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The United States is experiencing an epidemic of opioid use, addiction, and neonatal abstinence syndrome. Consequentially, a great deal of public, and public health, attention has turned toward the timely recognition of pregnant women who use drugs. We explore the clinical efficacy and ethical acceptability of different methods of identification—contrasting drug testing (using biologic samples such as urine) with screening (using an instrument or questionnaire) under both universal and selective approaches within the current legal and social landscape, which is fraught with potential adverse consequences for both the woman and her child. Unlike other medical conditions such as diabetes, the sequelae of drug use in pregnancy can go beyond the clinical, because its assessment may result in child removal as well as maternal arrest, prosecution, and punishment. Although universal voluntary screening using a validated instrument is the most reasonable public health strategy, physicians should advocate for that only as strongly as they advocate for social support and addiction care services for those subsequently identified.