One approach to do this would be to disseminate tailored messages through adolescent peer networks to modify norms favoring the concurrent use of these substances, and therefore alter peer influences condoning the use of one of these substances or the concurrent use of two these substances. Such messages could act as cues to action to halt peer influences facilitating the progression from use of one substance to using both, concurrently. Lastly, a policy-relevant implication of our finding that marijuana use appears to lead to more cigarette and alcohol use is that there may be unintended consequences for adolescent substance use from the legalization of marijuana in states. If such legalization leads to greater marijuana use among adolescents, our results suggest that more cigarette smoking and alcohol drinking behavior among adolescents might occur concurrently. This is a possibility that has received some research attention and should be given more consideration in future work.The opioid crisis has had a substantial effect on women who are pregnant and parenting, focusing both public health and policymaker attention on opioids and on other substance use in pregnancy and postpartum. The number of pregnant women with an opioid use disorder diagnosis at delivery quadrupled from 1999 to 2014,and the incidence of neonatal opioid withdrawal syndrome increased nearly seven-fold from 2000 to 2014.Alcohol use remains common, with 1 of 9 pregnant women endorsing past 30 day use, one third of whom reported binge drinking.Cannabis use is increasing, with daily or near-daily cannabis use in pregnancy increasing from <1% in 2002 to nearly 3.5% in 2017.Stimulant use, specifically methamphetamine, doubled in pregnancy from 2008 to 2015.These trends have contributed to an increase in drug-related deaths among women in general7 and during pregnancy and postpartum in particular,cannabis growing system with overdose among the leading causes of maternal death in the US today.Furthermore, the child welfare system response to substance use in pregnancy is straining already-limited resources.
From 2011 to 2017, the number of infants entering the U.S. foster care system grew by almost 10,000, and at least half of infant placements are associated with parental substance use.Below, we review the change over time in state-level policy environments around substance use in pregnancy and contrast the policy response with the principles and guidance from professional societies and federal agencies. As SUDs, particularly involving opioids, increasingly affects pregnant women and their families, it is important to better understand how state policy environments with respect to substance use in pregnancy have evolved and the nature of policies being enacted by states. Professional societies and federal agencies universally endorse supportive policies and oppose punitive policies. Statements from the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, the Centers for Disease Control and Prevention, the Substance Abuse and Mental Health Services Administration, the American Nurses Association, and several others all warn that policies penalizing pregnant women and imposing negative consequences for disclosing substance use to health care providers increase the fear of legal penalties and discourage women from seeking prenatal care and addiction treatment during pregnancy. Guidance documents and professional society committee opinions further suggest that punitive policies may lead to disengagement from care and poor pregnancy outcomes, although few studies have examined this issue. Expert consensus is grounded in the view of substance misuse in pregnancy as a medical condition requiring integrated care for both the pregnancy and the SUD and the recognition that supportive policies reduce barriers to care. For example, punitive policies enacted, in part, to reduce neonatal opioid withdrawal syndrome , have the opposite effect. Infants born in states that implemented policies that punish pregnant women for substance use had higher rates of NOWS than those born in states without such policies.The change in state policy environments with respect to substance use in pregnancy from 2000 to 2015 are detailed in the maps in Figure 1.
Six types of relevant policies were examined: those that define substance use in pregnancy as child abuse or neglect, criminalize it, or consider it grounds for civil commitment, mandate testing of infants with suspected prenatal substance exposure or pregnant women with suspected substance use; require reporting of suspected prenatal substance use to officials at local health and human services departments; create or fund targeted programs for pregnant and postpartum women with SUDs; prioritize pregnant women’s access to SUD treatment programs; and prohibit discrimination against pregnant women in publicly funded SUD treatment programs. Consistent with prior work and others’ approach,policies imposing legal consequences for substance use or requiring health professionals to test for or report suspected substance use to authorities were considered punitive. Policies reducing barriers for pregnant women with SUD or those that expand treatment were considered supportive. If a state enacted a policy with both punitive and supportive components, it was considered to have a mixed policy environment. Enactment dates were obtained from the Guttmacher Institute and supplemented with information from the National Conference of State Legislatures, ProPublica, and published studies retrieved through a targeted literature review.In addition, state statutes were reviewed to capture language illustrative of policy categories. Box 1 shows an example punitive policy enacted in North Dakota in 2003 and Box 2 contains a supportive policy enacted in Kentucky in 2015. Figure 1 shows substantial state policy activity in this area, with more states adopting punitive policies than supportive policies. This increase, from 18 states with at least one punitive policy in 2000 to 33 states in 2015, was primarily driven by states adopting policies considering substance use in pregnancy to be child abuse, grounds for civil commitment, or a criminal act, as well as policies requiring healthcare professionals to report suspected prenatal drug use. By 2015, states with only punitive policies increased from six to eight, while states with only supportive policies declined from 17 to 8.
