America's opioid crisis: States that penalize pregnant women for drug abuse see more newborns with withdrawal issues
The researchers recommend adopting approaches that focus on prevention to decrease the impact of the opioid crisis on mothers and their infants.
US states that penalize women for opioid misuse during pregnancy are causing a lot of harm. The reason: the number of newborns facing opioid withdrawal is significantly higher in states with punitive policies - such as considering drug use as a form of child abuse - as compared with those without them.
Punitive policies result in an excess of 14 newborns with withdrawal syndrome per 10,000 live births, according to researchers who examined 4,567,963 live births in eight US states, from 2003 to 2014. This includes Arkansas, Arizona, Colorado, Kentucky, Massachusetts, Maryland, Nevada, and Utah.
The findings, says the team, shows that punishing pregnant women for substance use increases the risk to infants as it leads to more newborns being born with an opioid withdrawal syndrome. Such stringent policies deter pregnant women from seeking necessary healthcare, posing risks for both women and their infants, according to the researchers from RAND Corporation and Boston University, among others.
The withdrawal syndrome is referred to as neonatal abstinence syndrome or NAS, which is a group of conditions that occurs when a baby withdraws from certain drugs he/she was exposed to in the mother’s womb.
The researchers found that the annual rate of neonatal abstinence syndrome was 46 cases per 10,000 live births in states during years without punitive policies. The rate was 57 cases of neonatal abstinence syndrome per 10,000 live births in states with punitive policies during the first full year after enactment, and 60 cases per 10,000 births in subsequent years.
"As policymakers adopt strategies intended to decrease the effect of substance use on infants, our findings suggest that punitive policies may have unintended consequences. Punishing pregnant women for substance use may cause them to disengage from the healthcare system, and make them less likely to seek prenatal care and substance use treatment", says Dr. Laura J. Faherty, lead author of the study and a physician-researcher at RAND, a non-profit research organization.
Policies that require the reporting of prenatal substance use - which may result in a referral to drug treatment or other intervention - were not associated with higher rates of neonatal abstinence syndrome, say researchers.
US opioid crisis
The opioid crisis in the US has affected a substantial number of pregnant women and their babies. The number of women with an opioid use disorder at the time of delivery quadrupled from 1999 to 2014, and diagnoses of neonatal abstinence syndrome went up seven-fold from 2000 to 2014.
The National Institute on Drug Abuse describes opioids as a class of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone, hydrocodone, codeine, and morphine, among others.
“Neonatal intensive care unit admissions for neonatal abstinence syndrome increased nearly four-fold between 2004 and 2013, and in some hospitals, NAS accounts for approximately half of all neonatal intensive care unit days. There is substantial state-to-state variation in NAS rates, as well as county-level variation associated with structural factors, such as higher rates of long-term unemployment and less access to mental health care practitioners. Neonates with NAS often require prolonged and costly hospitalizations, with total hospital costs for births with NAS exceeding $500 million by 2014,” says the study published in JAMA Network Open.
Experts say some states have sought to address opioid misuse during pregnancy by expanding access to treatment. However, many states have enacted punitive policies, such as laws that consider substance use during pregnancy to be a crime or evidence of child abuse or neglect. Others have responded by requiring healthcare professionals to report suspected prenatal substance use to authorities.
“From 2000 to 2015, the number of states with these punitive policies increased more than two-fold from 12 to 25. The number of states requiring healthcare professionals to report suspected prenatal drug abuse to child protective services or health officials increased from 12 to 23”, says the study.
The researchers used information from the Healthcare Cost and Utilization Project's State Inpatient Databases, compiled by RAND to examine the incidence of neonatal abstinence syndrome in eight states that enacted policies at different times during the study period. The states either adopted punitive penalties for drug use during pregnancy or policies that required reporting of pregnant women with suspected substance use. One state adopted both.
The team found that among births in states with punitive policies, the odds of neonatal abstinence syndrome were significantly greater both in the first full year following enactment and in subsequent years.
“The annual rate of NAS was 46 neonates with NAS per 10,000 live births in states without punitive policies; 57 during the first full year after policy enactment in states with punitive policies, an excess of 11 neonates with NAS per 10 000 live births; and 60 neonates with NAS per 10,000 live births in states with punitive policies in effect for more than one full year, or an excess of 14 neonates”, the findings state.
In contrast, mandated reporting of substance use in pregnancy to authorities was not significantly associated with an increase or decrease in rates of NAS. The researchers say they are uncertain as to why reporting policies did not have the same association as punitive policies.
“It may be that reporting policies were not associated with as great a disengagement from healthcare services as punitive policies. It is also possible that compared with punitive policies, reporting policies are more likely to result in conversations between clinicians and pregnant women that result in decreased opioid use or greater engagement in treatment for opioid-related complications, actions that may decrease rates of NAS,” they say.
The researchers recommend that instead of adopting punitive policies, lawmakers should consider approaches that focus on prevention to decrease the impact of the opioid crisis on mothers and their infants.
The team says it may be more productive for policymakers to pursue approaches that encourage pregnant women to seek evidence-based treatment for substance use disorder.
“Those approaches include expanding access to drug treatment programs designed for pregnant women, advocating for responsible prescribing of opioids to women of childbearing age, and increasing access to family planning services for women that aligns with their reproductive goals (most pregnancies among women with opioid use disorder are unplanned)”, says the study.
In an invited commentary, experts say that state policies criminalizing prenatal exposure are likely to result in fewer women seeking care and treatment and ultimately “jeopardize the health and well-being of the mother, infant, and family.” They say it is time to support, rather than punish pregnant women with substance use disorder.
“There is a great deal of work ahead to replace current written (and unwritten) policies that force pregnant women into hiding with policies that instead incentivize and facilitate access to treatment for substance use disorders. State policies should reflect current medical knowledge that opioid use disorder and other substance use disorders are chronic, life-threatening conditions for which evidence-based treatments are available and beneficial”, say the experts.