A Public Health Response to Opioid Use in Pregnancy

1 POLICY STATEMENT Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of all Children A Public Health Response to Opioid Use in Pregnancy Stephen W. Patrick, MD, MPH, MS, FAAP,a,b,c,d,e Davida M. Schiff, MD, FAAP,f COMMITTEE ON substance USE AND PREVENTION. The use of opioids during Pregnancy has grown rapidly in the past decade. abstract As Opioid use during Pregnancy increased, so did complications from their use, including neonatal abstinence syndrome. Several state governments responded to this increase by prosecuting and incarcerating pregnant aDepartments of Pediatrics and bHealth Policy, cMildred Stahlman women with substance use disorders; however, this approach has no proven Division of Neonatology, dVanderbilt Center for Health Services bene ts for maternal or infant Health and may lead to avoidance of prenatal Research, and eVanderbilt Center for Addiction Research, Vanderbilt University, Nashville, Tennessee.

2 And fDepartment of Pediatrics, Boston care and a decreased willingness to engage in substance use disorder Medical Center and Boston University School of Medicine, Boston, Massachusetts treatment programs. A Public Health Response , rather than a punitive approach to the Opioid epidemic and substance use during Pregnancy , Dr Schiff conceptualized and drafted the initial manuscript and critically reviewed the revised manuscript; Dr Patrick conceptualized is critical, including the following: a focus on preventing unintended the manuscript and critically reviewed and revised the manuscript;. and both authors approved the nal manuscript as submitted.

3 Pregnancies and improving access to contraception; universal screening for alcohol and other drug use in women of childbearing age; knowledge This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have and informed consent of maternal drug testing and reporting practices; led con ict of interest statements with the American Academy of Pediatrics. Any con icts have been resolved through a process improved access to comprehensive obstetric care, including Opioid - approved by the Board of Directors. The American Academy of replacement therapy; gender-speci c substance use treatment programs; Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

4 And improved funding for social services and child welfare systems. The Policy statements from the American Academy of Pediatrics bene t American College of Obstetricians and Gynecologists supports the value of from expertise and resources of liaisons and internal (AAP) and this clinical document as an educational tool (December 2016). external reviewers. However, policy statements from the American Academy of Pediatrics may not re ect the views of the liaisons or the organizations or government agencies that they represent. The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care.

5 Variations, taking INTRODUCTION into account individual circumstances, may be appropriate. All policy statements from the American Academy of Pediatrics substance use during Pregnancy occurs commonly in the United automatically expire 5 years after publication unless reaf rmed, revised, or retired at or before that time. States. In 2009, the substance Abuse and Mental Health Administration DOI: estimated that 400 000 infants each year are exposed to alcohol or illicit drugs in Although concern regarding substance use in Pregnancy Address correspondence to Stephen W. Patrick, MD, MPH, MS, FAAP. E-mail: is not new, it has recently increased among Health care providers, the Public , and policy makers as the Opioid epidemic's impact reached an PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

6 Increasing portion of the US population, including pregnant women Copyright 2017 by the American Academy of Pediatrics and their ,3 Several recent studies highlighted an increase in prescription Opioid use among women of childbearing age4 and among To cite: Patrick SW, Schiff DM, AAP COMMITTEE ON substance . USE AND PREVENTION. A Public Health Response to Opioid Use pregnant ,6 As Opioid use among pregnant women increased, the in Pregnancy . Pediatrics. 2017;139(3):e20164070. rate of infants in the United States experiencing Opioid withdrawal after Downloaded from by guest on July 30, 2018. PEDIATRICS Volume 139, number 3, March 2017:e20164070 FROM THE AMERICAN ACADEMY OF PEDIATRICS.

7 Birth, known as neonatal abstinence the proportion of unintended women, regardless of their age, race, syndrome (NAS), grew nearly fivefold pregnancies was higher than 85%.10 ethnicity, or socioeconomic over the past ,7 By 2012 Education and expansion of access to The benefits of drug testing in in the United States, on average, 1 effective contraception, particularly addition to screening during infant was born every 25 minutes long-acting reversible contraception Pregnancy remain uncertain. experiencing signs of withdrawal, (LARC) methods,11 are important Targeted urine drug-testing accounting for an estimated $ components of primary prevention.

8 Programs have been shown to billion in hospital The Access to LARC methods is supported disproportionately affect low-income issues surrounding substance use in by both the American Academy of women of racial or ethnic Pregnancy are complex and merit a Family Physicians (AAFP) and the minorities,20 23 prompting some to thoughtful Public Health Response American College of Obstetricians develop universal urine toxicology focused on prevention, expansion of and Gynecologists (ACOG)12,13 during testing protocols at the time of treatment to women with substance both the pre- and interconception Although urine toxicology use disorder, and improved funding periods.

9 However, there remain tests can provide objective evidence for child welfare systems to improve barriers to highly effective of drug use at 1 point in time, the Health of the substance -exposed contraception in many states. they do not enable providers to mother-infant dyad. For example, the ACOG supports determine the frequency of use or to placement of LARC devices during characterize the frequency or degree Primary Prevention the immediate postpartum period of ,26 Studies comparing the to improve the use of LARC among A Public Health approach to difference between verbal screening postpartum women13; however, substance use in Pregnancy should and urine drug testing are mixed; 1.

10 Bundled payments for delivery create begin with primary prevention: study found superior identification a relative financial disincentive to preventing substance and Opioid with verbal screening and another place LARC devices at the time of misuse before Pregnancy . In 2011, identified individuals with positive delivery. State Medicaid programs the White House Office of National urine drug test results who were play a critical role in ensuring access Drug Control Policy released a plan not previously known to have used to highly effective contraception at to respond to the prescription Opioid ,24 Consistent with ACOG.