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The fear of consequences, such as child welfare involvement, can also greatly deter pregnant individuals with OUD from seeking the care they need. This fear is particularly pronounced among people of color, who might already be facing systemic bias. In rural areas, the situation is even more dire, with fewer treatment options, less financial resources, and greater stigma from the community. The growing rate of neonatal abstinence syndrome (NAS) in rural areas stresses this issue.
April 8, 2024
To present an analysis of the challenges faced by pregnant individuals with Opioid Use Disorder (OUD), Valor Lakes emphasizes the urgent need for systemic change in healthcare delivery based on research put forth by SAMHSA Advisory. The opioid epidemic has brought to light not only the widespread issue of opioid addiction but also the unique and compounded difficulties pregnant people face in accessing effective treatment.
We recognize that diagnosis of OUD, based on the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9 CM), often doesn't capture the full complexity of individual cases, such as distinguishing between problematic prescription opioid or heroin use and those enrolled in opioid maintenance programs. This lack of nuance can lead to a one-size-fits-all approach to treatment, which may not be effective for all patients. Research has shown a disparity in prescription rates of buprenorphine—a medication used in the treatment of OUD—between White individuals and people of color. (See the link to research here.)
The fear of consequences, such as child welfare involvement, can also greatly deter pregnant individuals with OUD from seeking the care they need. This fear is particularly pronounced among people of color, who might already be facing systemic bias. In rural areas, the situation is even more dire, with fewer treatment options, less financial resources, and greater stigma from the community. The growing rate of neonatal abstinence syndrome (NAS) in rural areas stresses this issue.
The barriers to care for pregnant individuals with OUD remain significant. Providers have a critical role in addressing these barriers by enhancing their knowledge of state reporting requirements and understanding the unique needs of this population. There’s a pressing need for a compassionate, structured, and accountable approach in healthcare that promotes mental health, prevents substance misuse, and ensures equitable access to treatments and better outcomes. By adopting such an approach, healthcare providers can offer meaningful support and contribute to transformative change in the lives of pregnant individuals struggling with OUD. From 2018 to 2021, this program is instrumental in providing states with the necessary funding to support substance use treatment, prevention, and recovery services, with a focus on pregnant and postpartum individuals. During this period, the SUPTRS BG Program served a significant number of pregnant people, totaling 77,418 individuals. This statistic helps us understand the scope of SUD treatment among pregnant populations. Notably, most of those served were White, indicating potential disparities in service accessibility or utilization among different racial and ethnic groups. This observation aligns with broader trends in healthcare and highlights the need for targeted efforts to ensure equitable access to treatment for all demographics.
However, the data also reveals a concerning trend: a decrease in the number of clients served by the SUPTRS BG Program between 2019 and 2021. This decline, amounting to approximately 8 percent or 112,455 individuals, and a 3 percent reduction in 2020 and 2021, tells of potential gaps in service provision or accessibility. The reasons behind this decline could range from funding constraints, and changes in program implementation, to shifts in population needs or awareness. Investigating and addressing these factors is important to ensure continuous and adequate support for those in need. The geographic distribution of these services is also noteworthy, with five states—California, Florida, New York, Michigan, and New Jersey—serving most of the SUPTRS BG Program’s pregnant clients.
This data provides a clear call to action for healthcare providers. To effectively combat the opioid crisis and support pregnant individuals with OUD, providers must be knowledgeable about OUD during pregnancy and the available treatment options, including FDA-approved medications. Universal prenatal SUD screening and assessment are crucial for early identification and intervention. Such screenings should be standard practice at the first prenatal visit and include follow-up questions in subsequent visits to ensure ongoing support. Encouraging and prescribing pharmacological treatment for OUD during pregnancy is a topic for the healthcare industry to reimagine. The Consolidated Appropriations Act of 2023 removed the separate waiver requirement for prescribing buprenorphine, enhancing providers' opportunity to offer comprehensive care. This legislative change facilitates easier access to essential medication, potentially bridging some of the treatment gaps identified in the report.
The goal is to tailor care to each individual, acknowledging their specific circumstances and preferences. SAMHSA’s Person- and Family-centered Care and Peer Support webpage offers additional resources and information on implementing person-centered care. This approach aligns with SAMHSA's overarching mission to lead public health efforts that promote mental health, prevent substance misuse, and provide treatments and support for recovery while ensuring equitable access and better outcomes.
Another critical aspect of care for pregnant individuals with OUD is connecting them with life-saving medications and harm-reduction services. Given the alarming rates of opioid overdoses, providers should be equipped with harm-reduction strategies and knowledge about naloxone. This medication can rapidly reverse the effects of an opioid overdose. The American College of Obstetricians and Gynecologists (ACOG) advises that naloxone should be used in pregnant individuals in case of an opioid overdose, despite potential risks to the fetus. This clarifies the urgent need to prioritize immediate life-saving interventions. Providers should also be aware of local harm reduction organizations that offer services such as syringe programs, which can prevent bloodborne illnesses and infections. Screening and assessment are essential in supporting the treatment of OUD in pregnant individuals. Professional organizations like the Society for Maternal-Fetal Medicine (SMFM), ACOG, the American Society of Addiction Medicine (ASAM), and the U.S. Preventive Services Task Force recommend universal screening for substance use at the first prenatal visit. Using tools that are easily administered, acceptable to patients, and economical is crucial for this process. These screenings provide valuable information that allows providers to engage in brief interventions and make referrals to substance use disorder treatment programs as necessary. Universal screening also advances health equity, as it creates a standard practice that can reduce the stigma and fear associated with disclosing substance use.
