Reducing Barriers in Care for Patients with Opioid Abuse Disorder

A session at the recent Rx Drug Abuse & Heroin Summit shared research on barriers that prevent individuals from seeking treatment for opioid use disorder. In this video, Laura Faherty, MD, pediatrician, physician policy researcher, RAND Corporation, Santa Monica, CA, discusses her presentation “Treatment for Opioid Use Disorder -- Reducing Barriers to Engaging in Care.”

Read the transcript:

My name is Laura Faherty. I'm a general pediatrician and a physician policy researcher at the Rand Corporation. I had the pleasure of participating in a session at last week's Rx Summit. That session was called "Treatment for Opioid Use Disorder -- Reducing Barriers to Engaging in Care."

In that panel, we aimed to share research that my colleagues and I have conducted on multiple barriers that prevent individuals from seeking treatment for opioid use disorder, accessing it, and remaining in treatment.

Specifically, I focused on state policies that either support pregnant women in getting the treatment they need or take a punitive approach to substance use in pregnancy. I studied how these policies have changed over time and how they're related to infant health outcomes, in particular neonatal abstinence syndrome.

My colleague, Dr. Steven Patrick, presented a really interesting study where his research team made over 10,000 attempts to call and make an appointment to start either methadone or buprenorphine treatment, posing as a simulated patient with various characteristics like being either pregnant or not pregnant, insured by Medicaid or private insurance.

In that research, Dr. Patrick found that pregnant women had a harder time accessing opioid treatment than non-pregnant women and those with Medicaid were less likely to be accepted for appointments than those with private insurance.

Finally, my colleague, Dr. Ashley Leech presented her research on the challenges of keeping individuals who start buprenorphine treatment on that life-saving medication for the long term. She found that median time to discontinuation of this medication for opioid use disorder was about two months and that out-of-pocket costs may play a role.

Now we'll go into a little bit more detail on the key takeaways from my research. For years, more than 20 professional organizations, like the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, and federal agencies have endorsed a non-punitive approach to substance use in pregnancy.

It's really concerning that punitive state policies are actually becoming increasingly common around the country. These are policies that are intended to deter women from using substances in pregnancy.

They include policies that consider it to be child abuse, neglect, or even a criminal act, policies that require reporting of suspected prenatal substance abuse by healthcare providers, and those that require testing if substance abuse is suspected or even allow clinicians to perform a toxicology test on an infant without the consent of a parent or guardian.

My study aimed to answer the question "Are state policies that punish women for substance use in pregnancy associated with rates of neonatal abstinence syndrome?" We looked at over four and a half million births in eight states between the years of 2003 and 2014.

We compared states without punitive policies to states with these policies, both before and after the date that they were enacted, using logistic regression models. We found that in states with punitive policies, the odds of NAS were actually significantly greater both in the short- and longer-term.

The takeaway from this research is that reducing barriers to care and addressing stigma are, we think, more likely to be effective than punitive measures and that public health approaches are most likely to improve outcomes for mother-infant dyads affected by substance use.

I really hope that this study provides additional evidence for the need to enact policies that focus on prevention of the development of substance use disorders among women of reproductive age in the first place rather than punishing them once they arise.

These policies could support identifying and treating mental health conditions that may lead to opioid use disorder if they go untreated, policies that expand access to family planning options that align with people's reproductive goals, whatever they might be, and enacting policies that expand access to treatment for pregnant women and those with children rather than make it much harder.

I did want to mention that, in my study, we looked at neonatal abstinence syndrome as the main outcome. For our purposes, neonatal abstinence syndrome is a proxy for substance use in women of reproductive age, which is otherwise really difficult to measure.

However, I want to make the point that this outcome in and of itself is not meant to convey that an infant was harmed by exposure to substances before birth. I say that because, of course, neonatal abstinence syndrome can be caused either by exposure to elicit or prescribed opioids, such as methadone or buprenorphine for the treatment of opioid use disorder.

When an infant experiences withdrawal after birth because their mother was treated with evidence-based, life-saving medication during pregnancy, NAS, or neonatal abstinence syndrome, is an expected temporary condition. We have lots of tools at our disposal to help make the infant more comfortable until it resolves.

What's concerning is that many of the policies that consider prenatal substance use to be child abuse or neglect don't include any provisions for the complicated nature of substance use in pregnancy and the heterogeneity of neonatal abstinence syndrome.

In other words, these policies don't consider that neonatal abstinence syndrome can be the result of maternal use of a prescribed medication. That's changing in some states, but very slowly. That is a huge reason why many pregnant women are hesitant to get the treatment they need for their opioid use disorder.

I'll just close by saying that I'm very encouraged by progress in this area and by growing policy attention and focus on striking inequities in maternal health, especially and including behavioral health.

I'll just close by saying that I'm really encouraged by progress in this area and growing policy attention and focus on the striking inequities in maternal health, including behavioral health. Thank you very much for the chance to share our research.

Laura Faherty is a physician policy researcher at the RAND Corporation, an assistant professor of pediatrics at the Boston University School of Medicine, and a professor of policy analysis at the Pardee RAND Graduate School. A board-certified pediatrician with a public health and health services research background, Dr. Faherty’s research focuses on maternal-child health and pandemic preparedness and response, both in U.S. and non-U.S. settings. Her current work addresses COVID-19 testing in K-12 schools; equitable COVID-19 vaccine delivery; behavioral health in the perinatal period, including opioid use in pregnancy and perinatal depression; and behavioral health surveillance in the disaster context. Dr. Faherty is particularly interested in the impacts of policies on mother-infant dyads affected by substances. Her research has been funded by the National Institute on Drug Abuse, the Gates Foundation, the Rockefeller Foundation, CDC, the Office of the Assistant Secretary for Health, and other federal agencies. She completed her residency and chief residency in pediatrics at Boston Medical Center and Boston Children's Hospital. Dr. Faherty received her M.D. and M.P.H. in global epidemiology from Emory University, her M.S. in health policy research from the University of Pennsylvania, and her B.A. from Princeton University. Prior to joining RAND, she was a Robert Wood Johnson Clinical Scholar at the University of Pennsylvania.