Substance use disorder treatment admissions and state-level prenatal substance use policies: Evidence from a national treatment database

Substance Use-Associated Infant Maltreatment Report Rates in the Context of Complex Prenatal Substance Use Policy Environments

State responses to substance use during pregnancy have included policies designed to increase access to substance use treatment as well as punish such substance use. Prior research has found that punitive policies are associated with increased rates of child maltreatment reporting, but it is unclear if the presence of punitive-promoting policies also moderate the association between access-promoting polices and maltreatment reports. Using data from the National Child Abuse and Neglect Data System and state-level fixed effects models, this study investigates how interactions between access-promoting and punitive prenatal substance use policies are associated with rates of substance use-associated maltreatment reports among infants. In states with punitive policies, access-promoting policies were associated with smaller decreases in these reports than in states without punitive policies. In some cases, access-promoting policies were associated with greater increases in these reports when punitive policies were also present than when only one type of policy was adopted. Interactions between prenatal substance use policies may result in unintended and counterproductive consequences for maternal and child health and the child welfare system.

Pre-COVID Trends in Substance Use Disorders and Treatment Utilization During Pregnancy in West Virginia 2016-2019

Introduction: Access to prenatal care offers the opportunity for providers to assess for substance use disorders (SUDs) and to offer important treatment options, but utilization of treatment during pregnancy has been difficult to measure. This study presents pre-COVID trends of a subset of SUD diagnosis at the time of delivery and related trends in treatment utilization during pregnancy. Materials and Methods: A retrospective cohort design was used for the analysis of West Virginia Medicaid claims data from 2016 to 2019. Diagnosis of SUDs at the time of delivery and treatment utilization for opioid use disorder (OUD) and non-OUD diagnosis during pregnancy across time were the principal outcomes of interest. This study examined data from n = 49,398 pregnant individuals. Results: Over the 4-year period, a total of 2,830 (5.7%) individuals had a SUD diagnosis at the time of delivery. The frequency of opioid-related diagnoses decreased by 29.3%; however, non-opioid SUD diagnoses increased by 55.8%, with the largest increase in the diagnosis of stimulant use disorder (30.9%). Treatment for OUD increased by 13%, but treatment for non-opioid SUD diagnoses during pregnancy declined by 41.1% during the same period. Conclusions: Interventions enacted within West Virginia have improved access and utilization of treatment for OUD in pregnancy. However, consistent with national trends in the general population, non-opioid SUD diagnoses, especially for stimulants, have rapidly increased, while treatment for this group decreased. Early identification and referral to treatment by OB-GYN providers are paramount to reducing pregnancy and postpartum complications for the mother and neonate.

Punitive state policies targeting alcohol use during pregnancy and alcohol consumption among pregnant women

This study aimed to determine whether punitive state alcohol policies targeting pregnant women who drink alcohol are associated with decreased alcohol consumption among pregnant women over time. This study used data from the Pregnancy Risk Assessment Monitoring System (15 states) between 1990 and 2015. A difference-in-difference (DiD) approach was employed to determine whether passage of state laws changed alcohol consumption rates among pregnant women, while controlling for state and time fixed effects. The study specifically examined punitive state alcohol policies that clarify the admissibility of evidence in child welfare proceedings related to prenatal alcohol exposure, focusing on allegations of child abuse, child neglect, child deprivation, or child dependence, as well as proceedings seeking termination of parental rights. Punitive state alcohol policies were not significantly associated with decreased rates of alcohol consumption among pregnant women (+ 1.54%, 95% CI, -1.47-4.55), within 3 years of implementation. State alcohol policies that adopted a punitive stance toward pregnant women who drink alcohol did not result in the reduction of drinking during pregnancy. Given that punitive policies may not effectively reduce alcohol consumption during pregnancy, our findings highlight the need for reevaluation and potential reform to better address maternal/child health outcomes.

Training health professionals to reduce overreporting of birthing people who use drugs to child welfare

BACKGROUND

Health care providers are a key source of reports of infants to child welfare related to birthing people's substance use. Many of these reports are overreports, or reports that exceed what is legally mandated, and reflect racial bias. We developed and evaluated a webinar for health professionals to address overreporting related to birthing people's substance use.

METHODS

This evaluation study collected data from health professionals registering to participate in a professional education webinar about pregnancy, substance use, and child welfare reporting. It collected baseline data upon webinar registration, immediate post-webinar data, and 6 month follow-up data. Differences in both pre-post-and 6 month follow-up data were used to examine changes from before to after the webinars in beliefs, attitudes, and practices related to pregnant and birthing people who use drugs and child welfare reporting.

RESULTS

592 nurses, social workers, physicians, public health professionals, and other health professionals completed the baseline survey. More than half of those completing the baseline survey (n = 307, 52%) completed one or both follow-up surveys. We observed statistically significant changes in five of the eleven opioid attitudes/beliefs and in four of the nine child welfare attitudes/beliefs from baseline to follow-ups, and few changes in "control statements," i.e. beliefs we did not expect to change based on webinar participation. All of the changes were in the direction of less support for child welfare reporting. In particular, the proportion agreeing with the main evaluation outcome of "I would rather err on the side of overreporting to child welfare than underreporting to child welfare" decreased from 41% at baseline to 28% and 31% post-webinar and at 6-month follow up (p = 0.001). In addition, fewer participants endorsed reporting everyone at the 6 month follow-up than at baseline (12% to 22%) and more participants endorsed reporting no one at the 6-month follow-up than at baseline (28% to 18%), p = 0.013.

CONCLUSIONS

Webinars on the legal, scientific, and ethical aspects of reporting that are co-developed with people with lived experience may be a path to reducing health professional overreporting to child welfare related to birthing people's substance use.

Punitive legal responses to prenatal drug use in the United States: A survey of state policies and systematic review of their public health impacts

BACKGROUND

Punitive legal responses to prenatal drug use may be associated with unintended adverse health consequences. However, in a rapidly shifting policy climate, current information has not been summarized. We conducted a survey of U.S. state policies that utilize criminal or civil legal system penalties to address prenatal drug use. We then systematically identified empirical studies evaluating these policies and summarized their potential public health impacts.

METHODS

Using existing databases and original statutory research, we surveyed current U.S. state-level prenatal drug use policies authorizing explicit criminalization, involuntary commitment, civil child abuse substantiation, and parental rights termination. Next, we systematically identified quantitative associations between these policies and health outcomes, restricting to U.S.-based peer-reviewed research, published January 2000-December 2022. Results described study characteristics and synthesized the evidence on health-related harms and benefits associated with punitive policies. Validity threats were described narratively.

RESULTS

By 2022, two states had adopted policies explicitly authorizing criminal prosecution, and five states allowed pregnancy-specific and drug use-related involuntary civil commitment. Prenatal drug use was grounds for substantiating civil child abuse and terminating parental rights in 22 and five states, respectively. Of the 16 review-identified articles, most evaluated associations between punitive policies generally (k = 12), or civil child abuse policies specifically (k = 2), and multiple outcomes, including drug treatment utilization (k = 6), maltreatment reporting and foster care entry (k = 5), neonatal drug withdrawal syndrome (NDWS, k = 4) and other pregnancy and birth-related outcomes (k = 3). Most included studies reported null associations or suggested increases in adverse outcome following punitive policy adoption.

CONCLUSIONS

Nearly half of U.S. states have adopted policies that respond to prenatal drug use with legal system penalties. While additional research is needed to clarify whether such approaches engender overt health harms, current evidence indicates that punitive policies are not associated with public health benefits, and therefore constitute ineffective policy.

"They just looked at me like I was human": The experiences of parenting women and providers with substance use disorder treatment

BACKGROUND

The current US addiction treatment system does not effectively meet the needs of pregnant and parenting women with substance use disorder (SUD). The aim of this research was to identify barriers and facilitators to engagement and retention in SUD residential treatment for pregnant and parenting women. This research was part of a co-design process to collaboratively create a more patient-centered long-term residential program.

DESIGN AND METHODS

The study conducted semi-structured individual interviews with both parenting women with lived experience (WWLE) in residential SUD treatment and SUD treatment providers. Interviews aimed to elicit participants' experiences either receiving or providing care. The study team analyzed data in NVivo-12 using a deductive codebook based on the six principles of trauma informed care (TIC).

RESULTS

We conducted a total of 32 interviews (WWLE =13, SUD providers =19). The study identified four major themes: 1) peer relationships provide inspiration and diminish shame; 2) providing individuals safe space to stumble in recovery creates opportunities for growth and builds self-efficacy; 3) reasonable, clear boundaries create a structured, protective environment for early recovery; 4) nonjudgmental connections facilitate engagement and build trust. We identified small pivotal moments along the continuum of care that showed how the elements in the four themes enhanced engagement and retention in treatment. These interactions, along the care continuum, are either structural (workflow process) or relational (interpersonal).

