This blog was also published in STAT on February 8, 2023.
Though it may be hard for many to fathom, even pregnant people and new parents can have active substance use disorders. They need support, not criminalization.
The addiction and overdose crisis, which now claims more than 100,000 lives a year, shows little sign of abating, and emerging data highlight its startling impact on pregnant people: Overdose is now a leading cause of death during or shortly after pregnancy.
Columbia University researchers recently reported that drug overdose deaths among pregnant and postpartum people increased by 81% between 2017 and 2020. In September 2022, the Centers for Disease Control and Prevention released data showing that deaths related to mental health conditions, including substance use disorders (SUDs), account for 23% of deaths during pregnancy or in the year following it. This outstrips excessive bleeding, cardiovascular conditions, or other well-known complications of pregnancy.
These stunning data highlight just how important it is to ensure access to substance use disorder treatment for pregnant and postpartum people, including the need to eliminate barriers that interfere with this treatment.
In the United States, quality addiction treatment is notoriously hard to come by, especially in rural areas and especially for people from some racial and ethnic groups. Even for those with health insurance, addiction treatment is not covered equitably, so getting care may be expensive. And fewer than half of addiction treatment programs prescribe effective medications like buprenorphine for opioid use disorder.
People seeking treatment for addictions face additional obstacles, especially if they have children. Only a small minority of treatment facilities provide child care, creating yet another obstacle on top of securing transportation, housing, food, and other necessities, all of which can be more difficult for people who are also supporting children.
The barriers get even higher for pregnant people. In one recent study using a “secret shopper” approach, callers to addiction treatment providers in 10 states were 17% less likely to receive an appointment if they said they were pregnant. Pregnant Black and Hispanic people experience even greater challenges accessing addiction treatment, including being less likely to receive medication for opioid use disorder, a proven and cost-effective treatment.
Fear of criminal punishment deters many pregnant people from seeking help for drug or alcohol problems. Many U.S. states have punitive policies in place related to substance use in pregnancy, which may include regarding it as potential child abuse, or grounds for commitment or being charged with a criminal act. Penalties for substance use in pregnancy can include fines, loss of custody, involuntary commitment, or incarceration.
Between 2011 and 2017, the number of infants placed in foster care grew by 10,000 each year; at least half of those placements were associated with parental substance use. Children in states with punitive policies are less likely to be reunited with their parents than those in other states. Moreover, there are considerable inequalities within the child welfare system. Pregnant Black people are more likely to be referred to child welfare and less likely to be reunited with their infants than pregnant white people, and Black and American Indian/Alaska Native children are overrepresented in this system.
It’s no surprise that punitive policies cause pregnant people to fear disclosing their substance use to their health care providers or to avoid seeking treatment for a substance use disorder. These policies may also cause them to avoid or delay getting obstetric care.
Decades of research show that addiction is a chronic but treatable condition that drives people to use substances even if it harms their health, careers, and relationships. Punitive policies are not effective at addressing substance use disorder and, if anything, only exacerbate its societal risk factors, including worsening of racial health disparities. Punitive approaches also lead to more negative outcomes for parents and their children.
In states more likely to criminalize pregnant people with opioid use disorder, fewer receive medications for it. A 2022 analysis found that women living in states with punitive policies for substance use in pregnancy had a lower likelihood of receiving timely or quality care, both before and after pregnancy. In states with such policies, or which require doctors to report their patients’ substance use, prenatal care tends to be sought later in pregnancy. States with punitive policies toward pregnant people with substance use disorders have higher rates of infants born with neonatal abstinence syndrome.
In addition to increasing a mother’s risk of overdose, untreated opioid use disorder during pregnancy can cause fetal growth restriction, placental abruption (separation of the placenta from the uterus), preterm labor, and other problems, and sometimes even the death of the fetus. Treatment with methadone or buprenorphine reduces the rates of preterm delivery, low birth weight, and placental abruption. Treatment also helps people with substance use disorders stay employed, take care of their children, and engage with their families and communities.
Like other medical conditions, substance use disorders require effective treatment. Science is poised to help as ongoing research develops more safe and effective interventions, as well as better implementation models tailored to the needs of those seeking substance use disorder treatment during pregnancy.
Punitive policies toward substance use reflect the entrenched attitude that addiction is a deviant choice rather than a medical disorder. A shift away from criminalization will require a shift of societal understanding of addiction as a chronic, treatable condition from which people recover, underscoring the urgency to treat and not punish it.
Having a substance use disorder during pregnancy is not itself child abuse or neglect. Pregnant people with substance use disorders should be encouraged to get the care and support they need — and be able to access it — without fear of going to jail or losing their children. Anything short of that is harmful to individuals living with these disorders and to the health of their future babies. It is also detrimental to their families and communities, and contributes to the high rates of deaths from drug overdose in our country.
Nora D. Volkow is a psychiatrist, scientist, and director of the National Institute on Drug Abuse, which is part of the National Institutes of Health.