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Written by: Jennifer E. Moore , Brian T. Bateman , & Stephen W. Patrick

The nation’s opioid crisis is well documented; however, little attention has been paid to the epidemic’s effect on pregnant women and infants. In recent years, opioid use disorder during pregnancy has increased along with a concurrent increase in neonatal opioid withdrawal, also known as neonatal abstinence syndrome (NAS). Given that Medicaid covers roughly half of all births, and more than 80 percent of NAS births, additional efforts are needed to improve outcomes for pregnant and postpartum women as well as infants enrolled in the Medicaid program.

Women of reproductive age and pregnant women covered by the Medicaid program fill prescriptions for opioids more commonly than those not in the program. In the 2000s, 21.6 percent of pregnant women enrolled in Medicaid filled an opioid prescription, with rates ranging from 9.5 percent to 41.6 percent across states, which is significantly higher than the rates of opioid use during pregnancy observed in a commercially insured population. Medicaid is more likely to be the primary payer of substance use-related maternal hospital stays (75.0 percent compared to 13.7 percent in private insurance). Additionally, women enrolled in Medicaid are more likely to be offered and fill a prescription for opioids to address postpartum pain. In fact, more than 10 percent of Medicaid-enrolled women who deliver vaginally fill a prescription for opioids after delivery. For some women, use of prescription opioids during the postpartum period may be a trigger for persistent opioid use and subsequent opioid use disorder. Understanding root causes for these differences and ensuring that opioid prescribing is necessary and appropriate is vital.

Some have argued that Medicaid expansion has played a role in contributing to the opioid epidemic; however, there is little evidence to support these claims. In fact, Medicaid plays a critical role in providing coverage for individuals with opioid use disorder; including pregnant women and infants. In this post, we focus on how Medicaid could improve outcomes for pregnant women and infants affected by the opioid epidemic.

Barriers In Care Delivery

Efforts to address opioid use disorder amongst pregnant women and improve pregnancy outcomes include substance use counseling, medication-assisted treatment (MAT), and behavioral health evaluation and treatment. Use of MAT during pregnancy may increase the likelihood an infant will be born with NAS; however, there is strong evidence that these therapies reduce the risk of more severe outcomes for mom (for example, overdose) and baby (for example, preterm birth). However, the limited number of treatment facilities with programs specific to the needs of pregnant and postpartum women is a common barrier. Only 13 percent of outpatient-only substance use treatment, 13 percent of residential treatment facilities, and 7 percent of hospital inpatient treatment facilities offered programs tailored for pregnant and postpartum women. Despite evidence that MAT is effective among women of reproductive age admitted to a treatment facility, only 48.5 percent of those using heroin and 36.9 percent of women using other opioids received this evidence-based therapy.

Infants also encounter barriers to effective treatment. Increasingly, research suggests that standardized protocols to care for opioid-exposed infants improve outcomes, including shortening the length of treatment and length of hospital stay. Traditional approaches to NAS treatment include treatment of the infant in a neonatal intensive care unit, often separating mother and infant. However, minimizing this separation of mother and baby by allowing mother and infant to room together appears to improve clinical outcomes. Despite the potential benefits of these low-tech approaches, there is evidence that many hospitals have not adopted these approaches.

For families, the time immediately after hospital discharge is particularly vulnerable. Data suggest that infants with NAS are twice as likely as uncomplicated term infants to be readmitted to the hospital within 30 days of discharge. As families leave the hospital, there are numerous needs by mother and baby, and providers need to work together to coordinate evidence-based care. For instance, postpartum mothers may have their obstetric and addiction treatment follow-up appointments in addition to caring for their infant, who has follow-up appointments and home nurse visits, early intervention services such as IDEA Part C, and the involvement of child welfare services. Due to the complexity of needs for both the mother and infant and the numerous care providers and entities potentially involved in the care of families, there can be challenges in the coordination of this care.

Policy Barriers

In the Medicaid program, substance use disorder benefits such as psychotherapy and drug treatment programs vary by state. While every state provides MAT coverage for prescription medications used to treat opioid use disorder, including single-entity buprenorphine product, despite the availability of federal funding, methadone is not covered by every state Medicaid program. Evidence-based clinical guidelines, including those published by the Substance Abuse and Mental Health Services Administration (SAMHSA), suggest that both methadone and buprenorphine be available to pregnant women to tailor treatment to each individual.