CONCLUSION

This research increases understanding of the interplay of the structural and relational barriers and facilitators to engagement and retention in treatment. These seemingly minor positive or negative interactions along the care continuum are pivotal to fully operationalizing TIC and optimizing women's engagement in treatment. Improvement strategies that integrate the voices of WWLE and collaboratively co-design a more patient-centered system are critical steps to improving engagement in SUD treatment and more equitable SUD treatment services.

'It opened my eyes, my ears, and my heart': Codesigning a substance use disorder treatment programme

BACKGROUND

Pregnant and parenting women have low engagement and poor retention in substance use disorder (SUD) treatment. The aim of this study was to analyse the implementation of an adapted experience-based codesign (EBCD) process involving SUD treatment staff and pregnant or parenting women with lived experience (WWLE) of SUD to launch a residential treatment service where women could coreside with their children and receive long term comprehensive treatment for dual diagnosis of SUD and mental illness.

METHODS

A process evaluation was conducted utilising five data sources: two sets of semistructured interviews with WWLE and SUD treatment staff, ethnographic observation and transcripts from group events, and meeting minutes. Based on the Integrated Promoting Action on Research in Health Services framework constructs (context, recipients, facilitation, innovation) researchers applied thematic analysis to determine main themes within each construct.

RESULTS

The full sample across the implementation totalled 34 individuals (WWLE = 13 and SUD staff = 21). The EBCD process engaged both cohorts and supported group cohesion and collaborative brainstorming. WWLE felt respected, emotionally safe to share, and empowered by participation. A cohesive, multidisciplinary codesign planning group, inclusive of WWLE, supported a more equitable codesign process. The need for a virtual platform due to the COVID-19 pandemic impeded human connection and relationship building. The complex environment of residential regulations and uncertainties during start-up phase of an organisation presented implementation challenges.

CONCLUSION

These results highlight the feasibility of, and challenges to, effectively engaging WWLE in a codesign process. The findings also demonstrated a positive influence on WWLE's feelings of empowerment. Identified themes reinforce the purposeful components within EBCD that enhance participation, along with new insights to inform successful codesign with a vulnerable population. The author's team included a WWLE who collaborated throughout the full scope of the research process, enriching the overall research and ensuring the authenticity of the presentation of women in recovery's perspective. Utilising the codesign approach to design and implement new services should improve health equity by enhancing patient engagement and retention in care.

PATIENT CONTRIBUTION

Parenting WWLE of residential SUD treatment were involved in the full scope of the research process and the implementation being evaluated. For the actual codesign work WWLE were key members of the codesign planning team that met weekly throughout the implementation to plan, implement, problem solve and adapt the process over an 18 month timeframe. As is appropriate for codesign the actual ongoing workgroup participants had average 50% WWLE participation. For the research team, this research is a culmination of the lead author's doctoral dissertation. One member of the five-person dissertation committee was a recovery coach and a WWLE. She was an active participant across the entire research process overseeing and influencing the research design, conduct of the study, analysis, interpretation of findings and approval of the final manuscript. The findings were member checked with the larger codesign planning group that had additional WWLE members.

Self-fulfilling Prophecy: Does Structural and Interpersonal Bias Against Pregnant and Postpartum People With Substance Use Disorders Undermine Parenting Identity?

ABSTRACT

Pregnant and parenting people with substance use disorders are a highly stigmatized group. Structural and interpersonal bias contribute to reluctance to engage in prenatal, postpartum, and well-child care for this population. Two studies described in this issue of the Journal of Addiction Medicine explore the implications of health care provider-family relationships on experience of care for birthing people with substance use disorders and their infants. Patient voices describe how intensive monitoring of infants for sequelae of substance exposure and that being scrutinized as caregivers undermined their confidence as parents, contributed to self-blame, and damaged their trust in health care teams. Data from these studies suggest that the voices of pregnant and parenting individuals need to be present at local, regional, and national levels to mitigate harm when redesigning programs for this population.

Prenatal Substance Exposure and Neonatal Abstinence Syndrome: State Estimates from the 2016-2020 Transformed Medicaid Statistical Information System

INTRODUCTION

Estimating Neonatal Abstinence Syndrome (NAS) and prenatal substance exposure rates in Medicaid can help target program efforts to improve access to services.

METHODS

The data for this study was extracted from the 2016-2020 Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF) Research Identifiable Files (RIF) and included infants born between January 1, 2016 and December 31, 2020 with a either a NAS diagnosis or prenatal substance exposure.

RESULTS

Between 2016 and 2020, the estimated national rate of NAS experienced a 18% decline, while the estimated national rate of prenatal substance exposure experienced a 3.6% increase. At the state level in 2020, the NAS rate ranged from 3.2 per 1000 births (Hawaii) to 68.0 per 1000 births (West Virginia). Between 2016 and 2020, 28 states experienced a decline in NAS births and 20 states had an increase in NAS rates. In 2020, the lowest prenatal substance exposure rate was observed in New Jersey (9.9 per 1000 births) and the highest in West Virginia (88.1 per 1000 births). Between 2016 and 2020, 38 states experienced an increase in the rate of prenatal substance exposure and 10 states experienced a decline.

DISCUSSION

Estimated rate of NAS has declined nationally, but rate of prenatal substance exposure has increased, with considerable state-level variation. The reported increase in prenatal substance exposure in the majority of US states (38) suggest that substances other than opioids are influencing this trend. Medicaid-led initiatives can be used to identify women with substance use and connect them to services.

Pregnancy-specific alcohol policies and admissions to substance use disorder treatment for pregnant people in the USA

AIMS

We examined relationships between pregnancy-specific alcohol policies and admissions to substance use disorder treatment for pregnant people in the USA.

METHODS

We merged state-level policy and treatment admissions data for 1992-2019. We aggregated data by state-year to examine effects of nine pregnancy-specific alcohol policies on the number of admissions of pregnant women where alcohol was reported as the primary, secondary, or tertiary substance related to the treatment episode (N = 1331). We fit Poisson models that included all policy variables, state-level controls, fixed effects for state and year, state-specific time trends, and an offset variable of the number of pregnancies in the state-year to account for differences in population size and fertility.

RESULTS

When alcohol was reported as the primary substance, civil commitment [incidence rate ratio (IRR) 1.45, 95% CI: 1.10-1.89] and reporting requirements for assessment and treatment purposes [IRR 1.36, 95% CI: 1.04-1.77] were associated with greater treatment admissions. Findings for alcohol as primary, secondary, or tertiary substance were similar for civil commitment [IRR 1.31, 95% CI: 1.08-1.59] and reporting requirements for assessment and treatment purposes [IRR 1.21, 95% CI: 1.00-1.47], although mandatory warning signs [IRR 0.84, 95% CI: 0.72-0.98] and priority treatment for pregnant women [IRR 0.88, 95% CI: 0.78-0.99] were associated with fewer treatment admissions. Priority treatment findings were not robust in sensitivity analyses. No other policies were associated with treatment admissions.

CONCLUSIONS

Pregnancy-specific alcohol policies related to greater treatment admissions tend to mandate treatment rather than make voluntary treatment more accessible, raising questions of ethics and effectiveness.

Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023)

Background: The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments. Key Information: Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are specific benefits and risks for substance-exposed mother-infant dyads. Recommendations: This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For specific breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.

Assessing the clinical utility of toxicology testing in the peripartum period

BACKGROUND

Toxicology testing is frequently used as a means of gathering objective data about substance use in pregnancy, but little is known about the clinical utility of testing in the peripartum setting.

OBJECTIVE

This study aimed to characterize the utility of obtaining maternal-neonatal dyad toxicology testing at the time of delivery.

STUDY DESIGN

We performed a retrospective chart review of all deliveries in a single healthcare system in Massachusetts between 2016 and 2020, and identified deliveries with either maternal or neonatal toxicology testing at delivery. An unexpected result was defined as a positive test for a nonprescribed substance that was not known on the basis of clinical history, self-report, or previous toxicology testing within a week of delivery, excluding results for cannabis. We evaluated the characteristics of maternal-infant dyads with unexpected positive results, unexpected positive results by rationale for testing, changes in clinical management after an unexpected positive test, and maternal outcomes in the year after delivery using descriptive statistics.

RESULTS

Of the 2036 maternal-infant dyads with toxicology tests performed during the study period, there were 80 (3.9%) with an unexpected positive result. Diagnosis of substance use disorder with active use in the last 2 years was the clinical rationale for testing that yielded the greatest number of unexpected positive results (10.7% of total tests ordered for this rationale). Inadequate prenatal care (5.8%), maternal use of medication for opioid use disorder (3.8%), maternal medical indications such as hypertension or placental abruption (2.3%), history of substance use disorder in remission (1.7%), or maternal cannabis use (1.6%) yielded lower rates of unexpected results compared with a recent substance use disorder (within the last 2 years). Solely on the basis of findings from unexpected test results, 42% of dyads were referred to child protective services, 30% of dyads had no documentation of maternal counseling during delivery hospitalization, and 31% did not receive breastfeeding counseling after an unexpected test; 22.8% had monitoring for neonatal opioid withdrawal syndrome. Postpartum, 26 (32.5%) were referred to substance use disorder treatment, 31 (38.8%) attended a postpartum mental health visit, and only 26 (32.5%) attended a postpartum visit. Fifteen individuals (18.8%) were readmitted in the year after delivery, all for substance-related medical complications.

