Treatment outcomes for substance use disorder among women of reproductive age in Massachusetts: a population-based approach

Unmet need for alcohol use disorder treatment in reproductive-age females, with emphasis on pregnant and parenting populations in the United States: Findings from NSDUH 2015-2021

The negative effects of alcohol use can transmit intergenerational harm if alcohol use disorder (AUD) occurs during pregnancy and/or while parenting a child. Prenatal alcohol exposure is the leading preventable cause of congenital anomalies in the USA, and heavy drinking in women has been on the rise, further accelerated by the COVID-19 pandemic. This study describes the most recent patterns in the past year AUD prevalence and treatment among reproductive-aged women, with a specific focus on pregnant and parenting women, and barriers to treatment among those affected. We analyzed data on reproductive-age women from the National Survey on Drug Use and Health (2015-2021). We used generalized linear models to estimate prevalence ratios (PR) for past 12-month AUD and its treatment based on DSM-V criteria. We considered sociodemographic characteristics, including age, race/ethnicity, income, health insurance type, and arrest history. Pregnant and parenting women displayed lower risk for AUD (PR = 0.48, 95% CI:0.41-0.57; PR = 0.5 95% CI:0.48-0.54, respectively) relative to non-pregnant/non-parenting women. Excess risk for AUD was associated with education (some college vs. college graduates, PR = 1.07, 95% CI:1.01-1.13) and history of arrests (PR = 2.93, 95% CI:2.67-3.21). There were no clear differences in AUD treatment use based on parenting or pregnancy status. Among those with AUD, the prevalence of treatment was higher among individuals aged 35-49 years compared to those 18-25 years (PR = 1.6, 95% CI: 1.19-2.14) and in those enrolled in Medicaid vs. private insurance (PR = 2.62, 95%CI:1.97-3.47). Financial barriers and treatment not being a priority were the most frequently reported barriers to treatment. To promote well-being among parents and their children, healthcare providers should prioritize reproductive-age women at higher AUD risk. Decreasing the stigma attached to AUD and intensifying efforts to educate women about the dangers of AUD may improve treatment use among pregnant and parenting women.

Inpatients in substance use treatment with co-occurring psychiatric disorders: a prospective cohort study of characteristics and relapse predictors

BACKGROUND

The characteristics of substance use disorder (SUD) inpatients with co-occurring psychiatric disorders (COD) have been scantly described in the extant literature. This study investigated psychological, demographic and substance use characteristics in these patients, along with predictors of relapse 3 months post-treatment.

METHODS

Prospective data from a cohort of 611 inpatients were analyzed for demographics, motivation, mental distress, SUD diagnosis, psychiatric diagnoses (ICD-10) and relapse rate at 3 months post-treatment (retention rate = 70%).

RESULTS

Compared to patients without COD (n = 322), those with COD (n = 289) were younger, had higher mental distress, lower education and higher likelihood of no permanent residence. The relapse rate was also higher in patients with COD (39.8%) relative to patients without COD (26.4%) (OR = 1.85, 95% CI: 1.23-2.78). The relapse rate was particularly high for patients with COD who were diagnosed with cannabis use disorder (53.3%). Multivariate analysis revealed that among patients with COD, relapse was more likely for individuals with a cannabis use disorder (OR = 2.31, 95% CI: 1.34-4.00), and less likely for older ages (OR = 0.97, 95% CI: 0.94-1.00), females (OR = 0.56, 95% CI: 0.33-0.98) and for those with higher intrinsic motivation (OR = 0.58, 95% CI: 0.42-0.81).

CONCLUSION

This study showed that among SUD inpatients, those with COD had relatively persistent high levels of mental distress and an increased risk of relapse. Enhanced measures aimed at COD patients' mental health problems during the inpatient stay, along with close and personalized follow-up after discharge from residential SUD treatment may reduce the probability of relapse in this group.

