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…