CONCLUSION

Unexpected positive toxicology results at delivery were uncommon, particularly when tests were sent for frequently used clinical rationales for testing, suggesting a need to revisit guidelines surrounding appropriateness of indications for toxicology testing. The poor maternal outcomes in this cohort highlight a missed opportunity for maternal connection to counseling and treatment in the peripartum period.

Racial/ethnic differences in medication for addiction treatment for opioid use disorders among pregnant women in treatment facilities supported by state funds

INTRODUCTION

Medication for addiction treatment (MAT) for opioid use disorder (OUD) in pregnant women is known to improve neonatal health outcomes. Despite the benefits of this evidence-based treatment for OUD, MAT has been underutilized during pregnancy among certain racial/ethnic groups of women in the United States. The purpose of this study was to examine racial/ethnic differences and factors that affect MAT administration among pregnant women with OUD seeking treatment at publicly funded facilities.

METHODS

We used data from the 2010-2019 Treatment Episode Data Set system. The analytic sample included 15,777 pregnant women with OUD. We built logistic regression models to examine associations between race/ethnicity and MAT and determine differences and similarities in factors that may influence the use of MAT across racial/ethnic groups of pregnant women with OUD.

RESULTS

Although in this sample only 31.6 % received MAT, an increasing trend of MAT receipt has been observed during 2010-2019. Approximately 44 % of the Hispanic pregnant women received MAT, and this was significantly higher than non-Hispanic Black (27.1 %) and White (31.3 %) women. Even after adjusting for potential confounders, the adjusted odds of receiving MAT during pregnancy were lower for Black (AOR = 0.57, 95 % CI 0.44, 0.75) and White (AOR = 0.75, 95 % CI 0.61, 0.91) women compared to Hispanic women. Not being in the labor force increased the odds of receiving MAT in Hispanic women relative to their employed counterparts while homelessness or dependent living decreased the odds of MAT for White women compared to those living independently. Regardless of their racial/ethnic background, pregnant women younger than 29 years old were less likely to receive MAT relative to older women; however, if they were arrested once prior to admission to treatment, they had significantly higher odds of receiving MAT than those with no arrests. Treatment of at least 7 months was associated with a higher likelihood of MAT across all racial/ethnic groups.

CONCLUSIONS

This study highlights the underutilization of MAT, particularly among pregnant Black and White women who seek treatment for OUD in publicly funded treatment facilities. A multi-dimensional approach to MAT intervention programs is needed to increase MAT for all pregnant women and reduce racial/ethnic inequities.

Annual Research Review: Prenatal opioid exposure - a two-generation approach to conceptualizing neurodevelopmental outcomes

Opioid use during pregnancy impacts the health and well-being of two generations: the pregnant person and the child. The factors that increase risk for opioid use in the adult, as well as those that perpetuate risk for the caregiver and child, oftentimes replicate across generations and may be more likely to affect child neurodevelopment than the opioid exposure itself. In this article, we review the prenatal opioid exposure literature with the perspective that this is not a singular event but an intergenerational cascade of events. We highlight several mechanisms of transmission across generations: biological factors, including genetics and epigenetics and the gut-brain axis; parent-child mechanisms, such as prepregnancy experience of child maltreatment, quality of parenting, infant behaviors, neonatal opioid withdrawal diagnosis, and broader environmental contributors including poverty, violence exposure, stigma, and Child Protective Services involvement. We conclude by describing ways in which intergenerational transmission can be disrupted by early intervention.

Implementation of State Laws Giving Pregnant People Priority Access to Drug Treatment Programs in the Context of Coexisting Punitive Laws

BACKGROUND

In response to increased prenatal drug use since the 2000s, states have adopted treatment-oriented laws giving pregnant and postpartum people priority access to public drug treatment programs as well as multiple punitive policy responses. No prior studies have systematically characterized these state statutes or examined implementation of state priority access laws in the context of co-existing punitive laws.

METHODS

We conducted legal mapping to examine state priority access laws and their overlap with state laws deeming prenatal drug use to be child maltreatment, mandating reporting of prenatal drug use to child protective services, or criminalizing prenatal drug use. We also conducted interviews with 51 state leaders with expertise on their states' prenatal drug use laws to understand how priority access laws were implemented.

RESULTS

Thirty-three states and the District of Columbia have a priority access law, and more than 80% of these jurisdictions also have one of the punitive prenatal drug use laws described. Leaders reported major barriers to implementing state priority access laws, including the lack of drug treatment programs, stigma, and conflicts with punitive prenatal drug use laws.

CONCLUSIONS

Our results suggest that state laws granting pregnant and postpartum people priority access to drug treatment programs are likely insufficient to significantly increase access to evidence-based drug treatment. Punitive state prenatal drug use laws may counteract priority access laws by impeding treatment seeking. Findings highlight the need to allocate additional resources to drug treatment for pregnant and postpartum people.

Racial and ethnic disparities in chronic disease risk in adolescence after prenatal polydrug exposure: Examination of the Hispanic paradox

Racial disparities exist in fetal development which in turn can influence growth and development of chronic disease later in life. The purpose of this study was to explore potential racial and ethnic differences in chronic disease risk factors throughout the pediatric years given prenatal exposure to substance use. Data from the Maternal Lifestyle Study cohort was used for this analysis. Urine toxicology confirmed maternal substance use (y/n) and offspring height, weight, and systolic blood pressure (SBP) data at 16 years was analyzed. Linear mixed effects modeling with an interaction term for adolescent race/ethnicity and maternal drug use assessed growth trajectories (body mass index (BMI) percentile) and cardiovascular disease risk factors (elevated SBP). Of the sample (n = 1,388 mother/infant dyads), 23% (n = 319) of mothers used three substances during pregnancy and 14% (n = 200) used four or five. Controlling for BMI, Hispanic adolescents prenatally exposed to any singular substance had 13 mmHg higher SBP at age 16 than their unexposed counterparts (95% Confidence Interval [CI]: 12.24, 14.01). Prenatal exposure to >1 substance significantly lowered SBP in Hispanic adolescents only. Results here showed that Hispanic adolescents exposed to singular substance are at higher risk of elevated SBP in adolescence, but SBP decreased when exposed to >1 substance. The Hispanic paradox may play a role; future studies should continue to explore this. Additionally, barriers to prenatal care for Hispanic women should be addressed in order to prevent substance use during pregnancy which can reduce chronic disease risk in offspring adolescence.

Supportive alcohol policy as a key element of fetal alcohol spectrum disorder prevention

In Canada, a Four-Part Model of Fetal Alcohol Spectrum Disorder (FASD) Prevention has been developed that describes a continuum of multi-sectoral efforts, including broad awareness campaigns, safe and respectful conversations around pregnancy and alcohol use, and holistic and wraparound support services for pregnant and postpartum women with alcohol, and other health and social concerns. Supportive alcohol policy is at the centre of the four mutually reinforcing levels of prevention. The purpose of this narrative review is to describe alcohol policies related to specific levels of FASD prevention, and to consider the implications of alcohol policies on FASD prevention and women's and fetal health. The majority of the evidence focused on alcohol in pregnancy guidelines, alcohol warning labels, and knowledge and uptake of national or regional alcohol and pregnancy guidelines. Several US studies described shifts in alcohol and pregnancy policy over the 7-year period, including moves to punitive approaches that criminalize women's substance use or prompt child apprehension. This review indicates that more attention could be paid to the role of alcohol policy in FASD prevention and in promoting women's and fetal health, and that policy actions and advocacy could be important catalysts for both FASD prevention and women's health promotion. Moving forward, it is essential that alcohol policies are rooted in evidence; attend to and promote women's health including health during pregnancy; and are collaborative in order to prompt a higher standard of care, and more holistically respond to the factors that contribute to women's alcohol use during pregnancy.

The Implementation of the Tennessee Fetal Assault Law and Its Association With Out-of-State Births Among Residents of Tennessee

INTRODUCTION

This study analyzed the association between the implementation of the Tennessee Fetal Assault Law (TFAL), which allowed prosecutors to incarcerate people who used substances during pregnancy, and out-of-state births among residents of Tennessee.

