In sensitivity analyses, estimates using unimputed data were similar in direction and magnitude to estimates using multiply imputed data (Tables 1 and 2, Supplemental Digital Content, http://links.lww.com/MLR/B467). The overall adjusted difference between Medicaid-insured pregnant women and non-Medicaid pregnant women was 21.2 percentage points (95% CI, 4.6–37.9), indicating that Medicaid-insured pregnant women experienced higher rates of planned OAT use in coverage states versus no coverage states, which was over and above the higher rate experienced by non-Medicaid pregnant women (Table 3). However, these results varied by setting, with a significant adjusted difference in residential and intensive outpatient settings but not in nonintensive outpatient settings (13.2 percentage points, 95% CI, −1.1 to 27.4).
Overall, only about half of admissions of pregnant women to specialty OUD treatment had OAT as part of the treatment plan. While we found evidence that Medicaid coverage policies play a role, several other patient, provider, and policy factors likely contribute to low rates of OAT. Pregnant women with OUD may experience stigma and have negative perceptions of OAT, both of which serve as barriers to treatment and retention.35–38 Pregnant women may also be treated by providers who prefer non-OAT approaches, lack information about OAT, or doubt the clinical effectiveness of OAT.39–41 Furthermore, pregnant women may not receive OAT or may be given subtherapeutic doses because of concerns about neonatal abstinence syndrome, a postnatal withdrawal syndrome characterized by central nervous system hyperirritability and autonomic nervous system dysfunction, which is an expected and treatable outcome of maternal OAT.3,14,42,43 Finally, as of 2015, at least 18 states had laws considering substance use during pregnancy to be child abuse and 1 considered it assault.44,45 Research suggests such laws are linked with lower use of OAT, potentially because pregnant women fear that these laws apply to OAT.45
Despite their status as a more intensive level of care, we found that admissions to residential and intensive outpatient programs were much less likely to have OAT as part of their treatment plan than admissions to nonintensive outpatient programs (many of which are specialized opioid treatment programs). However, we found Medicaid coverage of methadone maintenance to be associated with higher rates of planned OAT use in residential (only significant in sensitivity analysis) and intensive outpatient settings (significant in both primary in sensitivity analyses). This finding suggests that Medicaid coverage policies could play a critical role in promoting access to OAT in settings that traditionally have not offered it.
This study has several limitations. First, TEDS only contains data from specialty treatment facilities that receive public funding, therefore we could not determine the impact of Medicaid coverage policies on OAT use in private facilities that do not receive public funding or in office-based care (stand-alone or embedded into prenatal care). If Medicaid-insured pregnant women in states without Medicaid coverage of methadone maintenance preferentially access or are referred to private facilities or office-based settings for OAT (ie, outside the scope of our data source), our estimates of OAT use in these states may be conservative. Second, as our study relies on cross-sectional data, we could not determine the causal impact of changing Medicaid coverage policies on OAT use. In sensitivity analyses, we found higher rates of OAT use among non–Medicaid-insured pregnant women in states with Medicaid coverage of methadone maintenance versus no coverage in nonintensive outpatient settings, suggesting that our findings may be due, at least in part, to differences between states other than Medicaid coverage of methadone maintenance. Third, pregnant women in residential treatment facilities may receive OAT outside of the treatment facility (eg, through a prenatal provider or an opioid treatment program) which may have resulted in an underestimate of planned OAT use in residential settings. Finally, as our data source only contains data from treatment admissions, we cannot determine treatment received over time (eg, planned taper vs. maintenance) or the impact of Medicaid coverage policies on maternal, fetal, or perinatal outcomes. Moreover, the postpartum period is a high-risk time for overdose death; however, Medicaid coverage through the pregnancy eligibility pathway ends 60 days postpartum.5,46,47 Changes in coverage status postpartum may disrupt access to OAT, particularly in states where Medicaid expansion did not occur. Further research is needed to assess the impact of OAT coverage policies on a broad range of outcomes in pregnant women.
1. Center for Substance Abuse Treatment. Medication-assisted Treatment for Opioid Addiction in Opioid Treatment Programs (Treatment Improvement Protocol (TIP) Series, No 43). Rockville, MD: Substance Abuse and Mental Health Services Administration; 2005.
2. Kaltenbach K, Berghella V, Finnegan L. Opioid dependence during pregnancy
. Effects and management. Obstet Gynecol Clin North Am. 1998;25:139–151.
