In our responses to the overdose epidemic, we cannot forget pregnant and postpartum people.

In 2021, there were over 100,000 drug overdose deaths in the United States (US). Death rates have increased faster among women than men, particularly among Black and Indigenous people. Although drug overdose is a leading cause of pregnancy-associated deaths, birthing people are rarely emphasized in discussions of overdose and research and services remain limited. Data show increases in drug use and deaths among women of child-bearing age, with risks continuing in the postpartum period. Harms experienced by birthing people who use drugs occur in the context of broader inequities in maternal morbidity and mortality that lead to disparate reproductive health outcomes. Shared structural antecedents (e.g. intersecting sexism and racism, stigma, and punitive policies) underlie overlapping epidemics of overdose and maternal morbidity and mortality. Here we discuss the unique challenges placed on birthing people who use drugs and make recommendations on how to mitigate harms by improving access to and delivery of quality care and addressing unjust policies and practices. We highlight the need for integrated health services, clearer guidelines rooted in equity, and the need for changes to policy and practice that support rather than punish. To better serve individuals and families impacted by substance use, we need multilevel solutions that advance gender equity and racial justice to reshape and/or dismantle the systems that undergird oppression.

Association of Pregnancy Intentions With Substance Use During Early Pregnancy.

OBJECTIVES: The goal of this study was to evaluate the association between pregnancy intentions and substance use in early pregnancy among pregnant women receiving prenatal care in a large, integrated healthcare system. METHODS: The sample comprised 29,787 Kaiser Permanente Northern California pregnant women (12.1% aged <25, 36.4% non-Hispanic White) screened for prenatal substance use in 2018 via a self-reported questionnaire and urine toxicology test given as part of standard prenatal care (at ∼8 weeks gestation). Multivariable logistic regression models tested for associations of pregnancy intentions with prenatal substance use (any use and specific substances) by self-report and/or a positive urine toxicology test. RESULTS: Adjusting for covariates, women with an unintended pregnancy (23.9% of the sample) had higher odds of any prenatal substance use than women with an intended pregnancy (28.8% vs 16.1%; adjusted odds ratio [aOR] = 1.80, 95% confidence interval [CI]:1.67-1.93). Having an unintended pregnancy was also associated with higher odds of using alcohol (14.4% vs 10.4%; aOR = 1.73, 95%CI:1.59-1.89), cannabis (15.6% vs 5.6%; aOR = 1.91, 95%CI:1.73-2.11), nicotine (3.8% vs 1.3%; aOR = 2.33, 95%CI:1.92-2.82), pain medication (2.3% vs 1.2%; aOR = 1.64, 95%CI:1.32-2.03), and stimulants (0.8% vs 0.3%; aOR = 1.85, 95%CI:1.23-2.79) early in pregnancy. DISCUSSION: Having an unintended pregnancy was associated with higher odds of substance use during early pregnancy. Connecting women of reproductive age with health education about pregnancy prevention and recognition of early signs of pregnancy, effective contraception, and early screening and interventions for prenatal substance use may help to reduce prenatal substance use and its associated consequences.

Trends in Cannabis Treatment Admissions in Adolescents/Young Adults: Analysis of TEDS-A 1992 to 2016.

OBJECTIVES: This study aims to evaluate changes in cannabis use patterns, referral sources, and admissions in adolescents and young adults (YAs). As the United States increasingly moves toward liberalization of cannabis laws, it is critical to have baseline information of use patterns in this population. METHODS: Data were drawn from Treatment Episode Data Set-Admissions (TEDS-A) for adolescents (12-17 years) and young adults (18-24 years) entering treatment from 1992 to 2016 for primary cannabis use (N = 3,794,213). Rao-Scott chi-square tests were used to test for significant changes in proportions of individuals admitted to treatment for primary cannabis use and between 4-year increments from 1992 to 2016 (N = 1,052,724). Logistic regression assessed odds of admissions for primary cannabis use versus other substances. RESULTS: Treatment admissions for cannabis among adolescents/YAs rose 3-fold from 1992 (49,996) to 1996 (125,858). The majority of referrals came from the criminal justice system (56%). Cannabis is increasingly the sole substance of use, with polysubstance use decreasing from 89% in 1992 to 59% in 2016. While alcohol-related treatment admissions were most common in 1992, admissions for treatment of cannabis use (followed by heroin and alcohol) were highest (38%) by 2016. Being an adolescent (odds ratio [OR] 3.1, 95% confidence interval [CI] 3.1-3.2), non-Hispanic black (OR 6.2, 95% CI 6.2-6.3), male (female OR 0.6, 95% CI 0.6-0.6) with co-occurring alcohol use (OR 25.9, 95% CI 25.7-26.1) was associated with admission for treatment of primary cannabis use as compared with other substances. CONCLUSIONS: Public health efforts will be needed to ensure ongoing access and referral to treatment as the legal status of cannabis continues to change. Prevention and treatment efforts should target co-occurring alcohol and cannabis use.

