Efficacy and Cost-Benefit of Onsite Contraceptive Services With and Without Incentives Among Women With Opioid Use Disorder at High Risk for Unintended Pregnancy

Abstract

IMPORTANCERates of in utero opioid exposure continue to increase in the US. Nearly all of these pregnancies are unintended but there has been little intervention research addressing this growing and costly public health problem.OBJECTIVE To test the efficacy and cost-benefit of onsite contraceptive services with and without incentives to increase prescription contraceptive use among women with opioid use disorder (OUD) at high risk for unintended pregnancy compared with usual care. DESIGN, SETTING, AND PARTICIPANTSA randomized clinical trial of 138 women ages 20 to 44 years receiving medication for OUD who were at high risk for an unintended pregnancy at trial enrollment between May 2015 and September 2018. The final assessment was completed in September 2019. Data were analyzed from October 2019 to March 2021. Participants received contraceptive services at a clinic colocated with an opioid treatment program.INTERVENTIONS Participants were randomly assigned to receive 1 of 3 conditions: (1) usual care (ie, information about contraceptive methods and community health care facilities) (n = 48); (2) onsite contraceptive services adapted from the World Health Organization including 6 months of follow-up visits to assess method satisfaction (n = 48); or (3) those same onsite contraceptive services plus financial incentives for attending follow-up visits (n = 42).MAIN OUTCOMES AND MEASURES Verified prescription contraceptive use at 6 months with a cost-benefit analysis conducted from a societal perspective. RESULTSIn this randomized clinical trial of 138 women (median age, 31 years [range, 20-44 years]), graded increases in verified prescription contraceptive use were seen in participants assigned to usual care (10.4%; 95% CI, 3.5%-22.7%) vs contraceptive services (29.2%; 95% CI, 17.0%-44.1%) vs contraceptive services plus incentives (54.8%; 95% CI, 38.7%-70.2%) at the 6-month end-of-treatment assessment (P < .001 for all comparisons). Those effects were sustained at the 12-month final assessment (usual care: 6.

Averting neonatal abstinence syndrome and treating addiction among rural, opioid‐using young women

“…Our findings suggest that this is indeed the case because 100% of the 17 women who opted for a MOUD referral started MOUD within 30 days of study enrollment. Thus, findings from the pilot both corroborate and extend the findings reported by Heil and colleagues 22 …”

“…Also, as a pilot study, the use of a one‐arm design greatly limits any inference relative to causality. Noteworthily, however, is that in the control arm of the study reported by Heil and colleagues 22 none of the women reported having a LARC implant in the subsequent 12 months. Although we cannot assume a value of zero as a likely outcome of not providing the EMC intervention to women with OUD, the obtained uptake of 40% suggest a robust intervention effect is likely to be found in the context of adequately powered RCT.…”

“…It is further important to note that having 40% of the women begin one of the two LARC methods represents substantial success in terms of both averting unintentional pregnancies and, by extension, NAS. Future studies should carefully construct cost–benefit analyses based on replicated findings from this pilot and the trial reported by Heil and colleagues 22 …”

“…Although issues relative to reproductive justice have been raised relative to pregnancy prevention aimed specifically toward women with MOUD, 20,21 a key principle involves providing women with options and encouraging free choice. For instance, a study recently appearing in JAMA Psychiatry used a three‐arm randomized controlled trial (RCT) to test the effects of a guided counseling session about contraception options administered to women receiving treatment for MOUD and reporting behaviors indicative of high risk for unintended pregnancy 22 . The first treatment arm comprised the nurse‐administered counseling session, followed by 13 follow‐up visits scheduled over a 6‐month period.…”

Interest in Co-located Reproductive and Sexual Health Services Among Women and Men Receiving Medication for Opioid Use Disorder in an Outpatient Treatment Clinic

“…Recent research shows that providing either face-to-face or computerized RSH services using a shared decision making approach, between provider and patient, to non-pregnant women receiving MOUD hold promise for increasing both decision making and follow through on a contraceptive practice decision compared to usual care ( 6 ). Increasing access to person-centered contraceptive counseling through co-located RSH services can help better fulfill the health needs of this patient population and have been shown to be cost effective ( 23 ).…”