DB 5

FROM THE AMERICAN ACADEMY OF PEDIATRICSPEDIATRICS Volume 139 , number 3 , March 2017 :e 20164070

A Public Health Response to Opioid Use in Pregnancy Stephen W. Patrick, MD, MPH, MS, FAAP, a,b,c,d,e Davida M. Schiff, MD, FAAP, f COMMITTEE ON SUBSTANCE USE AND PREVENTION

aDepartments of Pediatrics and bHealth Policy, cMildred Stahlman Division of Neonatology, dVanderbilt Center for Health Services Research, and eVanderbilt Center for Addiction Research, Vanderbilt University, Nashville, Tennessee; and fDepartment of Pediatrics, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts

Dr Schiff conceptualized and drafted the initial manuscript and critically reviewed the revised manuscript; Dr Patrick conceptualized the manuscript and critically reviewed and revised the manuscript; and both authors approved the fi nal manuscript as submitted.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have fi led confl ict of interest statements with the American Academy of Pediatrics. Any confl icts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Policy statements from the American Academy of Pediatrics benefi t from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not refl ect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffi rmed, revised, or retired at or before that time.

DOI: 10.1542/peds.2016-4070

Address correspondence to Stephen W. Patrick, MD, MPH, MS, FAAP. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2017 by the American Academy of Pediatrics

abstractThe use of opioids during pregnancy has grown rapidly in the past decade. As opioid use during pregnancy increased, so did complications from their

use, including neonatal abstinence syndrome. Several state governments

responded to this increase by prosecuting and incarcerating pregnant

women with substance use disorders; however, this approach has no proven

benefi ts for maternal or infant health and may lead to avoidance of prenatal

care and a decreased willingness to engage in substance use disorder

treatment programs. A public health response, rather than a punitive

approach to the opioid epidemic and substance use during pregnancy,

is critical, including the following: a focus on preventing unintended

pregnancies and improving access to contraception; universal screening

for alcohol and other drug use in women of childbearing age; knowledge

and informed consent of maternal drug testing and reporting practices;

improved access to comprehensive obstetric care, including opioid-

replacement therapy; gender-specifi c substance use treatment programs;

and improved funding for social services and child welfare systems. The

American College of Obstetricians and Gynecologists supports the value of

this clinical document as an educational tool (December 2016).

INTRODUCTION

Substance use during pregnancy occurs commonly in the United

States. In 2009, the Substance Abuse and Mental Health Administration

estimated that 400 000 infants each year are exposed to alcohol or illicit

drugs in utero. 1 Although concern regarding substance use in pregnancy

is not new, it has recently increased among health care providers, the

public, and policy makers as the opioid epidemic’s impact reached an

increasing portion of the US population, including pregnant women

and their infants. 2, 3 Several recent studies highlighted an increase in

prescription opioid use among women of childbearing age 4 and among

pregnant women.5, 6 As opioid use among pregnant women increased, the

rate of infants in the United States experiencing opioid withdrawal after

POLICY STATEMENT Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children

To cite: Patrick SW, Schiff DM, AAP COMMITTEE ON SUBSTANCE USE AND PREVENTION. A Public Health Response to Opioid Use

in Pregnancy. Pediatrics. 2017;139(3):e20164070

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FROM THE AMERICAN ACADEMY OF PEDIATRICS

birth, known as neonatal abstinence

syndrome (NAS), grew nearly fivefold

over the past decade. 2, 7 By 2012

in the United States, on average, 1

infant was born every 25 minutes

experiencing signs of withdrawal,

accounting for an estimated $1.5

billion in hospital charges. 2 The

issues surrounding substance use in

pregnancy are complex and merit a

thoughtful public health response

focused on prevention, expansion of

treatment to women with substance

use disorder, and improved funding

for child welfare systems to improve

the health of the substance-exposed

mother-infant dyad.

Primary Prevention

A public health approach to

substance use in pregnancy should

begin with primary prevention:

preventing substance and opioid

misuse before pregnancy. In 2011,

the White House Office of National

Drug Control Policy released a plan

to respond to the prescription opioid

epidemic that has 4 main pillars:

(1) improve public and provider

education about the abuse potential

of opioids, (2) reduce the abuse of

prescription opioids by bolstering

prescription drug monitoring

programs, (3) ensure that unused

opioids are properly disposed, and

(4) provide law enforcement with

the tools needed to stop illegal

prescribing or dispensing of opioids. 8

Public health and policy approaches

to the prescription opioid epidemic

will help eliminate the burden of

opioid use disorder before pregnancy

begins.