A systematic review of gender-responsive and integrated substance use disorder treatment programs for women with co-occurring disorders

Background: Integrated and gender-responsive interventions, designed to target co-occurring substance use and psychiatric disorders in women, may be effective in addressing gender-specific challenges.Objectives: This systematic review aims to identify integrated gender-responsive substance use disorder treatments for women, summarize evaluations of these treatments, and address gaps in the literature.Methods: We searched PsycINFO, PubMed, and MEDLINE on September 24, 2021, and March 10, 2022. Included articles were randomized-controlled trials, secondary analyses of naturalistic studies, or open-label studies of integrated and gender-responsive treatments from any year that assessed both substance use and mental health/trauma outcomes.Results: We identified N = 24 studies (participants = 3,396; 100% women) examining Seeking Safety, Helping Women Recover and Beyond Trauma, A Woman's Path to Recovery, Modified Trauma Recovery and Empowerment Model (TREM), Breaking the Cycle, VOICES, Understanding and Overcoming Substance Misuse, Women's Recovery Group, Female Specific Cognitive Behavioral Therapy, and Moment by Moment in Women's Recovery. Across treatments there were significant improvements over time; Seeking Safety, Helping Women Recover, and TREM were associated with significantly better substance use and mental health outcomes relative to the comparison groups.Conclusions: Integrated gender-responsive treatments are a promising approach to treating women with co-occurring substance use and mental health concerns, and broad clinical implementation stands to benefit women. However, there remains a lack of studies evaluating substance use treatments in women with severe mental illness (e.g., psychotic-spectrum disorders) who differ in their needs and capacity.

Risk factors for emergency room use and rehospitalization among opioid-exposed newborns in Massachusetts

OBJECTIVE

To determine the risk factors for receipt of emergency room (ER) care and rehospitalization among opioid-exposed newborns in Massachusetts.

DESIGN/METHODS

We analyzed two linked data sets from 2002 to 2010: (a) Massachusetts Pregnancy to Early Life Longitudinal Data System and (b) Massachusetts Bureau of Substance Abuse Services Management Information System. Generalized estimating equations were used to assess the independent association of maternal and infant characteristics with ER use and rehospitalization in the first year of life.

RESULTS

Four thousand and five hundred and twenty-four maternal-infant dyads affected by OUD were included in the analysis. In adjusted analysis, risk factors for receipt of ER care included Hispanic ethnicity (aOR 1.63 [95% CI 1.30-2.05]), lower education levels (aOR 1.54-1.69 [95% CI 1.12-2.31]), nonprivate insurance (aOR 1.44 [95% CI 1.11-1.86]), and presence of maternal chronic conditions (aOR 1.14 [95% CI 1.01-1.29]). Risk factors for rehospitalization included prematurity (aOR 1.44 [95% CI 1.14-1.82]), low birthweight (aOR 2.02 [95% CI 1.63-2.49]), and nonprivate insurance (aOR 1.58 [95% CI 1.13-2.22]). Prolonged infant birth hospitalization was protective against both ER use (aOR 0.84 [95% CI 0.73-0.96]) and rehospitalization (aOR 0.63 [95% CI 0.53-0.75]).

CONCLUSIONS

Clinical and sociodemographic characteristics are risk factors for receipt of ER care and rehospitalization among opioid-exposed newborns in Massachusetts.

Emerging Adults in Inpatient Substance Use Treatment: A Prospective Cohort Study of Patient Characteristics and Treatment Outcomes

INTRODUCTION

Compared to older adults, emerging adults treated for substance use disorders (SUDs) are more likely to have unfavorable outcomes. However, few studies have investigated the baseline characteristics and treatment outcomes of emerging adults in inpatient SUD treatment.

AIMS

This study investigated differences in demographic and clinical characteristics and treatment outcomes (relapse or treatment discontinuation) among emerging adult and adult inpatients. Prospective associations between baseline characteristics and unfavorable treatment outcomes were also analyzed across both patient groups.

METHODS

A prospective cohort study was conducted among inpatients (n = 499) at 4 SUD treatment centers in Norway. The sample included emerging adult patients aged 18-25 years (n = 149) and adult patients above 25 years (n = 350). Medical records provided data on sociodemographic variables, substance use characteristics, diagnoses, and treatment completion status. Self-reported measures, including age of onset of substance use, motivation, and mental distress, were completed within 2 weeks of admission to treatment. A telephone interview 3 months after discharge provided information about relapses.

RESULTS

Emerging adults had a more adverse risk profile in terms of demographic characteristics, clinical variables, and treatment outcomes. Multivariable results showed that polysubstance use and an attention deficit hyperactivity disorder (ADHD) diagnosis were the strongest predictors of unfavorable treatment outcomes for emerging adults. For older adults, only baseline mental distress was a significant predictor of unfavorable treatment outcomes.

