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Unmet substance use disorder treatment need among reproductive age women
Drug and Alcohol Dependence xxx (xxxx) xxxx
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Unmet substance use disorder treatment need among reproductive age women Caitlin E. Martina,*, Anna Sciallib, Mishka Terplanb,c a Department of Obstetrics and Gynecology & Institute for Drug and Alcohol Studies, Virginia Commonwealth University School of Medicine, 1250 E. Marshall St, Richmond, VA, 23298, USA b Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, 1250 E. Marshall St, Richmond, VA, 23298, USA c Friends Research Institute, 1040 Park Ave Suite 103, Baltimore, MD, 21202, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Addiction Substance use disorder Women Pregnancy Epidemiology Racial disparities
Background: Substance use disorder (SUD) is a chronic medical condition in need of long-term treatment. The objective of the study is to describe the current unmet SUD treatment need among reproductive age women living in the United States with a focus on pregnancy and parenting status. Methods: Data were drawn from the 2007–2014 National Survey of Drug Use and Health for women 18–44 years old. The primary outcomes were past year SUD treatment need and receipt. Women with a SUD treatment need included those with a SUD and/or expressing a need for SUD treatment. Women were classified as pregnant, parenting (living with their children) or not pregnant nor parenting. Multivariable logistic regression determined if pregnancy/parenting status was associated with treatment need and receipt controlling for demographic factors. Results: Among reproductive age women with a past year SUD treatment need, only 9.3 % (95 % CI 8.4–10.2 %) received treatment. Pregnant and parenting women were not more likely to receive treatment (pregnant AOR 0.9; 95 % CI 0.5–1.8 & parenting AOR 0.7; 95 % CI 0.5-0.9) compared to not pregnant nor parenting women. Black (AOR 0.3; 95 % CI 0.2-0.5) and Hispanic women (AOR 0.6; 95 % CI 0.4-0.9) were less likely to receive treatment. Conclusions: Few reproductive age women who need SUD treatment receive it in the US. Although pregnant women are considered a priority population, they are not receiving priority services. Racial disparities in unmet SUD treatment need exist. Barriers to SUD treatment, such as expanding gender informed services, must be addressed.
1. Introduction The opioid crisis has brought attention to the magnitude of unmet treatment need for individuals with substance use disorder (SUD). Although the annual treatment receipt for conditions such as depression (SAMHSA, 2017), hypertension (CDC, 2013b) and asthma (CDC, 2013a) approaches 70 %, only 11 % of individuals with a SUD report receipt of treatment (SAMHSA, 2017, 2018). Few (about 7 %) in need of SUD treatment receive it in the United States, and this has not improved over time (Creedon and Cook, 2016). Vulnerabilities to addiction differ by gender (McHugh et al., 2018) as do treatment needs (Greenfield et al., 2007). Women with substance use disorders carry a greater burden of medical and social co-morbidities than men including higher prevalences of trauma, co-occurring psychiatric diagnoses, and unemployment (Campbell et al., 2018; ⁎
McHugh et al., 2017). Pregnant women are considered a special population with regards to prioritizing addiction treatment access (ASAM, 2017) although prior data do not support that preferential treatment access occurs during pregnancy. For example, Terplan et al. in 2012 reported that pregnant women were no more likely to receive needed SUD treatment than non-pregnant women in both unadjusted and adjusted analyses (Terplan et al., 2012). Focusing solely on pregnancy is somewhat artificial, as the need for treatment for a chronic condition such as addiction extends beyond the gestational window. Preconception, postpartum and parenting are key parts of the lifecourse for treatment and recovery for many women with SUD (Muhuri and Gfroerer, 2009; Wilder et al., 2015). Therefore, the primary objective of the current study is to describe current substance use disorder treatment need and treatment receipt among reproductive age women living in the United States using the 2007–2014 National
Corresponding author at: 1250 E. Marshall St. Richmond, VA, 23298, Box #980034, USA. E-mail address: [email protected] (C.E. Martin).
https://doi.org/10.1016/j.drugalcdep.2019.107679 Received 23 July 2019; Received in revised form 7 October 2019; Accepted 7 October 2019 0376-8716/ © 2019 Elsevier B.V. All rights reserved.
Please cite this article as: Caitlin E. Martin, Anna Scialli and Mishka Terplan, Drug and Alcohol Dependence, https://doi.org/10.1016/j.drugalcdep.2019.107679
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Fig. 1. Flow diagram of study population. Using population weights provided by the National Survey of Drug use and Health, over 40 million reproductive age women between 2007 and 2014 had a need for substance use disorder treatment, but only 3.7 million (9.3 %) of these women with a need received treatment.
