigh potential risks of neonatal exposure to naltrexone.
Acamprosate: Acamprosate's effect on human breastmilk has not been studied. In animal studies, this medication was excreted in the milk of lactating rats. In reference to this lack of evidence, the product monograph of acamprosate lists pregnancy and breastfeeding among contraindications to the use of this medication. 134 However, available guidance on the neonatal risks of pharmacotherapies during lactation suggests that the use of this medication during breastfeeding is "probably safe" for neonates. 45,137 Gabapentin: Please Section 7.2.2, Alcohol withdrawal pharmacotherapy and lactation for a summary of evidence supporting the compatibility of gabapentin with breastfeeding.

# Child Protection
The prenatal period:
Clinicians in Canada do not have a legal obligation to report prenatal substance use or substance use during the course of pregnancy. Any antenatal referrals or reports should be made with the informed consent of the patient.
Integrated care programs and collaborative long-term support planning in the course of pregnancy may foster family stability and enable new parents to play an active role in their child's care with the help of resources available in her family and community. 157,158 The involvement of expecting parents, supportive family members, public health and community-based resources, and services provided by the BC Ministry of Children and Family Development (MCFD) prior to childbirth can help improve pregnancy outcomes. However, the involvement of these services should be considered on a case-by-case basis with the collaboration and consent of the pregnant patient.

# The neonate (and other children in the custody of patient):
Maternal substance use alone is not grounds for the apprehension of an infant or referral to MCFD. However, the health care team is legally obligated under Section 14 of the Child and Family and Community Service Act (CFCSA) to report child protection concerns to the MCFD. Prior to making a report, clinicians should refer to Section 13 of the CFCSA for a comprehensive outline of circumstances under which notifying MCFD is warranted. The decision to report should be made on a case-by-case basis in consultation with the full health care team. It should be noted that the apprehension of infants is associated with a range of negative long-term social and health outcomes for the mother and child.  If a child is temporarily apprehended during the immediate post-partum period, mothers should be offered appropriate supports to ensure that the outcomes they experience after the loss of their child do not become barriers to reunification. 159 

# Appendices Preface
The following appendices have been provided to support clinical practice and were developed through discussion and consensus of the guideline committee. The practice guidance herein was informed by review of existing national and international evidence-based clinical practice guidelines issued by recognized addiction medicine organizations and authorities. Where appropriate, Health Canada-approved drug product monographs were consulted to ensure compliance with provincial and national safety regulations and standards for practice.
Recommendations adhere to the CPSBC Professional Standards and Guidelines for Safe Prescribing of Drugs with the Potential for Misuse/Diversion (www.cpsbc.ca/files/pdf/PSG-Safe-Prescribing.pdf).

# Appendix 1 Alcohol Use Screening
In line with available guidelines, this document emphasises the key role of universal and regular substance use screening in health promotion, and specifically recommends screening pregnant patients for alcohol use in the first prenatal assessment (or at the first available opportunity) and re-screening routinely throughout pregnancy and post-partum and as clinically relevant. This appendix provides an instructive overview of the screening process in three steps: Step 1-Starting the Conversation using the Low-Risk Alcohol Drinking Guidelines, Step 2-Screening for High-Risk Alcohol Use, and Step 3 -Assessment and Diagnosis of an AUD.

# Step 1 Starting the Conversation
Introducing the topic of alcohol use to patients in a non-judgmental, conversational, and clear manner can foster a candid conversation and improve the accuracy of self-reported alcohol use. The following strategies are recommended to establish comfort and trust prior to beginning screening questions.

# Use Canada's Low-Risk Alcohol Drinking Guidelines as a Communication Tool
Briefly reviewing Canada's Low-Risk Alcohol Drinking Guidelines (LRADG) handout can help guide conversations toward alcohol use screening. Clinicians may use the LRADG handouts to provide patients with general information regarding the risks of alcohol use to the patient and fetus while clarifying concepts that would enhance the accuracy of alcohol screening, such as what is meant by "alcoholic beverages" and standard drink sizes.