Characteristics of Pregnant Women Reporting Cannabis Use Disorder at Substance Use Treatment Entry.

INTRODUCTION: The current study examined distinct characteristics of yearly trend, sociodemographic, and treatment-related variables of prenatal cannabis use as the primary drug of choice among pregnant women admitted to substance use treatment for the first time. METHODS: The Treatment Episode Data Set-Admission between 1992 and 2015 was used for a cross-sectional study focused on prenatal cannabis use reported at treatment admission. RESULTS: Among pregnant women admitted to substance use treatment for the first time (n = 489,796), 40.6% reported any level of cannabis use, and 40.8% reported cannabis use as the primary drug of choice at treatment admission. Adjusted for other characteristics, a statistically significant change in overall trends for any prenatal cannabis use, and also in cannabis use as the primary drug of choice over 20 years was detected. While pregnant women reporting cannabis use as the primary drug of choice were significantly less likely to co-use other substances, those involved in the criminal justice system were significantly more likely to co-use cocaine and opioids, but significantly less likely to co-use alcohol. DISCUSSION/CONCLUSION: Continued monitoring of prenatal cannabis use and patterns of other substance co-use is encouraged, given the perceived harm of cannabis use in young generations has lessened in recent years, coinciding with the legalization process. Targeted education materials and treatment options to treating prenatal cannabis use should be developed tailored to substance use characteristics and criminal justice involvement.

The Comprehensive Addiction and Recovery Act: Opioid Use Disorder and Midwifery Practice.

The federal response to the opioid use disorder crisis has included a mobilization of resources to encourage office-based pharmacotherapy with buprenorphine, an effort culminating in the 2016 Comprehensive Addiction and Recovery Act, signed into law as Public Law 114-198. The Comprehensive Addiction and Recovery Act was designed to increase access to treatment with special emphasis on services for pregnant women and follow-up for infants affected by prenatal substance exposure. In this effort, the Comprehensive Addiction and Recovery Act laudably expands eligibility for obtaining a waiver to prescribe buprenorphine to nurse practitioners and physician assistants. However, certified nurse-midwives and certified midwives, who care for a significant proportion of pregnant and postpartum women and attend a significant proportion of births in the United States, were not included in the Comprehensive Addiction and Recovery Act legislation. In this commentary, we argue that an "all-hands" approach to providing office-based medication-assisted treatment for opioid use disorder is essential to improving access to treatment. Introduced in the House of Representatives in September 2017, the Addiction Treatment Access Improvement Act (H.R. 3692) would allow midwives to apply for the federal waiver to prescribe buprenorphine and is supported by the American College of Obstetricians and Gynecologists and the American College of Nurse-Midwives. We support this change and encourage the U.S. Congress to act quickly to allow midwives to prescribe medication-assisted treatment for pregnant women with opioid use disorder.

Characteristics of pregnant women who reported alcohol use at admission to substance use treatment.

OBJECTIVES: The current study analyzed the sociodemographic, treatment-related, and other substance use characteristics among pregnant women who reported alcohol use and were admitted to substance use treatment for the first time. METHODS: The Treatment Episode Data Set-Admission (TEDS-A) between 1992 and 2012 was used for conducting a cross-sectional study. RESULTS: Among pregnant women admitted to substance use treatment for the first time (N=166,863), 43.1% reported alcohol use of whom half used alcohol as the primary drug of choice. The proportion of pregnant women reporting any alcohol use declined over the study period, while the proportions of subgroups within pregnant women reporting alcohol use remained stable within the population. Those reporting alcohol use only notably had the highest proportion of women aged 40 or older and non-Hispanic White who were more educated, employed, and married, compared to those reporting alcohol use as primary but also other substance use and those reporting other substance as primary drug of choice. Those reporting only alcohol also were more likely to be referred by the justice system to outpatient treatment. Marijuana was the most popular co-used substance among pregnant women who use alcohol as primary drug of choice in the dataset. CONCLUSIONS: Differences in sociodemographic, treatment-related, and other substance use characteristics between the three subgroups may help inform public health interventions aimed at mitigating the effects of prenatal alcohol use on maternal and child health.