hospitals) are not included. NSDUH uses a stratified multistage area probability sampling technique to capture data representative of the entire US. The target sample size during the study period was 67,500 interviews per year. Surveys are conducted face to face in the respondent’s household using Audio Computer-Assisted Self Interviewing (ACASI) (US-DHHS, 2015). For the current study, we aggregated publicly available data from the National Survey of Drug Use and Health (NSDUH) years 2007–2014. This period was chosen (1) to update the literature from a prior published study that presented unmet treatment needs of pregnant and non-pregnant women which used 2002–2006 NSDUH data (Terplan et al., 2012) and (2) because some NSDUH substance use survey methodology changed in 2015 precluding
Survey of Drug Use and Health. Our secondary objectives were to compare unmet SUD treatment need by pregnant and parenting status as well as describe sociodemographic factors associated with treatment need and receipt among reproductive age women. 2. Materials and methods The National Survey of Drug Use and Health (NSDUH) is an annual survey of the civilian, non-institutionalized population of the United States (US) aged 12 years or older conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA). Homeless, active duty military, and institutional residents (e.g., jails, nursing homes, 2
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Table 1 Weighted prevalence and 95 % CI of demographic factors among reproductive age women with past year substance use disorder treatment need. Demographic characteristics
Totala
Not pregnant nor parenting
Pregnant
Parenting
68.4% (66.9–69.9) 11.4% (13.1–15.3) 14.2% (13.1–15.3) 6.0% (5.3–6.8)
70.0% (68.5–71.5) 10.1% (9.2–11.0) 13.4% (12.2–14.5) 6.5% (5.6–7.5)
63.7% (57.3–70.0) 15.5% (11.1–20.0) 13.7% (9.8–17.5) 7.1% (3.2–11.1)
65.8% (63.0–68.5) 13.5% (11.7–15.3) 15.8% (13.8–17.9) 4.9% (3.6–6.2)
18.3% 29.2% 30.8% 21.7% 86.6% 27.1% 87.7%
(17.3–19.3) (28.2–30.2) (29.4–32.2) (20.6–22.7) (85.7–87.6) (25.8–28.4) (86.7–88.7)
26.1% 35.3% 25.9% 12.7% 89.1% 17.4% 87.9%
18.9% 32.2% 35.8% 13.0% 80.3% 42.8% 84.3%
3.2% (2.7–3.8) 17.1% (15.8–18.4) 39.7% (37.7–41.8) 39.9% (37.8–42.0) 82.6% (80.7–84.5) 44.2% (41.6–46.8) 87.7% (85.7–89.8)
56.5% 21.7% 21.8% 21.1% 35.6%
(55.1–58.0) (20.5–22.8) (20.5–23.1) (19.9–22.2) (33.5–37.8)
61.8% (60.3–63.3) 15.5% (14.3–16.8) 22.7% (21.1–24.3) 9.5% (8.5–10.5) 37.7% (34.7–40.7)
42.4% (35.1–49.8) 49.8% (42.7–56.9) 7.8% (5.3–10.4) 33.5% (27.1–39.9) 33.1% (24.1–42.1)
47.8% 30.7% 21.5% 42.2% 32.9%
20.2% (19.1–21.2) 40.6% (39.2–41.9) 28.6% (27.3–29.9) 9.0% (8.2–9.8) 1.7% (1.3–2.1)
21.6% (20.4–22.8) 41.8% (40.2–43.5) 27.0% (25.6–28.3) 8.1% (7.0–9.1) 1.5% (1.0–2.0)
22.3% (16.4–28.2) 41.0% (34.7–47.3) 27.2% (21.6–32.8) 8.8% (4.7–13.0) 0.7% (0.0–1.5)
17.2% (15.2–19.2) 38.0% (35.3–40.8) 31.8% (29.0–34.7) 10.8% (9.3–12.4) 2.1% (1.5–2.7)
†
Race/Ethnicity White Black Hispanic Other Age† ≤20 21-25 26-34 ≥35 High school diploma or equivalent† Receives government assistance † Employed Insurance status † Private Public None Married † Arrested in past year Health Status † Excellent Very Good Good Fair Poor a †
(24.8–27.4) (34.1–36.6) (24.2–27.6) (11.6–13.8) (88.1–90.1%) (16.4–18.5) (86.8–88.9)
(15.3–22.6) (26.9–37.5) (29.6–42.0) (7.0–19.1) (76.2–84.4) (36.1–49.5) (78.8–89.8)
(45.0–50.7) (28.4–33.0) (19.1–23.8) (39.6–44.7) (28.6–37.2)
Row data indicate column percentages. p < 0.001 between pregnancy/parenting groups.
controlling for sociodemographic factors. Specifically, variables determined a priori based on prior literature and clinical experience were selected to be included in the multivariable models. Analysis was performed in SAS 9.4 (Cary, NC). This study was exempt from IRB approval.
comparisons in subsequent years. Women between the ages of 18 and 44 were included in the study analysis. Women were divided into 3 groups based on their pregnancy or parenting status as this was the main exposure of interest. Pregnant women included those who self-reported a current pregnancy at the time of survey administration. Women reporting having at least one of their children aged less than 18 years living in the household were classified as parenting women. Women who were neither pregnant nor parenting comprised the third group. The primary outcomes assessed included past year treatment need and treatment receipt for substance use disorder. Respondents were classified with treatment need if they either met criteria for a substance use disorder (SUD; based on DSM-IV criteria) or expressed need for treatment. Nicotine addiction was not included. Treatment receipt was captured by self-report but encompassed a broad definition. SUD treatment could have been received at a specialty (i.e., hospital, drug or alcohol rehabilitation facility or mental health center) or any other treatment center (i.e., hospital, rehabilitation facility, mental health center, emergency room, private doctor’s office, prison or jail, self-help group). The proportion of women with a past year SUD treatment need who did not receive SUD treatment comprised the population with unmet addiction treatment need. Population adjusted frequencies and proportions were computed using the population weights assigned to each observation in the NSDUH public use data file to describe the current need for SUD treatment among reproductive age women. Prevalence of past year addiction treatment need among pregnant, parenting and neither pregnant nor parenting women was calculated, and proportions were compared between these 3 groups using chi-squared tests. Among pregnant women, the proportions of those in need of treatment were also compared by trimester (gestational age based on respondents’ selfreport). Similar analysis within and between groups was performed for SUD treatment receipt. Analysis of treatment need and receipt was also performed by substance type (e.g., alcohol, illicit drugs) and year. P values of < 0.05 were used to determine significance. Lastly, multivariable logistic regression was performed to assess if pregnant/parenting status was associated with need or receipt of SUD treatment
