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Opioid use disorder (OUD) in pregnant women increased by over 300% in the last 20 years, corresponding with the 5-fold increase in neonatal abstinence syndrome during the same period. Medicaid, the largest payer of both behavioral health and pregnancy related care in the US, plays a critical role in providing clinically recommended care ? counseling, coordinated prenatal care and medication assisted treatment (MAT) ? to pregnant women with OUD. However, of the 21 states most heavily affected by the opioid epidemic, only 6 had comprehensive, state-wide MAT programs targeted at pregnant and postpartum women.
A recent study identified trends and disparities in receipt of MAT in a nationally representative sample of pregnant women admitted to publicly funded OUD treatment. From 1999 to 2014, the authors observed a nearly 2.5-fold increase in pregnant admissions with OUD; however, the proportion of women receiving MAT remained relatively unchanged around 50%. The study highlighted significant geographic disparities in receipt of MAT, with the lowest rates in the South (<30%). Fewer treatment facilities per capita and general lack of coverage for MAT services in the South were potential contributors to the disparity. These findings have important clinical and policy relevance. Only 17 states provide pregnant women with priority access to substance use treatment programs and only 10 states explicitly prohibit publicly funded programs from discriminating against pregnant women. In order to improve access to essential OUD treatment services and ensure the health of both the mother and the newborn, these barriers must be addressed.
The Comprehensive Addiction and Recovery Act (CARA) introduced major provisions to improve access to substance use treatment services, supporting the continuum of care for pregnant and postpartum women with substance use disorders. A more recent federal law ? the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act ? further included important Medicaid provisions such as improved access to both mental and behavioral health services, early intervention, expanded use of tele-health, and MAT prescribing authority for nurse specialists and certified nurse midwives. Both CARA and SUPPORT are helpful, however, greater understanding of the impact of OUD during pregnancy at the individual and community level, provider education, and greater cohesion among state agencies is essential to stemming the rising tide of OUD.
This Health Policy Journal Club review is a collaboration between Policy Prescriptions® and the Satcher Health Leadership Institute. It is written by Zulqarnain Javed, PhD, MPH, MBBS. He is a Satcher Health Policy Leadership Fellow at Morehouse School of Medicine
Abstract
OBJECTIVE: To describe differences in geographic, demographic, treatment, and substance use characteristics by pharmacotherapy receipt among pregnant women entering publically funded treatment for opioid use disorder (OUD) in the United States.
METHODS: 1996 to 2014 Treatment Episode Data Set-Admissions data from pregnant admissions with OUD, defined as reporting opioids as the primary substance of use leading to the treatment episode, were analyzed for this cross-sectional study. The proportion of all pregnant admissions with OUD who received pharmacotherapy was calculated by year and U.S. census region. Trends across time were assessed using the Cochrane-Armitage Trend test. Associations between demographic, substance use, and treatment characteristics and pharmacotherapy receipt were assessed using Chi-square tests and multivariable logistic regression.
RESULTS: The proportion of pregnant admissions where opioids were the primary substance of use increased from 16.9% to 41.6% during the study period, while the proportion of pregnant admissions with OUD who received pharmacotherapy remained relatively unchanged at around 50%. Overall, pharmacotherapy recipients were generally older and white, more likely to receive treatment in an outpatient setting, be self-referred, and report heroin as the primary substance, daily substance use, and intravenous drug use, and less likely to have a co-occurring psychiatric problem compared to those who did not receive pharmacotherapy. Regional differences in pharmacotherapy utilization exist; the South consistently had the fewest pregnant admissions with OUD receiving pharmacotherapy.
CONCLUSION: Although the proportion of pregnant admissions to substance use treatment centers with OUD has increased since the mid-1990s, the proportion receiving pharmacotherapy has not changed. Significant variations in pharmacotherapy utilization exist by geography and demographic, substance use and treatment characteristics. Utilization of pharmacotherapy at publically funded treatment centers providing care for pregnant women with OUD should be expanded.
PMID: 29706175
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