Biden Administration Offers Plan to Get Addiction-Fighting Medicine to Pregnant Women

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Pregnant women are more likely to die of a drug overdose than the average woman of childbearing age, but less likely to be accepted for medication-based treatment.

Footprints of children born to women at Karen’s Place Maternity Center, an addiction recovery center in Louisa, Ky.
Credit...Hilary Swift for The New York Times

Emily Baumgaertner

Oct. 21, 2022

The Biden administration will use federal courts and health programs to expand the use of medication to treat substance use disorders in pregnant women, according to a report by the White House released Friday. The plan is part of the administration’s broader effort to combat a drug crisis that now kills more than 100,000 Americans annually.

Under the new initiative, the Justice Department, the Department of Veterans Affairs and the Indian Health Service will be responsible for improving women’s access to medicines like buprenorphine and methadone. These treatments have been controversial, but are increasingly being embraced as a scientifically proven way to reduce dependency and save lives.

Opioid use disorder among pregnant women has more than quadrupled in recent years, according to the Centers for Disease Control and Prevention, and is associated with low birth weight, preterm labor and miscarriage. Pregnant women are more likely to die of a drug overdose than the average woman of childbearing age, but less likely to be accepted for appointments with buprenorphine providers.

“This is a bold statement, a big moment, coming from the president and the vice president, to show that pregnancy is the golden opportunity to help women get into recovery,” said Dr. Anna Lembke, the medical director of addiction medicine at Stanford, who was not involved in the plan’s design.

But the administration’s blueprint is vague on funding, and some policy analysts worry that it falls short on the mechanisms and detail needed to push agencies and health institutions to move faster.

Most items in the plan do not require additional appropriations from Congress. But officials asked for hundreds of millions of dollars more toward various child welfare initiatives in fiscal year 2023, including tripling mandatory funding to $60 million from $20 million for one program focused on families navigating substance abuse.

Andrew Kessler, the founder of the behavioral health consultancy Slingshot Solutions, said that without sufficient funding from Congress, this initiative won’t amount to lasting change. He likened the administration’s “deeply researched” plan to the thick black outlines found in a coloring book.

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“It’s big and bold, no doubt,” he said. “But now it’s time to color it in.”

When a woman with a substance use disorder becomes pregnant, a striking dichotomy arises, addiction experts say: She is now among those most motivated to overcome addiction — but also among the least likely to receive care.

Women posing as pregnant in one study were 17 percent less likely to be accepted for opioid treatment appointments by providers who prescribed buprenorphine than women who did not mention a pregnancy. Among pregnant women, living in a rural community, not speaking English and being nonwhite were associated with a lower likelihood of receiving medicine for opioid use disorder.

“Imagine coming to see a doctor for a new cancer diagnosis and being told there is a 50-50 chance you’ll get treatment,” said Dr. Caleb Alexander, an opioid abatement expert and professor of epidemiology at Johns Hopkins who studies drug safety. “That’s about how well some studies suggest we do with pregnant women with opioid addiction.”

Pregnant women who reveal their disorder in order to seek treatment also have much to lose. Infants are now the fastest-growing age group in the U.S. foster care system, and of the 50,000 baby removals each year, about half are associated with substance use.

The overdose death rate for American Indians and Alaska Natives increased 39 percent from 2019 to 2020, and this group is represented in the child welfare system at almost three times the rate of the general population.

A report detailing the Biden administration’s plan stressed that having a substance use disorder in pregnancy “is not, by itself, child abuse or neglect,” and that “criminalizing S.U.D. in pregnancy is ineffective and harmful.”

State-to-state comparisons show that pregnant women are much more likely to stop using drugs in places where the behavior isn’t criminalized, Dr. Lembke said. But in the midst of an overdose epidemic, many states have cracked down, jailing pregnant women without providing treatment — in at least one case, for months.

Under the administration’s plan, officials at the Substance Abuse and Mental Health Services Administration, or SAMHSA, will train judges to incorporate the use of opioid replacement drugs into sentencing for pregnant women with substance use disorders. The goal is to increase the proportion of pregnant women who receive medication as part of their court-mandated treatment plan or as a condition of probation or parole.

Medication-assisted treatment has been controversial in the United States because opioid recovery drugs like buprenorphine (also known by the brand name Suboxone) and methadone are opioids themselves. While they do not generate a high at a prescribed dosage, they help satisfy cravings and reduce withdrawal symptoms as patients seek to cut back and quit heroin, fentanyl and other deadly opioids. The medicines have been shown to reduce the mortality rate among people addicted to opioids by half or more, but some officials and providers worry that the substance-replacement approach encourages ongoing drug use.

Under the proposal, addiction experts will focus on improving access to the medication in communities with the highest rates of addiction. Health care providers who treat veterans — more than one million of whom have been diagnosed with substance use disorder — will undergo training and start pilot programs to integrate medication into existing care models.

The Indian Health Service, which serves American Indians and Alaska Natives, will train employees to screen women who are pregnant or of childbearing age for opioid use disorders and will expand its prescribing dashboard to include access to buprenorphine. The move is “a technical but powerful nudge to normalize it, to make it part of the fabric of how we treat this condition,” Dr. Lembke said.

SAMHSA will track the number of obstetricians and midwives who are approved to prescribe buprenorphine, hire a dedicated associate administrator for women’s services, and develop national certification standards for peer recovery support specialists. The plan also includes tens of millions of dollars in various grants to organizations, hospitals and rural communities.

Some policy experts worried that, because the report emphasizes education for medical providers and court employees, without long-term financial incentives or consequences for institutions, health systems won’t move fast enough to boost their addiction care capacity.

Dr. Stefan Kertesz, a clinician and addiction researcher at the University of Alabama at Birmingham, and Mr. Kessler suggested, for example, that the Biden administration should have tied hospital credentialing standards or even federal funding to whether the institutions had the capacity to offer immediate addiction treatment to patients seeking care for any condition, whether pregnancy or a respiratory infection.

“If all health care institutions were ready to offer care, then it would be a lot easier to make that care happen” Dr. Kertesz said. Instead, he said, most obstetricians and addiction specialists have never been in the same room, and families enter into “chaotic, dysfunctional bureaucracies” that don’t have a robust, interdisciplinary response plan in place.

Experts also said that the plan, which was designed mostly with existing budget allocations, would have limited impact without exponentially higher appropriations from Congress. Without comprehensive addiction care “baked into Medicare and Medicaid,” Dr. Lembke said, stopgap efforts to take on the crisis will only last through a grant cycle.

“A great deal of expertise went into this plan,” Dr. Kertesz said, “and nonetheless, it is going to leave most of us on the front lines frustrated.”

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