Cost-effectiveness of treatment for drug-abusing pregnant women

A scoping review of costing methodologies used to assess interventions for underserved pregnant people and new parents

BACKGROUND

Lack of evidence about the long-term economic benefits of interventions targeting underserved perinatal populations can hamper decision making regarding funding. To optimize the quality of future research, we examined what methods and costs have been used to assess the value of interventions targeting pregnant people and/or new parents who have poor access to healthcare.

METHODS

We conducted a scoping review using methods described by Arksey and O'Malley. We conducted systematic searches in eight databases and web-searches for grey literature. Two researchers independently screened results to determine eligibility for inclusion. We included economic evaluations and cost analyses of interventions targeting pregnant people and/or new parents from underserved populations in twenty high income countries. We extracted and tabulated data from included publications regarding the study setting, population, intervention, study methods, types of costs included, and data sources for costs.

RESULTS

Final searches were completed in May 2024. We identified 103 eligible publications describing a range of interventions, most commonly home visiting programs (n = 19), smoking cessation interventions (n = 19), prenatal care (n = 11), perinatal mental health interventions (n = 11), and substance use treatment (n = 10), serving 36 distinct underserved populations. A quarter of the publications (n = 25) reported cost analyses only, while 77 were economic evaluations. Most publications (n = 82) considered health care costs, 45 considered other societal costs, and 14 considered only program costs. Only a third (n = 36) of the 103 included studies considered long-term costs that occurred more than one year after the birth (for interventions occurring only in pregnancy) or after the end of the intervention.

CONCLUSIONS

A broad range of interventions targeting pregnant people and/or new parents from underserved populations have the potential to reduce health inequities in their offspring. Economic evaluations of such interventions are often at risk of underestimating the long-term benefits of these interventions because they do not consider downstream societal costs. Our consolidated list of downstream and long-term costs from existing research can inform future economic analyses of interventions targeting poorly served pregnant people and new parents. Comprehensively quantifying the downstream and long-term benefits of such interventions is needed to inform decision making that will improve health equity.

Baseline Characteristics and Postdischarge Outcomes by Medication for Opioid Use Disorder Status Among Women with Polysubstance Use in Residential Treatment

Background

Within residential treatment, medication for opioid use disorder (MOUD) is rarely offered, so little is known about group differences by MOUD status. This study characterizes samples of women receiving and not receiving MOUD and explores postdischarge outcomes.

Methods

This is a secondary exploratory analysis of a residential clinical trial comparing women receiving treatment as usual (TAU) with those who also received computer-based training for cognitive behavioral therapy (CBT4CBT). Participants were N = 41 adult women with substance use disorder (SUD) who self-reported lifetime polysubstance use. Because 59.0% were prescribed MOUD (MOUD n = 24, no MOUD n = 17), baseline variables were compared by MOUD status; outcomes at 12 weeks postdischarge were compared by MOUD status and treatment condition using chi square and Mann-Whitney U tests.

Results

Participants were middle-aged (41.7 ± 11.6 years) and non-Latinx Black (80.4%). Most used substances in the No MOUD group were alcohol, cocaine, and cannabis, and in the MOUD group, most used substances were opioids, cannabis, and cocaine. Women in the MOUD group tended to have more severe SUD. Postdischarge substance use recurrence rates were twice as high in the MOUD group than in the No MOUD group. Among the women in the No MOUD group, those in the CBT4CBT condition increased the number of coping strategies twice as much as those receiving TAU.

Conclusion

Postdischarge substance use recurrence differed by MOUD status. CBT4CBT may be a helpful adjunct to personalized residential SUD treatment. The parent study is registered at [www.clinicaltrials.gov (ClinicalTrials.gov identifier: NCT03678051)].

Factors associated with treatment retention in pregnant women with opioid use disorders prescribed methadone or electing non-pharmacological treatment

Opioid use during pregnancy is rising, with an estimated 14-22% of women obtaining an opioid prescription during pregnancy. Methadone maintenance therapy (MMT) has been the gold standard for treatment of opioid use disorders during pregnancy; however, its use is limited in clinical practice due to availability, stigma, and reluctance on the part of clinicians. The present study compared against medical advice (AMA) treatment dropout from seven days of residential care between pregnant women diagnosed with opioid dependence who elected either MMT (n = 119) or non-pharmacological treatment (NPT) (n = 91) within the same treatment program in Baltimore, Maryland from 1996 to 1998. Multiple logistic regression analysis was conducted to compare the rate of AMA drop out between the two modalities. Patients who elected NPT were 2.77 times as likely to leave residential treatment as patients who elected MMT (adjusted odds ratio [OR = 2.77, 95% confidence interval [CI]: 1.23-6.17]. AMA was associated with interviewer-assessed drug severity and patient's rating of the importance of psychiatric treatment. The present findings further support the clinical utility of MMT and suggest that policies that facilitate the implementation of MMT in clinical practice would be beneficial to the engagement and retention of pregnant women with opioid use disorders.

Models of care for neonatal abstinence syndrome: What works?

Opioid use disorders and the prescription of long-acting medications for their treatment have increased dramatically over the last decade among pregnant women. Newborns who experience prolonged in utero opioid exposure may develop neonatal abstinence syndrome (NAS). Until recently, much of the focus on improving care for NAS has been on pharmacologically-based care models. Recent studies have illustrated the benefits of rooming-in and parental presence on NAS outcomes. Single center Quality Improvement (QI) initiatives demonstrate the benefits of non-pharmacologic care bundles and symptom prioritization in decreasing the proportion of infants pharmacologically treated and length of hospital stay. Little remains known about the impact of these varied cared models on maternal-infant attachment and mental health. In this review article, we will propose an optimal model of care to improve short- and long-term outcomes for newborns, their mothers and families, and perinatal care systems.

Cost-effectiveness of individual versus group female-specific cognitive behavioral therapy for alcohol use disorder

OBJECTIVE

To determine the relative cost-effectiveness of individual female-specific cognitive behavioral therapy (I-FS-CBT) versus group female-specific cognitive behavioral therapy (G-FS-CBT).

METHODS

This cost-effectiveness study is based on a randomized controlled trial in which 155 women seeking treatment for alcohol use disorder at an academic outpatient clinic were randomized to 12 manual-guided sessions of I-FS-CBT (n = 75) or G-FS-CBT (n = 80). The primary patient outcomes were the number of drinking days and the number of heavy drinking days during the 12-week treatment and 1-year follow-up periods. All cost data (including resource utilizations) were collected prospectively alongside the trial. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were used to determine the cost-effectiveness of I-FS-CBT relative to G-FS-CBT. Results are presented from the provider perspective.

RESULTS

During the 12-week treatment period, G-FS-CBT is likely to be cost-effective when the threshold value to decision-makers of one fewer drinking day (or one fewer day of heavy drinking) is less than $141 (or $258), and I-FS-CBT is likely to be cost-effective if the threshold is greater than $141 (or $258). During the 1-year follow-up period, G-FS-CBT is likely to be cost-effective when the threshold value to decision-makers of one fewer drinking day (or one fewer day of heavy drinking) is less than $54 (or $169), and I-FS-CBT is likely to be cost-effective if the threshold is greater than $54 (or $169). The results are robust to sensitivity analyses on several key cost parameters.

CONCLUSIONS

Compared to I-FS-CBT, G-FS-CBT holds promise as a cost-effective approach, in both the short run and the long run, for improving drinking outcomes of women with alcohol use disorder.

Neonatal abstinence syndrome

Neonatal abstinence syndrome refers to the signs and symptoms attributed to the cessation of prenatal exposure (via placental transfer) to various substances. This Primer focuses on neonatal abstinence syndrome caused by opioid use during pregnancy - neonatal opioid withdrawal syndrome (NOWS). As the global prevalence of opioid use has alarmingly increased, so has the incidence of NOWS. NOWS can manifest with varying severity or not at all, for unknown reasons, but is likely to be associated with multiple factors, both maternal (for example, smoking and additional substance exposures) and neonatal (gestational age, sex and genetics). Care for the infant with NOWS begins with addressing the issues experienced by pregnant women with opioid use disorder. Co-occurring mental illness, economic hardship, intimate partner violence, infectious diseases and limited access to care are common in these women and can result in poor maternal and neonatal outcomes. Although there is no consensus regarding optimal NOWS management, non-pharmacological interventions (such as breastfeeding and rooming-in of the mother and the baby) have become a priority, as they can ameliorate symptoms without the need for further opioid exposure. Untreated NOWS can be associated with morbidity in early infancy, and the long-term consequences of fetal opioid exposure are only beginning to be understood.

Neonatal Abstinence Syndrome: Trend and Expenditure in Louisiana Medicaid, 2003-2013

Objectives Determine trends in incidence and expenditure for perinatal drug exposure and neonatal abstinence syndrome (NAS) among Louisiana's Medicaid population. We also describe the maternal characteristics of NAS affected infants. Methods Retrospective cohort analysis using linked Medicaid and vital records data from 2003 to 2013. Conducted incidence and cost trends for drug exposed infants with and without NAS. Also performed comparison statistics among drug exposed infants with and without NAS and those not drug exposed. Results As rate of perinatal drug exposure increased, NAS rate per 1000 live Medicaid births also increased, from 2.1 (2003) to 3.6 (2007) to 8.0 (2013) (P for trend <0.0001). Total medical cost paid by Medicaid also increased from $1.3 million to $3.6 million to $8.7 million (P for trend <0.0001). Compared with drug exposed infants without NAS and those not drug exposed, infants with NAS were more likely to be white, have feeding difficulties, respiratory distress syndrome, sepsis, and seizures, all of which had an association at P < 0.0001. Over one-third (33.2%) of the mothers of infants with NAS had an opioid dependency in combination with a mental illness; with depression being most common. Conclusions for Practice Over an 11-year period, NAS rate among Louisiana's Medicaid infants quadrupled and the cost for caring for the affected infants increased six-fold. Medicaid, as the predominant payer for pregnant women and children affected by substance use disorders, must play a more active role in expanding access to comprehensive substance abuse treatment programs.

Medicaid Coverage of Methadone Maintenance and the Use of Opioid Agonist Therapy Among Pregnant Women in Specialty Treatment

BACKGROUND

Opioid agonist therapy (OAT) is the standard of care for pregnant women with opioid use disorder (OUD). Medicaid coverage policies may strongly influence OAT use in this group.

OBJECTIVE

To examine the association between Medicaid coverage of methadone maintenance and planned use of OAT in the publicly funded treatment system.

RESEARCH DESIGN

Retrospective cross-sectional analysis of treatment admissions in 30 states extracted from the Treatment Episode Data Set (2013 and 2014).

SUBJECTS

Medicaid-insured pregnant women with OUD (n=3354 treatment admissions).

MEASURES

The main outcome measure was planned use of OAT on admission. The main exposure was state Medicaid coverage of methadone maintenance. Using multivariable logistic regression models adjusting for sociodemographic, substance use, and treatment characteristics, we compared the probability of planned OAT use in states with Medicaid coverage of methadone maintenance versus states without coverage.

RESULTS

A total of 71% of pregnant women admitted to OUD treatment were 18-29 years old, 85% were white non-Hispanic, and 56% used heroin. Overall, 74% of admissions occurred in the 18 states with Medicaid coverage of methadone maintenance and 53% of admissions involved planned use of OAT. Compared with states without Medicaid coverage of methadone maintenance, admissions in states with coverage were significantly more likely to involve planned OAT use (adjusted difference: 32.9 percentage points, 95% confidence interval, 19.2-46.7).

CONCLUSIONS

Including methadone maintenance in the Medicaid benefit is essential to increasing OAT among pregnant women with OUD and should be considered a key policy strategy to enhance outcomes for mothers and newborns.

Economic evaluation of a behavioral intervention versus brief advice for substance use treatment in pregnant women: results from a randomized controlled trial

BACKGROUND

Substance use in pregnancy is associated with severe maternal and fetal morbidities and substantial economic costs. However, few studies have evaluated the cost-effectiveness of substance use treatment programs in pregnant women. The purpose of this study was to evaluate the economic impact of a behavioral intervention that integrated motivational enhancement therapy with cognitive behavioral therapy (MET-CBT) for treatment of substance use in pregnancy, in comparison with brief advice.

METHODS

We conducted an economic evaluation alongside a clinical trial by collecting data on resource utilization and performing a cost minimization analysis as MET-CBT and brief advice had similar effects on clinical outcomes (e.g., alcohol and drug use and birth outcomes). Costs were estimated from the health care system's perspective and included intervention costs, hospital facility costs, physician fees, and costs of psychotropic medications from the date of intake assessment until 3-month postpartum. We compared effects of MET-CBT on costs with those of brief advice using Wilcoxon rank sum tests.

RESULTS

Although the integrated MET-CBT therapy had higher intervention cost than brief advice (median = $1297/participant versus $303/participant, p < 0.01), costs of care during the prenatal period, delivery, and postpartum period, as well as for psychotropic medications, were comparable between the two groups (all p values ≥ 0.55). There was no statistically significant difference in overall cost of care (median total cost = $26,993/participant for MET-CBT versus $27,831/participant for brief advice, p = 0.90).

CONCLUSIONS

The MET-CBT therapy and brief advice resulted in similar clinical outcomes and overall medical costs. Further research incorporating non-medical costs, targeting women with more severe substance use disorders, and evaluating the impact of MET-CBT on participants' quality of life will provide additional insights.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00227903 . Registered 27 September 2005.

A therapeutic workplace for the long-term treatment of drug addiction and unemployment: eight-year outcomes of a social business intervention

This study evaluated the long-term effects of a therapeutic workplace social business on drug abstinence and employment. Pregnant and postpartum women (N = 40) enrolled in methadone treatment were randomly assigned to a therapeutic workplace or usual care control group. Therapeutic workplace participants could work weekdays in training and then as employees of a social business, but were required to provide drug-free urine samples to work and maintain maximum pay. Three-year outcomes were reported previously. This paper reports 4- to 8-year outcomes. During year 4 when the business was open, therapeutic workplace participants provided significantly more cocaine- and opiate-negative urine samples than controls; reported more days employed, higher employment income, and less money spent on drugs. During the 3 years after the business closed, therapeutic workplace participants only reported higher income than controls. A therapeutic workplace social business can maintain long-term abstinence and employment, but additional intervention may be required to sustain effects.

Costs of a motivational enhancement therapy coupled with cognitive behavioral therapy versus brief advice for pregnant substance users

Objectives

To determine and compare costs of a nurse-administered behavioral intervention for pregnant substance users that integrated motivational enhancement therapy with cognitive behavioral therapy (MET-CBT) to brief advice (BA) administered by an obstetrical provider. Both interventions were provided concurrent with prenatal care.

Methods

We conducted a micro-costing study that prospectively collected detailed resource utilization and unit cost data for each of the two intervention arms (MET-CBT and BA) within the context of a randomized controlled trial. A three-step approach for identifying, measuring and valuing resource utilization was used. All cost estimates were inflation adjusted to 2011 U.S. dollars.

Results

A total of 82 participants received the MET-CBT intervention and 86 participants received BA. From the societal perspective, the total cost (including participants’ time cost) of the MET-CBT intervention was $120,483 or $1,469 per participant. In contrast, the total cost of the BA intervention was $27,199 or $316 per participant. Personnel costs (nurse therapists and obstetric providers) for delivering the intervention sessions and supervising the program composed the largest share of the MET-CBT intervention costs. Program set up costs, especially intervention material design and training costs, also contributed substantially to the overall cost.

Conclusions

Implementation of an MET-CBT program to promote drug abstinence in pregnant women is associated with modest costs. Future cost effectiveness and cost benefit analyses integrating costs with outcomes and benefits data will enable a more comprehensive understanding of the intervention in improving the care of substance abusing pregnant women.

Perinatal smoking and depression in women with concurrent substance use

OBJECTIVE

The purpose of this report was to examine the course of smoking among pregnant women with concurrent substance use, and to assess the impact of depression on smoking.

METHODS

Data were gathered as part of a randomized controlled trial assessing the efficacy of substance abuse treatment in pregnant women. Women (n=176) were recruited before 28 completed weeks of pregnancy, and followed until 3months postpartum. Depression was assessed using the Inventory of Depressive Symptomatology and the MINI Neuropsychiatric Interview. Our outcome was the average number of cigarettes smoked per day. Linear mixed effects regression was used to measure differential changes in smoking.

RESULTS

66% of women smoked in the three months before pregnancy, 42% of pre-pregnancy smokers achieved abstinence before delivery and 60% of the baseline cohort smoked postpartum. Smoking did not differ significantly between depressed and non-depressed groups. After delivery both groups increased smoking at similar rates.

CONCLUSION

Smoking was common among our cohort of pregnant women with a history of substance use. Women were able to discontinue or decrease smoking during pregnancy, but were likely to resume or increase smoking postpartum. Having clinically significant depressive symptoms or a diagnosis of depression did not have an obvious effect on smoking behaviors.

Barriers to receiving substance abuse treatment among rural pregnant women in Kentucky

Research presenting outcomes for women who enter substance abuse treatment during pregnancy consistently shows benefits. While treatment has nearly universal benefits, there are many barriers to seeking substance abuse treatment for pregnant women. The purpose of this study is to explore barriers for rural pregnant women seeking substance abuse treatment. There were three eligibility criteria for study participation: (1) aged 18 and older, (2) pregnant, and (3) undergoing short-term inpatient detoxification at the University of Kentucky Chandler Medical Center. Eighty-five rural women (N = 85) were included in the analysis. Substance use history and previous treatment were assessed with measures adapted from the Addiction Severity Index. Treatment barriers were measured with three qualitative questions and were coded into four overarching categories: availability, accessibility, affordability, and acceptability barriers. This sample had an extensive substance use history. Almost all participants had used alcohol (98%), marijuana (98%), illicit opiates (99%), and cigarettes (97%). On average, participants reported about two barriers to receiving treatment (Mean = 1.8; SD = 1.3), with over 80% of the sample reporting having experienced any barrier to treatment. The majority experienced acceptability (51%) and accessibility (49%) barriers. Twenty-six percent (26%) of the sample reported availability barriers. A smaller percentage of participants reported affordability barriers (13%). Rural pregnant women seeking substance abuse treatment face many obstacles to receiving needed treatment. More studies on barriers to substance abuse treatment among rural pregnant women are needed. Identifying these barriers can help in improving treatment access and services.

The Opioid dependent mother and newborn dyad: non-pharmacologic care

Opioid dependent pregnant and post-partum women and their infants are a complex and vulnerable population requiring individualized, comprehensive and multidisciplinary treatment. Though methadone maintenance in the setting of comprehensive service provision during pregnancy significantly improves pregnancy outcomes for opioid dependent women, its use has implications for the infant, most notably the Neonatal Abstinence Syndrome (NAS). NAS is comprised of physiologic signs and behaviors that indicate a dysfunctional regulation of the central and autonomic nervous systems, and is variable in its expression in affected infants. The disorganized rather than adaptive behaviors displayed by each infant undergoing the effects of in-utero opioid exposure may impair basic functions such as feeding, sleeping, and the ability to be alert and communicate clear cues to caregivers. Understanding and responding to neurobehavioral dysfunction of the newborn may help to promote the infant's self-organization and self-regulating abilities. However, the substance abusing mother's physical and psychological wellbeing may be debilitated in the perinatal period, and her ability to recognize and respond to the newborn's cues may be limited. A multi-tiered comprehensive assessment and intervention of the methadone-maintained mother, her child, and the mother/infant dyad can improve early maternal nurturing interactions, a crucial component of early infant development, particularly in this vulnerable population. The purpose of this article is to review the contribution of maternal opioid dependency to the difficulties experienced by the mother-infant dyad and their treatment providers in the postnatal period, and the non-pharmacological treatment of the infants with suggestions for practical measures with emphasis on the treatment of the mother and baby as an interactional dyad.

Contingent incentives reduce cigarette smoking among pregnant, methadone-maintained women: results of an initial feasibility and efficacy randomized clinical trial

AIMS

This study examined the feasibility and efficacy of behavioral incentives for reducing cigarette smoking among pregnant methadone-maintained patients.

DESIGN

Participants (n = 102) were assigned randomly to: (i) contingent behavioral incentives (CBI: n = 42); (ii) non-contingent behavioral incentives (NCBI: n = 28); or (iii) treatment as usual (TAU: n = 32).

SETTING

Study procedures were implemented at the Center for Addiction and Pregnancy in Baltimore, MD.

PARTICIPANTS

Study participants were pregnant, methadone-maintained women enrolled in substance use disorder treatment.

MEASUREMENTS

Baseline carbon monoxide (CO) levels were calculated for each participant. Subsequently, breath samples were tested three times weekly to measure changes in smoking behavior. CBI participants received incentives for target reductions from baseline: any reduction (week 1); 10% reduction (weeks 2-4), 25% reduction (weeks 5-7), 50% reduction (weeks 8-9), 75% reduction (week 10-11); and abstinence [CO < 4 parts per million (p.p.m.)] (week 12 until delivery). NCBI participants received incentives independent of smoking CO measurement results. TAU participants received no incentives, the standard treatment at the program.

FINDINGS

CBI condition participants submitted significantly lower mean CO values than the NCBI and TAU conditions over the course of the intervention (P < 0.0001). Nearly half (48%) of the CBI participants met the 75% smoking reduction target and one-third (31%) met the abstinence target at week 12. In contrast, none of the NCBI met either the 75% or abstinence targets. Only 2% of the TAU participants met the 75% reduction and none of the TAU participants met the abstinence targets. These smoking behavior reductions did not yield significant differences in birth outcomes.

CONCLUSIONS

Cigarette smoking may be reduced significantly among pregnant, methadone-maintained women through the use of contingent reinforcement for gradual reductions in breath carbon monoxide levels.

Neonatal abstinence syndrome: transitioning methadone-treated infants from an inpatient to an outpatient setting

OBJECTIVE

Each year in the US ∼50 000 neonates receive inpatient pharmacotherapy for the treatment of neonatal abstinence syndrome (NAS). The objective of this study is to compare the safety and efficacy of a traditional inpatient only approach with a combined inpatient and outpatient methadone treatment program.

STUDY DESIGN

Retrospective review (2007 to 2009). Infants were born to mothers maintained on methadone in an antenatal substance abuse program. All infants received methadone for NAS treatment as inpatient. Methadone weaning for the traditional group (75 patients) was inpatient, whereas the combined group (46 patients) was outpatient.

RESULT

Infants in the traditional and combined groups were similar in demographics, obstetrical risk factors, birth weight, gestational age (GA) and the incidence of prematurity (34 and 31%). Hospital stay was shorter in the combined than in the traditional group (13 vs 25 days; P<0.01). Although the duration of treatment was longer for infants in the combined group (37 vs 21 days, P<0.01), the cumulative methadone dose was similar (3.6 vs 3.1 mg kg(-1), P=0.42). Follow-up information (at least 3 months) was available for 80% of infants in the traditional and 100% of infants in the combined group. All infants in the combined group were seen ≤72 h from hospital discharge. Breastfeeding was more common among infants in the combined group (24 vs 8% P<0.05). Following discharge there were no differences between the two groups in hospital readmissions for NAS. Prematurity (34 to 36 weeks GA) was the only predictor for hospital readmission for NAS in both groups (P=0.02, OR 5). Average hospital cost for each infant in the combined group was $13 817 less than in the traditional group.

CONCLUSION

A combined inpatient and outpatient methadone treatment in the management of NAS decreases hospital stay and substantially reduces cost. Additional studies are needed to evaluate the potential long-term benefits of the combined approach on infants and their families.

Should pregnant women with substance use disorders be managed differently?

Pregnant women with substance use disorders have multiple special needs, which might be best managed within a multiprofessional treatment setting involving medical, psychological and social care. Adequate treatment provision remains a challenge for healthcare professionals, who should undergo special training and education when working with this patient population. Careful assessment and screening is necessary to tailor interventions individually to the woman's needs in order to achieve beneficial clinical outcomes for mothers and newborns, whereas the choice of treatment options highly depends on the type of substance of abuse and evidence-based treatment interventions available. Economic considerations have shown that early multiprofessional treatment might yield better clinical outcomes and save healthcare costs over the lifespan.

Economic evaluation of drug abuse treatment and HIV prevention programs in pregnant women: a systematic review

Drug abuse and transmission of HIV during pregnancy are public health problems that adversely affect pregnant women, their children and surrounding communities. Programs that address this vulnerable population have the ability to be cost-effective due to resulting cost savings for mother, child and society. Economic evaluations of programs that address these issues are an important tool to better understand the costs of services and create sustainable healthcare systems. This study critically examined economic evaluations of drug abuse treatment and HIV prevention programs in pregnant women. A systematic review was conducted using the criteria recommended by the Panel on Cost-Effectiveness in Health and Medicine and the British Medical Journal (BMJ) checklist for economic evaluations. The search identified 6 economic studies assessing drug abuse treatment for pregnant women, and 12 economic studies assessing programs that focus on prevention of mother-to-child transmission (PMTCT) of HIV. Results show that many programs for drug abuse treatment and PMTCT among pregnant women are cost-effective or even cost-saving. This study identified several shortcomings in methodology and lack of standardization of current economic evaluations. Efforts to address methodological challenges will help make future studies more comparable and have more influence on policy makers, clinicians and the public.

HIV Sexual and Drug-Use Risk in Drug-Dependent Pregnant Patients in Comprehensive Drug Treatment

This secondary analysis study investigated HIV sexual and drug-use risk in drug-dependent pregnant patients over the first month postrandomization to reinforcement-based treatment (RBT) (n = 47) or usual care (UC) (n = 42). Analysis of primary outcomes had indicated that RBT participants spent significantly longer time in treatment and recovery housing than UC participants. The present study examined the ability of 9 risk markers-age, race, estimated gestational age at treatment entry, lifetime substance abuse treatment episodes, history of prostitution charges, history of serious depression, current heroin injection status, current housing status, and current partner substance use-to predict changes in HIV risks. Sexual risk declined for participant subgroups with prostitution-charge histories and unstable housing. Drug-use risk declined for heroin injectors and nondepressed participants. A relationship was found between number of lifetime drug treatment episodes and sexual and drug-use risk. The role of risk markers in the response of drug-dependent pregnant women to drug treatment require attention.

Treating the partners of opioid-dependent pregnant patients: feasibility and efficacy

BACKGROUND

Drug-dependent pregnant women with intimate partners who are also drug-dependent have been found to have compromised treatment outcomes. Thus, developing a treatment to reduce a male partner's drug use is the first step in a line of research with a distal goal of improving pregnant patient's treatment outcomes.

OBJECTIVE

This study examined a novel intervention for engaging the male partner in drug treatment.

METHODS

Men targeted for intervention were non-treatment-seeking opioid users. Motivational enhancement therapy (MET), an effective non-confrontational intervention approach for evoking behavioral change, was employed to encourage treatment participation. This six-session intervention was followed by a drug-abstinent contingency-based voucher incentive program. Moreover, to help maintain drug abstinence, male partners had rapid facilitation into either opioid detoxification with aftercare or methadone maintenance. Interwoven into treatment were both couple's counseling and a men's group educational program designed to strengthen the support provided by the men to their partners during pregnancy and post-delivery. Men (n = 45) received either the novel intervention package called HOPE (Helping Other Partners Excel) or a control condition (n = 17) that received weekly support and referrals for treatment.

RESULTS

Men in the HOPE condition, compared with the usual care condition, showed increased treatment retention, transient decreases in heroin use, increased involvement in recreational activities, less reliance on public assistance, and increased social support for their pregnant partners.

CONCLUSION AND CLINICAL SIGNIFICANCE

Results suggest that treatment of male partners is feasible and efficacious in the short term but modifications to the intervention are needed to sustain results.

Reinforcement-based treatment improves the maternal treatment and neonatal outcomes of pregnant patients enrolled in comprehensive care treatment

This randomized clinical trial examined the efficacy of comprehensive usual care (UC) alone (n = 42) or enhanced by reinforcement-based treatment (RBT) (n = 47) to produce improved treatment outcomes, maternal delivery, and neonatal outcomes in pregnant women with opioid and/or cocaine substance use disorders. RBT participants spent, on average, 32.6 days longer in treatment (p < .001) and almost six times longer in recovery housing than did UC participants (p = .01). There were no significant differences between the RBT and UC conditions in proportion of participants testing positive for any illegal substance. Neonates in the RBT condition spent 1.3 fewer days hospitalized after birth than UC condition neonates (p = .03), although the two conditions did not differ significantly in neonatal gestational age at delivery, birth weight, or number of days hospitalized. Integrating RBT into a rich array of comprehensive care treatment components may be a promising approach to increase maternal treatment retention and reduce neonatal length of hospital stay.

Assessment of benefits of a universal screen for maternal alcohol use during pregnancy

INTRODUCTION

The objective of this report is to estimate the benefits of universal meconium screening for maternal drinking during pregnancy. Fetal alcohol spectrum disorder (FASD), including its most severe manifestation fetal alcohol syndrome (FAS), is preventable and remains a public health tragedy. The incidences of FAS and FASD have been conservatively estimated to be 0.97 and 10 per 1000 births, respectively. Meconium testing has been demonstrated to be a promising at-birth method for detection of drinking during pregnancy.

METHODS

The current costs of FAS and FASD, alcohol treatment programs, and meconium screening were estimated by literature review. Monetary values were converted roughly to equal dollars in 2006.

RESULTS

Costs of adding meconium analysis to the current newborn screening program and of treatment for the identified mothers were estimated and compared to potential averted costs that may result from identification and intervention for mothers and affected infants. Three potential maternal treatment strategies are analyzed. Depending on the treatment type, the savings may range from $6 to $97 for every $1 spent on screening and treatment.

DISCUSSION

It needs to be emphasized, however, that such screening is premature and that to be effective this screening can be implemented only if there is a societal willingness to institute prevention and intervention programs to improve both women's and children's health. Future research should be directed at improving detection and developing in-depth prevention and remedial intervention programs. A thorough consideration of the ethical issues involved in such a screening program is also needed.

Treatment of cocaine abuse during pregnancy: translating research to clinical practice

In the late-1980s and early-1990s, much attention in America was focused on cocaine abuse. In particular, the effects of prenatal cocaine use on mothers and infants were in the news spotlight. Risks of adverse effects prompted funding for novel treatment programs. More recently, media attention has shifted elsewhere, and specialized treatment resources have grown scarce. This redirection of funding is unfortunate, as social stigma and fear of legal consequences continue to encourage cocaine-abusing pregnant women to hide drug use and avoid prenatal care. The purpose of this article is to summarize the most prominent adverse maternal and fetal/infant effects associated with prenatal cocaine use; review treatment options, focusing on comprehensive care programs of the 1990s as well as recent research on evidence-based practices and their applicability to pregnant women; and highlight the population of prenatal cocaine-abusing women uninterested in treatment, with a focus on promising strategies to promote drug abstinence and other positive health behaviors.

Effect of plasma proteins on buprenorphine transfer across dually perfused placental lobule

OBJECTIVE

The aim of this investigation is to determine the effect of human serum albumin (HSA) and alpha-acid glycoprotein (AAG) on buprenorphine (BUP) transplacental transfer and distribution.

METHODS

The technique of dual perfusion of placental lobule (DPPL) was utilised. BUP was co-perfused with the marker compound antipyrine (AP). In each experiment, the radiolabelled isotopes [(3)H]-BUP and [(14)C]-AP were added to enhance their detection limits. Human plasma proteins, HSA and AAG, were added to both the maternal and fetal circuits separately and in combination at their physiological concentrations in maternal and fetal circulations close to term.

RESULTS

Transplacental transfer of BUP, in absence of plasma proteins, is a two-step process: the first is its uptake by the syncytiotrophoblast from the maternal circuit, and the second is its transfer/release from the tissue to the fetal circuit. The addition of HSA to the perfusion medium affected only the second step of BUP transfer, but AAG affected both steps. The combined effect of HSA and AAG was not different from that observed in presence of the latter alone.

CONCLUSIONS

Binding of BUP to circulating AAG could have an important role in the transfer of the drug from the maternal to fetal circulation.

Neonatal findings among children of substance-abusing women attending a special child welfare clinic in Norway

Aims: A special child welfare clinic (SCWC) in Norway provides care for pregnant women with substance abuse problems to prevent the adverse effects of substances. The SCWC aims to give treatment without replacements. This article describes neonatal findings among children of substance-abusing women at the clinic. Methods: This was a retrospective cohort study including 62 children whose mothers had attended the SCWC during pregnancy. A comparison group with children of women with no substance abuse was included. Data were collected from medical records and by means of a questionnaire concerning neonatal data, health, and living conditions. SCWC mothers were divided into short-term users (substance use stopped within first trimester) and long-term users (continued moderate substance use throughout pregnancy). Results: Average birthweight and head circumference were significantly lower in the substance-abusing groups: 3084 g and 34.0 cm in the short-term group, 3048 g and 33.9 cm in the long-term group, and 3496 g and 34.8 cm in the comparison group. There was no difference in Apgar score. Substance abuse and psychiatric illness were associated with low birthweight. Long-term users were more likely than comparisons to experience premature birth and have low-birthweight children. This difference was not found among short-term users. We found no difference in Caesarean sections and vacuum extractions. Conclusions: Substance abusers who stop their drug use early in pregnancy tend to have birth outcomes that are similar to those of mothers with no substance abuse. The study indicates that attendance at a voluntary, low-threshold initiative for pregnant substance abusers, with a focus on prenatal care and substance abuse treatment without replacements, may reduce the harmful effect of the abuse on the newborn.

Incentives for retention of pregnant substance users: a secondary analysis

Retention of pregnant substance users in treatment is challenging. In a multisite clinical trial, 200 pregnant substance users entering outpatient treatment at one of four programs were randomized to either three individual sessions of Motivational Enhancement Therapy for Pregnant Substance users or three individual sessions normally provided. Retail scrip from $25 to $30 was provided for attendance of research visits but not treatment visits. A post hoc analysis of the non-methadone-maintained participants (n = 175) evaluated the hypotheses that monetary reinforcement for attendance would result in more consecutive, and overall, weeks of attendance of research versus nonincentivized treatment visits. Findings indicate participants were nearly three times as likely to attend 4 consecutive weeks of research visits versus treatment sessions. There was no effect for income while fewer dependents were associated with more consecutive weeks of attendance. Incentives in the $25-to-$30 range may serve to significantly increase attendance and retention.

Substance abuse in pregnant women. Experiences from a special child welfare clinic in Norway

BACKGROUND

Substance abuse during pregnancy may harm the foetus and can cause neonatal abstinence syndrome. Exposure to alcohol and other substances can influence the child for the rest of its life. A special child welfare clinic was set up in 1994 in Kristiansand, Norway, targeting pregnant women with substance abuse problems in the county of Vest-Agder. Pregnancy is not an indication for opioid replacement therapy in Norway, and one of the clinic's aims was to support the drug dependent women through their pregnancy without any replacements. The object of this paper is to describe concurrent health and social problems, as well as the predictors for stopping drug abuse, in the clinic's user group.

METHODS

Retrospective cohort study. Data was gathered from the medical records of all 102 women seen in the clinic in the period between 1992 and 2002. The study includes 59 out of 60 women that were followed until their children were two years old or placed in alternative care, and a comparison group of twice the size. Both groups were presented with a questionnaire concerning both the pregnancy and health and socio-economic issues.

RESULTS

Four (4.5 percent) of the women that completed their pregnancies did not manage to reduce their substance abuse. All the others reduced their substance abuse considerably. The odds ratio for stopping substance abuse within the first trimester was significantly associated with stopping smoking (O.R. 9.7) or being victims of rape (O.R. 5.3).

CONCLUSION

A low cost and low threshold initiative organised as a child welfare clinic may support women with substance abuse problems in their efforts to stop or reduce their substance abuse during pregnancy.

Substance abuse treatment entry, retention, and outcome in women: a review of the literature

This paper reviews the literature examining characteristics associated with treatment outcome in women with substance use disorders. A search of the English language literature from 1975 to 2005 using Medline and PsycInfo databases found 280 relevant articles. Ninety percent of the studies investigating gender differences in substance abuse treatment outcomes were published since 1990, and of those, over 40% were published since the year 2000. Only 11.8% of these studies were randomized clinical trials. A convergence of evidence suggests that women with substance use disorders are less likely, over the lifetime, to enter treatment compared to their male counterparts. Once in treatment, however, gender is not a significant predictor of treatment retention, completion, or outcome. Gender-specific predictors of outcome do exist, however, and individual characteristics and treatment approaches can differentially affect outcomes by gender. While women-only treatment is not necessarily more effective than mixed-gender treatment, some greater effectiveness has been demonstrated by treatments that address problems more common to substance-abusing women or that are designed for specific subgroups of this population. There is a need to develop and test effective treatments for specific subgroups such as older women with substance use disorders, as well as those with co-occurring substance use and psychiatric disorders such as eating disorders. Future research on effectiveness and cost-effectiveness of gender-specific versus standard treatments, as well as identification of the characteristics of women and men who can benefit from mixed-gender versus single-gender treatments, would advance the field.

The impact of managed care on drug-dependent pregnant and postpartum women and their children

In the shift from fee-for-service (FFS) to managed care (MC), many drug user treatment programs have eliminated all but basic services, lessening short-term costs without considering long-term consequences. This study explored maternal and infant outcomes at an urban drug user treatment center for pregnant drug-dependent women under FFS (1995) vs. MC (2000) service periods. The two groups had similar birth parameters, but the MC group had more fetal and infant deaths, decreased immunization rates, and greater incidences of social services intervention. While these data are correlational and need to be interpreted with caution, they suggest poorer outcomes for drug-exposed children under MC and invite further study of short- and long-term consequences of such change.

Service costs for women with co-occurring disorders and trauma

Several aspects of costs related to health care and other service use at 6-month follow-up are presented for women with co-occurring mental health and substance abuse disorders with histories of physical and/or sexual abuse receiving comprehensive, integrated, trauma-informed and consumer/survivor/recovering person-involved interventions (n = 1023) or usual care (n = 983) in a nine-site quasi-experimental study. Results show that, controlling for pre-baseline use, there are no significant differences in total costs between participants in the intervention condition and those in the usual care comparison condition, either from a governmental (avg. US dollars 13,500) or Medicaid reimbursement perspectives (avg. just over US dollars 10,000). When combined with clinical outcomes analyzed in other works in this issue by Cocozza et al. (2005) and Morrissey et al. (2005), which favored the intervention sites, these cost findings indicate that the treatment intervention services are cost-effective as compared with the usual care received by women at the comparison sites.

Promoting alcohol abstinence among pregnant women: potential social change strategies

Fetal Alcohol Syndrome Disorder (FASD) is one of the most preventable sources of developmental abnormalities, and has a singular cause-alcohol consumption during pregnancy. Estimates for the costs of treatment of a single case of FASD range often above one million dollars. The primary strategy for prevention currently centers on no alcohol consumption during pregnancy. However, a sizeable number of North American women currently drink during pregnancy. A literature review examined the behavior of maternal alcohol consumption in order to understand the rationale associated with drinking. Generally, it appears that pregnant women differ by their alcohol consumption habits and their reasons to drink. In an attempt to eliminate FASD, we review a number of educational, legal, and community-based programs that have been used to promote abstinence and examine where they have been successful. Unfortunately, social marketing strategies have received less attention. Several potential applications of social marketing directed to drinking-during- pregnancy campaigns are suggested, and possible contributions to the overall effort are explained.

Identifying pregnant women at risk for early attrition from substance abuse treatment

Greater treatment retention among pregnant substance abusers is associated with improved pregnancy and neonatal outcomes, so early identification of clients most at risk for early attrition is essential. Participants were 152 pregnant women enrolled in the initial 7-day residential component of a comprehensive substance abuse treatment program for pregnant women. Twenty-nine (19%) women left treatment within the first 5 days, primarily within the first 2 days. Clinical staff identified many, but not all, patients who eventually left treatment early as many indicated their desire to leave and were troubled by drug craving and withdrawal. Other predictors of attrition included not receiving methadone maintenance, being Caucasian, and reporting more prior drug treatment episodes, fewer medical problems and, to a lesser extent, more family/social and psychiatric and fewer drug problems on the Addiction Severity Index. Interventions are needed to target pregnant clients most at risk for early treatment attrition.

Substance abuse treatment for women: Changes in the settings where women received treatment and types of services provided, 1987–1998

Changes in social policies during the last 2 decades have had major implications for the provision of substance abuse treatment services to women. The goal of this analysis was to examine (a) changes in the proportion of women clients served within different types of treatment facilities and (b) the services provided in these facilities. Data were analyzed from national surveys of treatment providers for the period of 1987 to 1998. Overall, there were gradual increases in the proportion of women clients across treatment facilities and greater concentrations of women in more intensive treatment modalities. The provision of childcare increased over time, particularly in programs with only women clients. Treatment facilities in which there were higher proportions of women generally had higher rates of providing services related to pregnancy, parenting, and domestic violence. These findings can be used to assess the adequacy of service delivery to women in substance abuse treatment.

Parenting knowledge among substance abusing women in treatment

The purpose of this study was to assess parenting knowledge and beliefs among drug abusing pregnant and recently postpartum women engaged in a comprehensive substance abuse treatment program. The effects of a parenting skills training program for this population were evaluated. A Parenting Skills Questionnaire was developed and administered to a sample of 73 pregnant and drug-dependent women during their first week of substance abuse treatment and again approximately 7 weeks later, following parenting skills training. The questionnaire was designed to assess whether group and individual parenting sessions changed the subjects' knowledge and beliefs in four parenting domains: newborn care, feeding practices, child development and drug abuse during pregnancy. Pre-intervention scores for all parenting domains were low. Post- vs. pre-intervention comparisons showed significant increases in all domain scores after individual and group parenting skills training. Preliminary results obtained from this clinic-based sample suggest that these substance abusing mothers lacked important parenting knowledge and that this knowledge improved after comprehensive substance abuse treatment that included parenting training.

Effectiveness of substance abuse treatment programming for women: a review

Recent research has shown that women and men differ in substance abuse etiology, disease progression, and access to treatment for substance abuse. Substance abuse treatment specifically designed for women has been proposed as one way to meet women's distinctive needs and reduce barriers to their receiving and remaining in treatment. However, relatively few substance abuse treatment programs offer specialized services for women, and effectiveness has not been fully evaluated. This article reviews the literature on the extent and effectiveness of substance abuse treatment programming for women and provides an overview of what is known about the components of successful treatment programs for women. Thirty-eight studies of the effect on treatment outcomes of substance abuse treatment programming for women were reviewed. Seven were randomized, controlled trials, and 31 were nonrandomized studies. In our review, six components of substance abuse treatment programming for women were examined: child care, prenatal care, women-only programs, supplemental services and workshops that address women-focused topics, mental health programming, and comprehensive programming. The studies found positive associations between these six components and treatment completion, length of stay, decreased use of substances, reduced mental health symptoms, improved birth outcomes, employment, self-reported health status, and HIV risk reduction. These findings suggest that to improve the future health and well-being of women and their children, there is a continued need for well-designed studies of substance abuse treatment programming for women.

A partner's drug-using status impacts women's drug treatment outcome

The role that male sexual partners play in the treatment outcome of drug dependent pregnant women deserves greater attention. Pregnant women enrolled in a comprehensive treatment program with drug-free (n=85) or drug-using (n=82) male sexual partners completed a relationship survey and were compared on partner and psychosocial variables. Compared with male drug-free partners, male drug-using partners had more unemployment and more current legal involvement, less education, were less likely to be supportive of the pregnant woman's recovery efforts and were more likely to give them money to buy drugs. Male drug-free partners also had fewer medical, dental, legal and transportation needs than male drug-using partners. Data from treatment retention suggests that women with male drug-using partners are retained in a comprehensive treatment for a shorter time than women with male drug-free partners. A male partner's drug-using status should be considered when treating pregnant drug dependent women.

Bridging the gap: a hybrid model to link efficacy and effectiveness research in substance abuse treatment

Many behavioral and pharmacologic treatments for which there is strong empirical support are rarely used in clinical practice in the treatment of substance dependence. In an effort to facilitate greater emphasis on issues such as utility, practicality, and cost earlier in the evaluation of promising therapies, the authors propose a hybrid model to link efficacy and effectiveness research. A hybrid model may foster broader use of empirically validated treatments in substance abuse treatment programs and enhance the scientific yield of effectiveness research. The hybrid model retains essential features of efficacy research (randomization, use of control conditions, independent assessment of outcome, and monitoring of treatment delivery) while expanding the research questions to also address issues of importance in effectiveness studies. Such issues include diversity in settings, clinicians, and patients; cost-effectiveness of treatment; training issues; and patient and clinician satisfaction.

Reciprocal obligations: managing policy responses to prenatal substance exposure

Substance use during pregnancy poses substantial risks to the developing fetus and continues to generate considerable policy debate. Public policy responses to prenatal substance exposure (PSE) have varied depending in part on whether the substances in question are licit (e.g., tobacco and alcohol) or illicit (e.g., cocaine and heroin). The policy responses also have ranged from warning labels on the dangers to the developing fetus of using alcohol, to treating a pregnant woman's illicit substance use as child abuse. The most controversial case was Cornelia Whitner's criminal conviction in South Carolina for PSE after her newborn baby tested positive for cocaine metabolites. Although the conviction was upheld by the South Carolina Supreme Court, it is, to date, an isolated example (Whitner v. State of South Carolina, 492 S.E.2d 777 [S.C. 1997], cert denied, 523 U.S. 1145 [1998], but see Ferguson v. City of Charleston, 532 U.S. 67 [2001], and Ferguson v. City of Charleston, 308 F.3d 380 [4th Cir. 2002], ruling that PSE detection policies require the woman's informed consent).

Patient compliance and maternal/infant outcomes in pregnant drug-using women

Treatment compliance is an important variable in drug use intervention. For pregnant drug-misusing women, compliance with treatment has been particularly problematic, even in specialized and more intensive treatment programs. The present study, conducted from March 1999 to June 2000, compared maternal/infant outcomes in pregnant drug-using women who were either compliant or noncompliant with drug use interventions offered through a prenatal care clinic. Compliant women (N = 11) completed four therapy sessions (behavioral reinforcement of drug abstinence + brief motivational therapy), while noncompliant women (N = 20) participated in zero to three therapy sessions. The two groups were similar on demographic and drug use severity measures. Compliant mothers, however, gave birth to infants with higher birthweights than noncompliant mothers. Over half of compliant mothers were also drug-free at delivery, compared to one-fourth of noncompliant mothers. These data support an association between treatment compliance and birth outcomes, and highlight the need to develop strategies for improving compliance with such interventions.

Benefit-cost analysis of addiction treatment in Arkansas: specialty and standard residential programs for pregnant and parenting women

A benefit-cost analysis of specialty residential treatment (Specialty) and standard residential treatment (Standard) was conducted on a sample of pregnant and parenting substance abusers from Arkansas. Economic benefits were derived from client self-reported information at treatment entry and at 6-month postdischarge with the use of an augmented version of the Addiction Severity Index (ASI). The average cost of treatment in Specialty programs was US dollars 8035 versus US dollars 1467 for Standard residential treatment. Average net benefits (benefit-cost ratios) were estimated to be US dollars 17144 (3.1) for Specialty and US dollars 8090 (6.5) for Standard. The main policy implication of this research is that investment in Specialty residential treatment for pregnant and parenting substance-abusing women appears to be economically justified, but future evaluations should analyze larger and more comparable samples to improve power and precision in the benefit-cost statistics.