The harms of punishing substance use during pregnancy

The War on Drugs has Unduly Biased Substance Use Research

After working in the substance use field for several years and conducting research on substance use, it has come to my attention how deeply ingrained the War on Drugs propaganda is in substance use research. The lines of research demonstrating the potential benefits of substance use (including illicit substances), delineation of harm from stigma, and the societal impact of the War on Drugs is rather weak and lacking, despite numerous recent studies showing the benefits of certain substances and reports of individuals in therapy and online suggesing that illicit substances help them in some respects. There are numerous critical implications of this bias in substance use research. Suppose the field primarily produces studies that show that all substances are harmful in almost any circumstance and that substance use disorders (SUDs) are primarily driven by psychological deficits (e.g., willpower). In that case, we, as researchers, would be feeding into the War on Drugs, which is known for marginalizing individuals, promoting organized crime, exacerbating SUDs, feeding into a police and prison state, and killing individuals due to tainted substances. Substance use researchers and clinicians are among the first to recognize that the War on Drugs has failed. Yet, despite this belief, we seem to have not quite fully noticed how the propaganda has influenced how we conduct our jobs and the research we produce. In the current letter, I inform researchers who study substance use and clinicians who treat SUDs to acknowledge their own learned biases against substances and those who use substances; to be more cautious when interpreting substance use data in the future.

Racial Disparities in Newborn Drug Testing After Implementation of Question-Based Screening for Prenatal Substance Use

OBJECTIVE

To examine the association of universal question-based screening for prenatal substance use on racial inequities in prenatal and newborn drug testing.

METHODS

We conducted a retrospective cohort study of 32,802 live births of patients receiving prenatal care at an academic medical center in the midwestern United States from 2014 to 2022, before and after implementation of question-based screening in 2018. Primary outcomes included prenatal and newborn drug test orders. Logistic regression models using a generalized estimating equation framework assessed associations with question-based screening and results, birthing parent age, race, ethnicity, marital status, and insurance type. Charts of patients who indicated difficulties stopping substance use were audited for guideline-directed care.

RESULTS

A total of 12,725 of 14,992 pregnant people (85.3%) received question-based screening. Implementation of question-based screening was associated with a decrease in prenatal urine test orders (5.0% [95% CI, 4.6-5.3%] before implementation, 3.1% [95% CI, 2.8-3.4%] after implementation; P <.001), with Black birthing parents having the largest reduction in prenatal urine drug testing (10.3% [95% CI, 9.0-11.7%] before implementation, 4.9% [95% CI, 3.9-5.9%] after implementation). However, rates of newborn drug testing did not change (4.7% [95% CI, 4.4-5.0%] before implementation, 4.5% [95% CI, 4.2-4.8%] after implementation; P =.46), and clinicians continued to order significantly more newborn drug tests for newborns of Black birthing parents compared with other race and ethnicity groups.

CONCLUSION

Implementation of question-based screening for substance use in pregnancy was associated with decreased prenatal urine drug testing but no change in overall newborn drug testing or racial inequities in newborn drug testing for Black birthing people. Further policy efforts are warranted to improve substance use treatment and to eliminate racial inequities in punitive policies such as newborn drug testing and subsequent child protective services reporting.

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.

When Public Will Meets Legislative Resistance: Five Lessons from Ohio's Issue 2 Cannabis Legalization Controversy

In this paper, I explore the challenges of legalizing cannabis in Ohio, focusing on the passing of the Issue 2 Bill, legislative resistance, and public response. I propose five strategies for effective policy change: persistent advocacy post policy change success, establishing strong coalitions, empowering grassroots movements, promoting rigorous data-driven research, and launching public education campaigns. I offer a detailed analysis of the interaction between public opinion and legislative action in cannabis legalization and its implications for substance-related policy change.

Association of Implementation of Postoverdose Outreach Programs With Subsequent Opioid Overdose Deaths Among Massachusetts Municipalities

Importance

Nonfatal opioid overdose is the leading risk factor for subsequent fatal overdose and represents a critical opportunity to reduce future overdose and mortality. Postoverdose outreach programs emerged in Massachusetts beginning in 2013 with the main purpose of linking opioid overdose survivors to addiction treatment and harm reduction services.

