When we talk about the opioid crisis in the U.S., the first thing we tell people is that it affects everyone. From farmers in rural areas in the middle of the country to office workers in metropolitan areas on east and west coasts, opioid use disorder – a.k.a. opioid addiction – does not discriminate. No one is immune. Doctors and lawyers can develop OUD. Blue collar construction workers can develop OUD. Stay-at-home moms and dads can develop OUD. Corporate tech executives and IT support personnel can develop OUD: we’re not exaggerating – it’s everywhere.
It’s everywhere, and everyone who develops OUD is at risk of overdose and death. That’s also not an exaggeration.
The opioid crisis touches virtually every community in the U.S and has an adverse impact on virtually every demographic group. Young, old, rich, poor – there are no boundaries. Our old concepts of opioid addiction – which mostly involved heroin users in big cities – are outdated. That means we need to revise our approach to everything related to the crisis. From the treatments we use, to the way we provide treatment, to our overall approach to drug policies, we need a reset. That reset is not an abstract wish: it’s actually happening.
Around the country, access to treatment is increasing. Federal, state, and local authorities have increased funding for harm reduction initiatives, overdose prevention, addiction awareness, and access to evidence-based treatment.
While we navigate this new treatment landscape, there’s a specific population of individuals to think about that many people never consider: pregnant women with opioid use disorder. A paper published in September 2022 called “Impact Of Prenatal Substance Use Policies on Commercially Insured Pregnant Females with Opioid Use Disorder” focuses on this demographic group, with special attention to two types of public policies related to pregnant women with OUD:
- Supportive policies that improve access to treatment and support for pregnant women with OUD
- Punitive policies that criminalize pregnant women with OUD
This article will discuss the consequences of those policies, and offer evidence on the impact of the supportive approach to pregnant women with OUD as compared to the punitive approach to pregnant women with OUD.
Before we get to that data, however, we’ll offer a brief overview of the opioid crisis in the U.S.
The Opioid Crisis: An Overview
According to the Centers for Disease Control (CDC), the opioid crisis in the U.S. began well over twenty years ago. In the early 1990s, in response to concerns that acute and chronic were undertreated, physicians began prescribing more opioid analgesics than in the previous two decades. This coincided with the introduction of several new types of prescription opioids, including extended-release formulations, alongside reassurances from pharmaceutical companies that the new class of opioids posed little risk of harmful side effects, such as addiction.
These new formulations and prescribing practices were intended to help people manage acute pain related to surgeries and/or injuries, and help people manage chronic pain related to recurring medical conditions when other pain relievers were ineffective.
While these two goals were realized – opioids are effective for acute pain, and in some circumstances, the best option for chronic pain – an unintended consequence of these changes in opioid use was the first phase of what we now call the opioid crisis.
There are two parts to the crisis:
- An increase in opioid use disorder (OUD)
- A parallel increase in fatal opioid overdose
The statistics on fatal overdose indicate the severity of the OUD crisis:
- Between 1999 and 2005, fatal overdose increased by 212%
- From 2005 to 2014, fatal overdose increased by 61%
- Between 2014 and the 2021, fatal overdose opioid overdose increased by 99%
Those are the big picture trends in opioid overdose, covering the past twenty years. Now let’s take a look at what’s happened recently, with regards to overall fatal overdose, and fatal opioid overdose in particular.
The CDC reports the following numbers:
Fatal Overdose: All Drugs and Opioids
- All drugs:
- 2019: 67,697
- 2020: 78,056
- 2021: 107,306
- 2019: 50,178
- 2020: 69,061
- 2021: 73,453
These big picture numbers are disturbing. That’s why we call this a nationwide crisis. However, one thing these statistics don’t tell us is the prevalence of OUD among pregnant women. Let’s take a look at those numbers now.
