Pregnant People and Opioid Use: A Stigmatized Population in Crisis
By: Vivian Flanagan
Over the past two decades, the opioid crisis has claimed an astonishing number of lives despite clear and proven pathways to prevention, treatment, and support. As of 2021, approximately three quarters of fatal opioid overdoses occur among people aged 25 to 54, including those of typical reproductive age. Simultaneous with high usage trends in the United States, approximately one in five pregnant people will fill an opioid prescription. In a 2019 study, approximately 7% of pregnant people surveyed reported using prescribed opioids during pregnancy, and more than 20% used opioids for reasons other than pain or from a non-medical source.
Not only are parents being affected by opioid misuse, so are their children; neonatal abstinence syndrome has increased fifteen fold over the last two decades. The opioid crisis has devastated families and communities, and will continue if policies and programs fail to support parents who use and their children. In the national opioid settlement, two key core strategies were outlined as approved investments for settlement funds that can direct much needed resources to this vulnerable population:
- Provide treatment and supports during pregnancy and the postpartum period
- Expand services for neonatal opioid withdrawal syndrome
Impact of Opioid Use during Pregnancy
Maternal opioid dependence use during pregnancy is associated with several negative delivery outcomes, including increased probability of maternal death, heart attack, preterm labor, and additional medical intervention. Prenatal care is a form of preventative care intended to inform expecting parents about health choices and changes to their bodies throughout pregnancy; utilization of this type of care is low among pregnant people who use opioids, increasing the risk of child mortality. Despite a vast amount of factors indicating the importance of consistent care for pregnant individuals, the act of using drugs while pregnant is highly stigmatized through criminalization and involvement with child protective services.
Due to this stigma, providers should be aware that pregnant people may not disclose drug use voluntarily. Universal drug screening of pregnant people is recommended by the American College of Obstetrics and Gynecologists. However, urine drug tests are not recommended for pregnant people who use drugs because they do not indicate when drugs were used nor whether usage is problematic. Alternatively, acceptable screening tools include SBIRT, the 4Ps, CRAFFT, and NIDA Quick screen, which explore factors like familial drug use, illustrating the conditions in which pregnant individuals use drugs. Additionally, the Clinical Opiate Withdrawal Scale can be used to quantify withdrawal symptoms in pregnancy.
Treatment
Buprenorphine and methadone are two of the FDA approved treatment options for Opioid Use Disorder (OUD) and are approved for use in pregnant individuals. Buprenorphine is associated with lower risk of preterm birth and greater birthweight, while methadone is associated with greater treatment retention. Both medications are the standard of care for medication-assisted treatment, but remain underutilized. Naltrexone is not recommended for pregnant people due to detox requirements.
There are several factors which make it difficult for pregnant people who use drugs to access treatment services for opioid use disorder. Pregnant people who use drugs report fear of intervention by child protective services as a primary barrier to treatment, along with discrimination and stigma in medical spaces. Moreover, medication providers and opioid treatment programs frequently turn away pregnant patients seeking treatment. Finances pose a significant barrier to treatment as well; providers seldom offer Medicaid-covered appointments, barring low-income patients from receiving critical medication and therapeutic services.
Documented facilitators of treatment for drug use during pregnancy point toward systematic integration. Co-location of drug treatment and maternal health services in one facility can improve parents’ access to care. Additionally, communication among patients’ providers can improve when health care workers collaborate when providing clinical and non-clinical services. Finally, the quality of care delivered may improve if executed in group settings and supplemented with empathetic, trusting relationships with providers.
Actions for Decision-Makers
Decision-makers should consider the following recommendations when deciding how to invest opioid settlement funds concerning pregnant people who use opioids. Spend settlement dollars on programs that:
- Address the stigmatization and criminalization of pregnant people using opioids
- Some states require physicians to report any pregnant person using Medication for Opioid Use Disorder (MOUD). This perpetuates the stigma put upon this population by criminalizing their attempts to acquire treatment.
- States could consider programs like West Virginia’s Drug Free Moms and Babies (DFMB) program and New Jersey’s Plans of Safe Care, both of which aim to connect pregnant people who use to care providers and help families remain together throughout the treatment and recovery process.
- Train and Educate Care Teams
- Health care workers who develop positive attitudes towards patients taking MOUD report greater job satisfaction. Additionally, patients report better quality care when treated by sympathetic, non-judgmental staff members.
- Providers should be made aware of the MAT Act, which removes requirement of an X-waiver to prescribe buprenorphine and the limitation on the number of patients with OUD healthcare providers can treat at a time.
- Expand Maternal Opioid Misuse (MOM) Model
- Supports state-driven programs to work toward combining behavioral health services with OUD treatment among expecting parents.
- Addresses fragmentation of care for pregnant people who use drugs by improving quality of care, access to treatment, service delivery capacity, infrastructure, and payment strategies.
- Seek Implementation of Comprehensive Pregnant Person-Centered Models that Integrate Care
- Devise treatment models which provide consistent MOUD to patients seeking treatment while pregnant and emphasize postnatal breastfeeding’s positive impact on infant withdrawal, hospital stay, and pharmacotherapy
- Support nurse-driven, community-based programs to create patient care plans, which are found to improve breastfeeding initiation and continuation, neonatal birth weight, the prevalence of neonatal abstinence syndrome diagnosis and treatment, and referral to peer/family support services.
Including pregnant people who use drugs in state and country-wide initiatives delegating opioid settlement dollars is imperative. Drug usage among pregnant people is highly stigmatized; the fear of family separation leads some to not seek crucial prenatal care. There are established industry standards for medication-assisted treatment for pregnant people, and systematic integration of MOUD and maternal care may be a potential pathway to increase access. Decision-makers should address stigmatization and criminalization, educate providers interacting with pregnant people who use drugs, seek creative integration of different types of care utilized by pregnant people, and prioritize patient-centered treatment programs.
Vivian Flanagan is a Research Program Coordinator with the Bloomberg Overdose Prevention Initiative at the Johns Hopkins Bloomberg School of Public Health and a recent graduate from the University of Maryland.