Psychosocial interventions for pregnant women in outpatient illicit drug treatment programs compared to other interventions.

BACKGROUND: Illicit drug use in pregnancy is a complex social and public health problem. The consequences of drug use in pregnancy are high for both the woman and her child. Therefore, it is important to develop and evaluate effective treatments. There is evidence for the effectiveness of psychosocial interventions in drug treatment but it is unclear whether they are effective in pregnant women. This is an update of a Cochrane review originally published in 2007. OBJECTIVES: To evaluate the effectiveness of psychosocial interventions in pregnant women enrolled in illicit drug treatment programmes on birth and neonatal outcomes, on attendance and retention in treatment, as well as on maternal and neonatal drug abstinence. In short, do psychosocial interventions translate into less illicit drug use, greater abstinence, better birth outcomes, or greater clinic attendance? SEARCH METHODS: We conducted the original literature search in May 2006 and performed the search update up to January 2015. For both review stages (original and update), we searched the Cochrane Drugs and Alcohol Group Trial's register (May 2006 and January 2015); the Cochrane Central Register of Trials (CENTRAL; the Cochrane Library 2015, Issue 1); PubMed (1996 to January 2015); EMBASE (1996 to January 2015); and CINAHL (1982 to January 2015). SELECTION CRITERIA: We included randomized controlled trials comparing any psychosocial intervention vs. a control intervention that could include pharmacological treatment, such as methadone maintenance, a different psychosocial intervention, counselling, prenatal care, STD counselling and testing, transportation, or childcare. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by the Cochrane Collaboration. We performed analyses based on three comparisons: any psychosocial intervention vs. control, contingency management (CM) interventions vs. control, and motivational interviewing based (MIB) interventions vs. MAIN RESULTS: In total, we included 14 studies with 1298 participants: nine studies (704 participants) compared CM vs. control, and five studies (594 participants) compared MIB interventions vs. CONTROL: We did not find any studies that assessed other types of psychosocial interventions. For the most part, it was unclear if included studies adequately controlled for biases within their studies as such information was not often reported. We assessed risk of bias in the included studies relating to participant selection, allocation concealment, personnel and outcome assessor blinding, and attrition.The included trials rarely captured maternal and neonatal outcomes. For studies that did measure such outcomes, no difference was observed in pre-term birth rates (RR 0.71, 95% confidence interval (CI) 0.34 to 1.51; three trials, 264 participants, moderate quality evidence), maternal toxicity at delivery (RR 1.18, 95% CI 0.52 to 2.65; two trials, 217 participants, moderate quality evidence), or low birth weight (RR 0.72, 95% CI 0.36 to 1.43; one trial, 160 participants, moderate quality evidence). However, the results did show that neonates remained in hospital for fewer days after delivery in CM intervention groups (RR -1.27, 95% CI -2.52 to -0.03; two trials, 103 participants, moderate quality evidence). There were no differences observed at the end of studies in retention or abstinence (as assessed by positive drug test at the end of treatment) in any psychosocial intervention group compared to control (Retention: RR 0.99, 95% CI 0.93 to 1.06, nine trials, 743 participants, low quality evidence; and Abstinence: RR 1.14, 95% CI 0.75 to 1.73, three trials, 367 participants, low quality evidence). These results held for both CM and MIB combined. Overall, the quality of the evidence was low to moderate. AUTHORS' CONCLUSIONS: The present evidence suggests that there is no difference in treatment outcomes to address drug use in pregnant women with use of psychosocial interventions, when taken in the presence of other comprehensive care options. However, few studies evaluated obstetrical or neonatal outcomes and rarely did so in a systematic way, making it difficult to assess the effect of psychosocial interventions on these clinically important outcomes. It is important to develop a better evidence base to evaluate psychosocial modalities of treatment in this important population.

Integrating screening, brief intervention and referral to treatment (SBIRT) into an abortion clinic: an exploratory study of acceptability.