Preconception and interconception

(between pregnancies) care plays

an important role in improving

outcomes for pregnant women.

Counseling during these crucial

periods may play a role in identifying

and mitigating risk to mothers

and their infants. 9 Although 31%

to 47% of US pregnancies are

unintended, research suggests that,

for women with opioid use disorder,

the proportion of unintended

pregnancies was higher than 85%. 10

Education and expansion of access to

effective contraception, particularly

long-acting reversible contraception

(LARC) methods, 11 are important

components of primary prevention.

Access to LARC methods is supported

by both the American Academy of

Family Physicians (AAFP) and the

American College of Obstetricians

and Gynecologists (ACOG) 12, 13 during

both the pre- and interconception

periods. However, there remain

barriers to highly effective

contraception in many states.

For example, the ACOG supports

placement of LARC devices during

the immediate postpartum period

to improve the use of LARC among

postpartum women 13; however,

bundled payments for delivery create

a relative financial disincentive to

place LARC devices at the time of

delivery. State Medicaid programs

play a critical role in ensuring access

to highly effective contraception at

the time when it is desired, including

the time of delivery. However,

recent research suggests that states

are variable in aligning financial

incentives to ensure access to LARC

methods if elected at the time of

delivery. 14

Improved Identifi cation and Access to Treatment

The early identification of women

who use illicit substances during

pregnancy is vital to improving

outcomes for both mothers and

infants. Routine universal screening

through brief questionnaires for

drug, alcohol, and tobacco use

before and throughout pregnancy

is recommended by the ACOG and

AAFP. 9, 15, 16 The ACOG recommends

that screening consist of a mutual

dialogue between clinician and

patient and be performed in

partnership with the woman with the

use of validated screening tools, 17, 18

with her consent, and screening

should be applied equally to all

women, regardless of their age, race,

ethnicity, or socioeconomic status. 19

The benefits of drug testing in

addition to screening during

pregnancy remain uncertain.

Targeted urine drug-testing

programs have been shown to

disproportionately affect low-income

women of racial or ethnic

minorities, 20 – 23 prompting some to

develop universal urine toxicology

testing protocols at the time of

delivery.24 Although urine toxicology

tests can provide objective evidence

of drug use at 1 point in time,

they do not enable providers to

determine the frequency of use or to

characterize the frequency or degree

of use. 25, 26 Studies comparing the

difference between verbal screening

and urine drug testing are mixed; 1

study found superior identification

with verbal screening and another

identified individuals with positive

urine drug test results who were

not previously known to have used

opioids. 17, 24 Consistent with ACOG

policy, informed consent should

occur at the time of drug testing

and a woman should be informed

how a positive test result will be

used for both medical treatment and

reporting to child welfare agencies.19

Drug screening and testing in

pregnancy should be used to identify

women with substance use disorder

and enable access to comprehensive

treatment. Access to comprehensive

prenatal care and treatment of

women with substance use disorders

is associated with fewer preterm

deliveries, small-for-gestational-age

infants, and infants with low birth

weight. 27 – 30 The literature suggests

that pregnancy can motivate women

with substance use disorders to

seek treatment.31 However, there

remains a dearth of comprehensive

treatment programs geared toward

pregnant and parenting women. Only

19 states have treatment programs

specifically designed for pregnant

women. 32 Furthermore, only 15%

of current treatment centers across

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PEDIATRICS Volume 139 , number 3 , March 2017

the country offer specific services

for pregnant women with substance

use disorders, and the majority of

these are located in urban areas. 33

Women with substance use disorder

report high rates of past trauma,

including physical and sexual abuse,

and need access to gender-specific,

family-friendly addiction treatment

programs, psychosocial services,

and mental health treatment. 34 –36

Trauma-informed services should

be framed by an understanding of

the effects of interpersonal violence

and victimization of women with

substance use disorders, with a

focus on creating a strengths-based

environment to foster resiliency

and to minimize the possibility of

retraumatization. 37 In addition,

pregnant and parenting women

are likely to remain in treatment

if on-site child care and child

services are provided and staff

work to develop collaborative and

nonjudgmental therapeutic alliances

through the use of trauma-informed

care approaches. 38, 39 Positive

outcomes of treatment in pregnant

and parenting women who complete

treatment programs include

employment, less engagement in

criminal activity, and lower risk of

relapse. 40, 41

For women with opioid use disorder,

the abrupt discontinuation of opioids

in pregnancy can result in preterm

labor, fetal distress, or fetal demise.