3. Results From 2007–2014, a total of 118,587 reproductive age women aged 18–44 years participated in NSDUH equivalent to a population of 429,381,394 women. Among this total population of reproductive age women, 4 % were pregnant at the time of survey administration (4.1 %; 95 % CI 3.9–4.3%). Among those with trimester data (61 missing observations), about a third each were within the first (31.2 %; 95 % CI 29.3–33.1%), second (35.8 %; 95 % CI 33.9–37.6%) and third trimesters (33 %; 95 % CI 31.1–35%). Approximately half of the remaining women were parenting (53.2 %; 95 % CI 52.7–53.8%) or neither pregnant nor parenting (42.7 %; 85 % CI 42.1–43.3%). Almost a tenth (9.4 %; 95 % CI 9.1–9.6%) of reproductive age women had a past year substance use disorder (SUD) treatment need (Fig. 1). Most women across parenting groups with a treatment need met DSM-IV criteria for a SUD (99 %; 95 % CI 98.7–99.3%). A smaller proportion of women (6.1 %; 95 % CI 5.4–6.8%) expressed a need for SUD treatment (data not shown). This did not differ by parenting groups with 5.8 % of both pregnant (95 % CI 2.5–9.1%) and not pregnant nor parenting women (95 % CI 4.9–6.2%) as well as 6.9 % (95 % CI 5.7–8.1%) of parenting women expressing a past year SUD treatment need (data not shown). A few women expressed a past year need for treatment but did not meet use disorder criteria at the time of survey administration (1 %; 95 % CI 0.7–1.3%), and 5 % (5.1 %; 95 % CI 4.4–5.8%) both met SUD criteria and expressed a perceived need for treatment (data not shown). The majority of women with an addiction treatment need were white, young, unmarried, employed, with public or private insurance and at least a high school education. They also rated their current health status as excellent or very good (Table 1). Across parenting groups, more women needed treatment for alcohol use disorder (7.4 %; 95 % CI 6.6–8.3%) than another SUD (Table 2). 3
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Table 2 Past year substance use disorder treatment need among all reproductive age women (ages 18–44). Totala
Substance use disorder diagnosis
Pregnant†
Not pregnant nor parenting
1st trimester Any past year substance use disorder treatment need§ Alcohol use disorder Illicit drug use disorderǁ Opioid use disorder
9.4% (9.1–9.6) 7.4% (7.2–7.7) 3.0% (2.9–3.2)
¶
1.1% (1.0–1.2)
13.9% (13.6–14.3)
7.6% 9.5% 5.5% 7.6% 3.3% 3.7% 1.2% 1.3%
11.3% (11.0–11.6) 4.6% (4.3–4.8) 1.4% (1.2–1.6)
(6.7–8.6) (7.8–11.2) (4.7–6.3) (6.0–9.3) (2.7–3.9) (2.7–4.8) (0.8–1.5) (0.7–1.9)
2nd trimester
3rd trimester
7.7% (6.0–9.4)
5.7% (4.2–7.2)
5.0% (3.7–6.3)
4.0% (2.8–5.2)
3.4% (2.2–4.5)
2.8% (1.9–3.6)
1.2% (0.6–1.8)
1.0% (0.3–1.7)
Parenting
P values‡
5.8% (5.5–6.1)
< 0.001 0.006 < 0.001 0.002 < 0.001 0.396 < 0.001 0.766
4.5% (4.2–4.8) 1.8% (1.6–1.9) 0.8% (0.7–0.9)
a
Row data indicate column percentages. 61 observations are missing trimester data. ‡ Top P values are those comparing groups by pregnancy/parenting status and bottom P values are by trimester. § Data includes those receiving addiction treatment who met criteria for substance use disorder and/or expressed past year need for treatment. ǁ Data include those meeting criteria for use disorder using cannabis, cocaine, hallucinogens, inhalants, methamphetamines, heroin, or prescription psychotherapeutic drugs. ¶ Data include those meeting criteria for use disorder using heroin or pain relievers. †
did not express a treatment need (8.7 %; 95 % CI 7.8–9.6 %; p < 0.0001; data not shown). More women with illicit drug use disorder (17.1 %; 95 % CI 6.6–8.3 %) received treatment than those with an alcohol use disorder (7.4 %; 95 % CI 6.6–8.3 %). Among women with alcohol use disorder, a significantly smaller proportion of neither pregnant nor parenting women received treatment than those for pregnant or parenting women (p = 0.02). A quarter (23.6 %; 95 % CI 18.9–28.2 %) of women with opioid use disorder received treatment with significantly fewer parenting women receiving treatment (p = 0.03). Among pregnant women, treatment receipt did not differ by trimester for any substance (p = 0.2), including illicit drugs (p = 0.2), alcohol (p = 0.5) and opioids (p = 0.2; Table 3). In the multivariable analysis, both pregnant (AOR 0.6; 95 % CI 0.40.9) and parenting (AOR 0.6; 95 % CI 0.5-0.7) women had lower odds of needing SUD treatment than neither pregnant nor parenting women when adjusting for race, age, marital status, health status, and arrest in past year. Similarly, Black women had half the odds of needing treatment (AOR 0.5; 95 % CI 0.4-0.6) compared to White women. Married (AOR 0.6; 95 % CI 0.5-0.8), older (AOR 0.7; 95 % CI 0.5-0.8 for > 35 years) and employed women (AOR 0.8; 95 % CI 0.6–1.0) had lower odds of needing treatment (Table 4).