Some pregnant individuals may be hesitant to disclose substance use due to fears of social and legal consequences. Providers play a pivotal role in reassuring patients that the aim of screening is to identify and address health concerns, not to penalize them. Understanding a patient’s history with substances, including prescribed and illicit drug use, is vital for providing comprehensive care. Providers must also be aware of state-specific regulations regarding substance use during pregnancy. This knowledge is essential for providing the best possible care while navigating legal requirements and ensuring that pregnant individuals with OUD receive priority access to treatment programs where available. The approach to treating pregnant individuals with OUD must be carefully approached, involving person-centered care, harm reduction strategies, comprehensive screening and assessment, and an understanding of state-specific regulations. By adopting these practices, providers can significantly contribute to the health and well-being of pregnant individuals with OUD and their babies, aligning with SAMHSA's mission to foster recovery and ensure equitable access to care.
The guidance on the use of universal toxicology tests for pregnant people with Opioid Use Disorder (OUD) advocates for a nuanced and patient-centered approach. The recommendation against routine toxicology tests is based on several key considerations. Firstly, such tests may not accurately capture occasional substance use or detect all types of substances. More importantly, a positive result does not definitively indicate that the person has a Substance Use Disorder (SUD). Universal toxicology testing might deter pregnant individuals from seeking and engaging in regular prenatal care due to the fear of stigmatization and consequences. Instead of universal testing, the guidance suggests using biological testing of urine or blood in specific situations where objective evidence of substance use is necessary.
Providers are encouraged to have open and empathetic conversations with patients about toxicology screening, inviting them to share their concerns and preferences. This approach respects the patient’s autonomy and promotes a trusting patient-provider relationship. It’s also important for providers to offer support and assistance in case a positive result is confirmed, such as helping the patient reduce or abstain from substance use. Regarding the initiation of pharmacotherapy for OUD in pregnant individuals, there is consensus among leading health organizations, including SAMHSA, SMFM, ACOG, ASAM, and the World Health Organization. Medications like buprenorphine and methadone are considered safe and effective for treating OUD during pregnancy. These medications not only address the individual's OUD but also contribute to better health outcomes for both the mother and the baby. This includes reducing the risk of recurrence, limiting illicit substance-related effects on the developing fetus, and preventing family separation.
The combined approach of medication for OUD and comprehensive prenatal care is associated with reduced risk of obstetric complications and positive neonatal outcomes, such as increased birth weight and gestational age at delivery. The emphasis is on starting treatment as soon as possible once a diagnosis of OUD is made to achieve the best outcomes for both the pregnant person and their baby.
The treatment of Opioid Use Disorder (OUD) during pregnancy requires careful consideration of the medications used, as they have varying impacts and methods of administration. Methadone has been a standard treatment since the 1970s, known for its effectiveness in reducing opioid use, maternal mortality, and enhancing engagement in prenatal care. More recently, buprenorphine has also been approved for treating OUD in pregnant individuals, demonstrating effectiveness in reducing mortality and overdose deaths. However, there are key differences between these two medications regarding dispensation and their impact on retention in care. Methadone and buprenorphine differ in how they are dispensed. While both can be administered in a hospital setting, buprenorphine offers more flexibility as it can be prescribed on an outpatient basis, via telehealth by DEA-registered practitioners, at medical clinics, or opioid treatment programs (OTPs). Methadone, on the other hand, is typically dispensed at OTPs. The introduction of mobile methadone vans has provided additional dispensation options, enhancing accessibility.
For healthcare providers, supporting individuals with OUD who are planning a pregnancy is crucial. This support includes educating them about the effects of OUD on the baby, the benefits and risks of continuing pharmacotherapy during pregnancy, and changes in medication dosing throughout the perinatal period. It's also important to address the potential development of Neonatal Opioid Withdrawal Syndrome (NOWS), the need to manage polysubstance use, and safe pain management options during and after pregnancy. Additionally, ensuring access to comprehensive recovery supports, including counseling and services for housing and food, is essential to holistic treatment.
Before starting buprenorphine, pregnant patients should undergo a period of opioid withdrawal, which varies depending on the opioid used. Close monitoring during this period is essential due to the potential negative impacts of withdrawal on both the pregnant individual and the fetus, such as tachycardia, increased metabolism, and the risk of preterm delivery. Buprenorphine has fewer known drug interactions compared to methadone, which can interact significantly with many medications, including those for HIV. In terms of neonatal outcomes, infants born to individuals taking buprenorphine have shown higher average gestational age at birth, larger head circumference, and higher average birth weight compared to those born to individuals on methadone.
However, less data is available on the long-term effects of buprenorphine, as it is a newer medication compared to methadone. In contrast, studies of methadone use during pregnancy have indicated no significant effect on cognitive development in children up to five years old. While both methadone and buprenorphine are effective for treating OUD during pregnancy, they differ in administration methods, effects on patient retention, and interactions with other drugs. Awareness of these differences is part of innovative approaches for healthcare providers to offer the most appropriate and supportive care to pregnant individuals with OUD.