Furthermore, medically supervised

withdrawal from opioids in opioid-

dependent women is currently not

recommended during pregnancy,

because the literature suggests

that withdrawal is associated with

high relapse rates. 16 Opioid agonist

therapy, also known as medication-

assisted treatment, with methadone

or buprenorphine has emerged as the

standard for pregnant women with

opioid use disorder. 42 Opioid agonist

therapy has been shown to be safe

and effective in pregnancy 16, 43, 44 and

is associated with improved maternal

and infant outcomes. 45, 46

Knowledge of substance use

during pregnancy is vital to the

pediatrician’s ability to effectively

provide care for substance-exposed

infants. For example, exposure to

opioids in utero may lead to an infant

developing NAS. The presentation

of NAS may be delayed for several

days depending on several factors

(eg, timing of maternal drug use,

drug type, infant metabolism), 47 and

clinical signs of NAS can be vague

(eg, irritability, poor feeding). Each of

these factors creates the possibility

that a diagnosis of NAS may be

missed without the knowledge of

opioid exposure, potentially leading

to poor outcomes for infants. 47

Teamwork between all health care

providers, including but not limited

to obstetric, pediatric, family, and

addiction medicine, is vital to optimal

care of substance-exposed infants.

When inadequate information

about drug exposure exists, testing

an infant’s urine, meconium,

or umbilical cord tissue can be

important in ensuring the optimal

care of the infant.

Criminal Justice Approaches to Substance Use in Pregnancy

In recent years, a number of state

legislatures have passed new

laws or applied existing child

endangerment laws to prosecute

pregnant women for illicit drug use

during pregnancy. 32, 48 The American

Academy of Pediatrics (AAP) first

published recommendations on

substance-exposed infants in 1990

and reaffirmed its position in 1995

that “punitive measures taken toward

pregnant women, such as criminal

prosecution and incarceration, have

no proven benefits for infant health”

and argued that “the public must

be assured of nonpunitive access

to comprehensive care that meets

the needs of the substance-abusing

pregnant woman and her infant.” 49, 50

More than 20 national organizations

have since published statements

against the prosecution and

punishment of pregnant women who

use illicit substances: these include

the American Medical Association,

the AAFP, the ACOG, the American

Public Health Association, the

American Nurses Association, the

American Psychiatric Association,

the National Perinatal Association,

the American Society of Addiction

Medicine, the March of Dimes, and

the Association of Women’s Health,

Obstetric and Neonatal Nurses. 51 –60

Despite the strong consensus from

the medical and public health

communities affirming that a

punitive approach during pregnancy

is ineffective and potentially harmful,

there has been a recent increase in

the number of states passing and

considering criminal prosecution

laws that selectively target pregnant

women with substance use

disorders. 61 – 63

The existing literature supports the

position that punitive approaches

to substance use in pregnancy are

ineffective and may have detrimental

effects on both maternal and

child health. Qualitative research

performed in pregnant women with

substance use disorders shows that

women may avoid prenatal care for

fear of being reported to the police

and child protective services. 23, 64 – 66

In addition, surveys of pregnant

women found that punitive laws

targeted at pregnant women who

use drugs are a significant deterrent

to obtaining regular prenatal care

and agreeing to drug testing, 67

and women who deliver without

receiving any prenatal care are more

likely have a history of substance

use. 68 For these reasons, the AAP

supports an approach toward

substance use in pregnancy that

focuses on a public health approach

of primary prevention, improving

access to treatment, and promoting

the provider-patient relationship

rather than punitive measures

through the criminal justice system.