Objective

To evaluate whether the implementation of postoverdose outreach programs among Massachusetts municipalities was associated with lower opioid fatality rates compared with municipalities without postoverdose outreach programs.

Design, Setting, and Participants

This retrospective interrupted time-series analysis was performed over 26 quarters (from January 1, 2013, through June 30, 2019) across 93 municipalities in Massachusetts. These 93 municipalities were selected based on a threshold of 30 or more opioid-related emergency medical services (EMS) responses in 2015. Data were analyzed from November 2021 to August 2022.

Exposures

The main exposure was municipality postoverdose outreach programs. Municipalities had various program inceptions during the study period.

Main Outcomes and Measures

The primary outcome was quarterly municipal opioid fatality rate per 100 000 population. The secondary outcome was quarterly municipal opioid-related EMS response (ambulance trips) rates per 100 000 population.

Results

The mean (SD) population size across 93 municipalities was 47 622 (70 307), the mean (SD) proportion of female individuals was 51.5% (1.5%) and male individuals was 48.5% (1.5%), and the mean (SD) age proportions were 29.7% (4.0%) younger than 25 years, 26.0% (4.8%) aged 25 to 44 years, 14.8% (2.1%) aged 45 to 54 years, 13.4% (2.1%) aged 55 to 64 years, and 16.1% (4.4%) aged 65 years or older. Postoverdose programs were implemented in 58 municipalities (62%). Following implementation, there were no significant level changes in opioid fatality rate (adjusted rate ratio [aRR], 1.07; 95% CI, 0.96-1.19; P = .20). However, there was a significant slope decrease in opioid fatality rate (annualized aRR, 0.94; 95% CI, 0.90-0.98; P = .003) compared with the municipalities without the outreach programs. Similarly, there was a significant slope decrease in opioid-related EMS response rates (annualized aRR, 0.93; 95% CI, 0.89-0.98; P = .007). Several sensitivity analyses yielded similar findings.

Conclusions and Relevance

In this study, among Massachusetts municipalities with high numbers of opioid-related EMS responses, implementation of postoverdose outreach programs was significantly associated with lower opioid fatality rates over time compared with municipalities that did not implement such programs. Program components, including cross-sectoral partnerships, operational best practices, involvement of law enforcement, and related program costs, warrant further evaluation to enhance effectiveness.

Prospective acceptability of digital phenotyping among pregnant and parenting people with opioid use disorder: A multisite qualitative study

Background

While medications for opioid use disorder (MOUD) effectively treat OUD during pregnancy and the postpartum period, poor treatment retention is common. Digital phenotyping, or passive sensing data captured from personal mobile devices, namely smartphones, provides an opportunity to understand behaviors, psychological states, and social influences contributing to perinatal MOUD non-retention. Given this novel area of investigation, we conducted a qualitative study to determine the acceptability of digital phenotyping among pregnant and parenting people with opioid use disorder (PPP-OUD).

Methods

This study was guided by the Theoretical Framework of Acceptability (TFA). Within a clinical trial testing a behavioral health intervention for PPP-OUD, we used purposeful criterion sampling to recruit 11 participants who delivered a child in the past 12  months and received OUD treatment during pregnancy or the postpartum period. Data were collected through phone interviews using a structured interview guide based on four TFA constructs (affective attitude, burden, ethicality, self-efficacy). We used framework analysis to code, chart, and identify key patterns within the data.

Results

Participants generally expressed positive attitudes about digital phenotyping and high self-efficacy and low anticipated burden to participate in studies that collect smartphone-based passive sensing data. Nonetheless, concerns were noted related to data privacy/security and sharing location information. Differences in participant assessments of burden were related to length of time required and level of remuneration to participate in a study. Interviewees voiced broad support for participating in a digital phenotyping study with known/trusted individuals but expressed concerns about third-party data sharing and government monitoring.

Conclusion

Digital phenotyping methods were acceptable to PPP-OUD. Enhancements in acceptability include allowing participants to maintain control over which data are shared, limiting frequency of research contacts, aligning compensation with participant burden, and outlining data privacy/security protections on study materials.

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.