3. ACOG Committee on Health Care for Underserved Women, American Society of Addiction Medicine. ACOG Committee Opinion No. 524: opioid abuse, dependence, and addiction in pregnancy
. Obstet Gynecol. 2012;119:1070–1076.
4. Finnegan LP. Treatment issues for opioid-dependent women during the perinatal period. J Psychoactive Drugs. 1991;23:191–201.
5. Mehta PK, Bachhuber MA, Hoffman R, et al. Deaths from unintentional injury, homicide, and suicide during or within 1 year of pregnancy
in Philadelphia. Am J Public Health. 2016;106:2208–2210.
6. Joseph H, Stancliff S, Langrod J. Methadone maintenance
treatment (MMT): a review of historical and clinical issues. Mt Sinai J Med. 2000;67:347–364.
7. O'Connor PG, Fiellin DA. Pharmacologic treatment of heroin-dependent patients. Ann Intern Med. 2000;133:40–54.
8. Kakko J, Svanborg KD, Kreek MJ, et al. 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence
in Sweden: a randomised, placebo-controlled trial. Lancet. 2003;361:662–668.
9. Gerra G, Ferri M, Polidori E, et al. Long-term methadone maintenance
effectiveness: psychosocial and pharmacological variables. J Subst Abuse Treat. 2003;25:1–8.
10. Amato L, Davoli M, Perucci CA, et al. An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research. J Subst Abuse Treat. 2005;28:321–329.
11. Jones HE, O'Grady KE, Malfi D, et al. Methadone maintenance
vs. methadone taper during pregnancy
: maternal and neonatal outcomes. Am J Addict. 2008;17:372–386.
12. Goler NC, Armstrong MA, Taillac CJ, et al. Substance abuse treatment linked with prenatal visits improves perinatal outcomes: a new standard. J Perinatol. 2008;28:597–603.
13. Svikis DS, Golden AS, Huggins GR, et al. Cost-effectiveness of treatment for drug-abusing pregnant women. Drug Alcohol Depend. 1997;45:105–113.
14. Jones HE, Kaltenbach K, Heil SH, et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure. N Engl J Med. 2010;363:2320–2331.
15. Young JL, Martin PR. Treatment of opioid dependence in the setting of pregnancy
. Psychiatr Clin North Am. 2012;35:441–460.
16. Stein BD, Pacula RL, Gordon AJ, et al. Where is buprenorphine dispensed to treat opioid use disorders? The role of private offices, opioid treatment programs, and substance abuse treatment facilities in urban and rural counties. Milbank Q. 2015;93:561–583.
17. Dick AW, Pacula RL, Gordon AJ, et al. Growth in buprenorphine waivers for physicians increased potential access to opioid agonist treatment, 2002-11. Health Aff (Millwood). 2015;34:1028–1034.
18. Substance Abuse and Mental Health Services Administration. 2011 Opioid Treatment Program Survey: Data on Substance Abuse Treatment Facilities with OTPs BHSIS Series S-65, HHS Publication No (SMA) 14-4807. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2011.
19. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Treatment Episode Data Set (TEDS): 2004-2014 State Admissions to Substance Abuse Treatment Services BHSIS Series S-85, HHS Publication No (SMA) 16-4987. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015.
20. Bachhuber MA, Southern WN, Cunningham CO. Profiting and providing less care: comprehensive services at for-profit, nonprofit, and public opioid treatment programs in the United States. Med Care. 2014;52:428–434.
21. Bachhuber MA, Cunningham CO. Changes in testing for human immunodeficiency virus, sexually transmitted infections, and hepatitis C virus in opioid treatment programs. JAMA. 2013;310:2671–2672.
22. Hand DJ, Short VL, Abatemarco DJ. Substance use, treatment, and demographic characteristics of pregnant women entering treatment for opioid use disorder
differ by United States census region. J Subst Abuse Treat. 2017;76:58–63.
23. Murphy K, Kershner D. 2014 Maternal and Child Health Update: States Are Using Medicaid
and CHIP to Improve Health Outcomes for Mothers and Children. Washington, DC: National Governors Association Center for Best Practices; 2015.
24. Jones CM, Logan J, Gladden RM, et al. Vital signs: demographic and substance use trends among heroin users—United States, 2002-2013. MMWR Morb Mortal Wkly Rep. 2015;64:719–725.