CONCLUSIONS

Treatment and follow-up initiatives could be better tailored for emerging adults. Identification of treatment needs among emerging adults manifesting polysubstance use and ADHD may reduce the likelihood of unfavorable treatment outcomes in this patient group.

Diagnosis and treatment of substance use disorder among pregnant women in three state Medicaid programs from 2013 to 2016

Substance use disorder (SUD) during pregnancy increases risks of adverse outcomes for mothers and children. Because Medicaid covers about half of all births and maternal SUD is a costly problem, describing the timing of enrollment and health care that Medicaid-enrolled pregnant women with SUDs receive is critical to understanding gaps in the timeliness and specificity of SUD diagnosis and treatment for pregnant women with SUDs. We used linked maternal and infant Medicaid claims and enrollment data and infant birth records from three states (n=72,086 mother-infant dyads) to estimate the share of sample women diagnosed with a specified SUD (e.g., opioid use disorder) before or during the birth month, with a specified SUD after the birth month, and with only an unspecified SUD diagnosed (e.g., drug use disorder complicating pregnancy). We also examined the timing of first observed Medicaid enrollment, SUD diagnosis and treatment, and maternal and infant costs. In the 24 months surrounding birth, 3.6% of women had a specified SUD diagnosis first observed before or during the birth month, 1.7% had a specified SUD diagnosis first observed after the birth month, and 6.0% had an SUD diagnosis that was not specified. Most women with a specified SUD diagnosis were enrolled in Medicaid before or early in pregnancy and initiated prenatal care in the first or second trimester, yet nearly one-third of these women received their specified SUD diagnosis after the birth month. Less than two-thirds of women with a specified SUD diagnosis received any SUD treatment during the study period (59.9% among those identified before or during the birth month and 63.1% among those observed after the birth month), and women with an unspecified SUD were about half as likely to get treatment (28.6%). Among treated women, more than two-thirds had the first observed treatment in the same month as their first observed SUD diagnosis. Findings point to a critical need for interventions as well as substantial opportunities to improve the identification of substance use-related needs and provision of treatment among women who birth in Medicaid. Changes in Medicaid and other public policy to reduce disincentives for pregnant and parenting women to report substance use during medical visits and to increase providers' abilities and motivation to equitably screen for as well as treat women with SUDs before, during, and after pregnancy could improve outcomes for mothers and their children. Improvements in SUD diagnosis would also improve prevalence estimates of specific types of SUD, which could contribute to better Medicaid policies aimed at prevention and treatment.

Unmet substance use disorder treatment need among reproductive age women

BACKGROUND

Substance use disorder (SUD) is a chronic medical condition in need of long-term treatment. The objective of the study is to describe the current unmet SUD treatment need among reproductive age women living in the United States with a focus on pregnancy and parenting status.

METHODS

Data were drawn from the 2007-2014 National Survey of Drug Use and Health for women 18-44 years old. The primary outcomes were past year SUD treatment need and receipt. Women with a SUD treatment need included those with a SUD and/or expressing a need for SUD treatment. Women were classified as pregnant, parenting (living with their children) or not pregnant nor parenting. Multivariable logistic regression determined if pregnancy/parenting status was associated with treatment need and receipt controlling for demographic factors.

RESULTS

Among reproductive age women with a past year SUD treatment need, only 9.3 % (95 % CI 8.4-10.2 %) received treatment. Pregnant and parenting women were not more likely to receive treatment (pregnant AOR 0.9; 95 % CI 0.5-1.8 & parenting AOR 0.7; 95 % CI 0.5-0.9) compared to not pregnant nor parenting women. Black (AOR 0.3; 95 % CI 0.2-0.5) and Hispanic women (AOR 0.6; 95 % CI 0.4-0.9) were less likely to receive treatment.

CONCLUSIONS

Few reproductive age women who need SUD treatment receive it in the US. Although pregnant women are considered a priority population, they are not receiving priority services. Racial disparities in unmet SUD treatment need exist. Barriers to SUD treatment, such as expanding gender informed services, must be addressed.

