SUD Policy and Access to Care: Implications for Pregnant and Postpartum Persons

June 26, 2024 | Maryssa Sadler, Zachary Thornhill

It is 2024, and the US continues to battle an unbelievable fight with opioids. We stand at a critical time in addressing the healthcare needs of pregnant persons dealing with substance use disorder. Substance use disorder among pregnant individuals has been linked to maternal mortality. We must acknowledge their unique challenges and commit to providing early, comprehensive, and compassionate care. By fostering collaboration among healthcare providers, community organizations, and policymakers, we can create a supportive environment where every pregnant individual receives the treatment and support they deserve to improve the overall wellness of both parent and baby.

Substance Use Disorder and Policy

A substance use disorder (SUD) is a clinical condition that limits a person’s ability to control their use of a substance, licit or illicit, despite negative, harmful consequences. Pharmaceutical interventions have been used for SUD treatment for decades, and in 2015, the American Board of Medical Specialties acknowledged addiction medicine as a unique specialization, signaling further practice-based integration of behavioral health and physical health services. Still, medication is only one option among many in a comprehensive array of treatment and recovery services, including individual and group therapy, residential treatment programs, and peer support services.

Access to SUD treatment has shifted significantly since Congress passed the Mental Health Parity and Addiction Equity Act (MHPAEA) in 2008. The law essentially prohibits health insurance companies from covering behavioral health services at a lower threshold than physical health care on group plans. This was also extended to public health plans like Medicaid; only states with fee-for-service Medicaid are exempt. This means that while the MHPAEA was positive progress for health equity, evidenced by increased utilization of SUD treatment services in states with stronger parity, it still leaves room for improvement.

Over 40% of births in the US are covered by Medicaid, covering over half of all births in Louisiana, Mississippi, New Mexico, and Oklahoma. And, in cases where Medicaid coverage was used, the prevalence rate of babies born to a birthing parent with opioid use disorder (OUD) is nearly twice that of non-Medicaid cases. Given the number of births it pays for and how many cases are impacted by OUD, Medicaid programs are in a prime position to address this disparity. We know that, in pregnancy and postpartum, a parent with OUD has unique needs related to treatment and care, considering the perceived and real health, social, and financial consequences at risk if their substance use is uncovered.

Access to Care for Prenatal and Postpartum Individuals

According to SAMHSA, pregnant and postpartum individuals face a heightened risk of fatal opioid overdose. Disturbingly high rates indicate a significant uptick in OUD mortality among this demographic, prompting numerous organizations and advocacy groups to sound the alarm. State Medicaid programs, which provide support to pregnant individuals throughout their postpartum period, also play a pivotal role in addressing this issue, specifically for OUD. Opioid use during pregnancy and in the postpartum period has been associated with adverse health outcomes for both mother and baby. These risks include preterm birth, maternal mortality, stillbirth, poor fetal development, birth defects, and neonatal abstinence syndrome.

A 2017 report by the Kaiser Family Foundation revealed that nearly four in ten adults with OUD were covered by Medicaid. This statistic underscores the importance of prevention, intervention, and support for pregnant women by facilitating access to care and emphasizing the necessity of OUD treatment to mitigate mortality rates.

With the cases of OUD during pregnancy and postpartum, many providers are offering Medication for Opioid Use Disorder (MOUD). Commonly prescribed medicines for MOUD are methadone and buprenorphine, both of which can reduce the severity of neonatal opioid withdrawal syndrome in newborns. Medications such as buprenorphine can be prescribed by both primary and emergency room settings, not just addiction medication. Integrating MOUD with comprehensive social support can significantly enhance outcomes for pregnant and postpartum individuals and their babies. Recent research indicates that new parents who breastfeed require less pain medication following birth, as skin to skin contact and breastfeeding are associated with fewer symptoms of neonatal opioid withdrawal syndrome.

Lessons From the Field

According to the CDC, “taking MOUD as prescribed during pregnancy has benefits that outweigh the risks. Healthcare providers and people who are pregnant need to work together to manage medical care, including substance use, during pregnancy and after delivery.” Supportive interventions are crucial for addressing the uptick in OUD pregnant and postpartum individuals with the promotion of recovery and overall well-being. Key components to support those experiencing OUD include:

• Personalized case management through Medicaid-managed care organizations to support the overall well-being of parents and babies.
• Peer support to connect individuals with those who have lived experiences and can offer encouragement and understanding through treatment and care.
• Integration of care to support all health service areas, from mental health, behavioral health, and substance use, with a comprehensive healthcare framework.
• Community support that will allow individuals to connect with local resources to address social determinants of health.
  • Family-centered care aiding in reducing the sigmas to supportive systems between mother to baby.

By integrating MOUD with a range of social supports, healthcare providers and support professionals can address the complex needs of pregnant and postpartum individuals with OUD, ultimately improving outcomes for both mothers and their infants.

State Perspectives

Virginia’s OB MOTIVATE Clinic

The OB MOTIVATE Clinic was created in 2019 and is the only program in central Virginia that provides an interdisciplinary, integrated approach to women with substance use disorders, treating women across their life course, including during and after pregnancy. The MOTIVATE clinic provides evidence-based, person-centered care through OB-GYN care, addiction treatment, and recovery services. The clinic has offered many women from pregnancy to postpartum an outlet for supportive services that align with research and improved telehealth capacities to ensure patients seek treatment sooner, along with immediate follow-up visits. This type of space for specialized care allows individuals to seek the care they need and have one-on-one care with their providers.

Learn more about the impact the VCU OB MOTIVATE Clinic has on patients' lives by watching Nichole Hollie's story.

Nurture Oregon

Nurture Oregon grew out of Project Nurture, which kicked off in 2015 as a pilot project grounded in stigma-free, integrated care utilizing best practices in an urban area to support pregnant and parenting women with OUD. After a few years of positive outcomes, such as reduced rates of child maltreatment and placement in foster care, the Oregon legislature funded the expansion into four rural counties and one frontier. Some key takeaways about the change in environment:

• Peer supports play an integral role in nearly half of all care plans, not just navigation.
• Providers can be isolated from other providers without much partnership in care.
• Multidisciplinary provider type needed to expand access with limited resources.
• Limiting the number of appointments, drive time, and other required resources is particularly important in rural and frontier spaces due to infrastructure capacity.

Looking forward, it may be beneficial for states to invest in new federally qualified health centers or certified community behavioral health clinics. Both of these options support integrated care, with access to various providers in one container and incentives for efficient, multidisciplinary care. They both already hold stigma-free care at the core of caring for vulnerable communities.

Conclusion

New policies have extended postpartum services for postpartum individuals to provide longevity of care and comprehensive services for members. Many states have adopted this new benefit for members and allow members one year of postpartum coverage for comprehensive maternity services. Legislation such as the MHPAEA even requires that group health plans offer behavioral health services at the same level as they provide medical and surgical care. However, gaps in care persist. Various factors can inform why state-level enforcement of parity is insufficient—politics, lack of cohesive focus, varied interpretations of the law, and poor internal infrastructure at health insurance companies. Increasing the capacity of the Centers for Medicare and Medicaid Services to provide field-based audits and oversight of state Medicaid systems could surely increase compliance with MHPAEA provisions and improve access to care for pregnant and postpartum individuals seeking care for OUD and other SUDs.