Three percent (95 % CI 2.9–3.2%) of women were in need of treatment for an illicit drug use disorder, and 1.1 % (95 % CI 1.0–1.2%) were in need of treatment for opioid use disorder. Overall, SUD treatment need differed by parenting status (Fig. 1) with less pregnant and parenting women needing treatment than neither pregnant nor parenting (p < 0.001). Among pregnant women, the proportion needing treatment decreased by gestational trimester (p = 0.006). The direction of these trends persisted regardless of substance (Table 2). Few women with a current past year SUD treatment need received treatment (9.3 %; 95 % CI 8.4–10.2%; Fig. 1). Throughout study years, treatment need among reproductive age women remained stable varying between 8.8 % (in 2007 and 2014) and 9.9 % (in 2008). Treatment receipt did not increase significantly during this timeframe with only 2.8 % more women in need of SUD treatment receiving in 2014 (10.2 %) compared to 2007 (7.5 %; data not shown). Slightly more pregnant (12.8 %; 95 % CI 8.7–16.9 %) than parenting (9.9 %; 95 % CI 8.5–11.4 %) or neither pregnant nor parenting women (8.8 %; 95 % CI 7.7–9.8 %) received treatment (Fig. 1), but this was not statistically significant (p = 0.06; Table 3). A greater proportion of women who expressed a need for SUD treatment received it (18.7 %; 95 % CI 14.6–22.9 %) than women who met SUD criteria but
Table 3 Past year substance use disorder treatment receipt among reproductive age women in need of treatment. Substance use disorder diagnosis
Totala
Any past year substance use disorder treatment need§
9.3% (8.4–10.2)
Alcohol use disorder
7.4% (6.6–8.3)
Illicit drug use disorderǁ
Opioid use disorder¶
17.1% (15.5–18.7)
23.6% (18.9–28.2)
Not pregnant nor parenting
8.8% (7.7–9.8)
6.8% (5.9–7.7)
17.0% (14.8–19.2)
31.1% (27.0–35.1)
Pregnant† 1st trimester
2nd trimester
3rd trimester
12.8% (8.7–16.9) 12.5% (7.3–17.7)
9.4% (4.7–14.0)
18.7% (5.5–32.0)
11.8% (7.2–16.5) 11.7% (5.8–17.6)
9.0% (3.3–14.7)
16.2% (2.6–29.9)
13.2% (5.1–21.3)
29.2% (8.5–49.9)
20.0% (3.5–36.5)
31.1% (0.0–63.7)
21.8% (13.9–29.6) 26.0% (15.1–36.8) 34.7% (20.7–48.7) 54.2% (30.2–78.1)
a
Parenting
P values‡
9.9% (8.5–11.4)
0.063 0.246
8.2% (6.6–9.9)
0.021 0.505
16.5% (13.7–19.3)
0.439 0.187
23.6% (18.9–28.2)
0.033 0.152
Row data indicate column percentages. 61 observations are missing trimester data. ‡ Top P values are those comparing groups by pregnancy/parenting status and bottom P values are by trimester. § Data includes those receiving addiction treatment who met criteria for substance use disorder and/or expressed past year need for treatment. ǁ Data include those meeting criteria for use disorder using cannabis, cocaine, hallucinogens, inhalants, methamphetamines, heroin, or prescription psychotherapeutic drugs. ¶ Data include those meeting criteria for use disorder using heroin or pain relievers. †
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Table 4 Characteristics associated with having past year substance use disorder treatment need among all reproductive age womena – Multivariable analysis. Demographic characteristic Reproductive Status Not pregnant, not parenting Pregnant Parenting Race/Ethnicity White Black Hispanic Other Age ≤20 21-25 26-34 ≥35 High school diploma or equivalent† Government Assistance Employed Insurance† Private Public None Married Arrested in past year† Health Status† Excellent Very Good Good Fair Poor
Crude OR (95% CI)
Adjusted OR (95% CI)
ref 0.5 (0.45–0.58) 0.4 (0.36–0.40)
Ref 0.6 (0.42–0.86) 0.6 (0.49–0.69)
Ref 0.7 (0.63–0.76) 0.6 (0.58–0.71) 0.6 (0.51–0.68)
Ref 0.5 (0.38–0.59) 0.7 (0.61 – 0.91) 0.9 (0.65 – 1.20)
Ref 1.0 (0.91–1.03) 0.5 (0.50–0.59) 0.3 (0.30–0.35) 0.9 (0.93–0.99) 1.2 (1.13–1.28) 0.6 (0.58–0.70)
Ref 1.1 (0.89 0.9 (0.71 0.7 (0.53 1.0 (0.85 0.9 (0.81 0.8 (0.64
Ref 1.3 (1.18–1.35) 1.2 (1.15–1.34) 0.3 (0.27–0.31) 3.3 (2.93–3.74)
————————————————————————————— ————————————————————————————— ————————————————————————————— 0.6 (0.50 – 0.75) —————————————————————————————
Ref 1.4 (1.31- 1.53) 1.6 (1.47–1.73) 1.8 (1.62–2.09) 2.2 (1.73–2.82)
————————————————————————————— ————————————————————————————— ————————————————————————————— ————————————————————————————— —————————————————————————————
– – – – – –
1.25) 1.09) 0.82) 1.18) 1.10) 0.95)
a Data are for women with past year addiction treatment need which included those meeting criteria for substance use disorder and/or expressing need for substance use treatment in past year. † Removed from multivariable logistic regression based on a priori determination of analysis.
