Addressing Barriers to Successful Treatment for Opioid Use Disorder for Pregnant and Postpartum Individuals

The national opioid crisis claimed more than 80,000 lives last year, a number that’s grown 10-fold over the last two decades, and opioid overdose is the leading cause of injurious death in the U.S. Meanwhile, millions of Americans continue to suffer from opioid use disorder despite the availability of highly effective medicines like buprenorphine. Scientific research into how different populations respond to treatment is critical to combating the crisis and understanding how to better treat addiction and prevent death by overdose. Assistant Professor Brandon Knettel, PhD, co-authored an examination of research to identify predictors of treatment success for opioid use disorder during and after pregnancy and found that early intervention and appropriate dosages were keys to better outcomes. Knettel is also Associate Director of the Duke Center for Global Mental Health and Assistant Research Professor of Global Health within the Duke Global Health Institute.

Early Screening is a Must

The study, titled “Factors associated with medications for opioid use disorder (MOUD) treatment success during the pregnancy and postpartum periods: A scoping review,” was published in the journal Drug and Alcohol Dependence. Knettel and his co-authors discovered that, when providers were overly conservative in MOUD dosages for pregnant [people], this resulted in higher rates of relapse. “It’s a real cost-benefit analysis of making sure that we’re not giving medication at a dosage that could negatively affect the fetus but making sure that the [patients] are treated effectively,” Knettel said, “because if they go back to using heroin, for example, that’s going to be much, much more harmful.”

The study also showed that the earlier medication was introduced for treatment, the more likely patients would be to continue treatment during pregnancy and postpartum, which was associated with improved outcomes for both parent and child.

“We need to be screening for and initiating opioid use treatment early on in our contacts with pregnant [people],” Knettel said. “The earlier people initiated, the better off they did.” Often young people don’t engage in the health care system, he said, because they feel fine and don’t seek care except for acute issues. When patients come in with a first-time pregnancy, or wanting to get pregnant, it’s important to take the opportunity when they are seeking care to ask the right questions, especially when it comes to opioid use.

“We wanted to understand the research that’s already out there on trying to get pregnant people involved in substance use treatment, and what has worked and what hasn’t worked, and who might be at higher risk and who might be at lower risk out of this population, in terms of their success in getting treated,” Knettel said. “It’s a really important group for us to be paying attention to and supporting, in that they’re often young people, so they have their whole lives ahead of them.”

Guilt, Mental Health, Financial Constraints, and More are Barriers to Treatment

Knettel and his colleagues started by reviewing nearly 7,000 opioid studies and narrowed this list down to 15 studies that met their inclusion criteria and assessed treatment success for pregnant and postpartum individuals. While MOUD have been proven to reduce overdose deaths and improve health outcomes, the research indicated that pregnant and postpartum people face unique barriers to treatment. Guilt over opioid use disorder, comorbid and postpartum mental health conditions, along with lack of transportation, financial constraints and lack of childcare were obstacles to receiving consistent treatment.

Social determinants of health have a big impact on how pregnant people fare with MOUD as well. Those who were having issues with housing security or homelessness, those who were involved with the legal system, and those living in rural areas were more likely to drop out and struggle with care, Knettel said.

“We need to flip the script and really attend to rural populations because they have a separate set of challenges regarding access to treatment,” Knettel said. Long travel distances coupled with things like homelessness and large copays make treatment difficult. Finding other methods for care, like telemedicine, can help combat health inequities created by physical distance and socioeconomics. The review of studies did not indicate inpatient treatment was more advantageous than telehealth, Knettel said. Findings like this will allow other researchers and providers a better foundation for MOUD treatments for pregnant individuals.

“The goal is really to inform effective outreach and treatment strategies, including large statewide treatment programs,” Knettel said, noting that their review highlights patterns in the studies’ data, which will help fine-tune interventions. “We hope this work will be considered by other researchers, program administrators, and policymakers around the country who are looking for good data to inform their programs.”

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