Elevated maternal and child mortality among women with multiple DUI convictions compared with socio-demographically matched controls

AIMS

To assess whether having multiple convictions for driving while under the influence of alcohol (MDUI) in women is a risk factor for maternal, infant and child mortality.

DESIGN

Retrospective cohort design using record linkage, comparing women with MDUI convictions with propensity-matched women without alcohol-related driving offences ascertained through state records, on rates of maternal, infant and child mortality.

SETTING

Missouri, United States.

PARTICIPANTS

MDUI women (n = 1658) and women with no alcohol-related driving convictions (control, n = 184 252) who gave birth from 2000 to 2004.

MEASUREMENTS

Data were obtained from state administrative records and US Census data. The outcomes were maternal, infant and child mortality. The input variable was presence or absence of MDUI convictions. Propensity-matching variables were maternal (smoking during pregnancy, delayed prenatal care, previous child deaths, age at birth, mother Missouri-born, education, pre-pregnancy obesity, marital status), reproductive partner (un-named partner, race/ethnicity, education, DUI status) and census tract (socio-economic advantage, urbanicity) characteristics.

FINDINGS

Women with MDUI convictions had higher odds of maternal, infant and child mortality than propensity-matched controls [odds ratio (OR) = 2.65, 95% confidence interval (CI) = 2.07-3.40 and OR = 1.75, 95% CI = 1.17-2.61, respectively].

CONCLUSIONS

Having multiple convictions for driving under the influence of alcohol in women appears to be a risk factor for increased maternal, infant and child mortality.

Relapse after inpatient substance use treatment: A prospective cohort study among users of illicit substances

AIMS

The main aim was to investigate the relative roles of mental distress and intrinsic motivation for relapse after inpatient substance use disorder (SUD) treatment, while adjusting for demographics and treatment variables.

METHODS

The study is based on a prospective multicenter study with a baseline gross sample of 607 patients with SUD (response rate = 84%) admitted to an inpatient stay at one of five specialized SUD treatment centers in Norway. The analytical sample consisted of patients with illicit drug use (n = 374) who took part in a follow-up interview three months after discharge from inpatient treatment (n = 249) (retention rate = 67%). Data were collected using information from electronic medical records, a self-report questionnaire at treatment entry, and a follow-up interview.

RESULTS

Relapse occurred among 37% of the sample by three-month follow-up. Results of multivariable analysis showed that younger age and having a psychiatric diagnosis were associated with an elevated relapse risk. Patients who received treatment at a short-term clinic (2-4 months), as opposed to a long-term clinic (>6 months) were also at increased risk of relapse, regardless of their length of stay. Reduced risk of relapse was predicted by having completed the inpatient treatment stay.

CONCLUSION

Identifying the treatment needs of young patients and patients with co-occurring psychiatric diagnoses during and following inpatient SUD treatment may contribute to reduced post-treatment relapse rates. Further research is needed to illuminate the treatment-related factors that contribute to reduced risk of relapse after inpatient SUD treatment.

Mothers and Mentors: Exploring Perinatal Addiction and Recovery Through Digital Storytelling

Substance use disorders (SUDs) are a growing problem for pregnant and parenting women. Woman-to-woman peer support may positively influence perinatal outcomes but little is known about the impact of such support on the women who are providing support. The purpose of this study was to describe experiences of addiction in pregnancy, recovery, and subsequently serving as a peer mentor to other pregnant women with active SUD among women in recovery in a rural setting. We conducted one digital storytelling workshop with five women serving as peer mentors with lived experience of perinatal SUD. The mentors faced significant stigma in pregnancy. They had each done the "inside work" to achieve recovery, and maintained recovery by staying balanced. Peer mentoring supported their own recovery, and story sharing was integral to this process. Peer-led support models may be an effective, self-sustaining method of providing pregnancy-specific peer support for SUD.

Pregnant women with opioid use disorder and their infants in three state Medicaid programs in 2013-2016

BACKGROUND

Maternal opioid use disorder (OUD) has serious consequences for maternal and infant health. Analysis of Medicaid enrollee data is critical, since Medicaid bears a disproportionate share of costs.

METHODS

This study analyzes linked maternal and infant Medicaid claims data and infant birth records in three states in the year before and after a delivery in 2014-2015 (2013-2016) examining health, health care use, treatment, and neonatal outcomes. Diagnosis and procedure codes identify OUD and other substance use disorders (SUDs).