Table 5 Characteristics associated with receiving substance use disorder treatment among reproductive age women with past year treatment needa – Multivariable analysis. Demographic characteristic Reproductive Status Not pregnant, not parenting Pregnant Parenting Race/Ethnicity White Black Hispanic Other Age ≤20 21-25 26-34 ≥35 High school diploma or equivalent Government Assistance Employed† Insurance Private Public None Married Arrested in past year Health Status† Excellent Very Good Good Fair Poor
Crude OR (95% CI)
Adjusted OR (95% CI)
ref 1.5 (1.02–2.29) 1.1 (0.95–1.40)
ref 0.9 (0.48 –1.82) 0.7 (0.47 – 0.91)
ref 0.7 (0.51–0.94) 0.7 (0.52–0.95) 0.7 (0.47–0.97)
ref 0.3 (0.23 – 0.49) 0.6 (0.39 – 0.90) 0.7 (0.47 – 1.19)
ref 1.0 1.6 1.7 0.6 2.8 0.4
(0.82–1.21) (1.26–2.02) (1.30–2.31) (0.45–0.68) (2.30–3.44) (0.29–0.52)
ref 1.1 (0.76 – 1.63) 1.9 (1.21 – 3.08) 1.9 (1.16 – 3.21) 1.1 (0.79–1.41) 1.9 (1.36 – 2.62) —————————————————————————————
ref 3.2 1.9 0.8 2.7
(2.6–4.0) (1.54–2.37) (0.63–1.05) (2.12–3.43)
ref 2.1 1.2 0.9 2.8
(1.47 (0.86 (0.60 (2.13
– – – –
2.96) 1.71) 1.30) 3.65)
————————————————————————————— ————————————————————————————— ————————————————————————————— ————————————————————————————— —————————————————————————————
Ref 1.1 (0.76–1.53) 2.4 (1.72–3.41) 3.4 (2.48–4.74) 3.6 (2.0–6.54)
a Data are for women receiving past year addiction treatment among those with treatment need (i.e., meeting criteria for substance use disorder and/or expressing need for substance use treatment in past year). † Removed from multivariable logistic regression based on a priori determination of analysis.
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Care Act (ACA) narrowed gaps in racial disparities in insurance coverage, race continues to influence disparities in addiction care (Hansen et al., 2013; Kaiser, 2019). Our finding of a lower prevalence of SUD among pregnant than nonpregnant women is consistent with prior studies (Muhuri and Gfroerer, 2009; Terplan et al., 2012), as is increasing abstinence rates with greater gestational age (Ebrahim and Gfroerer, 2003; Terplan et al., 2009). These consistent findings highlight the unique opportunity pregnancy brings to many women who use substances with regards to motivation for behavioral change. Women who continue to use substances during pregnancy likely have a use disorder, and therefore linkage with timely treatment is vital (ASAM, 2017). Women’s health providers, including obstetrician-gynecologists, are primed to play a key role in closing this treatment gap through universal, directed screening and referral to treatment as well as integration of SUD treatment into reproductive/sexual health (e.g., X buprenorphine waiver to manage opioid use disorder pharmacotherapy during prenatal care visits). Notably, the burden of alcohol use disorder among US women exceeded that of other SUD, including opioids and other illicit drugs. Historically, alcohol use disorder has been more common among men than women, although this gender gap is shrinking (Erol and Karpyak, 2015). Women experience more alcohol related medical problems such as liver (Becker et al., 1996) and cardiovascular disease (Corrao et al., 2000), and women die at younger ages from these causes than men (Haberman and Natarajan, 1989; Holman et al., 1996). These co-morbidities compound the well-known teratogenic effects of alcohol exposure (Easey et al., 2019). With the attention to the opioid crisis, it is important that efforts targeting other substances, especially alcohol and tobacco, not be compromised as their health effects remain substantial and treatment needs high. NSDUH data does not query postpartum status. We were therefore unable to investigate treatment need and receipt in the year following delivery. Postpartum is a period of increased vulnerabilities for women with SUD (Metz et al., 2016; Smid et al., 2019) especially for disease recurrence (Ebrahim and Gfroerer, 2003). Most notably, overdose has become a significant contributor to maternal deaths in the US, with the majority occurring after delivery (CDC-Foundation, 2018; Schiff et al., 2018; Smid et al., 2019). To better characterize the relationship between SUD and maternal mortality, it would be helpful if national-level data more clearly captured the year following delivery. All people with addiction face barriers to treatment such as workforce shortage, cost of care and discrimination (SAMHSA, 2018). In our study, we found that only 9 % of reproductive age women in need of SUD treatment received it. This is slightly lower than the most recently reported 12 % treatment receipt within the general population (SAMHSA, 2018). This difference may reflect the additional unique barriers women face such as childcare responsibilities and co-morbid mood disorders (Greenfield et al., 2007) as well as the national shortage of women centered services (Terplan et al., 2015). Additionally, for pregnant and parenting women, fear of child protective service reporting and consequence is a barrier to care commonly described by women with addiction (Elms et al., 2018). A better understanding of the role of the child welfare system in SUD treatment seeking, entry and retention is much needed. Lastly, only 5.1 % of women with a SUD treatment need also expressed a past year need for treatment, and this finding did not differ by pregnancy/parenting groups. This low prevalence of perceived treatment need is consistent with prior work using NSDUH data which has identified ‘not being ready to stop using’ as the most common barrier closely followed by financial reasons (Chen et al., 2013). Nonetheless, the absence of comprehensive treatment availability in many parts of the US may influence treatment need disclosure. Further, we know that pregnant people who use drugs and alcohol experience great prejudice and discrimination which may also affect disclosure of need for treatment.
