Pregnant Patients Struggle to Get Treatment for OUD

It’s already difficult for people with opioid use disorder (OUD) to get treatment, and that’s especially true for minorities, people in rural areas, and those who are pregnant, who may face incarceration or lose custody of their children if their opioid use is discovered.

One 37-year-old woman in Tuscumbia, Alabama, knows this situation well. She had two children before she finally managed to address her substance use with the help of the medication Suboxone. She didn’t feel comfortable sharing her name, due to the stigma that often accompanies OUD.

“I had been an addict for over 10 years, and it took my grandfather’s death for things to get really bad, which was when I started treatment with Suboxone,” she says. “It has been the longest stretch of sobriety in my life since.”

Suboxone contains both buprenorphine, which is used to treat opioid addiction, and naloxone, which blocks the effects of opioids at the receptor sites.

The Alabama mother had been taking Suboxone successfully for three months when she realized that she was expecting a third child — which meant she might have to stop her current treatment. “It was devastating when I found out I was pregnant,” she says.

Due to limited research on Suboxone during pregnancy, only methadone or buprenorphine are recommended by the Centers for Disease Control and Prevention (CDC) to treat OUD in pregnant people. But while buprenorphine can be prescribed for at least a month, methadone sometimes requires daily pickup from a pharmacy or clinic, which can be impractical or impossible and often serves as a barrier to treatment.

Navigating an unplanned pregnancy while accessing medication for OUD can be particularly scary, especially in Alabama, a state known for more punitive approaches to activities deemed to be criminal, including substance use during pregnancy.

That reality made the Tuscumbia woman consider coming off Suboxone, which could have put her at significant risk. According to the American College of Obstetricians and Gynecologists, the Substance Abuse and Mental Health Services Administration, and the CDC, quickly stopping opioids during pregnancy may result in preterm labor, fetal distress, and miscarriage.

Although the nurse practitioner at the woman’s ob/gyn suggested she discontinue medication-assisted treatment, her family doctor agreed to prescribe her buprenorphine. That crucial access and nonjudgmental approach allowed her to continue treatment, and to be a more present mother for her children.

But that didn’t mean all her troubles were over. “I was worried about the Alabama Department of Human Resources apprehending my baby,” she says, “or even being charged with chemical endangerment, as my state is No. 1 in the country for prosecuting mothers if any substances are found during pregnancy.”

Alabama’s harsh chemical endangerment law is concerning. A study published in January 2022 in JAMA Network Open found that 39.7 percent of jails did not allow the continuation of OUD treatment during pregnancy, and only 31.9 percent allowed for the initiation of OUD treatment during pregnancy. That means that addressing substance use becomes even more complicated for pregnant people navigating criminal charges.

Barriers to OUD Treatment Can Lead to Toxic Stress for Those Who Are Pregnant

Of course, such stress may further jeopardize the health of pregnant people, as well as the baby — yet those are the precarious circumstances many confront when navigating OUD.

“That sort of toxic stress is not good for the pregnant person or their baby,” says Stephen Patrick, MD, who works as an attending neonatologist at Monroe Carell Jr. Children’s Hospital at Vanderbilt in Nashville, Tennessee.

“One of the misconceptions people often have is thinking that someone gets pregnant and they start using an opioid,” Dr. Patrick says. “The truth is for most people, I would say 99.9 percent that I have met, this begins years before and it’s the result of a slew of trauma, lack of economic opportunity, education, etc. As someone from a small rural town, I think the truth of the matter is when it comes to the opiate crisis, like so many things, this could be any one of us.”

Patrick understands firsthand the barriers pregnant people face when trying to begin treatment for opioid use. He coauthored a study published in August 2020 in JAMA Network Open that found that pregnant women were less likely to be able to obtain an appointment with a clinician who could prescribe buprenorphine, compared with nonpregnant women. The study also found that many clinicians didn’t accept insurance and would only grant an appointment if the women paid in cash, with appointments costing $250 on average.

But those weren’t the only barriers. “One of the things that we learned from that qualitative research was the difficulties women had even once they got someone on the phone,” Patrick says. “They were often treated in a demoralizing way. And there were structural issues of just calling a provider that may not be used to serving pregnant people, so they transfer you or just say no and hang up on you.”

Bringing OUD Treatment to the Ob/Gyn’s Office

Last year, Patrick’s research spurred him to help create Firefly, a local Nashville program that offers prenatal and postpartum care in conjunction with OUD treatment. “The stories are pretty incredible. People that were going through relapse and felt unsupported are now developing skills and recovering,” he says. “Recovery is possible and it can happen. It means understanding that addiction is a chronic relapsing medical condition, and I take care of a lot of people with chronic relapsing medical conditions. I treat more complications of diabetes than I do with opioid use.”

