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Punishing pregnant women for opioid use increases risks to infants

November 13, 2019

State policies that impose punitive action against pregnant women who use illicit substances are associated with higher rates of infants being born with opioid withdrawal, suggesting policymakers should instead focus on public health approaches that bolster prevention and expand access to treatment, according to a new RAND Corporation study.

Researchers found that infants born in states with punitive policies such as considering drug use as a form of child abuse were more likely be born with a withdrawal syndrome experienced by some opioid-exposed infants after birth (neonatal abstinence syndrome) than those born in states without punitive policies. The association was observed both shortly after the policies were enacted and over the longer term.

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. The study, published by the journal JAMA Network Open, examined nearly 4.6 million births in eight states from 2003 to 2014.

"As policymakers adopt strategies intended to decrease the effect of substance use on infants, our findings suggest that punitive policies may have unintended consequences," said Dr. Laura J. Faherty, lead author of the study and a physician researcher at RAND, a nonprofit research organization. "Punishing pregnant women for substance use may cause them to disengage from the health care system, and make them less likely to seek prenatal care and substance use treatment."

Researchers say it may be more productive for policymakers to pursue approaches that encourage pregnant women to seek evidence-based treatment for substance use disorder, as well as expand treatment access for this population, strategies favored by public health officials.

The opioid crisis in the U.S. 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 rose sevenfold from 2000 to 2014.

Infants born after exposure to opioids often require prolonged hospitalizations to manage their needs, with those cumulative costs totaling more than $500 million by 2014.

Some states have sought to address opioid misuse during pregnancy by expanding access to treatment. However, many states have enacted punitive polices, such as laws that consider substance use during pregnancy to be a crime or evidence of child neglect. The number of states with such punitive policies increased from 12 in 2000 to 25 in 2015.

Others have responded by requiring health care professionals to report suspected prenatal substance use to authorities. The number of states with reporting policies increased from 12 to 23 over the same period.

RAND researchers used information from the Healthcare Cost and Utilization Project's State Inpatient Databases, compiled by the Agency for Healthcare Research and Quality to examine the incidence of neonatal abstinence syndrome in eight states that enacted policies at different times during the study period.

Those states -- Arkansas, Arizona, Colorado, Kentucky, Massachusetts, Maryland, Nevada and Utah -- adopted either punitive penalties for drug use during pregnancy or policies that required reporting of pregnant women with suspected substance use. One state adopted both.

Researchers 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 study found that the annual rate of neonatal abstinence syndrome was 46 cases per 10,000 live births in states during years without punitive polices. Meanwhile, the rate was 57 cases of neonatal abstinence syndrome per 10,000 live births in states with punitive polices during the first full year after enactment, and 60 cases per 10,000 births in subsequent years.

"Our findings are consistent with other studies showing that policies that penalize pregnant women for substance use deter them from seeking necessary health care," said Dr. Bradley D. Stein, senior author of the study and director of the RAND Opioid Policy Tools and Information Center. "Disengaging from the health care system poses risks both for pregnant women and their infants."

Researchers say that instead of adopting punitive policies, lawmakers should consider approaches favored by public health officials that focus on prevention as a way to decrease the impact of the opioid crisis on mothers and their infants.

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).
Support for the study was provided by the National Institute on Drug Abuse. Other authors of the study are Ashley M. Kranz, Joshua Russell-Fritch, and Jonathan Cantor of RAND, and Dr. Stephen W. Patrick of the Vanderbilt University School of Medicine.

RAND Health Care promotes healthier societies by improving health care systems in the United States and other countries.

RAND Corporation

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