Pregnancy and Opioid Use Disorder: Facts and Figures
The CDC published a report in 2017 describing the rates of OUD among pregnant women and the prevalence of neonatal abstinence syndrome (NAS). Note: NAS occurs when a mother with a substance use disorder (SUD) gives birth, and the newborn develops symptoms of withdrawal related to the substance used by the mother. The following statistics are specific to NAS for children born to mothers with OUD.
Here’s the data:
- Between 1999 and 2014:
- OUD during pregnancy quadrupled
- Between 2002 and 2009:
- Neonatal abstinence syndrome (NAS) increased five-fold
- In 2009, one baby was born with NAS every 30 minutes
- In 2018, that number doubled: one baby was born with NAS every 15 minutes
Another study, this one published in January 2021, reported rates of NAS and OUD among pregnant women hospitalized during delivery between 2010 and 2017. Researchers collected data on over 750,000 women, a sample size which enables us to make population-level generalizations on rates of NAS and OUD among pregnant women in the U.S.
Here’s the data:
- Prevalence of NAS:
- 2010: 4.0 per 1,000
- 2017: 7.3 per 1,000
That’s a relative increase of 82%
- Prevalence of maternal OUD:
- 2010: 3.5 per 1,000
- 2017: 8.2 per 1,000
That’s a relative increase of 131%
Those numbers are larger than most people realize – and the increases mirror the trends in the opioid crisis. These trends are a problem, and present a serious health risk for pregnant women with OUD. The paper Opioid Use Disorder in Pregnancy outline the following specific risks of OUD during pregnancy:
- Premature labor
- Fetal convulsions
- Fetal complications related to cycles of opioid use and withdrawal
- Premature birth
- Unhealthy birth weight (low weight)
- Elevated rate of birth defects, including but not limited to:
- Cardiac defects
- Spina bifida
- Gastrointestinal problems
- Neonatal abstinence syndrome (NAS)
The prevalence of maternal OUD and the complications associated with both maternal OUD and NAS mean this is secondary public health crisis. However, evidence shows that there’s a way to help pregnant women with OUD: medication-assisted treatment (MAT).
The Benefits of MAT During Pregnancy
We’ve arrived back at the purpose behind this article.
The title asks the question:
What helps mothers with OUD?
What helps pregnant mothers with OUD?
There’s a clear, evidence-based answer to this question: medication-assisted treatment helps pregnant mothers with OUD. MAT is the use of three specific medications – methadone, buprenorphine, and naltrexone – in combination with therapy and counseling – to mitigate withdrawal symptoms, reduce cravings, and improve treatment outcomes for people with OUD.
The use of these medications for pregnant women is not without controversy. Many people are wary of using opioid-based medications for the treatment of OUD, and outright resistant to their use among pregnant women.
However, The American College of Obstetricians and Gynecologists endorses the use of MAT for pregnant women. Here’s a statement released by ACOD member Dr. Maria Mascola, in which she addresses the hesitancy with regard to MAT among pregnant women with OUD:
“Concern about medication-assisted treatment must be weighed against the negative effects of ongoing misuse of opioids, which can be much more detrimental to mom and baby. Medication-assisted treatment improves adherence to prenatal care and addiction treatment programs and has been shown to reduce the risk of pregnancy complications.”
Properly supervised and managed MAT during pregnancy can:
- Prevent withdrawal symptoms
- Decrease likelihood of relapse
- Decrease infectious disease transmission
- Improve adherence to prenatal care
- Improve adherence to addiction treatment
- Reduce risk of miscarriage
- Reduce risk of premature birth
- Increase birthweight
- Decrease pregnancy-related death for mothers
- Decrease severe OUD-related morbidity (disease/illness)
We know what helps pregnant mothers with OUD: medication-assisted treatment. Now it’s time to discuss the study that prompted us to explore this topic and pose the question in the first place.
Supportive Policies or Punitive Policies: Which Helps Mothers More?
To recap, the study that has our attention analyzed the impact of two types of State-level, public policies on pregnant women with substance use disorder, specifically opioid use disorder: supportive policies or punitive policies.