To prescribe and dispense single-entity buprenorphine products, physicians must complete a waiver application and training to become a Drug Addiction Treatment Act (DATA)-waived physician. In 2016, policies expanded the number of patients who could receive MAT from a single DATA-waived clinician and expanded the types of clinicians (that is, nurse practitioners and physician assistants) who could prescribe buprenorphine. Despite these efforts, there remains significant gaps in the number of total clinicians available to meet the needs of individuals across the US, making it difficult for pregnant women to access the care they need. Contributing to this gap is the exclusion of certified nurse-midwives, an important women’s health provider in the US, from the expanded list of clinicians.

Furthermore, states have adopted laws that criminalize drug use during pregnancy, creating additional barriers for women, including those enrolled in Medicaid, from accessing treatment that they need and further contributing to the stigma surrounding opioid use disorders. Forty-four states will prosecute women for prenatal illicit drug use, 24 states and the District of Columbia consider prenatal drug use as child abuse or neglect, and four states recognize substance use as grounds for civil commitment. Several national organizations, including the American Academy of Pediatrics, have cautioned against criminal justice approaches to addressing opioid use amongst pregnant women; instead, opting for policies focused on medical interventions including prevention and expansion of MAT treatment options.

Opportunities To Improve Outcomes For Pregnant Women And Infants Affected By Opioid Use In Medicaid

As the payer for approximately 50 percent of all births and more than 80 percent of infants with NAS nationwide, Medicaid has the potential to play a critical role in improving care and outcomes for pregnant women and opioid-exposed infants. As the nation continues to focus on the opioid epidemic, it is important to consider the specific needs of pregnant women enrolled in Medicaid. There are key research and policy opportunities to consider that build upon SAMHSA’s final strategy recommendations in its 2017 Report to Congress.

Research Opportunities

Medical Research To Evaluate Causes Of Opioid Use Focused On Pregnant And Postpartum Women

To diminish the stigma harbored by society and clinicians, further research is needed to understand the causes of opioid use disorder, especially for women covered by Medicaid. Expanding research efforts to include an understanding of causes from the perspective of clinicians, individuals, and families will enhance overall efforts to address this epidemic.

Evidence-Based Interventions Designed To Address Opioid Use Disorders Amongst Pregnant And Postpartum Women And Infants

As more state and federal efforts are launched to address the opioid epidemic, it is critical that interventions and programs be evaluated for their efficacy in expanding access to treatment and improving quality of treatment, among other factors. Understanding the unique needs of pregnant and postpartum women and infants enrolled in the Medicaid program should include challenges in addressing social determinants of health to optimize treatment. The findings from the evaluation of the interventions should be disseminated widely, including in peer-reviewed journals to continue to build the growing evidence base on this topic.

Policy Opportunities

Opioid Treatment Programs Should Be Considered As Replacements For Criminal Penalties, Prosecution, And Incarceration Of Pregnant And Postpartum Women

Current criminal penalties and state laws can pose a barrier for pregnant and postpartum women misusing opioids to access care and treatment. Destigmatizing substance use disorder for pregnant women and treating it as a chronic medical condition will better enable those who are suffering from opioid addiction to receive behavioral therapy and MAT.

Streamlined And Efficient Enrollment Processes For Pregnant Women

Ideally, eligible pregnant women should be enrolled in Medicaid as quickly as possible to facilitate expedited access to routine prenatal care. In doing so, pregnant women misusing opioid prescriptions and illicit opioids may gain access to MAT services earlier in pregnancy, improving birth outcomes.

Expansion Of Workforce Development To Increase The Number Of Clinicians Trained To Prescribe And Provide MAT, Including Nurse-Midwives

Currently, the demand for opioid treatment vastly outweighs the number of available clinicians. The gap of available clinicians makes it difficult for priority groups, such as pregnant and postpartum women, to receive the treatment they need. Expanding the types of clinicians who can prescribe as part of MAT to include certified nurse-midwives will be beneficial for pregnant and postpartum women.

Current policy-making efforts focused on addressing the opioid epidemic in the US through prevention and treatment are crucial; however, we must not overlook the unique needs of pregnant and postpartum women enrolled in the Medicaid program. The US Congress is currently considering several pieces of legislation and regulatory actions focused on the opioid epidemic; however, their efforts have largely not included pregnant women or infants. As they consider legislative action to stem the tide of the opioid epidemic, it is imperative to consider the needs of this vulnerable population; including plans of safe care for infants and care coordination for both the mother and infant. The national interest in this topic provides Congress with any opportunity to invest resources to improve outcomes for our nation’s future by targeting funds to pregnant women and infants.

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Contact

Amy Tolliver, Director
West Virginia Perinatal Partnership
(304) 558-0530 ext. 5
atolliver@wvperinatal.org