RESULTS

In the year before and after delivery, 2.2 percent of the sample had an OUD diagnosis, and 5.9 percent had a SUD diagnosis other than OUD. Of the women with OUD, 72.8% had treatment for a SUD in the year before and after delivery, but most had none in an average enrolled month, and only 8.8% received any methadone treatment in a given month. Pregnant women with OUD had delayed and lower rates of prenatal care compared to women with other substance use disorders (SUDs). Infants of mothers with OUD did not differ from infants of mothers with other SUDs in rate of preterm or low birth weight but had higher NICU admission rates and longer birth hospitalizations. Health care costs for women with an OUD were higher than those with other SUDs.

CONCLUSIONS

There is an urgent need for comprehensive, evidence-based OUD treatment integrated with maternity care. To fill critical gaps in care, workforce and infrastructure innovations can facilitate delivery of preventive and treatment services coordinated across settings.

Substance Use in Pregnant Women Using the Emergency Department: Undertested And Overlooked?

Introduction

The objective was to determine if pregnant women visiting the emergency department (ED) are tested for substance use as frequently as non-pregnant women.

Methods

We captured all ED visits over a six-year period (2010–2016) from a single community hospital and identified women of childbearing age, defined for our study as 11–50 years old. We collected demographic data including age in years, ethnicity, body mass index, marital status, disposition, last encounter department, method of arrival, and day of week. An independent binary variable was created based on whether the woman was tested for alcohol or drugs (amphetamines, barbiturates, benzodiazepines, cannabis, cocaine, opioids) during her visit. We then compared rates of testing for substance use by pregnancy status.

Results

We identified 61,222 ED visits by women of childbearing age (range 11–50, mean 30.5, standard deviation 9.6) over a six-year period from 2010–2016. Of the 57,360 non-pregnant women, 4.14% were tested compared to 1.04% of the 3,862 pregnant women tested with a relative risk of 0.25 (p<0.001, 95% confidence interval [CI] [0.183–0.341]). The most highly tested chief complaints for all women – psychiatric or substance use concerns – showed pregnant women were still 37% and 54% less likely to be tested, respectively (risk ratio [RR] 0.46, 95% CI [0.19–1.13]; RR 0.63, 95% CI [0.41–0.96]). Beyond pregnancy status, we found no significant interaction between patient demographics and substance use testing.

Conclusion

Pregnant women presenting to the ED were 75% less likely to be tested for drug or alcohol use than non-pregnant women. Our study showed only pregnancy status as a statistically significant variable in drug- and alcohol-screening rates when pregnant and non-pregnant patient chief complaints and demographics were compared. Increased attention to the screening of pregnant women for substance use may be necessary to provide adequate care and intervention to this population.

The Prevalence and Impact of Substance Use Disorder and Treatment on Maternal Obstetric Experiences and Birth Outcomes Among Singleton Deliveries in Massachusetts

Objectives Despite widely-known negative effects of substance use disorders (SUD) on women, children, and society, knowledge about population-based prevalence and impact of SUD and SUD treatment during the perinatal period is limited. Methods Population-based data from 375,851 singleton deliveries in Massachusetts 2003-2007 were drawn from a maternal-infant longitudinally-linked statewide dataset of vital statistics, hospital discharges (including emergency department (ED) visits), and SUD treatment records. Maternal SUD and SUD treatment were identified from 1-year pre-conception through delivery. We determined (1) the prevalence of SUD and SUD treatment; (2) the association of SUD with women's perinatal health service utilization, obstetric experiences, and birth outcomes; and (3) the association of SUD treatment with birth outcomes, using both bivariate and adjusted analyses. Results 5.5% of Massachusetts's deliveries between 2003 and 2007 occurred in mothers with SUD, but only 66% of them received SUD treatment pre-delivery. Women with SUD were poorer, less educated and had more health problems; utilized less prenatal care but more antenatal ED visits and hospitalizations, and had worse obstetric and birth outcomes. In adjusted analyses, SUD was associated with higher risk of prematurity (AOR 1.35, 95% CI 1.28-1.41) and low birth weight (LBW) (AOR 1.73, 95% CI 1.64-1.82). Women receiving SUD treatment had lower odds of prematurity (AOR 0.61, 95% CI 0.55-0.68) and LBW (AOR 0.54, 95% CI 0.49-0.61). Conclusions for Practice SUD treatment may improve perinatal outcomes among pregnant women with SUD, but many who need treatment don't receive it. Longitudinally-linked existing public health and programmatic records provide opportunities for states to monitor SUD identification and treatment.