States with both types of policies doubled from 12 in 2000 to 25 by 2015, and only 10 states had no policies specific to substance use in pregnancy in 2015, down from 16 in 2000. While encouraging that 28 states had supportive policies in 2000, only 4 additional states adopted supportive policies in the subsequent 15 years. The maps in Figure 1 are consistent with a pattern described in 1998 of more states enacting punitive policies than policies expanding treatment for women with SUD and echo the punitive approaches taken towards women with crack cocaine use in the 1980s and 1990s.These policies disproportionately affected Black women and women living inpoverty,and continue to do so today.While the government’s current approach to substance use in the general population is “remarkably less punitive” than its approach a few decades ago, it has recently been observed that “…pregnancy may represent an exception to the overall national willingness to treat the opioid epidemic as an issue of public health and not of law enforcement.”In addition, as one journalist put it, “There’s a growing consensus in the U.S. that drug addiction is a public health issue, and sufferers need treatment, not prison time. But good luck if you are pregnant.”Despite overwhelming consensus on the principle of a non-punitive approach towards substance use in pregnancy , the increase in punitive policies over the past two decades suggests that the gap between principles and practice is widening. What is needed is a holistic, public health-and prevention-oriented approach to substance use in pregnancy, consistent with the statements in Table 1. Imagine for a moment that pregnant women with diabetes, or epilepsy, or major depressive disorder, all of which are chronic medical conditions that confer some level of risk to the fetus, faced criminal charges and imprisonment if convicted of harming their infants. These examples illustrate just how differently many in the public and medical community view addiction. Addiction is a chronic medical condition, but pregnancy is a temporary period in the life course of a woman dealing with the recurring and remitting illness of addiction. Yet, too often, policies, health systems, and health services are designed to engage individuals in treatment only during pregnancy which is insufficient. Instead, women with SUD should be engaged throughout their life course. Women with SUD need comprehensive, coordinated, evidence-based, trauma-informed,flood table family-centered care not only during the 40 or so weeks of pregnancy but in the preconception, postpartum, and inter-conception periods—as well as throughout the life course for those not able to or not choosing to have children. This care should be delivered in a compassionate and non-punitive environment, and clinicians, policymakers, and public health officials all have a role to play in achieving this goal. There are encouraging examples of sound policy at both the federal and state levels.For example, recent federal legislation takes a much-needed public health approach to this issue, building on prior efforts to address gaps in the continuum of care for women who are pregnant and postpartum and strengthening Plans of Safe Care for infants with prenatal substance exposure. There has been a slow but noticeable shift in federal policy language towards less stigmatizing terminology and “people-first” language, such as an “individual in recovery” as opposed to a “drug addict,” and replacing “NAS baby” with “infant experiencing withdrawal.” Certain states are taking a dyadic approach to the challenge of mothers and infants affected by opioids. Medicaid policy levers have also shown promise. In Virginia, the Addiction and Recovery Treatment Services program,launched in 2017 to increase access to services for Medicaid members with SUDs, increased residential treatment capacity and removed the 16-bed reimbursement limit, which was a barrier to children and mothers remaining together during the mother’s treatment.
ARTS successfully increased the percentage of pregnant women with SUDs receiving treatment from 2% to 18% a year after implementation. Further research is needed to examine factors that may influence state-level variation in both the implementation and impact of different policy responses to substance use among pregnant women, but these are promising models. It is also encouraging that both federal and state policymakers are testing innovative ways to expand SUD treatment for women who are pregnant and parenting, including through telehealth and through telementoring and remote capacity building, based on the Project ECHO model.Importantly, public health and health systems are collaborating to address the often-overlooked “fourth trimester” the vulnerable early postpartum period in which a lot of the support and services a pregnant woman was eligible for rapidly fall away. Finally, the recommendation by multiple professional societies to extend postpartum Medicaid coverage to one year postpartum is garnering much-needed attention from policymakers.In conclusion, effectively addressing SUD, including opioid misuse, among pregnant women is a pressing public health issue, given both the dramatic increase in NOWS2 as well as the deleterious effects of untreated maternal opioid use disorder on both mothers and young children.10 Policymakers are aware of this issue, given the rapid pace of enacting policies addressing substance use in pregnant women. However, the greater increase in punitive compared to supportive policies is a concern. Better understanding how policies related to prenatal substance use affect maternal and child outcomes is essential as decision makers seek to best support pregnant women with SUDs. Substance use during pregnancy is a critical public health concern with significant consequences to both mother and infant . Women who use substances during pregnancy are at increased risk for poor perinatal outcomes, including preterm labor, low birth weight, congenital abnormalities, and stillbirths, and there can be additional long lasting physical, mental, behavioral and neurodevelopmental consequences for their children . Recognizing prenatal substance use as a primary cause of preventable birth defects, US guidelines consider substance use screening and referral to be essential for prenatal care . Prenatal alcohol use is associated with structural impairments, increased risk for adverse birth outcomes , fetal alcohol spectrum disorder and fetal alcohol syndrome, and neurodevelopmental problems in childhood . Prenatal nicotine use is associated with pregnancy complications , poor infant outcomes , sudden infant death syndrome, birth defects, and long-term health issues in childhood . National data indicate that alcohol use is increasing over time, and nicotine use is decreasing over time, among US women of reproductive age . However, corresponding with growing awareness of the potential harms of alcohol and nicotine use during pregnancy, initial data suggest that prenatal alcohol and nicotine use are decreasing over time . For example, data from the National Survey of Drug Use and Health indicate that among US adult pregnant women, any past-month use of alcohol during pregnancy decreased non-significantly from 9.6% in 2002 to 8.4% in 2016, and any past month cigarette smoking decreased significantly from 17.5% in 2002 to 10.3% in 2016 .