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FROM THE AMERICAN ACADEMY OF PEDIATRICS

Role of Child Welfare Systems

The Child Abuse Protection and

Treatment Act mandates that

states have in place “policies and

procedures to address the needs of

infants born with and identified as

being affected by illegal substance

abuse or withdrawal symptoms from

prenatal drug exposure.” 69 Reporting

requirements for in utero illicit

substance exposure to child welfare

systems have been interpreted

differently by each state. More than

25% of states currently have statutes

that consider illicit substance use

during pregnancy to be reportable

as child abuse or neglect. 32 Health

care providers caring for pregnant

women with substance use

disorders and their infants should

be knowledgeable about their state

requirements and be able to educate

women during pregnancy. Notably,

although the incidence of NAS has

increased in recent years, 2, 7 federal

funding for child welfare systems has

not changed, 70 even as some state

child welfare systems are reporting

an increased workload attributable

to NAS. 71 In recent years, Congress

has addressed the issue of substance-

exposed infants in child welfare

systems; however, there has not been

a substantial increase in funding to

state child welfare systems to bolster

the response to the growing number

of opioid-exposed infants. There is an

urgent need for improved funding to

child welfare systems to ensure the

safety of infants and to promote the

well-being of families.

RECOMMENDATIONS

Opioid use in pregnancy is

increasingly common, with an

associated increase in opioid-

exposed infants. This critical public

health issue demands a public health

approach grounded in science. For

these reasons, the AAP recommends

the following:

1. The treatment of pregnant women

with substance use disorder

requires a coordinated, evidence-

based, public health approach.

The AAP reaffirms its position that

punitive measures taken toward

pregnant women are not in the

best interest of the health of the

mother-infant dyad.

2. Primary prevention strategies

should be bolstered to educate

the public about the addictive

potential of prescription

opioids and enhance access to

reproductive health services,

including effective forms of

contraception such as LARC.

3. The ACOG policy that universal

substance use screening of all

pregnant women via validated

screening tools such as

questionnaires should occur at

routine health care visits and at

several points throughout prenatal

care and be applied equally to all

women, regardless of age, race,

ethnicity, or socioeconomic status,

should be supported. If urine drug

testing is performed, a reasonable

effort to obtain a woman’s informed

consent should be made before

collecting the sample, and the

woman should be aware of the

results and who will have access to

the results.

4. Access should be improved

to comprehensive prenatal

care for pregnant women with

substance use disorders, including

medication-assisted treatment

and gender-specific substance use

treatment programs that provide

nonjudgmental, trauma-informed

services.

5. Health care providers caring

for women who use substances

during pregnancy should be

knowledgeable about their state’s

reporting mandates around illicit

drug use and educate pregnant

women prenatally about these

requirements. In addition, states

should clarify which substances

constitute mandated reporting

and explicitly define the health

care provider’s role in reporting.

6. To adequately ensure the safety of

substance-exposed infants and to

provide optimal care to families,

social support services and child

welfare systems are in need of

additional funding.

The American College of

Obstetricians and Gynecologists

supports the value of this clinical

document as an educational tool

(December 2016).

AUTHORS

Stephen W. Patrick, MD, MPH, MS, FAAP

Davida M. Schiff, MD, FAAP

COMMITTEE ON SUBSTANCE USE AND PREVENTION, 2016–2017

Sheryl A. Ryan, MD, FAAP, Chairperson

Joanna Quigley, MD, FAAP

Pamela K. Gonzalez, MD, MS, FAAP

Stephen W. Patrick, MD, MPH, MS, FAAP

Leslie R. Walker, MD, FAAP

FORMER COMMITTEE MEMBERS

Sharon J.L. Levy, MD, MPH, FAAP

Lorena Siqueira, MD, MSPH

LIAISONS

Vivian B. Faden, PhD – National Institute on

Alcohol Abuse and Alcoholism

Gregory Tau, MD, PhD – American Academy of

Child and Adolescent Psychiatry

STAFF

Renee Jarrett, MPH

4

ABBREVIATIONS

AAFP:  American Academy of

Family Physicians

ACOG:  American College of

Obstetricians and

Gynecologists

LARC:  long-acting reversible

contraception

NAS:  neonatal abstinence

syndrome

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PEDIATRICS Volume 139 , number 3 , March 2017

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FINANCIAL DISCLOSURE: The authors have indicated they do not have a fi nancial relationship relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.

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