HealthAffairs Blog –
Although much policy focus is currently directed toward mitigation of COVID-19, vaccine development and distribution, and hospital capacity, the pandemic is converging with an ongoing opioid crisis. Fortunately, policymakers have initiated important changes designed to increase access to care for individuals with opioid use disorder (OUD); however, like the opioid policy response, these changes have generally not focused on pregnant and postpartum women with OUD and their infants, who have complex health care needs.
Opioid use and misuse during pregnancy can result in health consequences for mothers and infants. OUD during pregnancy is associated with a 4.6-fold increase in maternal death during hospitalization. Rates of neonatal abstinence syndrome (NAS), a postnatal drug withdrawal syndrome in infants identified at birth, increased over 400 percent between 2004 and 2014. Moreover, individuals with OUD are at increased risk for COVID-19 and have higher prevalence of known risk factors for COVID-19. OUD can be harmful to heart and lung health, and pregnant women in treatment for OUD are more likely to smoke tobacco, which can also increase COVID-19 risk. Additionally, pregnant women are included in the CDC’s increased risk category for severe COVID-19 illness.
Pregnant and postpartum women with OUD face many barriers to care including availability, cost, stigma, and fear of legal consequences and/or child welfare involvement. In an attempt to reduce prenatal substance use and its consequences, some states adopted pre-pandemic punitive policies that consider prenatal substance use as the legal equivalent of child abuse or neglect. Opponents of these policies express concern they could magnify fear and stigma and lead to an avoidance of health care. In a recent Health Affairs article, we examined the effects of punitive policies on NAS births and substance use treatment admissions for pregnant women.
In short, we found no evidence to suggest that these policies were effective in reducing rates of NAS or maternal narcotic exposure at birth. We found, however, that punitive prenatal substance use policies led to a reduction in the proportion of pregnant women admitted to substance use treatment and reduced the proportion of pregnant women admitted to treatment via health care referral.
Pregnant and postpartum women with OUD experienced significant unmet health care needs and barriers to care before the pandemic. COVID-19 has and will continue to exacerbate these barriers. Here, we focus on this vulnerable population and discuss the role of policy in further addressing barriers to care, particularly in the context of COVID-19, but caution that these policy changes may be inadequate if women avoid care due to fear of legal consequences or child welfare involvement.
In response to COVID-19, the Centers for Medicare and Medicaid Services (CMS) issued guidance to states on the use of telehealth during the pandemic. These provisions aim to enable providers to maintain care for patients without physical visits or unnecessary public transportation usage, promoting social distancing and safety. Following these guidelines, most states took steps to expand telehealth, but there is variation in state telehealth policies in terms of reimbursement for services, mode of telehealth (video, audio), types of providers, originating sites, and other considerations.
If physical visits with patient spacing are not advisable, these changes in virtual access to health care can be amenable to prenatal care, which is important for maternal and infant outcomes and the identification of problems or risk factors, including substance use. Telehealth in prenatal and postpartum care has been previously utilized in rural areas where low provider density limits health care access. Additionally, recent evidence exists showing perinatal OUD treatment with relapse prevention therapy and buprenorphine delivered through telemedicine results in comparable outcomes to in-person treatment.
While telehealth presents opportunities to maintain continuity of care, challenges remain. First, pregnancy and the postpartum period provide an opportunity to engage women with OUD in treatment through increased health care interaction. If frequency of prenatal care visits declines due to distancing measures, essential contact with health care providers would decrease along with opportunities for screening and referrals to or provision of treatment for OUD. Second, increased reliance on telehealth requires access to high-speed broadband, computers, and other necessities for virtual connections for both the patient and provider. To the extent that the amount or quality of care is affected for lower income and/or rural patients, we may see worsening health disparities, which could disproportionately affect pregnant women with OUD since NAS is more common in rural areas, and 82 percent of NAS births are covered by Medicaid.
Finally, for providers, telemedicine utilization from physician to patient was low before the pandemic at 15.4 percent for all specialties and 12.7 percent for primary care. Ramping up telehealth utilization in response to COVID-19 may be particularly challenging for OB/GYN practices, with only 9.3 percent reporting telemedicine use in 2016.
The federal government and states have relaxed some regulations to increase access to treatment for OUD during the COVID-19 pandemic. For example, states that have declared a state of emergency can request a waiver for Opioid Treatment Programs (OTPs) to dispense up to 28 days of methadone for stable patients and 14 days for less stable patients. The Drug Enforcement Agency (DEA) has issued new guidelines about prescribing controlled substances during the pandemic. DATA-waivered clinicians (i.e., those who can prescribe buprenorphine in an office-based setting to a limited number of patients) are now able to initiate buprenorphine via telemedicine (if certain requirements are met), including via audio-only, without the requirement of an in-person visit.
Access to medication-assisted treatment (MAT) was limited for pregnant and postpartum women before the pandemic. In 2018, only 23 percent of substance-use treatment facilities had programs for pregnant and postpartum women. Of those programs, 24 percent provided methadone, and 44 percent provided buprenorphine. Improvements in access are important because the standard treatment of OUD in pregnancy with methadone or buprenorphine (plus counseling) is associated with improved outcomes for mother and infant.