Qualitative description of outreach and engagement in perinatal substance treatment in Finland

BACKGROUND

Women with perinatal substance problems experience a multitude of barriers to care. They have specific early intervention needs, they endure societal stigma, and both substances and mental health issues influence the way they navigate within support and treatment systems. Early interventions for women with perinatal substance problems are underresearched contexts. The aim of the study is to describe building relationships and engagement within an outreach and low threshold service encounter tailored for pregnant women with SUD (substance use disorder).

METHODS

The data consist of online written narratives from 11 workers involved in the program and feedback from 504 families in the recovery process comprising 228 open-ended answers. The data were analyzed with a thematic analysis.

RESULTS

The programs are characterized by flexibility and the implementation of inclusive ways to approach families. The themes for enhancing relationships and engagement within outreach and low threshold programs are Acceptance and attitude: a sensitive approach of approval; flexibility within strictness to allow for diversity and individuality; availability and space to ensure a trustful atmosphere; negotiating via doing to build connections; and everyday life changes: imagining recovery. The themes represent the need of being available, focusing on the worker's attitudes and building connections by doing together, and visioning recovery together.

CONCLUSIONS

The study results can add to the understanding of SUD outreach and low threshold work during pregnancy. The elements described in this study need further theoretical development, research and critical assessment. Building relationships during pregnancy were characterized by connecting within everyday life situations and supporting the development of an attachment relationship between the baby and the parents. To promote recovery, a comprehensive approach in which substance-related issues and mental health conditions are interconnected can be favored. Engaging early on during pregnancy might enhance success during future rehabilitation.

Trends in buprenorphine treatment disparities during the COVID pandemic in Massachusetts

Background: Racial, sex, and age disparities in buprenorphine treatment have previously been demonstrated. We evaluated trends in buprenorphine treatment disparities before and after the onset of the COVID pandemic in Massachusetts. Methods: This cross-sectional study used data from an integrated health system comparing 12-months before and after the March 2020 Massachusetts COVID state of emergency declaration, excluding March as a washout period. Among patients with a clinical encounter during the study periods with a diagnosis of opioid use disorder or opioid poisoning, we extracted outpatient buprenorphine prescription rates by age, sex, race and ethnicity, and language. Generating univariable and multivariable Poisson regression models, we calculated the probability of receiving buprenorphine. Results: Among 4,530 patients seen in the period before the COVID emergency declaration, 57.9% received buprenorphine. Among 3,653 patients seen in the second time period, 55.1% received buprenorphine. Younger patients (<24) had a lower likelihood of receiving buprenorphine in both time periods (adjusted prevalence ratio (aPR), 0.56; 95% CI, 0.42-0.75 before vs. aPR, 0.76; 95% CI, 0.60-0.96 after). Male patients had a greater likelihood of receiving buprenorphine compared to female patients in both time periods (aPR: 1.05; 95% CI, 1.00-1.11 vs. aPR: 1.09; 95% CI, 1.02-1.16). Racial disparities emerged in the time period following the COVID pandemic, with non-Hispanic Black patients having a lower likelihood of receiving buprenorphine compared to non-Hispanic white patients in the second time period (aPR, 0.85; 95% CI, 0.72-0.99). Conclusions: Following the onset of the COVID pandemic in Massachusetts, ongoing racial, age, and gender disparities were evident in buprenorphine treatment with younger, Black, and female patients less likely to be treated with buprenorphine across an integrated health system.

State-level changes in health insurance coverage and parental substance use-associated foster care entry

For many families whose children are placed in foster care, initial contact with the child welfare system occurs due to interactions with the healthcare system, particularly in the context of the opioid epidemic and increased attention to prenatal drug exposure. In the last decade, many previously uninsured families have gained Medicaid health coverage, which has implications for their access to healthcare services and visibility to mandatory reporters. Using administrative foster care case data from the Adoption and Foster Care Analysis and Reporting System Foster Care Files and health insurance data from the American Community Survey, this study analyzes the associations between state-level health insurance coverage and rates of foster care entry due to parental substance use between 2009 and 2019. State-level fixed effects models revealed that public, but not private, health insurance rates were positively associated with rates of foster care entry due to parental substance use. These results support the hypothesis that health insurance coverage may promote greater contact with mandatory reporters among low-income parents with substance use disorders. Furthermore, this study illustrates how healthcare policy may have unintended consequences for the child welfare system.