# Sample Script:
" Have you heard about Canada's Low-Risk Alcohol Drinking Guidelines? I talk to all of my patients about these guidelines. They contain important information about safer alcohol use that everyone needs to know. "

# Secure consent and assure the patient of the confidentiality of the conversation
Patients' reluctance to share information about their alcohol use can be a barrier to obtaining accurate screening results and establishing an effective therapeutic relationship for next steps. It is important to::
- Ask the patient's permission before screening - Assure the patient of the confidentiality of the information they share - Emphasize that you ask all your patients about alcohol use

# Sample Script:
" I regularly ask my patients about alcohol and other substance use. Would it be alright for us to talk about this now?"
" Now that we've talked about some of the effects of alcohol, would you mind if I ask you some questions about your alcohol use?"
Step 2 Screening for High-Risk Alcohol Use
In consideration of the time constraints reported by clinicians providing prenatal care, this guideline has recommended a simplified and stepped screening method using a single alcohol screening question (SASQ) to identify alcohol use in pregnant individuals. In addition to a brief sample script for this abbreviated screening process, this appendix presents alternative screening methods validated for pregnant patients. Clinicians are encouraged to select a screening approach based on their clinical experience and judgement.

# SASQ sample script
" Do you sometimes drink beer, wine, or other alcoholic beverages?"
No: Screening is complete.
- Offer encouragement.
- Review the LRADG, emphasising that abstinence is recommended during pregnancy.
- If patient reports not drinking, ask about their alcohol use history:
- Offer encouragement to patients with a personal or family history of AUD who have stopped drinking since they have become pregnant; ask if they have encountered challenges in the process, and offer encouragement and support as needed.
- Rescreen annually frequently depending on personal and family history.

# Yes:
Positive result for high-risk drinking.
- Ask about the patient's average weekly alcohol consumption in standard drinks over the past three months to assess risk and determine whether a diagnostic test is needed (record amounts for follow-up sessions):
- Ask patient: "On average, how many days a week do you drink alcohol?"
- Ask patient: "On a typical drinking day, how many drinks do you have?"
- (Drinking days x number of drinks per drinking day = weekly average).
- If deemed useful, clinicians may choose to use an additional pregnancy-validated screening tool (e.g., AUDIT, AUDIT-C, T-ACE, TWEAK) to assess risk prior conducting the diagnostic test (See below for a review of additional screening tools).
- If patient's self-reported drinking is above low-risk limits for non-pregnant female adults, or if their responses are vague or inconsistent with the clinician's observations, proceed to diagnosis and assessment for AUD (Step 3).
- All patients screening positive for alcohol use should receive brief intervention (Appendix 2).

# Additional screening tools AUDIT and AUDIT-C
The Alcohol Use Disorders Identification Test (AUDIT) was developed by the World Health Organization (WHO) to assist in the early identification of "hazardous" g or "harmful" h alcohol consumption. The AUDIT is a well-studied and commonly used alcohol screening tool which has been validated for a wide range of settings and populations, including pregnant individuals. This tool consists of 10 questions that may enable the administrator to obtain relatively comprehensive information about a patient's alcohol consumption patterns at present and over the past year. 5 Each question is assigned a score between 0-4 that corresponds to frequency of occurrence, resulting in a total score ranging from 0 to 40 points. For adult patients, a score of 8 or higher is associated with "problem drinking, " while 13 or more indicates alcohol dependence. This AUDIT questionnaire takes approximately 3-4 minutes to complete and score.
The condensed AUDIT-Consumption (AUDIT-C) tool, which consists of three questions focusing on frequency and quantity of alcohol use, uses sex-specific cut-off points: in adult patients who were assigned female at birth, a score of 3 or higher indicates hazardous or harmful drinking. This condensed questionnaire takes approximately one minute to complete and score.
The WHO and the US Preventive Health Services Task Force recommend use of the AUDIT or AUDIT-C for detection of hazardous or harmful drinking in all adult primary care patient populations. 61,162,163 Similarly, a recent article examining the potential of adequate alcohol screening and harmonized data collection for the prevention of FASD has found that the AUDIT-C contains the required elements for clinicians to ascertain pregnant patients' pattern of alcohol use in a relatively compact format. 164 However, provider-level barriers, including lack of experience and time constraints (which are of particular concern in the context of pregnancy), have been cited as barriers to more widespread uptake and use of these tools in primary care. 11,48, As an alternative, self-administered print and electronic versions of these questionnaires are available and can be provided to patients to complete in advance of scheduled clinical appointments or while they are waiting to be seen. Self-administered versions of the AUDIT and AUDIT-C appear to be as effective as clinician-administered screening for the identification of hazardous or harmful alcohol use. 168 Another potential limitation of the AUDIT and AUDIT-C is that the low-risk limits and standard drink sizes used in these instruments are slightly different from those indicated in Canada's Low-Risk Alcohol Drinking Guidelines. The US Centers for Disease Control and Prevention have made adaptations in the standard drink size and cut-off points for use in the United States of America; a similar adjustment in accordance to the LRADG would significantly enhance the utility of AUDIT-C as a validated compact tool for alcohol screening during pregnancy. 164 The AUDIT and AUDIT-C questionnaires are provided in Boxes 1 and 2 below.
g Hazardous use: A pattern of alcohol use that increases the risk of harmful physical and/or mental health consequences as well as social consequences for the individual. Hazardous use occurs in the absence of addiction or alcohol use disorder. h Harmful use: A pattern of alcohol use associated with health consequences and/or that causes damage to health. Damage may be physical or mental.
Harmful use commonly, but not invariably, has adverse social consequences, but social consequences alone are not sufficient to justify a diagnosis of harmful use. Harmful use occurs in the absence of addiction or alcohol use disorder. (ICD-10 code, previously known as "non-dependent use" in .