The study, which involved retrospective analysis of commercial insurance records from a thirteen-year period between 2006 and 2019, included:
- A total of 145,538 females between the ages of 18 and 45
- Each participant met clinical criteria for OUD at least once during the study
- 18,920 participants were pregnant at least once during the study period.
In their analysis of the records, researchers evaluated the type of prenatal substance use policies active in the regions where pregnant mothers made insurance claims. These records are available from the Guttmacher Institute publication “Substance Use During Pregnancy.” The types of policies they evaluated included:
- Punitive PSUPs that criminalize prenatal substance use or defined as child maltreatment
- Supportive PSUPs that offered pregnant females priority access to SUD treatment
- Supportive PSUPs with funding for SUD treatment programs for pregnant females
They cross-referenced these policies with records of engagement in social services by the study participants, which were included with the insurance claim data. Here’s what the researchers found:
The Impact of SUD Policy on Pregnant Women
- Among pregnant participants:
- 12% received MAT:
- 11.2% received buprenorphine
- 0.4% received naltrexone
- 0.6% received methadone
- 10.5% received social services for SUD treatment
- 12% received MAT:
- Among women who engaged in SUD treatment programs for pregnant women, following supportive PSUP implementation:
- Opioid overdose decreased by 45%
- Use of OUD medication increased 11%
- Buprenorphine was the most common drug used
- Receipt of psychosocial services increased
- Following punitive PSUP implementation:
- Participation in psychosocial services for SUD decreased by 12%
- Receipt of methadone decreased by 30%
- Receipt of buprenorphine decreased by 9.6%
- Overall receipt of MAT for OUD decreased by 11.1%
- Opioid overdoses increased 45%
The last set of statistics comes from states with the most punitive policies around pregnancy and drug use. Those are the states where any substance use by pregnant women in criminalized, meaning the presence of any substance of misuse can result in:
- Charges of maltreatment or neglect
- Termination of parental rights
- Placement of child in protective services
The states with those policies reported the least favorable outcomes for pregnant women diagnosed with OUD. When we look at the most disturbing metric in the study – opioid overdose – and compare outcomes between the states with supportive policies and states with punitive policies:
In states with supportive policies, overdose decreased by 45 percent.
In states with punitive policies, overdose increased by 45 percent.
Based on that metric alone, we have the answer to our question: the statistics indicate punitive PSUPs are associated with negative outcomes, while supportive PSUPs are associated with positive outcomes. In other words, supportive policies help pregnant mothers with OUD, whereas punitive policies often increase the harm experienced by pregnant women with OUD.
Support Means Medication and Social Services
Medication is an important part of MAT, but it’s not the only component. Additional components include therapy, counseling, lifestyle changes, and community support. These additional components fall under the category we identify above as receipt of social services for SUD treatment.
The results tell us that 10.5 percent of pregnant women with OUD received social services, and 12 percent of women with OUD received MAT. Quick math tells us that 87.5 percent of women who received MAT also received social services. Therefore, in the group with the best outcomes – a 45 percent decrease in overdose – all the participants received MAT, and almost all of them received some form of SUD treatment, such as therapy, counseling, or community support.
What that tells us is that in addition to validating the use of MAT for pregnant women with OUD, this study also offers provisional validation for the integrated treatment for pregnant women with OUD. That makes perfect sense to us, because we think a woman who’s pregnant and has clinical OUD needs more than a prescription: she needs a full suite of integrated treatment services. Previous evidence shows that MAT for pregnant women improves outcomes across almost all measures. This study shows that MAT in combination with supportive policies for prenatal SUD not only reduces rates of overdose, but also increases participation in social support services that can be life-changing for the mother.
These life changes can – with commitment and work – allow an expecting mother with OUD to engage in treatment, increase the likelihood of creating a safe, stable, and healthy environment for her child, and increase her own chances of achieving sustainable, lifelong recovery.