One strategy to increase access to SUD treatment includes involving more primary care physicians in addiction medicine. Of OB/GYNs who accept Medicaid, 1.8 percent have a DATA waiver, and 9 percent of counties have a Medicaid-claimant OB/GYN with a DATA waiver. To facilitate DATA waivers among OB/GYNs, in February 2020, the American Society of Addiction Medicine (ASAM) and American College of Obstetricians and Gynecologists (ACOG) announced a partnership to provide ASAM’s waiver qualifying course with an obstetrics and gynecology focus. Additionally, a subspecialty fellowship in addiction medicine is now offered to those who have completed residency in a primary specialty, including obstetrics, under the Accreditation Council for Graduate Medical Education.
The Role Of Medicaid
Medicaid plays a central role in access to care for pregnant and postpartum women in several important ways. First, states must cover pregnant women in Medicaid up to 138 percent of the Federal Poverty Level (FPL), but most states cover pregnant women well above that threshold. Following pregnancy, many low-income women lose Medicaid coverage after two months postpartum when Medicaid eligibility changes from states’ pregnancy to parental income thresholds.
Median income eligibility levels for parents under Medicaid are lower in non-expansion states relative to expansion states (to date, 12 states have not expanded Medicaid). For expansion states, median income eligibility levels are 203 percent of the FPL for pregnancy-related Medicaid but are 138 percent FPL for parents. In non-expansion states, median income eligibility levels change from 199 percent FPL during pregnancy to 41 percent FPL for parents. This loss of coverage is particularly dangerous for postpartum women with OUD. Between 2007-2016, the pregnancy-associated mortality rate involving opioids increased more than 200 percent.
Second, increasing access to MAT through Medicaid could have important implications for pregnant and postpartum women with OUD; however, barriers exist. As of 2018, Medicaid programs in 10 states did not cover methadone, eight states required copays, and 15 states placed other limitations, like prior authorization, on coverage. Medicaid covered buprenorphine in all states and DC; however, 21 states required copays, and 19 placed limitations like prior authorization requirements and lifetime limits. Prior authorization requirements are associated with a lower likelihood that substance-use treatment facilities offer buprenorphine. Private health insurance and self-pay are the most common forms of payment for office-based buprenorphine (almost 75 percent), which further limits access for pregnant and postpartum women with Medicaid.
Finally, in January 2020, CMS made grants to 10 states for Maternal Opioid Misuse (MOM) model programs designed to increase quality of care, improve maternal and infant outcomes, and expand access to treatment. The initial start date for the program was January 2021 but has been delayed until July 2021 due to the public health emergency.
The Role of Punitive Policies
In our Health Affairs study, we found that punitive policies that treat prenatal substance use as child abuse or neglect are ineffective in reducing rates of NAS and maternal narcotic exposure at birth; however, they decrease the proportion of pregnant women entering treatment, particularly through referral from a health care provider. Given these findings, policy changes increasing access to telehealth, OUD treatment, and more generous Medicaid coverage might be less effective in states with punitive policies.
Moreover, punitive policies are at odds with the federal Child Abuse and Neglect Prevention and Treatment Act (CAPTA) of 2010, which requires states to address health and substance-use treatment needs, of both infants exposed to substances in utero and their families, through development of plans of safe care and referrals for supports and services. Variation in state compliance with CAPTA exists, however, and may limit access to care and supportive services.
We have evidence-based treatments for OUD in pregnancy that improve outcomes for mothers and infants. However, structural barriers and stigma, exacerbated by punitive approaches to prenatal substance use, inhibit the treatment of OUD in pregnancy, which means worse outcomes for those the policies were intended to protect. We ask policymakers to prioritize the vulnerable populations of pregnant and postpartum women and their infants as they make timely decisions regarding COVID-19.
First, we ask policymakers to ensure that pregnant women have access to physical and/or virtual prenatal care through state Medicaid programs (e.g., state Medicaid expansion, extended postpartum Medicaid coverage, telehealth policies). Care should be taken to ensure that the digital divide does not exacerbate preexisting disparities in health care access and outcomes. Second, states should relax restrictions to MAT in order to protect those currently in treatment and to expedite treatment for those looking to initiate. This could be accomplished through office- or clinic-based MAT changes (e.g., increasing the number of patients a DATA-waivered physician can oversee, continuing to allow initiation via telemedicine, or eliminating waiver requirements altogether), as well as increasing funding for and access to facility-based substance use treatment for pregnant and postpartum women and removing prior authorization and lifetime limits.
Third, states should encourage primary care physicians and OB/GYNs to become DATA-waivered buprenorphine providers to help expand access to comprehensive care for pregnant women with OUD. Finally, we encourage states to adopt policies and procedures under CAPTA to increase access to treatment and supportive services for infants affected by substance use and their families. Although effective treatments for OUD in pregnancy exist, increases in maternal OUD and preventable, pregnancy-associated deaths due to overdose highlight the need for policy changes to support this vulnerable population. Given that more than 80 percent of NAS births are covered by Medicaid, Medicaid policy changes could have particular impact.
We also encourage researchers to consider the effects of these policy changes for pregnant and postpartum women and their infants, women who use or misuse substances, and the intersection of these groups. In many ways, the response to COVID-19 has catalyzed long-awaited changes to health care delivery, access, and reimbursement. The majority of these changes, however, are temporary. We have a unique opportunity to understand the impacts of policies increasing access to telehealth and OUD treatment to inform future policymaking.Addiction Services COVID-19 NAS Neonatal Abstinence Syndrome Opioid Epidemic Recovery Assistance Treatment