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an effective means of identifying problematic substance use. We evaluated the acceptability of SBIRT in an abortion clinic via an anonymous survey of 100 participants. Clients were comfortable being asked about their substance use, receiving counseling, and treatment referral (mean Likert 1.1, 1.5, and 1.6, respectively) and were only minimally embarrassed when asked about substance use (mean Likert 3.6). These findings suggest that integrating SBIRT into an abortion clinic may be feasible. However, future studies are needed to assess the efficacy of abortion clinic SBIRT in reducing risky substance use.

Recent trends in treatment admissions for marijuana use during pregnancy.

OBJECTIVES: The objective of this study was to investigate recent trends in substance abuse treatment admissions for marijuana use during pregnancy in the United States. METHODS: Data were obtained from the Treatment Episodes Data Set from 1992 to 2012 and analyzed for trends over time using χ, Cochran-Armitage, and Moran's I tests. RESULTS: The proportion of treatment admissions for women who were pregnant remained stable at 4%; however, admissions of pregnant women reporting any marijuana use increased substantially from 29% to 43% (P < 0.01). The West North Central census division (20%) experienced the greatest increase followed by the Middle Atlantic (18%) and Pacific (14%) divisions. The demographic characteristics of pregnant marijuana admissions changed over time, with white non-Hispanic women, criminal justice referrals, and those with a psychiatric comorbidity becoming more common whereas polysubstance users decreased (P < 0.01). CONCLUSIONS: Even though more women using marijuana are seeking and receiving substance abuse treatment during pregnancy, targeting certain risk groups while improving screening and treatment referral systems by health care providers, such as prenatal caregivers, should be emphasized.

Heterogeneity in search strategies among Cochrane acupuncture reviews: is there room for improvement?

OBJECTIVE: Given the international focus and rigorous literature searches employed in Cochrane systematic reviews, this study was undertaken to evaluate strategies employed in Cochrane reviews and protocols assessing acupuncture as a primary or secondary intervention. METHODS: The Cochrane Collaboration of systematic reviews was searched in February 2009 for all reviews and protocols including information on acupuncture. Information was abstracted from all retrieved articles on review status, type and number of English and Chinese language databases searched, participation of at least one Chinese speaking author and language restriction. Frequencies were calculated and bivariate analyses were performed stratifying on interventions of interest to assess differences in search strategy techniques, language restrictions and results. RESULTS: The search retrieved 68 titles, including 48 completed reviews, 17 protocols and three previously withdrawn titles. Acupuncture was the primary intervention of interest in 44/65 (67.7%) of the retrieved reviews and protocols. While all articles searched at least one English language database, only 26/65 (40.0%) articles searched Chinese language databases. Significantly more articles where acupuncture was the primary intervention of interest searched Chinese language databases (53% vs 9%, p<0.01). Inconclusive findings as to the effectiveness of acupuncture were found in 28/48 (58.3%) of all completed reviews; this type of finding was more common in reviews which did not search any Chinese language databases. CONCLUSIONS: It is important for reviews assessing the effectiveness of acupuncture to search Chinese language databases. The Cochrane Collaboration should develop specific criteria for Chinese language search strategies to ensure the continued publication of high-quality reviews.

"Compassionate coercion": factors associated with court-mandated drug and alcohol treatment in pregnancy 1994-2005.

OBJECTIVES: : To describe trends in court-mandated treatment in pregnancy. In particular, to determine whether pregnant women who enter treatment via the criminal justice system differ from women who enter voluntarily. METHODS: : Data were obtained from the Treatment Episode Data Set, an administrative data set that captures admissions to federally funded treatment centers in the United States. Demographic and treatment-related measures were examined among pregnant women comparing referral source and stratified by year of admission to assess trends over time. RESULTS: : Throughout the study period, the proportion of pregnant women entering substance abuse treatment via the criminal justice system increased more rapidly than the increase observed among men or nonpregnant women reaching 30.9% by 2005. Compared with voluntary admissions, admissions originating in the criminal justice system were more likely to be white, young, and employed. The primary substances compelling court-mandated treatment for pregnant women were alcohol and cocaine in 1994, and by 2005 it had shifted to amphetamine and marijuana. CONCLUSION: : The increase in criminal justice referrals parallels the growth of drug courts. The demographic characteristics of the pregnant referrals, however, suggest the presence of gaps in both screening and treatment in pregnancy.