Association of Punitive and Reporting State Policies Related to Substance Use in Pregnancy With Rates of Neonatal Abstinence Syndrome

Faherty, Laura J.; Kranz, Ashley M.; Russell-Fritch, Joshua; Patrick, Stephen W.; Cantor, Jonathan; Stein, Bradley D.

doi:10.1001/jamanetworkopen.2019.14078

Cited by 103 publications

(71 citation statements)

References 36 publications

(82 reference statements)

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“…Health policy related to mandatory reporting laws for pregnant and postpartum women with OUD should be evidence‐based and therapeutic in nature. States with punitive reporting policies have higher rates of NAS, possibly the consequence of women avoiding care out of fear of being reported 28 …”

Section: Discussionmentioning

confidence: 99%

The Lived Experience of Postpartum Women Attending Outpatient Substance Treatment for Opioid or Heroin Use

Proulx

Fantasia

2020

J Midwife Womens Health

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Introduction The current opioid crisis and associated heroin epidemic have exhausted the limited community services that are available to substance users, with only about 12% of substance use treatment facilities offering special programs for pregnant women. Little information is known about the lived experience of postpartum women in outpatient substance use treatment programs, who are working toward abstinence and caring for a newborn. The purpose of this phenomenological study was to explore the lived experience of postpartum women attending outpatient substance use treatment for illicit opioid or heroin use. Methods Individual interviews were conducted between December 2017 and November 2018, with 10 postpartum women with opioid use disorder (OUD) engaged in outpatient substance use treatment programs. A 4‐step conceptual framework as suggested by Moustakas was used to understand and synthesize the lived experiences shared by the women. Results Five themes emerged from the raw data: the presence of a stigma in providers of health care services, a fear of being reported to family services, children are primary motivators to remain engaged in treatment, concern for the welfare of the infant, and barriers to treatment. Discussion Postpartum women with OUD and their infants have complex needs that may best be served by treatment programs that offer comprehensive care. The fear of being reported to family services and possible loss of custody influenced all aspects of their decision‐making.

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Section: Discussionmentioning

confidence: 99%

The Lived Experience of Postpartum Women Attending Outpatient Substance Treatment for Opioid or Heroin Use

Proulx

Fantasia

2020

J Midwife Womens Health

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“…However, as the recent analysis of state policy and NAS rates in the study by Faherty et al 1 suggested, punitive approaches are counterproductive and instead are associated with higher rates of NAS.…”

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confidence: 99%

It’s Time to Support, Rather Than Punish, Pregnant Women With Substance Use Disorder

Whalen

Hodder

2019

JAMA Netw Open

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Increasing prevalence of opioid use disorder (OUD) among pregnant women in recent years has led state policy makers and health care professionals alike to focus on reducing rates of neonatal abstinence syndrome (NAS) and associated complications experienced by families. Policy makers in some states have responded by adopting punitive laws that criminalize substance use during pregnancy, considering it grounds for civil commitment or presuming child abuse or neglect.However, as the recent analysis of state policy and NAS rates in the study by Faherty et al 1 suggested, punitive approaches are counterproductive and instead are associated with higher rates of NAS.Faherty et al 1 hypothesized that pregnant women were less likely to engage with the health care system and pursue interventions, such as substance use disorder treatment, owing to these punitive polices, leaving the substance use untreated and NAS a more likely outcome. We applaud the authors' conclusion that states should pursue policies that instead focus on primary prevention strategies.However, framing the discussion about perinatal opioid use using NAS reduction as a primary outcome is problematic. From the maternal-fetal perspective, decreasing substance exposure is an important goal; polysubstance exposure is associated with overall increased risk for the mother, fetus, and neonate, including greater severity, longer duration, and increased need for pharmacologic treatment of NAS. 2 Maternal OUD treatment improves all of these outcomes. However, maternal OUD treatment also causes NAS, making the presence of NAS diagnosis a nonspecific measure, as it does not differentiate exposure to nonprescribed drugs vs maternal OUD treatment. Symptoms of NAS may also be exacerbated by other maternal medications (eg, SSRIs) that were appropriately prescribed for cooccurring mental health disorders, such as depression, anxiety, and posttraumatic stress disorder. The finding in the study by Faherty et al 1 that NAS rates were higher in counties with better access to maternal substance use treatment programs illustrates this point.Faherty et al 1 reported no apparent association between rates of NAS and the enactment of policies that require reporting of prenatal substance use to child protection services (CPS), suggesting that "reporting policies are more likely to result in conversations between clinicians and pregnant women that result in decreased opioid use or greater engagement in treatment for opioidrelated complications, actions that may decrease rates of NAS." We are not convinced. Qualitative studies on this topic have suggested that women who fear losing custody of their children may not see much distinction between policies defining maternal substance use as child abuse and those which require reporting substance use to CPS based on prenatal substance exposure alone. For example, a study by Stone 3 reported that 73% of the women interviewed were afraid of their drug use being detected specifically due to fear of losing custody or legal consequences. A st...

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“…A second barrier includes the punitive consequences stemming from state laws regarding prenatal substance use, which can result in patients not wanting to disclose and physicians not wanting to learn about their patients' behaviors. [53][54][55] Hence, in addition to patients' previous fears about stigmatization because of use, disclosure could now pose a legal risk. 56 An example of a punitive policy includes treating substance use during pregnancy as child abuse or neglect.…”

Section: Barriers To Early Identification By Screeningmentioning

confidence: 99%

Maternal Substance Use: Consequences, Identification and Interventions

Chang¹

2020

ARCR

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Alcohol, tobacco, and cannabis are the substances most frequently used during pregnancy, and opioid-exposed pregnancies have increased fourfold. The purpose of this review is to describe the prevalence and consequences of prenatal exposure to alcohol, tobacco, cannabis, and opioids. Currently available screening questionnaires for prenatal substance use are summarized and contrasted with the measures available for prenatal alcohol use. Because screening for prenatal alcohol and substance use is but the prelude to efforts to mitigate the potential adverse consequences, attempts for the modification of these consequences are briefly reviewed. In addition, areas of future research related to the criminalization of prenatal substance use, which may inhibit both inquiry and disclosure, are discussed. Indeed, the full potential of effective interventions has yet to be realized.

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Association of Punitive and Reporting State Policies Related to Substance Use in Pregnancy With Rates of Neonatal Abstinence Syndrome

Abstract: This cross-sectional study examines the association of state-level punitive or reporting policies related to substance use during pregnancy with rates of neonatal abstinence syndrome.

Cited by 103 publications

References 36 publications

The Lived Experience of Postpartum Women Attending Outpatient Substance Treatment for Opioid or Heroin Use

The Lived Experience of Postpartum Women Attending Outpatient Substance Treatment for Opioid or Heroin Use

It’s Time to Support, Rather Than Punish, Pregnant Women With Substance Use Disorder

Maternal Substance Use: Consequences, Identification and Interventions

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