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Diagnosis, Treatment of Opioid Use Disorder in Pregnancy Tied to State Laws in US

March 14, 2019

By Marilynn Larkin

NEW YORK—Patterns of diagnosis and treatment of opioid use disorder (OUD) in pregnant women in the U.S. vary significantly by region and by whether the disorder is criminalized by state laws, researchers say.

"The striking finding was the lower prevalence of recorded OUD and lower medication-assisted treatment rates in states that have criminal or civil statutes prosecuting women with an OUD diagnosis," Dr. Fadia Shaya of the University of Maryland School of Pharmacy in Baltimore told Reuters Health by email.

Women may not disclose opioid use "due to fear of stigma or fear of losing custody of her newborn, or fear of losing their job or insurance," she said. "It might also be due to a lower availability of treatment options, which limit access to treatment."

Dr. Shaya and colleagues studied data from 2007 to 2015 on more than 110,000 US pregnant women (mean age, 30) with a code indicating a delivery and commercial insurance enrollment nine months before and 12 months after delivery.

Women were categorized into four regions of residence: South, Midwest, West and Northeast. They were further stratified by whether or not they lived in one of the 18 states that impose civil or criminal penalty on women with OUD during pregnancy: Arkansas, Colorado, Florida, Illinois, Indiana, Iowa, Louisiana, Minnesota, Nevada, Oklahoma, Rhode Island, South Carolina, South Dakota, Texas, Virginia, Wisconsin, Alabama, and Tennessee.

As reported online March 8 in JAMA Network Open, 277 women (0.25%) had a diagnosis of OUD and 312 (0.28%) received medication for the disorder (buprenorphine, methadone or naltrexone). Among those diagnosed with OUD, close to half (45.9%) received treatment.

Statistically significant differences in OUD diagnosis and treatment were found among regions. In the Midwest, 0.05% had an OUD diagnosis and 0.05% received treatment. In the Northeast, 0.09% had a diagnosis and 0.08% received treatment. In the South, 0.06% were diagnosed with OUD and 0.10% were treated. In the West, 0.06% had a diagnosis and 0.05% were treated.

The prevalence of OUD diagnoses was significantly lower in states where the condition was criminalized. In those states, 0.07% of women had an OUD diagnosis, compared with 0.18% in states with no criminal statutes.

However, there was no significant difference in prevalence of treatment for the disorder: criminalization, 0.12%; no criminalization, 0.17%

"In summary, in a cohort of 110,285 commercially insured pregnant women, 25 in every 10,000 women had a recorded OUD diagnosis and 28 in every 10,000 received treatment," the authors state. "Variations by region and by presence of criminal or civil statutes were observed in the diagnosis of OUD. Statistically significant regional variations were observed in the receipt of treatment. No statistically significant variations were observed in the receipt of treatment by presence of criminal or civil statutes."

"These results call for a drastic change in our approach to OUD, especially during pregnancy," Dr. Shaya said. "The unintended consequences of civil or criminal statutes have to be fully considered as well, so that they may promote and not stifle the patient-physician relationship. Physicians acting in their patients' best interest should be able to diagnose and treat OUD without putting patients at risk."

"Professional and social organizations can take the lead in highlighting the danger of criminal and civil statutes in that they can fuel instead of stopping the opioid epidemic," she concluded.

Dr. Diane Abatemarco, director of the Maternal Addiction Treatment, Education and Research Program (MATER) at Thomas Jefferson University Hospitals in Philadelphia, told Reuters Health, "This article reflects what we know and highlights the statistical findings to support our hypothesis that criminality of substance use disorder prevents women from seeking care and receiving treatment during pregnancy."

"States that have criminal consequences may affect the rates of care throughout the U.S.," she said by email. "Women come into treatment feeling like criminals as a result of the U.S. policy that drug use is a criminal behavior rather than a medical disorder."

"Additionally, women with substance use disorder must have long-term treatment in programs such as Jefferson's MATER," she said. The success of such programs "are based on treating the women with respect and providing long-term comprehensive care and treatment to engage women throughout their recovery and inadvertent relapses that may occur because of stress related to poverty, the stigma of drug use disorder and the long-term biologic effects of substance use."

"The American Medical Association, American Public Health Association, and American College of Obstetricians and Gynecologists, as well as other powerful associations should take the lead and mandate congress to enact federal laws that remove the criminality of those who seek treatment, especially pregnant women who bravely enter care to protect their fetus and newborns," Dr. Abatemarco concluded.


JAMA Netw Open 2019.

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