Table of Contents
Clinical Takeaway
Prenatal alcohol exposure frequently occurs alongside use of other substances including cannabis, tobacco, and opioids, meaning clinical screening must address polysubstance use rather than alcohol alone. Identifying co-occurring substance use patterns during pregnancy allows providers to offer more targeted counseling and appropriate referrals. No amount of alcohol has been established as safe during pregnancy, and concurrent substance use may compound 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.
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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. Polysubstance use during pregnancy is driven partly by maternal mental health problems and partly by socioeconomic stress, not randomly distributed.
Why This Matters Clinically
Clinicians screening for prenatal alcohol exposure need to ask about concurrent substance use, since the risk profile changes when multiple substances are involved. Understanding whether a patient is using alcohol alone versus alcohol-plus helps guide counseling and may reveal underlying mental health or social determinants that need independent attention.
Study Snapshot
| Study Design | Cross-sectional analysis from a prospective multicenter longitudinal cohort (HBCD Study) |
| Population | 1,426 pregnant individuals from a 27-site US study examining effects of alcohol, cannabis, tobacco, and opioids |
| Intervention | Observational; no intervention. Substance use measured by self-report and ethanol biomarkers |
| Primary Outcome | Prevalence and patterns of prenatal alcohol use with and without concurrent other substances |
| Key Result | 12.7% used more-than-minimal alcohol; of those, 37% used alcohol plus at least one other substance (most commonly alcohol, cannabis, and/or nicotine). Mental health disorders associated with both patterns; higher SES with alcohol-only, lower SES with polysubstance use |
Where This Paper Deserves Skepticism
This is a descriptive cross-sectional snapshot, not a causal study, so the associations with mental health and SES are correlational and we cannot infer direction or mechanism. The abstract does not specify how ‘more-than-minimal’ was defined or whether the comparison group truly abstained or simply fell below the threshold, which could affect the apparent prevalence. Reliance on self-report for substance use in pregnancy is subject to underreporting bias, and the degree to which biomarkers validated self-report is unclear from this abstract. We also do not know the demographic breakdown of the sample or whether the 27 sites are representative of the US pregnant population.
Dr. Caplan’s Take
This study fills a useful gap by documenting that polysubstance use is common among pregnant drinkers and is not random. The associations with mental health and SES suggest we are looking at populations under stress, not simply bad choices. For clinicians, this means screening for concurrent cannabis, tobacco, and opioid use when we identify prenatal alcohol exposure, and routinely assessing mental health and social stressors rather than assuming substance use is purely volitional. The data align with what we see clinically: pregnancy does not cure addiction or anxiety, and poverty and untreated psychiatric illness drive polysubstance patterns.
Clinical Bottom Line
Screen pregnant patients who use alcohol for concurrent substance use and underlying mental health or socioeconomic stressors. Polysubstance use during pregnancy is common enough and patterned enough to warrant routine inquiry and targeted intervention beyond alcohol counseling alone.
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