key: cord-0727344-vxzp5ciz
authors: Lensch, Ashley C.; Hairston, Essence; Carter, Ginny; Jones, Hendrée E.
title: Pregnant Patients Using Opioids: Treatment Access Barriers in the Age of COVID-19
date: 2021-02-17
journal: J Addict Med
DOI: 10.1097/adm.0000000000000826
sha: 807954ed3527ef0c3c876481dc846b7f194462a7
doc_id: 727344
cord_uid: vxzp5ciz

Before the COVID-19 pandemic, many pregnant patients experienced barriers in accessing opioid use disorder (OUD) medication. This project surveyed buprenorphine treatment clinics to determine how many accepted pregnant women before and then during the pandemic. Of those clinics accepting pregnant patients during the pandemic, respondents were asked what services were provided and what forms of payment they accepted. METHODS: Between July and September 2020, phone contact was made with every sixth unduplicated clinic in North Carolina listed in the Substance Abuse and Mental Health Administration treatment locator (N = 490 clinics). The response rate was 53%. RESULTS: Of the 128 clinics responding, 62 clinics (48%) failed to treat pregnant patients both before and during the pandemic, whereas 66 clinics (52%) accepted pregnant patients before the COVID-19 pandemic, with only 44 (66%) of these clinics accepting pregnant patients during the pandemic. Thus, 33% fewer clinics accepted pregnant women for OUD treatment. Of these 44 clinics, 52% provided same-day intake, 45% prescribed naltrexone, and 57% offered detoxification with opioid agonists. Self-pay (95%), private insurance (77%), and Medicaid (55%) were accepted as payment. Clinics commonly reported providing individual counseling (86%). No clinics provided childcare or transportation. CONCLUSIONS: Almost half of the buprenorphine clinics in North Carolina turned away pregnant patients before the pandemic. During the pandemic, only 34% accepted pregnant patients, with 33% clinics that had provided medication treatment before the pandemic declining to treat pregnant patients for OUD. Thus, it is critical that policymakers ensure OUD treatment clinics accept pregnant patients.

P regnant women with an opioid use disorder (OUD) often face barriers in accessing treatment: locating a provider, insurance coverage, and transportation to and from the facility. Effective treatment improves the outcomes for both mothers and their infants. 1 Therefore, it is important to understand how the COVID-19 pandemic has affected access to care. On March 11, 2020, the World Health Organization declared coronavirus disease 2019 (COVID-19) a pandemic. 2 To control its human-to-human spread healthcare, including OUD treatment, shifted to reduce patient volumes and/or to a virtual format including medication induction/management. 3 Abrupt care treatment transitions may exacerbate the significant existing care barriers for pregnant patients seeking treatment for OUD. 4 However, data to support such speculation are not yet available. Prepandemic reports showed that clinics providing medication for OUD were less likely to treat pregnant than non-pregnant patients (75% vs 91%; P < 0.01). 5 Moreover, buprenorphine clinics often accepted cash (89%) from pregnant women whereas Medicaid and private insurance were accepted at lower rates (55% and 60%, respectively). 5 Given that clinics providing OUD medication often did not accept pregnant patients nor their insurance even before the pandemic, this project aimed to examine the percentage of buprenorphine treatment clinics accepting pregnant patients during the pandemic compared to prepandemic conditions. Among those buprenorphine treatment clinics accepting pregnant patients, data regarding the wait times, types of services provided, types of medications to treat OUD, and the types of payments accepted were collected.

This study was deemed Non-Human Subject Research by the University of North Carolina at Chapel Hill Institutional Review Board. 5 times in a 3-month period to allow each clinic the same opportunity to respond.

Phone-surveys were conducted July to September, 2020 using a standard script that asked the clinic responder 19 trinary questions (yesjnojdo not know) in 4 main categories regarding services provided to pregnant patients receiving OUD medication. About 128/240 provided data (53% response rate). Nonresponding clinics (n ¼ 112) never answered the phone or returned voice mail messages after each of the 5 attempts.

Respondents were asked the questions in the same order, including if the clinic was accepting pregnant patients for OUD medication treatment during the pandemic, if they were accepting pregnant patients before the pandemic, and if and how long were wait times for treatment intake during the pandemic. If the clinic did not accept pregnant patients, did they refer pregnant patients anywhere and if so, where. For clinics accepting pregnant patients during the pandemic, respondents were queried about resources provided to pregnant patients with OUD during the pandemic, the types of opioid medication offered to pregnant patients, and types of payment accepted.

Responding clinics and nonresponding clinics did not significantly differ by county, zip code, office-based opioid treatment, opioid treatment program, academic setting, or obstetrical provider status. Of the 128 responding clinics, 48% were office-based opioid treatment providers, 20% were opioid treatment programs, 23% were academic settings, and/ or 14% were obstetrical providers (categories were not mutually exclusive). Of 128 responding clinics, 66 (52%) reported accepting pregnant patients before the pandemic, whereas 44 (34%) reported accepting pregnant patients during the pandemic. Thus, 22/66 (33%) clinics ceased accepting pregnant patients for OUD medication treatment (Fig. 1) .