METHODS

The main data source is vital records on singleton births in hospitals to people aged 15-44 years during the period January 2010 to June 2016. We include data from 33 states and the District of Columbia where birth certificate data are comparable over this time period. The statistical significance of the difference in outcomes observed before and after TFAL implementation was tested using a difference-in-differences analysis between Tennessee and the comparison group.

RESULTS

After TFAL implementation, the odds of having an out-of-state birth increased by 13% for residents of Tennessee (odds ratio, 1.13; 95% confidence interval, 1.09-1.16) relative to residents of the comparison states. When we adopted different thresholds for travel distances to the birth hospital, the odds of residents of Tennessee having an out-of-state birth more than 75 miles away increased by 17% (odds ratio, 1.17; 95% confidence interval, 1.13-1.21) after TFAL implementation.

CONCLUSION

The results of this study suggest that the implementation of a policy allowing incarceration of people who use substances during pregnancy is associated with an increase in out-of-state births, potentially putting pregnant people and their infants at greater risk.

Development and Implementation of State and Federal Child Welfare Laws Related to Drug Use in Pregnancy

Policy Points Over the past several decades, states have adopted policies intended to address prenatal drug use. Many of these policies have utilized existing child welfare mechanisms despite potential adverse effects. Recent federal policy changes were intended to facilitate care for substance-exposed infants and their families, but state uptake has been incomplete. Using legal mapping and qualitative interviews, we examine the development of state child welfare laws related to substance use in pregnancy from 1974 to 2019, with a particular focus on laws adopted between 2009 and 2019. Our findings reveal policies that may disincentivize treatment-seeking and widespread implementation challenges, suggesting a need for new treatment-oriented policies and refined state and federal guidance.

CONTEXT

Amid increasing drug use among pregnant individuals, legislators have pursued policies intended to reduce substance use during pregnancy. Many states have utilized child welfare mechanisms despite evidence that these policies might disincentivize treatment-seeking. Recent federal changes were intended to facilitate care for substance-exposed infants and their families, but implementation of these changes at the state level has been slowed and complicated by existing state policies. We seek to provide a timeline of state child welfare laws related to prenatal drug use and describe stakeholder perceptions of implementation.

METHODS

We catalogued child welfare laws related to prenatal drug use, including laws that defined child abuse and neglect and established child welfare reporting standards, for all 50 states and the District of Columbia (DC), from 1974 to 2019. In the 19 states that changed relevant laws between 2009 and 2019, qualitative interviews were conducted with stakeholders to capture state-level perspectives on policy implementation.

FINDINGS

Twenty-four states and DC have passed laws classifying prenatal drug use as child abuse or neglect. Thirty-seven states and DC mandate reporting of suspected prenatal drug use to the state. Qualitative findings suggested variation in implementation within and across states between 2009 and 2019 and revealed that implementation of changes to federal law during that decade, intended to encourage states to provide comprehensive social services and linkages to evidence-based care to drug-exposed infants and their families, has been complicated by existing policies and a lack of guidance for practitioners.

CONCLUSIONS

Many states have enacted laws that may disincentivize treatment-seeking among pregnant people who use drugs and lead to family separation. To craft effective state laws and support their implementation, state policymakers and practitioners could benefit from a treatment-oriented approach to prenatal substance use and additional state and federal guidance.

Association of State Child Abuse Policies and Mandated Reporting Policies With Prenatal and Postpartum Care Among Women Who Engaged in Substance Use During Pregnancy

Importance

Some states have implemented policies that consider substance use during pregnancy as child abuse and require mandated reporting of substance use during pregnancy. Implications of these policies for health care receipt among pregnant people who engage in substance use are unknown.

Objective

To examine the association of state child abuse policies and mandated reporting policies with prenatal and postpartum care among women who engaged in substance use during pregnancy.

Design, Setting, and Participants

In this cross-sectional study, data from the 2016-2019 Pregnancy Risk Assessment Monitoring System survey were analyzed. The study population included 4155 women from 23 states who reported substance use during pregnancy. Data were analyzed between August and November 2021.

Exposures

Delivery in a state with a child abuse policy only (n = 6), a mandated reporting policy only (n = 4), both policies (n = 7), or neither policy (n = 5). One state switched from a mandated reporting policy only to having both policies.

Main Outcomes and Measures

Month of gestation at prenatal care initiation (ie, months 1-10, with a higher number of months indicating later initiation), receipt of adequate prenatal care, and receipt of a postpartum health care visit 4 to 6 weeks after delivery. Sample characteristics were calculated using unweighted frequencies and weighted percentages and means. Associations of state policies with the outcomes were examined using generalized linear regression with generalized estimating equations, adjusting for potential confounders and accounting for the complex sampling design of the Pregnancy Risk Assessment Monitoring System survey.

Results

The study sample included 4155 women who reported substance use during pregnancy; 33.9% of these women delivered in states with a child abuse policy only, 16.4% in states with a mandated reporting policy only, 32.9% in states with both policies, and 16.8% in states with neither policy. Overall, 14.7% of women were Black, 69.0% were White, and 64.6% were aged 18 to 29 years at delivery. Women who delivered in states with a child abuse policy only, mandated reporting policy only, or both policies initiated prenatal care at a later month of gestation (β = 0.44 [95% CI, 0.10-0.78], 0.32 [95% CI, 0.04-0.59], and 0.40 [95% CI, 0.09-0.72], respectively) and had a lower likelihood of adequate prenatal care (risk ratio, 0.85 [95% CI, 0.79-0.91], 0.94 [95% CI, 0.87-1.01], and 0.95 [95% CI, 0.89-1.03], respectively) and a postpartum health care visit (risk ratio, 0.89 [95% CI, 0.82-0.96], 0.89 [95% CI, 0.80-0.98], and 0.92 [95% CI, 0.83-1.02], respectively) compared with women who delivered in states with neither policy.

Conclusions and Relevance

The results indicate that state child abuse policies and mandated reporting policies are associated with reduced receipt of prenatal and postpartum care among women who engage in substance use during pregnancy.

Impact of prenatal substance use policies on commercially insured pregnant females with opioid use disorder

INTRODUCTION

States' approaches to addressing prenatal substance use are widely heterogeneous, ranging from supportive policies that enhance access to substance use disorder (SUD) treatment to punitive policies that criminalize prenatal substance use. We studied the effect of these prenatal substance use policies (PSUPs) on medications for opioid use disorder (OUD) treatment, including buprenorphine, naltrexone, and methadone, psychosocial services for SUD treatment, opioid prescriptions, and opioid overdoses among commercially insured pregnant females with OUD. We evaluated: (1) punitive PSUPs criminalizing prenatal substance use or defining it as child maltreatment; (2) supportive PSUPs granting pregnant females priority access to SUD treatment; and (3) supportive PSUPs funding targeted SUD treatment programs for pregnant females.

METHODS

We analyzed 2006-2019 MarketScan Commercial Claims and Encounters data. The longitudinal sample comprised females aged 15-45 with an OUD diagnosis at least once during the study period. We estimated fixed effects models that compared changes in outcomes between pregnant and nonpregnant females, in states with and without a PSUP, before and after PSUP implementation.

RESULTS

Our analytical sample comprised 2,438,875 person-quarters from 164,538 unique females, of which 13% were pregnant at least once during the study period. We found that following the implementation of PSUPs funding targeted SUD treatment programs, the proportion of opioid overdoses decreased 45% and of any OUD medication increased 11%, with buprenorphine driving this increase (13%). The implementation of SUD treatment priority PSUPs was not associated with significant changes in outcomes. Following punitive PSUP implementation, the proportion receiving psychosocial services for SUD (12%) and methadone (30%) services decreased. In specifications that estimated the impact of criminalizing policies only, the strongest type of punitive PSUP, opioid overdoses increased 45%.

CONCLUSION

Our findings suggest that supportive approaches that enhance access to SUD treatment may effectively reduce adverse maternal outcomes associated with prenatal opioid use. In contrast, punitive approaches may have harmful effects. These findings support leading medical organizations' stance on PSUPs, which advocate for supportive policies that are centered on increased access to SUD treatment and safeguard against discrimination and stigmatization. Our findings also oppose punitive policies, as they may intensify marginalization of pregnant females with OUD seeking treatment.

Association between U.S. state prenatal drug use laws and child welfare reporting in Alabama, Maryland and Utah

BACKGROUND

Over the past decade, states have passed several laws on prenatal drug use, including "maltreatment laws" deeming prenatal drug use child maltreatment, "reporting laws" requiring providers to report prenatal drug use to Child Protective Services (CPS) and "criminalization laws" that criminalize prenatal drug use.

METHOD

We examined the association between a 2012 Utah maltreatment law, a 2013 Alabama maltreatment and criminalization law, and a 2014 Maryland reporting law on the rate of infant CPS reports using 2010-2017 National Child Abuse and Neglect Data System data. We conducted an event study comparing CPS reporting pre/post law in each treatment state with reporting in a pool of control states over the same period. Regression models included state and year fixed effects and state-level demographics. We triangulated quantitative results with qualitative interviews of 11 state leaders whose professional responsibilities included implementation of the state law.