Among women with treatment need, those who were pregnant (AOR 0.9; 95 % CI 0.5–1.8) or parenting (AOR 0.7; 95 % CI 0.5–0.9) had a similar odds of treatment receipt compared to neither pregnant nor parenting women adjusting for race, age, marital status, health status, insurance, government assistance, arrested in past year, and employment. Compared to White women, Black (AOR 0.3; 95 % CI 0.2–0.5) and Hispanic (AOR 0.6; 95 % CI 0.4-0.9) women had much lower odds of receiving addiction treatment. Even though older women had a greater odds of treatment receipt (AOR 1.9; 95 % CI 1.1–3.2 for > 35 years), women with at least a high school education (AOR 1.1; 95 % CI 0.8–1.4) did not. Those receiving government assistance (AOR 1.9; 95 % CI 1.4–2.6) or with public insurance (AOR 2.1; 95 % CI 1.5–3.0) had greater odds of receiving treatment compared to those not receiving such services or with private insurance, respectively. Lastly, women who had been arrested within the year had 3 times the odds of receiving treatment than women who had not been arrested (AOR 2.8; 95 % CI 2.1–3.7; Table 5). 4. Discussion 4.1. Key findings Among reproductive age women in the US with a substance use disorder (SUD) treatment need, only 9.3 % received past year treatment. Although pregnant women are considered a priority population by the Substance Abuse and Mental Health Services Administration (SAMHSA) and should receive preferential access to addiction treatment (ASAM, 2017), our results do not indicate that pregnant women receive priority services. In addition, we identify marked racial disparities in addiction treatment receipt with Black and Hispanic women being especially less likely to receive care. Previous reports have described a large addiction treatment gap in the US (Bernstein et al., 2015; Creedon and Cook, 2016). Still, our finding of the current unmet SUD treatment need among reproductive age women is striking. Less than 1 in 10 women with a need for addiction treatment received it during the study timeframe. Further, as was found from 2002 to 2006 (Terplan et al., 2012), only a minority of pregnant women received any SUD treatment and were not more likely to receive treatment than non-pregnant women. The prevalence of treatment receipt did not increase by trimester, again suggesting that treatment engagement does not increase as pregnancy progresses. With the opioid crisis, we have subjectively witnessed an increased attention to substance use in pregnancy (Haight et al., 2018), but our data are consistent with other sources that this increased attention has not translated into improved treatment utilization (Short et al., 2018). In the multivariable analysis, socioeconomic status factors were associated with treatment receipt rather than pregnancy/parenting status. Women who had been arrested in the past year had 3 times the odds of receiving treatment. Addiction treatment received through the criminal justice system is commonly mandatory. Patients with this lack of autonomy commonly do not feel like these treatment avenues meet their needs (Rosenberg et al., 2018). Overall treatment outcomes appear to be as good as those receiving non-mandated treatment but vary by setting (Longinaker and Terplan, 2014). This issue is especially pertinent given the continued criminalization of pregnant women who use drugs (AI, 2017), a stark contrast to the call for provision of compassionate, person centered addiction care (Martin et al., 2018). Next, women with public insurance were more likely than women with private insurance to receive treatment. This finding highlights two important points. First, addressing the structural barriers to accessing SUD treatment across socioeconomic groups through Medicaid expansion, for example, is an important step to increase service utilization. Second, some barriers to addiction treatment utilization, such as stigma, do cross traditional socio-economic boundaries and should also be addressed. Lastly, we found a higher unmet addiction treatment need among Black and Hispanic than white women. Although the Affordable 6
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4.2. Strengths and weaknesses
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5. Conclusions Addiction, like other chronic conditions, merits early and long-term treatment to reduce adverse consequences. Nationally, few women in need of substance use disorder treatment are receiving it. This high unmet treatment need highlights the role of behavioral health in both observed decreases in life expectancy (Evans et al., 2015) and increases in maternal deaths (Gemmill et al., 2019; Metz et al., 2016; Schiff et al., 2018; Smid et al., 2019). Untreated addiction has lasting impacts on families that go beyond the risk of its neonatal effects (Klaman et al., 2017) to include others such as those associated with postpartum depression (Chapman and Wu, 2013), violence (Koch and Geller, 2017) and children entering foster care (Simkiss et al., 2013). Assessment for substance use must be integrated into all domains of women’s health (ACOG, 2017), treatment capacity expanded (Clemans-Cope et al., 2019) and gender focused substance use research prioritized (Meyer et al., 2019). Contributors MT conceived the study. CEM and MT participated in study design. AS designed and performed the statistical analysis. All authors participated in manuscript drafting. All authors read and approved the final manuscript. Role of funding source This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of Competing Interest The authors report no conflict of interest. Acknowledgements None. 7
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Full length article
Unmet substance use disorder treatment need among reproductive age women Caitlin E. Martina,*, Anna Sciallib, Mishka Terplanb,c a Department of Obstetrics and Gynecology & Institute for Drug and Alcohol Studies, Virginia Commonwealth University School of Medicine, 1250 E. Marshall St, Richmond, VA, 23298, USA b Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, 1250 E. Marshall St, Richmond, VA, 23298, USA c Friends Research Institute, 1040 Park Ave Suite 103, Baltimore, MD, 21202, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Addiction Substance use disorder Women Pregnancy Epidemiology Racial disparities
Background: Substance use disorder (SUD) is a chronic medical condition in need of long-term treatment. The objective of the study is to describe the current unmet SUD treatment need among reproductive age women living in the United States with a focus on pregnancy and parenting status. Methods: Data were drawn from the 2007–2014 National Survey of Drug Use and Health for women 18–44 years old. The primary outcomes were past year SUD treatment need and receipt. Women with a SUD treatment need included those with a SUD and/or expressing a need for SUD treatment. Women were classified as pregnant, parenting (living with their children) or not pregnant nor parenting. Multivariable logistic regression determined if pregnancy/parenting status was associated with treatment need and receipt controlling for demographic factors. Results: Among reproductive age women with a past year SUD treatment need, only 9.3 % (95 % CI 8.4–10.2 %) received treatment. Pregnant and parenting women were not more likely to receive treatment (pregnant AOR 0.9; 95 % CI 0.5–1.8 & parenting AOR 0.7; 95 % CI 0.5-0.9) compared to not pregnant nor parenting women. Black (AOR 0.3; 95 % CI 0.2-0.5) and Hispanic women (AOR 0.6; 95 % CI 0.4-0.9) were less likely to receive treatment. Conclusions: Few reproductive age women who need SUD treatment receive it in the US. Although pregnant women are considered a priority population, they are not receiving priority services. Racial disparities in unmet SUD treatment need exist. Barriers to SUD treatment, such as expanding gender informed services, must be addressed.