Of the 84 clinics not accepting pregnant patients during the pandemic, only 17 (20%) reported specific places where they referred pregnant patients for treatment (eg, health department, women-only treatment programs).

Of the 44 clinics accepting pregnant patients, 52% reported accepting patients for intake on the same day they called for treatment, whereas 14 clinics reported delayed intakes with a mean delay of 4.5 days (SD ¼ 3.8, range ¼ 2-14 days, inclusive) and 7 clinics did not know their wait times. Of these 44 clinics, Figure 2A shows that the most common resource provided was individual counseling (86%), followed by mental health screening, treatment or referrals (61%). Only 43% and 39%, respectively, of the clinics reported providing interpersonal violence screening/treatment/referrals or case management on-site/referrals. Employment assistance or women-only group services were rarely provided and no clinic reported providing childcare or transportation during the COVID-19 pandemic.

Regarding OUD medication treatment for pregnant women, almost all respondents provided buprenorphine (95%; 2 responders did not know). Of note, 45% reported providing naltrexone (it is unknown if it was oral and/or injectable) to pregnant women and 57% provided detoxification. Figure 2B shows that 95% of clinics took self-pay, 77% private insurance, 55% Medicaid, and 32% Tri-care (insurance for military service members and/or their dependents). A total of 33% of respondents took all forms of payment, and only 10% took only self-pay. Ã Assuming a baseline 5% reduction in clinics providing services to pregnant patients following onset of the pandemic due to either transient (eg, need to change clinic site) or enduring (eg, staffing, cost) factors, a binominal single-sample test of proportions indicates that this 33% reduction exceeds chance expectations (P < 0.001).

Pregnant patients with OUD have struggled historically to find medication providers to treat their OUD. 5 Roughly half the clinics surveyed were willing to provide OUD medication to treat pregnant patients before the pandemic. During the pandemic, the percentage of clinics willing to provide OUD medication treatment to pregnant patients dropped by one third. This is a concerning low rate of buprenorphine clinics accepting pregnant patients during the pandemic compared to prepandemic conditions. Such a response may reflect increased pressures on treatment (eg, staff shortages due to personal or family illness, social distancing reducing patient treatment capacity).

Although 95% of clinics reported provided buprenorphine, 45% of clinics also reported offering naltrexone. Such results suggests that providers are reassured by research documenting the relative safety and efficacy of both buprenorphine and naltrexone during pregnancy. 6 Many clinics (57%) offered detoxification to pregnant patients which lacks supportive evidence 7 and is not a recommended treatment intervention. 8 However, amongst the clinics that reported accepting pregnant patients only 55% and 77%, respectively, report taking Medicaid or private insurance. This finding in North Carolina mirrors prepandemic conditions, with 55% Medicaid and 60% private insurance. 5 The implication of these 2 findings is that pregnant patients must sign up for such insurance coverage, if they qualify, or pay out-ofpocket for care. Such care includes an intake cost of $20 to $175 and buprenorphine costs of $35 to $245 per week. 5 A possibly even greater cost hardship during the COVID-19 pandemic.

Among clinics accepting pregnant patients, wait time was, on average, 4 1/2 days, similar to a wait time reported during pre-pandemic times (3.5 days). 5 This study extends the previous study by summarizing the types of services provided to pregnant patients.

Even when pregnant patients with OUD have been able to access and begin treatment, ongoing obstacles interfere with treatment attendance. 1 Given that treatment attendance and retention are the best predictors of successful treatment 9 and the adverse effects of untreated opioid use in pregnancy are known, 8 it is imperative that all such barriers facing pregnant patients are minimized or eliminated to support both initiation and continuance of treatment.

This study has several limitations. First, the sample was drawn from one state, so generalizability of findings is unknown. However, this study allows comparison with published data. Second, the sample comprises clinics listed on the Substance Abuse and Mental Health Administration buprenorphine treatment locator. Thus, the extent to which similar outcomes would be found with methadone treatment clinics and/or buprenorphine clinics not agreeing to be publicly listed is unknown. Third, the effect of asking retrospective questions about prepandemic clinic practices may limit results, yet the recent timeframe for recall tempers this concern. Fourth, the survey response rate was less than 100% yielding possible bias between responding and nonresponding clinics on unmeasured characteristics; however, a 53% response rate for a survey with no compensation is noteworthy and similar 

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We thank Dr Kevin E. O'Grady for statistical support and editorial review of the manuscript. We also thank the clinics for their participation in sharing their time and information with us. We thank NIDA for support of R01-047867.