25. Saha TD, Kerridge BT, Goldstein RB, et al. Nonmedical prescription opioid use and DSM-5 nonmedical prescription opioid use disorder
in the United States. J Clin Psychiatry. 2016;77:772–780.
26. Stein BD, Mendelsohn J, Gordon AJ, et al. Opioid analgesic and benzodiazepine prescribing among Medicaid
-enrollees with opioid use disorders: the influence of provider communities. J Addict Dis. 2017;36:14–22.
27. Saloner B, Karthikeyan S. Changes in substance abuse treatment use among individuals with opioid use disorders in the United States, 2004-2013. JAMA. 2015;314:1515–1517.
28. Saloner B, Stoller KB, Barry CL. Medicaid
coverage for methadone maintenance
and use of opioid agonist therapy in specialty addiction treatment. Psychiatr Serv. 2016;67:676–679.
29. Burns RM, Pacula RL, Bauhoff S, et al. Policies related to opioid agonist therapy for opioid use disorders: the evolution of state policies from 2004 to 2013. Subst Abus. 2016;37:63–69.
30. Gelber Rinaldo S, Rinaldo DW. Availability Without Accessibility? State Medicaid
Coverage and Authorization Requirements for Opioid Dependence Medications; In Advancing Access to Addiction Medications: Implications for Opioid Addiction Treatment. Chevy Chase, MD: Medicine ASoA; 2013.
31. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Treatment Episode Data Set (TEDS) State Instruction Manual With State TEDS Submission System (STTS) Guide Version 32. Rockville, MD: SAMHSA; 2014.
32. Herberlein M, Brooks T, Alker J, et al. Getting into Gear for 2014: Findings From a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid
and CHIP, 2012-2013. Washington, DC: The Henry J. Kaiser Family Foundation; 2013.
33. White IR, Royston P, Wood AM. Multiple imputation using chained equations: issues and guidance for practice. Stat Med. 2011;30:377–399.
34. Vittinghoff E, Glidden DV, Shiboski SC, et al. Regression Methods in Biostatistics. New York, NY: Springer; 2012.
35. Jones HE, Deppen K, Hudak ML, et al. Clinical care for opioid-using pregnant and postpartum women: the role of obstetric providers. Am J Obstet Gynecol. 2014;210:302–310.
36. Schempf AH, Strobino DM. Drug use and limited prenatal care: an examination of responsible barriers. Am J Obstet Gynecol. 2009;200:412.e411–410.
37. Roberts SC, Nuru-Jeter A. Women’s perspectives on screening for alcohol and drug use in prenatal care. Womens Health Issues. 2010;20:193–200.
38. Roberts SC, Pies C. Complex calculations: how drug use during pregnancy
becomes a barrier to prenatal care. Matern Child Health J. 2011;15:333–341.
39. Rieckmann T, Daley M, Fuller BE, et al. Client and counselor attitudes toward the use of medications for treatment of opioid dependence. J Subst Abuse Treat. 2007;32:207–215.
40. Knudsen HK, Abraham AJ, Oser CB. Barriers to the implementation of medication-assisted treatment for substance use disorders: the importance of funding policies and medical infrastructure. Eval Program Plann. 2011;34:375–381.
41. Knudsen HK, Ducharme LJ, Roman PM. The adoption of medications in substance abuse treatment: associations with organizational characteristics and technology clusters. Drug Alcohol Depend. 2007;87:164–174.
42. Jones HE, Martin PR, Heil SH, et al. Treatment of opioid-dependent pregnant women: clinical and research issues. J Subst Abuse Treat. 2008;35:245–259.
43. Calvin C, Moriarty H. A special type of “hard-to-reach” patient: experiences of pregnant women on methadone. J Prim Health Care. 2010;2:61–69.
44. Guttmacher Institute. State Policies in Brief: Substance Abuse During Pregnancy
. Washington, DC: Guttmacher Institute; 2015.
45. Angelotta C, Weiss CJ, Angelotta JW, et al. A moral or medical problem? The relationship between legal penalties and treatment practices for opioid use disorders in pregnant women. Womens Health Issues. 2016;26:595–601.
46. Metz TD, Rovner P, Hoffman MC, et al. Maternal deaths from suicide and overdose in Colorado, 2004-2012. Obstet Gynecol. 2016;128:1233–1240.
47. Gifford K, Walls J, Ranji U, et al. Medicaid
Coverage of Pregnancy
and Perinatal Benefits: Results From a State Survey. Washington, DC: The Henry J. Kaiser Family Foundation; 2017.