# Box 1 The Alcohol Use Disorders Identification Test ( AUDIT ) 169
Read questions as written. Record answers carefully. Begin the AUDIT by saying "Now I am going to ask you some questions about your use of alcoholic beverages during this past year." Explain what is meant by "alcoholic beverages" by using local examples of beer, wine, vodka, etc. Code answers in terms of "standard drinks". Place the correct answer number in the box at the right.
- How often do you have a drink containing alcohol? In female patients, a score of 3 or more is considered positive for hazardous drinking.
If score is positive, proceed to diagnosis and assessment for AUD.
Total score:

# T-ACE
The Tolerance, Annoyed, Cut down, Eye opener (T-ACE) is the first screening tool validated for pregnant patients, and is currently recommended by the American College of Obstetrics and Gynecology and the National Institute of Alcohol Abuse and Alcoholism. 60 This tool is regularly used as a part of primary care for this population due to its brevity, clarity, and ease of administration. 60 The T-ACE was developed through a substantial simplification of the 25-question Michigan Alcohol Screening Test (MAST) into a 4-item questionnaire which has a similar structure to the CAGE tool. 171 The T-ACE takes approximately one minute to conduct and score. The T-ACE questionnaire is provided in Box 3.

# Box 3 The T-ACE Tool T-ACE

# Questions Points
Tolerance How many drinks does it take to make you feel the first effect (before pregnancy)? 3 or more = 2 points

# Annoyed
Have people ever annoyed you by criticizing you about your drinking?
Yes = 1 point

# Cut down
Do you sometimes feel the need to cut down your drinking? Yes = 1 point Eye Opener Do you sometimes take a drink in the morning when you first get up?
Yes = 1 point Patients who score 2 or higher on the T-ACE should be referred for further assessment for alcohol use disorder.

# TWEAK
Tolerance, Worry, Eye-opener, Amnesia, Cut down (TWEAK) is a 5-question screening tool developed specifically for pregnant patients. As a slight variation of the T-ACE, TWEAK combines features from CAGE and MAST. This method is suitable for use in primary care settings and takes less than 2 minutes to administer and score. The result is calculated on a 7-point scale, and a score of 2 or higher indicates high risk drinking.5,54
The TWEAK questionnaire is provided in Box 4. 

# Worried
Have close friends or relatives worried or complained about your drinking in the past year?
Yes = 2 points Eye Opener Do you sometimes take a drink in the morning when you first get up?
Yes = 1 point Amnesia (stands for blackouts)
Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?
Yes = 1 point Eye Opener Do you sometimes feel the need to cut down on your drinking?
Yes = 1 point
Step 3 Assessment and Diagnosis of an Alcohol Use Disorder
Any continued alcohol use in the course of pregnancy constitutes high-risk drinking and indicates the need for further assessment, and, if appropriate, a structured interview using the DSM-5 criteria to confirm the diagnosis and severity of AUD (see Box 5 below).
Patients who are drinking above low-risk limits but do not have an AUD should receive a brief counselling intervention and be encouraged to discontinue alcohol consumption during pregnancy(see Appendix 2).
Brief intervention alone is not an effective intervention for individuals with an AUD.172 Patients who are diagnosed with an AUD should be offered treatment and care options for withdrawal management and continuing care. Baseline assessment and other withdrawal management considerations, including sample dosing schedules, are outlined in Appendix 3. Appendix 4 offers an instructive overview of continuing AUD pharmacotherapies while Appendix 5 outlines the key principles and considerations for motivational interviewing, a recommended evidence-based psychosocial intervention for AUD.