RESULTS

We found no association between Alabama's simultaneous maltreatment and criminalization laws and infant reporting. Maryland's reporting law (28.2 fewer reports per 1000 infants, 95%CI: [-42.9, -13.6], 4-years post-law) and Utah's maltreatment laws (31.0 fewer CPS reports per 1000 infants, 95%CI: [-61.2, -0.8], 6-years post-law) were associated with declines in infant CPS reports. Qualitative results suggest that the reduced reporting associated with Maryland's reporting and Utah's maltreatment laws may be due to increased perceived stigma resulting from the law, and health providers' distrust of CPS and/or confusion about reporting to CPS.

CONCLUSION

Future research should characterize differential policy implementation across states and counties and identify policy impacts on treatment seeking behavior.

Prenatal substance use policies and newborn health

We study the effect of punitive and priority treatment policies relating to illicit substance use during pregnancy on the rate of neonatal drug withdrawal syndrome, low birth weight, low gestational age, and prenatal care use. Punitive policies criminalize prenatal substance use, or define prenatal substance exposure as child maltreatment in child welfare statutes or as grounds for termination of parental rights. Priority treatment policies are supportive and grant pregnant women priority access to substance use disorder treatment programs. Our empirical strategy relies on administrative data from 2008 to 2018 and a difference-in-differences framework that exploits the staggered implementation of these policies. We find that neonatal drug withdrawal syndrome increases by 10%-18% following the implementation of a punitive policy. This growth is accompanied by modest reductions in prenatal care, which may reflect deterrence from healthcare utilization. In contrast, priority treatment policies are associated with small reductions in low gestational age (2%) and low birth weight (2%), along with increases in prenatal care use. Taken together, our findings suggest that punitive approaches may be associated with unintended adverse pregnancy outcomes, and that supportive approaches may be more effective for improving perinatal health.

Association of prenatal substance use with prenatal and postpartum care: Evidence from the Pregnancy Risk Assessment Monitoring System, 2016-2019

The objective of this study was to build on existing qualitative research to estimate the association of prenatal substance use with prenatal and postpartum care. We used data from the 2016-2019 Pregnancy Risk Assessment Monitoring System for 9 states. We conducted adjusted linear regression to compare month of gestation of first prenatal visit and adjusted logistic regression to compare receipt of adequate prenatal care and a postpartum healthcare visit among women who reported prenatal use of any opioids, prescription opioids, marijuana, and illicit drugs to those who did not report use of each substance. Women who reported prenatal use of any opioids (Risk Difference(RD) = 0.16; 95% Confidence Interval (CI) = 0.04, 0.28), prescription opioids (RD = 0.16; 95% CI = 0.04, 0.28), marijuana (RD = 0.25; 95% CI = 0.10, 0.41) and illicit drugs (RD = 0.52; 95% CI = 0.09, 0.95) initiated prenatal care later than those who did not report use of each substance. Women who reported prenatal use of any opioid (Odds Ratio (OR) = 0.82; 95% CI = 0.68, 1.00), prescription opioids (OR = 0.84; 95% CI = 0.69, 1.02), marijuana (OR = 0.59; 95% CI = 0.48, 0.73) and illicit drugs (OR = 0.29; 95% CI = 0.20, 0.42) were less likely to receive adequate prenatal care. Women who reported prenatal use of any opioid (OR = 0.82, 95% CI = 0.65, 1.04), prescription opioids (OR = 0.83; 95% CI = 0.66, 1.05), marijuana (OR = 0.65; 95% CI = 0.51, 0.82) and illicit drugs (OR = 0.47; 95% CI = 0.30, 0.72) had a lower likelihood of a postpartum visit than those who did not report use of each substance. Results indicate potential intervention points for pregnant women who use substances.

“We Have to Keep Advocating and Helping and Doing What We Can”: Examining Perinatal Substance Use Services in the Absence of Integrated Treatment Programs

Effective treatment of substance-exposed pregnancies requires gender-responsive care coordinated across agencies and systems. A deeper understanding of the perspectives, experience, and practices of professionals providing these services is needed to improve care. This study examines service provision for perinatal substance use through the perspectives and experiences of healthcare and social service professionals. Using a constructivist grounded theory design, data were collected over a 7-year period. Data collection consisted of interviews and focus groups with professionals as well as observations of professional meetings and workshops where practices and procedures were discussed. A multi-level model of service delivery is described. The role of affect, particularly around issues of custody, is discussed along with structural level actions that develop in the absence of integrated treatment. Structural support both within and across systems of care is crucial to developing coordinated and compassionate care and to increasing engagement in care services.

Child Abuse Prevention and Treatment Act, family care plans and infants with prenatal substance exposure: Theoretical framework and directions for future research

In May 2021, a reauthorization of the Child Abuse Prevention and Treatment Act (CAPTA) was introduced in the U.S. Senate. This reauthorization substantially amends provisions concerning infants affected by prenatal substance exposure and decidedly shifts the policy from a child safety- to a public health-focused approach to achieve the larger goals of healthy and safe child development and caregiver recovery from substance use disorder. Despite its honorable aspirations, no research has tested whether CAPTA "works". To advance scholarship on this policy, we summarize the service needs for this population and clarify how the CAPTA reauthorization aims to address these needs. We then apply a health utilization theory to understanding the mechanisms of effect on maternal-child outcomes. Based on this theoretical analysis, we discuss directions for future research.

Prenatal Substance Use Policies And Infant Maltreatment Reports

We studied the effect of state punitive and supportive prenatal substance use policies on reports of infant maltreatment to child protection agencies. Punitive policies criminalize prenatal substance use or define it as child maltreatment, whereas supportive policies provide pregnant women with priority access to substance use disorder treatment programs. Using difference-in-differences methods, we found that total infant maltreatment reports increased by 19.0 percent after punitive policy adoption during the years of our study (2004-18). This growth was driven by a 38.4 percent increase in substantiated reports in which the mother was the alleged perpetrator. There were no changes in unsubstantiated reports after the adoption of punitive policies. We observed no changes in infant maltreatment reports after the adoption of supportive policies. Findings suggest that punitive policies lead to large increases in substantiated infant maltreatment reports, which in turn may lead to child welfare system involvement soon after childbirth in states with these policies. Policy makers should design interventions that emphasize support services and improve well-being for mothers and infants.

"I Grew Up Amidst Alcohol and Drugs:" a Qualitative Study on the Lived Experiences of Parental Substance Use Among Adults Who Developed Substance Use Disorders Themselves

Experiencing parental substance use (PSU) has been associated with a heightened risk of developing substance use disorders (SUDs) in offspring. The primary goal of this study was to explore perspectives of adult children with lived experience of PSU who also developed SUDs themselves through first-hand experience. This study was conducted in Flanders (Belgium). A qualitative exploratory research design was applied. Seventeen semi-structured interviews were conducted with adult children of parents with SUDs (range: 29-48 years) who themselves had developed SUDs. All interviews were audio-taped and transcribed verbatim. Three overarching themes emerged through thematic analysis: 1) loneliness and neglect in childhood; 2) stigma and the self; and 3) the role of social connection in substance use and recovery. The narratives highlighted the central role of feelings of loneliness, isolation and belonging among children of parents with SUDs in childhood and adulthood. Increasing public awareness on the impact of PSU on children and accessible support is needed to overcome stigma and remove barriers to social inclusion for children of parents with SUDs. Findings may prove valuable in informing policy, program and treatment development aimed at breaking maladaptive intergenerational cycles.

Does self-reported consumption of heroin correlate with dose of methadone among pregnant people with opioid use disorder?

BACKGROUND

The prevalence of opioid use disorder (OUD) during pregnancy is increasing in the United States. However, evidence to guide appropriate dosing of pharmacotherapy for treatment of OUD, such as methadone, based on self-reported opioid use during pregnancy is scant.

OBJECTIVE

To examine the relationship between self-reported consumption of heroin and methadone dose among pregnant people with opioid use disorder (OUD) admitted to the hospital for methadone (MTD) titration.

STUDY DESIGN

This is an analysis of a single-site retrospective cohort of pregnant people admitted for management of OUD at an urban, tertiary care center between 2013 and 2020. Patient-reported consumption of heroin was evaluated by clinical staff and described as self-reported dollar amount of heroin consumed per day. The primary outcome was MTD dose at the time of discharge. The secondary outcome was MTD dose at time of delivery. Bivariate and linear regression modeling were performed. A priori covariates included in the model were: epoch of admission, Clinical Opioid Withdrawal Scale score at time of admission, gestational age at admission, and need for readmission due to recurrent opioid use. A sensitivity analysis was performed using propensity score matching. Statistical significance was set at p < 0.05.