This conceptualization aligns well with the perspective of Max Jordan Nguemeni Tiako, MD, a resident physician in internal medicine at Brigham and Women’s Hospital in Boston. “Addiction medicine is a central component of health, especially when thinking about chronic disease management,” Dr. Tiako says. “It should be embedded in medical education and continuing medical knowledge. Just as you learn to manage some amount of hypertension, diabetes, and so on, addiction is no less of a chronic illness like that.”

If ob/gyns treat other chronic health conditions in the course of pre- and postnatal care, Tiako says, OUD treatment should be just as common. But Tiako knows that’s just not the reality. He was the lead researcher on a study published in December 2020 in JAMA Network Open that found that only 1.8 percent of ob/gyns nationwide had obtained the so-called “X-waiver” necessary to prescribe buprenorphine for OUD.

But not all pregnant people have access to an ob/gyn, so other healthcare providers should also be able to prescribe OUD medications, Tiako says: “For instance, allowing midwives to prescribe would help, because in some rural counties, there may not be a single ob/gyn practice.” Unfortunately, these types of regulations can vary from state to state.

The X-Waiver as a Primary Barrier to OUD Treatment

Before April 2021, getting an X-waiver required that doctors complete an eight-hour course, while physician assistants and nurse practitioners had to take a 24-hour course in order to be able to prescribe the gold standard in OUD treatment.

Then, the Biden administration removed the X-waiver requirement to prescribe buprenorphine for any physician treating 30 or fewer patients with OUD. These providers have to file a notice of intent to prescribe buprenorphine, though, and providers prescribing to more than 30 patients are still required to get the X-waiver.

Tricia Wright, MD, says that this small rule change wasn’t enough. “I don’t think it’s changed anything at all,” says Dr. Wright, who serves as a member of the opioid and addiction medicine expert workgroup for the American College of Obstetricians and Gynecologists. Because providers still have to declare their intent to prescribe it to patients, she says, “there’s still this idea that it’s difficult medicine to prescribe. It just keeps the stigma going.”

Wright says that the registration process that is still required maintains that stigma against those who have navigated substance use challenges, even though there are no education requirements around it. “I think that is actually the worst because a little bit of education is helpful, but then having to register to use it is just another barrier,” she says.

OUD Stigma Extends in Multiple Directions

Mishka Terplan, MD, an ob/gyn and addiction specialist who serves as the medical director and senior research scientist for the Friends Research Institute in Baltimore, says that we need to get rid of the X-waiver altogether, given how it contributes to OUD stigma for pregnant people.

“Stigma is a mark of otherness,” Dr. Terplan says, “but when we think about how we treat people, that’s actually not stigma, but discrimination. People who use drugs, in particular people who are pregnant and use drugs, often experience a more complex and multilayered stigma.”

Substance use is often seen negatively in society, Terplan says, but it may also be seen as a deviation from the norms of motherhood. “As a consequence, pregnant women with OUD experience a greater form of prejudice and discrimination by healthcare providers,” he says.

Terplan says that some discrimination from providers may be rooted in ignorance, which education may address, but there are also times when prejudice may be more intentional. “It’s not that they don’t understand, but they think these people are not deserving of dignity and respect,” he says.

Terplan points to actions like withholding pain medications during birth, stepping in to remove the infant from the parent’s care, and notifying child welfare services as examples of ways that healthcare providers assume that using substances is incompatible with safe parenting.

“If they think that there are classifications of people who are unworthy, they’re not going to jump through the hoops to get the buprenorphine waiver,” Terplan says. “And they are certainly not going to integrate that dimension of medical care into their practice. In many ways, it’s similar to racial discrimination and other forms of denying people their basic humanity.”

Based on all of these factors, it’s no wonder that the 37-year-old Alabama woman described herself as sick with worry as she navigated her third pregnancy. “I felt like I had to be beyond reproach with everything,” she says. “I kept a folder with all my drug screens, and my paperwork from my doctor saying that I do get a prescription. I mean, I had all that, but I still worried.”

She reflects on how difficult it was to navigate pregnancy in a rural area with OUD treatment. “Here, the medical professions are not really well informed about medication-assisted treatment. I thought about driving to Birmingham to have a progressive hospital with better doctors, but that was two hours away, and my previous labors had been extremely quick.”

Having heard horror stories from friends who were being treated for OUD in which hospital staff would not let them breastfeed their babies — despite that being the best practice in such situations, according to the CDC — she feared that potential outcome too. Considering the limited professional resources available to her, she was grateful to at least have her family on her side. “I had such a supportive family,” she says. “They all love my children and really stepped up when I was on drugs. For people who don’t have that support system, I don’t know how they do it.”

Thankfully, the woman had a good birth experience. Her baby daughter didn’t have to be medicated for withdrawal, and she was born on her due date. The nurses encouraged her to breastfeed, and she and her baby were able to go home together. The Alabama Department of Human Resources did come to their house once to ensure that they had prepared for the baby, but they have not been involved in the three years since that time.

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