1. Introduction The opioid crisis has brought attention to the magnitude of unmet treatment need for individuals with substance use disorder (SUD). Although the annual treatment receipt for conditions such as depression (SAMHSA, 2017), hypertension (CDC, 2013b) and asthma (CDC, 2013a) approaches 70 %, only 11 % of individuals with a SUD report receipt of treatment (SAMHSA, 2017, 2018). Few (about 7 %) in need of SUD treatment receive it in the United States, and this has not improved over time (Creedon and Cook, 2016). Vulnerabilities to addiction differ by gender (McHugh et al., 2018) as do treatment needs (Greenfield et al., 2007). Women with substance use disorders carry a greater burden of medical and social co-morbidities than men including higher prevalences of trauma, co-occurring psychiatric diagnoses, and unemployment (Campbell et al., 2018; ⁎
McHugh et al., 2017). Pregnant women are considered a special population with regards to prioritizing addiction treatment access (ASAM, 2017) although prior data do not support that preferential treatment access occurs during pregnancy. For example, Terplan et al. in 2012 reported that pregnant women were no more likely to receive needed SUD treatment than non-pregnant women in both unadjusted and adjusted analyses (Terplan et al., 2012). Focusing solely on pregnancy is somewhat artificial, as the need for treatment for a chronic condition such as addiction extends beyond the gestational window. Preconception, postpartum and parenting are key parts of the lifecourse for treatment and recovery for many women with SUD (Muhuri and Gfroerer, 2009; Wilder et al., 2015). Therefore, the primary objective of the current study is to describe current substance use disorder treatment need and treatment receipt among reproductive age women living in the United States using the 2007–2014 National
Corresponding author at: 1250 E. Marshall St. Richmond, VA, 23298, Box #980034, USA. E-mail address: [email protected] (C.E. Martin).
https://doi.org/10.1016/j.drugalcdep.2019.107679 Received 23 July 2019; Received in revised form 7 October 2019; Accepted 7 October 2019 0376-8716/ © 2019 Elsevier B.V. All rights reserved.
Please cite this article as: Caitlin E. Martin, Anna Scialli and Mishka Terplan, Drug and Alcohol Dependence, https://doi.org/10.1016/j.drugalcdep.2019.107679
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Fig. 1. Flow diagram of study population. Using population weights provided by the National Survey of Drug use and Health, over 40 million reproductive age women between 2007 and 2014 had a need for substance use disorder treatment, but only 3.7 million (9.3 %) of these women with a need received treatment.
hospitals) are not included. NSDUH uses a stratified multistage area probability sampling technique to capture data representative of the entire US. The target sample size during the study period was 67,500 interviews per year. Surveys are conducted face to face in the respondent’s household using Audio Computer-Assisted Self Interviewing (ACASI) (US-DHHS, 2015). For the current study, we aggregated publicly available data from the National Survey of Drug Use and Health (NSDUH) years 2007–2014. This period was chosen (1) to update the literature from a prior published study that presented unmet treatment needs of pregnant and non-pregnant women which used 2002–2006 NSDUH data (Terplan et al., 2012) and (2) because some NSDUH substance use survey methodology changed in 2015 precluding
Survey of Drug Use and Health. Our secondary objectives were to compare unmet SUD treatment need by pregnant and parenting status as well as describe sociodemographic factors associated with treatment need and receipt among reproductive age women. 2. Materials and methods The National Survey of Drug Use and Health (NSDUH) is an annual survey of the civilian, non-institutionalized population of the United States (US) aged 12 years or older conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA). Homeless, active duty military, and institutional residents (e.g., jails, nursing homes, 2
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Table 1 Weighted prevalence and 95 % CI of demographic factors among reproductive age women with past year substance use disorder treatment need. Demographic characteristics
Totala
Not pregnant nor parenting
Pregnant
Parenting
68.4% (66.9–69.9) 11.4% (13.1–15.3) 14.2% (13.1–15.3) 6.0% (5.3–6.8)
70.0% (68.5–71.5) 10.1% (9.2–11.0) 13.4% (12.2–14.5) 6.5% (5.6–7.5)
63.7% (57.3–70.0) 15.5% (11.1–20.0) 13.7% (9.8–17.5) 7.1% (3.2–11.1)
65.8% (63.0–68.5) 13.5% (11.7–15.3) 15.8% (13.8–17.9) 4.9% (3.6–6.2)
18.3% 29.2% 30.8% 21.7% 86.6% 27.1% 87.7%
(17.3–19.3) (28.2–30.2) (29.4–32.2) (20.6–22.7) (85.7–87.6) (25.8–28.4) (86.7–88.7)
26.1% 35.3% 25.9% 12.7% 89.1% 17.4% 87.9%
18.9% 32.2% 35.8% 13.0% 80.3% 42.8% 84.3%
3.2% (2.7–3.8) 17.1% (15.8–18.4) 39.7% (37.7–41.8) 39.9% (37.8–42.0) 82.6% (80.7–84.5) 44.2% (41.6–46.8) 87.7% (85.7–89.8)
56.5% 21.7% 21.8% 21.1% 35.6%
(55.1–58.0) (20.5–22.8) (20.5–23.1) (19.9–22.2) (33.5–37.8)
61.8% (60.3–63.3) 15.5% (14.3–16.8) 22.7% (21.1–24.3) 9.5% (8.5–10.5) 37.7% (34.7–40.7)
42.4% (35.1–49.8) 49.8% (42.7–56.9) 7.8% (5.3–10.4) 33.5% (27.1–39.9) 33.1% (24.1–42.1)
47.8% 30.7% 21.5% 42.2% 32.9%
20.2% (19.1–21.2) 40.6% (39.2–41.9) 28.6% (27.3–29.9) 9.0% (8.2–9.8) 1.7% (1.3–2.1)
21.6% (20.4–22.8) 41.8% (40.2–43.5) 27.0% (25.6–28.3) 8.1% (7.0–9.1) 1.5% (1.0–2.0)
22.3% (16.4–28.2) 41.0% (34.7–47.3) 27.2% (21.6–32.8) 8.8% (4.7–13.0) 0.7% (0.0–1.5)
17.2% (15.2–19.2) 38.0% (35.3–40.8) 31.8% (29.0–34.7) 10.8% (9.3–12.4) 2.1% (1.5–2.7)
†
Race/Ethnicity White Black Hispanic Other Age† ≤20 21-25 26-34 ≥35 High school diploma or equivalent† Receives government assistance † Employed Insurance status † Private Public None Married † Arrested in past year Health Status † Excellent Very Good Good Fair Poor a †
(24.8–27.4) (34.1–36.6) (24.2–27.6) (11.6–13.8) (88.1–90.1%) (16.4–18.5) (86.8–88.9)
(15.3–22.6) (26.9–37.5) (29.6–42.0) (7.0–19.1) (76.2–84.4) (36.1–49.5) (78.8–89.8)
(45.0–50.7) (28.4–33.0) (19.1–23.8) (39.6–44.7) (28.6–37.2)
Row data indicate column percentages. p < 0.001 between pregnancy/parenting groups.