RESULTS

Of 100 people admitted during the study period, 53 and 47 individuals met inclusion criteria for the primary and secondary outcome, respectively. On bivariate and multivariate linear regression modeling, self-reported dollar amount of heroin consumed per day was independently associated with dose of MTD at the time of discharge. For every ten dollars of heroin consumed, the dose of MTD increased by 1.3 mg (95% CI: 0.4 mg to 2.2 mg). On sensitivity analysis with use of a propensity score, self-reported dollar amount of heroin consumed per day was independently associated with dose of MTD at the time of discharge. There was no significant relationship between self-reported dollar amount of heroin consumed per day and MTD dose at time of delivery.

CONCLUSIONS

Self-reported dollar amount of heroin consumed per day was independently associated with dose of MTD at the time of discharge, but not at time of delivery. These data can be useful in clinical counseling and management of pregnant people with OUD admitted for initiation of MTD.

Black clients in expansion states who used opioids were more likely to access medication for opioid use disorder after ACA implementation

INTRODUCTION

Black people in the United States who use opioids receive less treatment and die from overdoses at higher rates than White people. Medication for opioid use disorder (MOUD) decreases overdose risk. Implementation of the Affordable Care Act (ACA) in the United States was associated with an increase in MOUD. To what extent racial disparity exists in MOUD following ACA implementation remains unclear. Using a national sample of people seeking treatment for opioids (clients), we compared changes in MOUD after the ACA to determine whether implementation was associated with increased MOUD for Black clients relative to White clients.

METHODS

We identified 878,110 first episodes for clients with opioids as primary concern from SAMHDA's Treatment Episodes Dataset-Admissions (TEDS-A; 2007-2018). We performed descriptive and logistic regression analyses to estimate odds of MOUD for Black and White clients by Medicaid expansion status. We interacted ACA implementation with racial group and performed subpopulation analyses for Medicaid enrollees and criminal justice-referred clients.

RESULTS

In expansion states post-ACA, MOUD increased from 33.6% to 51.3% for White clients and from 36.2% to 61.7% for Black clients. Pre-ACA, Black clients were less likely than White clients to use MOUD (adjusted odds ratio (aOR) = 0.88, 99th Confidence Interval (CI) = [0.85, 0.91]), and post-ACA, the change in odds of MOUD did not differ. Criminal justice-referred clients experienced less of a change in odds of MOUD among Black clients than among White clients (aOR = 0.74, CI = [0.62, 0.89]). Among Medicaid-insured clients, the change in odds of MOUD among Black clients was larger (aOR = 1.16, CI = [1.03, 1.30]). In the non-expansion states before 2014, Black clients were less likely to receive MOUD (aOR = 0.86, CI = [0.77, 0.95]) than White clients. After 2014, the change in odds of MOUD increased more for Black clients relative to White clients (aOR = 1.24, CI = [1.07, 1.44]). We did not find significant changes in MOUD for clients referred through the criminal justice system or with Medicaid.

CONCLUSION

The ACA was associated with increased use of MOUD among Black clients and reduction in treatment disparity between Black and White clients. For criminal justice-referred Black clients, disparities in MOUD persist. Black clients with Medicaid in expansion states had the greatest reduction in disparities.

Gender Dynamics in Substance Use and Treatment: A Women's Focused Approach

Gender impacts substance use initiation, substance use disorder development, engagement with treatment, and harms related to drug and alcohol use. Using the biopsychosocial model of addiction, this review provides a broad summary of barriers and facilitators to addiction services among women. It also reviews substance use among pregnant and parenting women and approaches to care. Given the increasing rates of substance use among women, there is a need to implement and scale-up gender-responsive addiction programming and pursue advocacy at the policy level that addresses the root drivers of substance use inequities among women.

Association between punitive policies and neonatal abstinence syndrome among Medicaid-insured infants in complex policy environments

AIMS

To estimate the association between punitive policies for women with substance use during pregnancy and odds of neonatal abstinence syndrome (NAS) diagnosis among Medicaid-insured infants, and to estimate this association controlling for the presence of four other policies related to substance use in pregnancy.

DESIGN, SETTING AND PARTICIPANTS

Analysis of live births in Medicaid claims data from 39 US states in varying years between 2006 and 2014 using weighted generalized linear models with clustered standard errors and state and year fixed-effects.

MEASUREMENTS

NAS rates in states without punitive policies were compared with rates in states with policies before and after policy enactment using logistic regression models adjusted for individual and county-level factors and including state and year fixed-effects. We estimated odds of NAS controlling for the presence of a potentially treatment-deterring policy requiring reporting of suspected prenatal substance use, and three treatment-supportive policies that create targeted programs for pregnant and postpartum women, prioritize pregnant women's access to substance use disorder treatment programs and prohibit discrimination towards pregnant women in treatment programs.

FINDINGS

Among 9 714 798 weighted live births (1 896 082 unweighted), 49 670 (0.51%) had an NAS diagnosis. The findings were inconclusive as to whether or not punitive policies were associated with odds of NAS either in the short or long term. Odds of NAS among infants born in states with reporting policies were lower than those born in states without such policies [adjusted odds ratio (aOR) = 0.77, 95% confidence interval (CI) = 0.61-0.98].

CONCLUSIONS

In the United States, punitive policies for women with substance use during pregnancy do not appear to be associated with lower odds of neonatal abstinence syndrome (NAS). Reporting policies, which are heterogenous in their components and implementation, appear to be associated with lower odds of NAS when controlling for other relevant policies.

Provider Perspectives of Barriers to Contraceptive Access and Use among Women with Substance Use Disorders

OBJECTIVES

Previous studies conducted from the patient perspective indicate that women with substance use disorders (SUDs) experience extensive barriers to contraceptive access and use (CAU), but there is limited research investigating this topic from the provider perspective. We explored provider perspectives on the barriers to CAU for women with SUDs. As a secondary objective, we highlighted provider contraceptive counseling strategies to address patient CAU barriers.

METHODS

We conducted 24 qualitative interviews with a purposeful sample of women's health providers, including medical doctors, nurse practitioners, and certified nurse-midwives. We used thematic analysis to code the interviews with inductive codes and organized findings according to levels of influence within the Dahlgren and Whitehead rainbow model, a socioecological model of health.

RESULTS

Provider-reported barriers to CAU were identified at four levels of socioecological influence and included reproductive misconceptions; active substance use; trauma, interpersonal violence, and reproductive coercion; limited social support; lack of housing, employment, health insurance, and transportation; stigma; discrimination; and punitive prenatal substance use policies and child welfare reporting requirements. Strategies for addressing CAU barriers mainly focused on patient-centered communication, including open information exchange, shared decision-making, and relationship building. However, providers described disproportionately highlighting the benefits of long-acting reversible contraception (LARC) and directing conversations toward LARC when they perceived that such methods would help patients to overcome adherence and other challenges related to active substance use or logistical barriers. Notably, there was no mention of CAU facilitators during the interviews.

CONCLUSIONS

Providers perceived that women with SUDs experience a range of CAU barriers, which they addressed within the clinical setting through use of both patient-centered communication and highlighting the benefits of LARC when they perceived that such methods would help clients to overcome barriers. Improving CAU for women with SUDs will require multidisciplinary, multipronged strategies that prioritize reproductive autonomy and are implemented across clinical, community, and policy settings.

Estimating the impact on initiating medications for opioid use disorder of state policies expanding Medicaid and prohibiting substance use during pregnancy

BACKGROUND

Medicaid expansion increased access to addiction treatment services for pregnant women. However, states' imposition of civil or criminal child abuse sanctions for drug use during pregnancy could inhibit access to treatment. We estimated the effects of Medicaid expansion on pregnant women's medications for opioid use disorder (MOUD) use, and its interaction with statutes that prohibit substance use during pregnancy.

METHODS

Using the Treatment Episode Dataset for Discharge (2010-2018), we identified the initial treatment episode of pregnant women with opioid use disorder (OUD). We described changes in MOUD use and estimated adjusted difference-in-differences and event study models to evaluate differences in changes in MOUD between states that prohibit substance use during pregnancy and states that do not.

FINDINGS

Among a total of 16,070 treatment episodes for pregnant women with OUD from 2010 to 2018, most (74%) were in states that expanded Medicaid. By one year post-expansion, the proportion of episodes receiving MOUD in states not prohibit substance use during pregnancy increased by 8.7% points (95% CI: 2.7, 14.7) from the pre-expansion period compared to a 5.6% point increase in states prohibiting substance use during pregnancy (95% CI: -3.3, 14.8). In adjusted event study analysis, the expansion was associated with an increase in MOUD use by 15.3% by year 2 in states not prohibiting versus 1.5% percentage points in states prohibiting substance use during pregnancy, respectively.

CONCLUSIONS

State policies prohibiting substance use during pregnancy may limit the salutary effects of Medicaid expansion for pregnant women who could benefit from MOUD treatment.

A Non-Randomized Trial of In-Person Versus Text/Telephone Screening, Brief Intervention and Referral to Treatment for Pregnant and Postpartum Women

Background

Systems of care that improve mental health and substance use disorder Screening, Brief Intervention and Referral to Treatment (SBIRT) for pregnant and postpartum women are needed.

Aims

The aim of this study is to determine if women receiving prenatal care from January 2020 to April 2021 are more likely to be screened, screen positive, be referred for treatment and attend treatment with technology facilitated SBIRT, compared to women receiving prenatal care and in-person SBIRT January 2017 to December 2019.

Materials & Methods

Technology facilitated SBIRT, designated Listening to Women (LTW), includes text message-based screening, phone-based brief intervention, and referral to treatment by a remote care coordinator. A total of 3535 pregnant and postpartum women were included in the quasi-experimental study and data were collected via text message and Electronic Health Record.

Results

In-person SBIRT was completed by 65.2% (1947/2988) of women while 98.9% (547/553) of women approached agreed to take part in LTW and 71.9% (393/547) completed SBIRT via LTW. After controlling for potentially confounding variables, women enrolled in LTW were significantly more likely to be screened (relative risk [RR]: 1.10, 95% CI 1.03-1.16), screen positive (RR 1.91, 95% CI 1.72-2.10), referred to treatment (RR 1.55, 95% CI 1.43-1.69) and receive treatment (RR 4.95, 95% CI 3.93-6.23), compared to women receiving in-person SBIRT. Black women enrolled in LTW were significantly more likely to screen positive (RR 1.65, 95% CI 1.35-2.01), be referred to treatment (RR 1.54, 95% CI 1.35-1.76) and attend treatment (RR 5.49, 95% CI 3.69-8.17), compared to Black women receiving in-person SBIRT.

Discussion

LTW appears to increase the proportion of pregnant and postpartum women receiving key elements of SBIRT.

Heterogeneity in prenatal substance use screening despite universal screening recommendations: findings from the Pregnancy Risk Assessment Monitoring System, 2016-2018

BACKGROUND

The American College of Obstetricians and Gynecologists recommends universal screening for tobacco, alcohol, and drug use as a part of routine prenatal care. However, little is known about the prevalence of prenatal substance use screening or factors that may contribute to differential rates of screening during prenatal care.

OBJECTIVE

This study aimed to describe the prevalence of prenatal substance use screening by substance, year, state, and state-level prenatal substance use policies and to examine individual-level factors associated with receipt of screening.

STUDY DESIGN

We analyzed 2016 to 2018 data from 103,608 women participating in the Pregnancy Risk Assessment Monitoring System, a population-based survey among women with recent live births. The Pregnancy Risk Assessment Monitoring System survey sampling weights were applied to all analyses. We described the percentage of individuals asked by a healthcare worker about substance use during a prenatal care appointment by substance, year, and state. Using chi-squared tests, we examined differences in the prevalence of screening by state-level prenatal substance use policies, including policies regarding classification of prenatal substance use as child abuse or neglect, mandatory testing or reporting of prenatal substance use, and targeted treatment funding and access for pregnant individuals with substance use disorders. Finally, we estimated the association between individual-level characteristics and receipt of prenatal substance use screening using logistic regression, controlling for year and state fixed effects and accounting for missingness using multiple imputation.

RESULTS

In 2018, approximately 95% individuals reported being asked about cigarette or alcohol use during a prenatal care appointment, whereas only 80% reported being asked about drug use. The percentage of individuals who were asked about substance use during a prenatal care appointment increased overall between 2016 and 2018, with variability across states. For all substances, states with laws designating prenatal drug use as child abuse or neglect had lower prevalence of screening, whereas states with laws mandating providers to test for substance use in pregnancy had higher prevalence of screening. Several individual-level characteristics were associated with increased odds of reported prenatal substance use screening for one or more substances, including being younger, less educated, unmarried, Black (vs White), non-Hispanic, or publicly insured (vs privately insured), receiving adequate prenatal care, and having a history of prepregnancy cigarette use.

CONCLUSION

Our study finds that despite recommendations for universal prenatal substance use screening, there are differences in who is actually asked about substance use during prenatal care appointments. This may be influenced by state-level prenatal substance use policies and selective screening approaches in which certain individuals are more likely to be asked about substance use during their prenatal care appointment. A better understanding of the repercussions of selective screening approaches on outcomes and the roles that policies, systems, and provider biases play in perpetuating these approaches is needed to advance guideline implementation efforts in prenatal care settings.

Modernizing Perinatal Substance Use Management

The increase in prescription and illicit opioid use since 2000 has become an urgent public health crisis. While the opioid epidemic spans racial, regional, and socioeconomic divides, women have surfaced as one demographic affected by opioid use and related sequelae. Certain federal and state regulations, secondary to the Child Abuse Prevention and Treatment Act, strip pregnant women with opioid use disorders of the ability to engage autonomously with their health care clinician while simultaneously impeding their ability to achieve and sustain recovery. The purpose of this article is to explore current health policy that impacts pregnant women who use opioids. Recommendations to improve care, broadly, will be highlighted to include access to contraceptive services, universal screening for perinatal substance use, and access to appropriate treatment strategies. Policy modifications to facilitate these recommendations are discussed. The Centers for Disease Control and Prevention Policy Analytical Framework was utilized to derive recommendations. The recommendations are relevant to advanced practice registered nurses and midwives who have the potential to treat substance use in women, to women's health and pediatric registered nurses, and to nursing administrators who are involved in decision-making in obstetric and pediatric settings.

Association Between State-Level Criminal Justice-Focused Prenatal Substance Use Policies in the US and Substance Use-Related Foster Care Admissions and Family Reunification

Importance

States have enacted criminal justice-related substance use policies to address prenatal substance use and protect infants from adverse health effects of parental substance use. However, little is known about the consequences of these policies for permanency outcomes among infants in the foster care system in the United States.

Objectives

To evaluate the consequences of criminal justice-related prenatal substance use policies for family reunification and to examine differences in parental reunification by racial/ethnic group.

Design, Setting, and Participants

In this cohort study using data from the 2005 to 2017 Adoption and Foster Care Analysis and Reporting System, 13 cohorts of infants who entered the foster care system were followed up. States with criminal justice-related prenatal substance use policies were compared with states without such policies before and after their enactment using a discrete-time hazard model adjusted for individual covariates, state, and cohort fixed effects. The sample consisted of 350 604 infants 1 year or younger who had been removed from their home because of parental drug or alcohol use.

Main Outcomes and Measures

Length of time from entering the child welfare system to first reunification with a parent and hazard rates (HRs).

Results

Of the 350 604 infants 1 year or younger, 182 314 (52%) were boys, 251 572 (72%) were non-Hispanic white children, and 160 927 (46%) lived in US states with a criminal justice-focused prenatal substance use policy. Among those who were reunified, 36% of the reunifications occurred during the first year and 45% in the second year. Foster care infants who were removed from their homes because of parental substance use who live in states that have adopted criminal justice-oriented policies had a lower chance of reunification with a parent compared with states that have not adopted those policies (HR, 0.95; 95% CI, 0.94-0.96). Specifically, non-Hispanic black children who live in a state that has adopted criminal justice-oriented policies had a lower chance of reunification with a parent than non-Hispanic black children who live in a state that has not adopted those policies (HR, 0.87; 95% CI, 0.81-0.94).

Conclusions and Relevance

Given the child welfare system's legal mandate to make every effort toward parental reunification, a more comprehensive treatment and supportive policy approach toward parental substance use might be warranted.

Maternal Substance Use: Consequences, Identification, and Interventions

Alcohol, tobacco, and cannabis are the substances most frequently used during pregnancy, and opioid-exposed pregnancies have increased fourfold. The purpose of this review is to describe the prevalence and consequences of prenatal exposure to alcohol, tobacco, cannabis, and opioids. Currently available screening questionnaires for prenatal substance use are summarized and contrasted with the measures available for prenatal alcohol use. Because screening for prenatal alcohol and substance use is but the prelude to efforts to mitigate the potential adverse consequences, attempts for the modification of these consequences are briefly reviewed. In addition, areas of future research related to the criminalization of prenatal substance use, which may inhibit both inquiry and disclosure, are discussed. Indeed, the full potential of effective interventions has yet to be realized.

Consensus Guidelines and State Policies: The Gap Between Principle and Practice at the Intersection of Substance Use and Pregnancy

The opioid crisis has had a substantial effect on women who are pregnant and parenting, focusing both public health and policymaker attention on opioids and on other substance use in pregnancy and postpartum. There is overwhelming consensus on the principle of a non-punitive approach towards substance use in pregnancy. Experts universally endorse supportive policies, which reduce barriers to care, and oppose punitive policies, which can increase the fear of legal penalties, discouraging women from seeking prenatal care and addiction treatment during pregnancy. We review the change over time in state-level policy environments around substance use in pregnancy and contrast the policy response with the principles and guidance from professional societies and federal agencies. Between 2000 and 2015, more states adopted punitive policies than supportive policies, in direct contrast with guidance from professional societies and federal agencies. The increase in punitive policies over the past two decades suggests that the gap between principles and practice is widening. Furthermore, the increase in punitive policies is occurring in the context of significant structural barriers to comprehensive health care across the woman's entire life course, a growing awareness of racial and ethnic inequities in maternal morbidity and mortality, and increasing restrictions at the state level on abortion access. Women with substance use disorder (SUD) need comprehensive, coordinated, evidence-based, trauma-informed, family-centered care. This care should be delivered in a compassionate and non-punitive environment, and clinicians, policymakers, and public health officials all have a role to play in achieving this goal.

Assessment of Racial and Ethnic Disparities in the Use of Medication to Treat Opioid Use Disorder Among Pregnant Women in Massachusetts

Importance

Racial and ethnic disparities persist across key health and substance use treatment outcomes for mothers and infants. The use of medications, such as methadone or buprenorphine, for the treatment of opioid use disorder (OUD) has been associated with improvements in the outcomes of mothers and infants; however, only half of all pregnant women with OUD receive these medications. The extent to which maternal race or ethnicity is associated with the use of medication to treat OUD, the duration of the use of medication to treat OUD, and the type of medication used to treat OUD during pregnancy are unknown.

Objective

To examine the extent to which maternal race and ethnicity is associated with the use of medications for the treatment of OUD in the year before delivery among pregnant women with OUD.

Design, Setting, and Participants

This retrospective cohort study used a linked population-level statewide data set of pregnant women with OUD who delivered a live infant in Massachusetts between October 1, 2011, and December 31, 2015. Of 274 234 total deliveries identified, 5247 deliveries among women with indicators of having OUD were included in the analysis. Maternal race and ethnicity were defined as white non-Hispanic, black non-Hispanic, or Hispanic based on self-reported data on birth certificates.

Main Outcomes and Measures

Main outcomes were the receipt of any medication for OUD, the consistency of the use of medication (at least 6 continuous months of use before delivery, inconsistent use, or no use) for the treatment of OUD, and the type of medication (methadone or buprenorphine) used to treat OUD. Multivariable models were adjusted for maternal sociodemographic characteristics, comorbidities, and any significant interactions between the covariates and race and ethnicity.

Results

The sample included 5247 pregnant women with OUD who delivered a live infant in Massachusetts during the study period. The mean (SD) maternal age at delivery was 28.7 (5.0) years; 4551 women (86.7%) were white non-Hispanic, 462 women (8.8%) were Hispanic, and 234 women (4.5%) were black non-Hispanic. A total of 3181 white non-Hispanic women (69.9%) received any type of medication for the treatment of OUD in the year before delivery compared with 228 Hispanic women (49.4%) and 108 black non-Hispanic women (46.2%). Compared with white non-Hispanic women, black non-Hispanic and Hispanic women had a substantially lower likelihood (adjusted odds ratio [aOR], 0.37; 95% CI, 0.28-0.49 and aOR, 0.42; 95% CI, 0.35-0.52, respectively) of receiving any medication for the treatment of OUD. Stratification by maternal age identified greater disparities among younger women. Black non-Hispanic and Hispanic women also had a lower likelihood (aOR, 0.24; 95% CI, 0.17-0.35 and aOR, 0.34; 95% CI, 0.27-0.44, respectively) of consistent use of medication for the treatment of OUD compared with white non-Hispanic women. With respect to the type of medication used to treat OUD, black non-Hispanic and Hispanic women had a lower likelihood (aOR, 0.60; 95% CI, 0.40-0.90 and aOR, 0.77; 95% CI, 0.58-1.01, respectively) than white non-Hispanic women of receiving buprenorphine treatment compared with methadone treatment.

Conclusions and Relevance

This study found racial and ethnic disparities in the use of medications to treat OUD during pregnancy, with black non-Hispanic and Hispanic women significantly less likely to use medications consistently or at all compared with white non-Hispanic women. Further investigation of patient, clinician, treatment program, and system-level factors associated with these findings is warranted.

Medications for opioid use disorder among pregnant women referred by criminal justice agencies before and after Medicaid expansion: A retrospective study of admissions to treatment centers in the United States

BACKGROUND

Criminal justice involvement is common among pregnant women with opioid use disorder (OUD). Medications for OUD improve pregnancy-related outcomes, but trends in treatment data among justice-involved pregnant women are limited. We sought to examine trends in medications for OUD among pregnant women referred to treatment by criminal justice agencies and other sources before and after the Affordable Care Act's Medicaid expansion.

METHODS AND FINDINGS

We conducted a serial, cross-sectional analysis using 1992-2017 data from pregnant women admitted to treatment facilities for OUD using a national survey of substance use treatment facilities in the United States (N = 131,838). We used multiple logistic regression and difference-in-differences methods to assess trends in medications for OUD by referral source. Women in the sample were predominantly aged 18-29 (63.3%), white non-Hispanic, high school graduates, and not employed. Over the study period, 26.3% (95% CI 25.7-27.0) of pregnant women referred by criminal justice agencies received medications for OUD, which was significantly less than those with individual referrals (adjusted rate ratio [ARR] 0.45, 95% CI 0.43-0.46; P < 0.001) or those referred from other sources (ARR 0.51, 95% CI 0.50-0.53; P < 0.001). Among pregnant women referred by criminal justice agencies, receipt of medications for OUD increased significantly more in states that expanded Medicaid (n = 32) compared with nonexpansion states (n = 18) (adjusted difference-in-differences: 12.0 percentage points, 95% CI 1.0-23.0; P = 0.03). Limitations of this study include encounters that are at treatment centers only and that do not encompass buprenorphine prescribed in ambulatory care settings, prisons, or jails.

CONCLUSIONS

Pregnant women with OUD referred by criminal justice agencies received evidence-based treatment at lower rates than women referred through other sources. Improving access to medications for OUD for pregnant women referred by criminal justice agencies could provide public health benefits to mothers, infants, and communities. Medicaid expansion is a potential mechanism for expanding access to evidence-based treatment for pregnant women in the US.

Neonatal Abstinence Syndrome and Childhood Mental Health Conditions, 2009-2015: Commercial Versus Medicaid Populations

OBJECTIVE

This study aimed to examine mental health conditions of children diagnosed with neonatal abstinence syndrome (NAS) in a commercially insured population and compare them with a multistate Medicaid-insured population identified in prior research.

METHODS

Data from the IBM MarketScan Commercial Database from January 1, 2009, to September 30, 2015, were used to identify mental health conditions among children ages 1-5 both with and without NAS. Frequency analyses were conducted to ascertain intrapopulation differences and differences between the commercially insured and Medicaid populations.

RESULTS

The NAS rate in the Medicaid population was 28.7 times higher than in the commercially insured population. Although the sample of children with NAS was small, and the results must be interpreted with caution, elevated rates of childhood mental health conditions observed in the commercially insured population were comparable to the Medicaid population.

CONCLUSIONS

This analysis emphasizes the difference in rates of NAS between commercially insured and Medicaid populations.

Substance use disorder treatment services for pregnant and postpartum women in residential and outpatient settings

The increasing prevalence of opioid use disorders among pregnant and postpartum women (PPW) has generated a need for greater availability of specialized programs offering evidence-based and comprehensive substance use disorder treatment services tailored to this population. In this study, we used data from the 2007 to 2018 National Survey of Substance Abuse Treatment Services to describe recent time trends and the geographic distribution of treatment facilities with specialized programs for PPW. We also compared differences in the availability of opioid agonist medication treatments (MT), key ancillary services, and health insurance acceptance between PPW Programs and Other Programs, overall and by residential and outpatient settings. We found that the prevalence of PPW Programs increased from 17% in 2007 to 23% in 2018, for a total of 3,429 PPW Programs and 11,230 Other Programs in 2018. The prevalence of PPW Programs was lowest in some states in the South and Midwest. Compared to Other Programs, PPW Programs were more likely to accept Medicaid (75% vs. 64%) and offer opioid agonist MTs methadone (24% vs. 6%), buprenorphine (44% vs. 30%), or both (18% vs. 4%). PPW Programs were also more likely to offer other key ancillary services such as childcare (16% vs. 3%), transportation (50% vs. 42%), and domestic violence assistance (51% vs. 35%). Compared to PPW Programs in outpatient settings, PPW Programs in residential settings were more likely to offer these key ancillary services but less likely to offer methadone or accept Medicaid. Our findings reflect considerable variation in the availability of PPW Programs over time and across states, as well as substantial gaps in key services offered in PPW Programs, let alone in Other Programs.