Table of Contents
Clinical Takeaway
Prenatal alcohol exposure frequently occurs alongside use of cannabis, tobacco, or opioids rather than in isolation, making co-use an important clinical reality providers should screen for actively. Identifying concurrent substance use during pregnancy allows for more targeted counseling and coordinated care to reduce compounded fetal risk.
#3 Substance use patterns among individuals who consume alcohol during pregnancy: Results from a US multi-site study.
Citation: Bakhireva Ludmila N et al.. Substance use patterns among individuals who consume alcohol during pregnancy: Results from a US multi-site study.. Drug and alcohol dependence. 2026. PMID: 41797178.
Design: 2 Journal: 0 N: 4 Recency: 3 Pop: 3 Human: 1 Risk: 0
Methodological Considerations:
- Self-reported outcomes — recall and social-desirability bias risk
Abstract: INTRODUCTION: Prenatal alcohol exposure (PAE) is common and associated with adverse outcomes, yet the impact of concurrent substance use remains poorly understood. Using HEALthy Brain and Child Development (HBCD) data (n = 1426), we described alcohol use patterns-with and without other substances-and examined factors associated with alcohol use in pregnancy. METHODS: Data were obtained from the HBCD Study public release 1.0, a 27-site longitudinal cohort examining normative development and the effects of four primary substances (alcohol, cannabis, tobacco, and opioids). More-than-minimal PAE was assessed by self-report and ethanol biomarkers. Participants were classified into 3 study groups: a) Alcohol-Only; b) Alcohol-Plus (alcohol with ≥1 other substance); and c) Comparison (alcohol use below the threshold and negative ethanol biomarkers). Correlates of alcohol use were assessed via polychotomous logistic regression contrasting two alcohol-use categories relative to a common reference group. RESULTS: More-than-minimal alcohol use occurred in 12.7% of participants, with 37% of these also using other substances. The most common polysubstance use pattern was a combination of alcohol, cannabis, and/or nicotine, which occurred, in different combinations, among 28% of participants. Maternal mental health disorders were positively associated with both Alcohol-Only and Alcohol-Plus use. Higher socioeconomic status (SES) was associated with Alcohol-Only use, whereas lower SES was associated with Alcohol-Plus use. CONCLUSIONS: Over one-third of pregnant individuals who used alcohol also used at least one additional substance. Observed associations with maternal mental health and SES highlight opportunities for targeted policy, enhanced screening, and tailored interventions to support maternal and child health.
What This Study Teaches Us
Among pregnant people who drink alcohol, more than one-third are also using cannabis, tobacco, or opioids. Maternal mental health disorders and socioeconomic status emerge as key correlates, with lower SES linked to polysubstance use patterns rather than alcohol alone.
Why This Matters Clinically
Clinicians screening for prenatal alcohol exposure need to know that asking about alcohol alone misses a substantial portion of pregnant patients with concurrent substance use, which likely compounds risk. Understanding the demographic and mental health profiles associated with these patterns can sharpen screening priorities and intervention design.
Study Snapshot
| Study Design | Multi-site prospective cohort study using baseline data from the Healthy Brain and Child Development (HBCD) Study |
| Population | 1,426 pregnant individuals from 27 US sites; alcohol use assessed by self-report and ethanol biomarkers |
| Intervention | Observational study; no intervention. Participants classified into three groups based on alcohol use patterns with or without concurrent cannabis, tobacco, or opioids |
| Primary Outcome | Prevalence and patterns of polysubstance use among those with prenatal alcohol exposure; demographic and clinical correlates (mental health, socioeconomic status) |
| Key Result | 12.7% of participants had more-than-minimal alcohol use; 37% of those also used at least one additional substance. Maternal mental health disorders associated with both alcohol-only and polysubstance use; lower SES associated with alcohol-plus patterns |
Where This Paper Deserves Skepticism
The abstract is sparse on methodological detail: we don’t know study completion rates, how substances were ascertained (biomarker vs. self-report), or what ‘more-than-minimal’ alcohol exposure actually means quantitatively. The cross-sectional baseline snapshot tells us about prevalence and associations, not causation or longitudinal outcomes. No mention of how well the 27-site sample represents the broader US pregnant population, and the timing of substance use measurement during pregnancy is unclear from the abstract alone.
Dr. Caplan’s Take
This study validates what many clinicians see in practice: pregnant patients using alcohol often have other substance involvement, and these patterns cluster with mental health comorbidity and economic stress. The finding that lower SES predicts polysubstance use (not alcohol-only) is important because it suggests different intervention leverage points depending on the patient profile. We should be screening more systematically for concurrent cannabis and nicotine use in pregnant patients who acknowledge any alcohol, and we should treat maternal depression and anxiety as central levers, not peripheral factors. The data don’t tell us optimal screening tools or interventions yet, but they frame the problem more honestly.
Clinical Bottom Line
Prenatal alcohol screening is incomplete without concurrent questions about cannabis, tobacco, and opioid use. Mental health assessment and socioeconomic context are essential to understanding why a pregnant person drinks during pregnancy, not just whether they do.
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