Maternal Substance Use Disorders and Infant Outcomes in the First Year of Life among Massachusetts Singletons, 2003-2010

OBJECTIVE

To determine the association of maternal substance use disorders (SUDs) during pregnancy with adverse neonatal outcomes and infant hospital re-admissions, observational stays, and emergency department utilization in the first year of life.

STUDY DESIGN

We analyzed 2 linked statewide datasets from 2002 to 2010: the Massachusetts Pregnancy to Early Life Longitudinal data system and the Massachusetts Bureau of Substance Abuse Services Management Information System. Generalized estimating equations were used to assess the association of maternal SUDs and neonatal outcomes and infant hospital-based care in the first year of life, controlling for maternal and infant characteristics.

RESULTS

Maternal SUDs increased from 19.4 per 1000 live births in 2003 to 31.1 per 1000 live births in 2009. In the adjusted analysis, exposed neonates were more likely to be born preterm (aOR 1.85; 95% CI 1.75-1.96) and low birthweight (aOR 1.94; 95% CI 1.80-2.09). After controlling for maternal characteristics and preterm birth, SUD-exposed neonates were more likely to have intrauterine growth restriction, cardiac, respiratory, neurologic, infectious, hematologic, and feeding/nutrition problems, prolonged hospital stay, and higher mortality (aOR range 1.26-3.80). Exposed infants were more likely to be rehospitalized (aOR 1.10; 95% CI 1.04-1.17) but less likely to have an observational stay (aOR 0.90; 95% CI 0.82-0.99) or use the emergency department (aOR 0.87; 95% CI 0.83-0.90) in the first year of life.

CONCLUSIONS

Infants born to mothers with SUD are at higher risk for adverse health outcomes in the perinatal period and are also more likely to be rehospitalized in the first year of life.

Receipt of addiction treatment as a consequence of a brief intervention for drug use in primary care: a randomized trial

BACKGROUND AND AIMS

Screening, brief intervention and 'referral to treatment' programs have been promoted widely as US federal policy. Little is known about the efficacy of the RT component (referral to treatment) of brief intervention for motivating patients with unhealthy drug use identified by screening to use addiction treatment. This study aimed to compare receipt of addiction treatment following two types of brief intervention for drug use versus a no-intervention control group among primary care patients screening positive for drug use.

DESIGN

Secondary analyses from a single-site randomized controlled trial.

SETTING

Massachusetts, USA.

PARTICIPANTS

A total of 528 adults with Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) drug-specific scores ≥ 4.

INTERVENTIONS

Random assignment to: (1) a 10-15-minute brief negotiated interview (BNI) conducted by health educators (n = 174), (2) a 30-45-minute adaptation of motivational interviewing by Masters-level counselors (MOTIV) (n = 177) or (3) no BI (n = 177). All received a list of treatment and mutual help resources; both intervention protocols included dedicated staff for treatment referrals.

MEASUREMENTS

Receipt of any addiction treatment within 6 months after study entry, assessed in a state-wide database and hospital electronic medical record linked to trial data.

FINDINGS

Among 528 participants, the main drugs used were marijuana (63%), cocaine (19%) and opioids (17%); 46% met past-year drug dependence criteria (short form Composite International Diagnostic Interview); and 10% of MOTIV, 18% of BNI and 17% of control participants had any addiction treatment receipt within 6 months after study entry. There was no significant difference in addiction treatment receipt for BNI versus control [adjusted odds ratio (AOR) = 1.11; 95% confidence interval (CI) = 0.57, 2.15, Hochberg adjusted P = 0.76]. The MOTIV group had lower odds of linking to treatment (AOR = 0.36, 95% CI = 0.17, 0.78, Hochberg adjusted P = 0.02) compared with the no BI group.

CONCLUSION

Brief intervention delivered in primary care for screen-identified drug use did not increase addiction treatment receipt significantly; a motivational interviewing approach appeared to be counterproductive.