# Box 5 DSM-5 Diagnostic Criteria for Alcohol Use Disorder 173
A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period, indicates presence of an AUD.

# Sample Clinical Interview Questions 174
In the past year (12 months), have you...
Alcohol is often taken in larger amounts or over a longer period than was intended Had times when you ended up drinking more, or longer, than you intended?
There is a persistent desire or unsuccessful efforts to cut down or control alcohol use More than once wanted to cut down or stop drinking, or tried to, but couldn't? 
Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol Continued to drink even though it was making you feel depressed or anxious, or adding to another health problem? Or, continued drinking after having a memory blackout?
Tolerance, as defined by either of the following: a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect b) A markedly diminished effect with continued use of the same amount of alcohol Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before?
Withdrawal, as manifested by either of the following: a) The characteristic withdrawal syndrome for alcohol b) Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms
Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, restlessness, nausea, sweating, a racing heart, or a seizure? Or sensed things that were not there?
Severity: MILD: presence of 2-3 symptoms, MODERATE: presence of 4-5 symptoms, SEVERE: presence of 6 or more symptoms.
Modifiers for the diagnosis include:
- Early remission: After full criteria for AUD were previously met, none of the criteria for AUD have been met (with the exception of craving) for at least 3 months but less than 12 months. - Sustained remission: After full criteria for AUD were previously met, none of the criteria for AUD have been met
(with the exception of craving) during a period of 12 months or longer. - Controlled environment: If the individual is in an environment where access to alcohol is restricted.
Ask Be mindful of the impact our behaviors can have on people with a history of trauma:
- Utilize universal precautions for creating a calm and welcoming environment. This includes minimizing noise, decreasing clutter, maintaining a comfortable temperature
- Be aware of internal emotions and thoughts and focus on those that bolster support for the patient - Be aware of your tone of voice and physical space as you introduce yourself and your role and explain the collaborative process planned (Practical note: ensure that you do not physically block the patent's pathway to the door)
- Respond and communicate respectfully (e.g., ask what name they would like to be called, their gender, their partner's gender, and what pronouns they prefer. Validate patient's gender identity, sexual orientation, and preferences for how they wish to be addressed)
- Listen intently to understand responses and their context
- Commit to setting aside your own judgements and thoughts about screening results
- Maintain awareness of your language and tone of voice when responding.
- Screen patient for alcohol use. See Appendix 1 for detailed guidance on screening
- Express appreciation for answering sensitive screening questions

# Advise
- Clearly describe the screening result and its implications on the health of the patient and fetus
- Provide direct personalized recommendations
- Where possible, relay relevant health risks in reference to patient's concerns, including risks to the fetus:
"You are drinking more than is medically safe, and this is putting your health (and the health of the fetus) at risk...."
"I recommend that you cut down or stop drinking."

# Assess
- Engage patient in a brief conversation to assess and encourage motivation, ability to reduce or discontinue their alcohol use at this time - Identifying strengths rather than deficits will enhance change talk; use this approach when discussing how to achieve a higher number if that's their goal
- Recognize that anything the patient is willing to do to address the issue is a step in the right direction
- Connect the patient to others who may be able to meet any needs that are outside your scope of practice
- Reinforce that you are here to help and that this is an ongoing discussion. Ideally, you want patients to always feel comfortable to discuss these issues with you during visits
- Document the agreed upon plan so you can engage in informed follow-up during the next appointment

# Arrange
If patient has met, or made progress towards, planned intervention goal:
- Congratulate, reinforce, and support continued change
- Coordinate care with referral partners if the patient has accessed additional support. Communicate with external/community agencies on patient's progress
- Assess and address any co-occurring medical conditions and mental health symptoms (e.g., insomnia, depression, anxiety) noting that these may improve with reduction in alcohol use
- With the patient's consent, assist with identifying new goals according to patient's intentions, and schedule follow-up appointments
If patient has been unable to meet planned intervention goal: