The Rx for Moms Who Misuse Opioids

The number of pregnant women with opioid use disorder (OUD) at labor and delivery more than quadrupled from 1999 to 2014, according to the Centers for Disease Control and Prevention (CDC). While some jurisdictions see criminal sanctions as a solution, for three decades public health professionals have recommended against such punitive measures and recently reaffirmed support for expanded screening and treatment options. “The existing literature supports the position that punitive approaches to substance use in pregnancy are ineffective and may have detrimental effects on both maternal and child health,” notes the American Academy of Pediatrics.

Guidelines for treating pregnant women with OUD
Between 2015 and 2018, key players in the OUD and maternal health fields—including federal agencies and professional associations—published consistent treatment guidelines for pregnant women with OUD. They unanimously recommend universal screening and coordination of OUD treatment with comprehensive care that addresses this vulnerable population’s physical and mental health and social needs. They also agree that infants born to women with OUD should receive screening and compassionate treatment for neonatal abstinence syndrome (NAS), which is curable. Among those publishing guidelines: CDC, Substance Abuse and Mental Health Services Administration (SAMHSA), American College of Obstetricians and Gynecologists (ACOG) and the American Society for Addiction Medicine (ASAM).

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Challenges in meeting the guidelines
While the consensus is welcome, a range of challenges creates barriers to providing the recommended care. For example:

• Providers’ lack of knowledge of best practices: Neither primary care providers nor gynecologists have traditionally received training to address substance use disorders (SUD). Providers need education about SUD screening, treatment recommendations such as the use of medication assisted treatment (MAT) and information about locally available treatment services for women with positive screenings.
• Late entry into prenatal care by women with OUD: Pregnant women who use drugs are more likely to receive little or no prenatal care. Women with OUD often face simultaneous barriers to accessing prenatal care such as lack of health insurance and transportation challenges. Women also fear the effects of drug use on their baby’s health and the risk of a run-in with Child Protective Services.
• Fractured health care and social services financing: ACOG, ASAM and SAMHSA guidelines all recommend MAT with either methadone or buprenorphine for pregnant women. However, accessing MAT can be a challenge: only 60 percent of treatment facilities accepted Medicaid in 2014, and some areas lack sufficient MAT providers to meet treatment demand.

Medicaid delivery system reforms
Medicaid covers nearly half of births nationwide and is the single largest payer in the United States for behavioral health services, including mental health and SUD services. Thus, CMS and state Medicaid agencies are in a position to address the needs of pregnant women and new mothers who misuse opioids. Medicaid models that incorporate alternative payment methodologies and encourage integration of health care with social services can provide tools that help providers deliver comprehensive care for pregnant women with OUD.

Through our work with federal and state clients, Abt is helping address some of the underlying factors that complicate full compliance with OUD treatment guidelines for pregnant women, including those in public insurance programs. Abt serves as an evaluator for the Centers for Medicare & Medicaid Services Accountable Health Communities (AHC) initiative. AHC is testing whether systematically identifying and addressing the health-related social needs – housing, transportation, food – of Medicare and Medicaid enrollees will improve health outcomes and reduce health care costs. Through the Massachusetts Delivery System Reform Incentive Payment Technical Assistance Marketplace, Abt coordinates a technical assistance program in which national experts work with healthcare and community providers to improve health outcomes for Massachusetts Medicaid enrollees.

The projects are two examples of the power of linking health care with social services. Doing so will keep mother and infant together and provide treatment for both. That is the best outcome for the physical and mental health of both mother and child. Criminal sanctions that put the mother in prison would have the opposite effect, not outweighed by any benefits. Compassionate, comprehensive care--not a jail cell--is the remedy for this growing health care problem.