controlling for sociodemographic factors. Specifically, variables determined a priori based on prior literature and clinical experience were selected to be included in the multivariable models. Analysis was performed in SAS 9.4 (Cary, NC). This study was exempt from IRB approval.
comparisons in subsequent years. Women between the ages of 18 and 44 were included in the study analysis. Women were divided into 3 groups based on their pregnancy or parenting status as this was the main exposure of interest. Pregnant women included those who self-reported a current pregnancy at the time of survey administration. Women reporting having at least one of their children aged less than 18 years living in the household were classified as parenting women. Women who were neither pregnant nor parenting comprised the third group. The primary outcomes assessed included past year treatment need and treatment receipt for substance use disorder. Respondents were classified with treatment need if they either met criteria for a substance use disorder (SUD; based on DSM-IV criteria) or expressed need for treatment. Nicotine addiction was not included. Treatment receipt was captured by self-report but encompassed a broad definition. SUD treatment could have been received at a specialty (i.e., hospital, drug or alcohol rehabilitation facility or mental health center) or any other treatment center (i.e., hospital, rehabilitation facility, mental health center, emergency room, private doctor’s office, prison or jail, self-help group). The proportion of women with a past year SUD treatment need who did not receive SUD treatment comprised the population with unmet addiction treatment need. Population adjusted frequencies and proportions were computed using the population weights assigned to each observation in the NSDUH public use data file to describe the current need for SUD treatment among reproductive age women. Prevalence of past year addiction treatment need among pregnant, parenting and neither pregnant nor parenting women was calculated, and proportions were compared between these 3 groups using chi-squared tests. Among pregnant women, the proportions of those in need of treatment were also compared by trimester (gestational age based on respondents’ selfreport). Similar analysis within and between groups was performed for SUD treatment receipt. Analysis of treatment need and receipt was also performed by substance type (e.g., alcohol, illicit drugs) and year. P values of < 0.05 were used to determine significance. Lastly, multivariable logistic regression was performed to assess if pregnant/parenting status was associated with need or receipt of SUD treatment
3. Results From 2007–2014, a total of 118,587 reproductive age women aged 18–44 years participated in NSDUH equivalent to a population of 429,381,394 women. Among this total population of reproductive age women, 4 % were pregnant at the time of survey administration (4.1 %; 95 % CI 3.9–4.3%). Among those with trimester data (61 missing observations), about a third each were within the first (31.2 %; 95 % CI 29.3–33.1%), second (35.8 %; 95 % CI 33.9–37.6%) and third trimesters (33 %; 95 % CI 31.1–35%). Approximately half of the remaining women were parenting (53.2 %; 95 % CI 52.7–53.8%) or neither pregnant nor parenting (42.7 %; 85 % CI 42.1–43.3%). Almost a tenth (9.4 %; 95 % CI 9.1–9.6%) of reproductive age women had a past year substance use disorder (SUD) treatment need (Fig. 1). Most women across parenting groups with a treatment need met DSM-IV criteria for a SUD (99 %; 95 % CI 98.7–99.3%). A smaller proportion of women (6.1 %; 95 % CI 5.4–6.8%) expressed a need for SUD treatment (data not shown). This did not differ by parenting groups with 5.8 % of both pregnant (95 % CI 2.5–9.1%) and not pregnant nor parenting women (95 % CI 4.9–6.2%) as well as 6.9 % (95 % CI 5.7–8.1%) of parenting women expressing a past year SUD treatment need (data not shown). A few women expressed a past year need for treatment but did not meet use disorder criteria at the time of survey administration (1 %; 95 % CI 0.7–1.3%), and 5 % (5.1 %; 95 % CI 4.4–5.8%) both met SUD criteria and expressed a perceived need for treatment (data not shown). The majority of women with an addiction treatment need were white, young, unmarried, employed, with public or private insurance and at least a high school education. They also rated their current health status as excellent or very good (Table 1). Across parenting groups, more women needed treatment for alcohol use disorder (7.4 %; 95 % CI 6.6–8.3%) than another SUD (Table 2). 3
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Table 2 Past year substance use disorder treatment need among all reproductive age women (ages 18–44). Totala
Substance use disorder diagnosis
Pregnant†
Not pregnant nor parenting
1st trimester Any past year substance use disorder treatment need§ Alcohol use disorder Illicit drug use disorderǁ Opioid use disorder
9.4% (9.1–9.6) 7.4% (7.2–7.7) 3.0% (2.9–3.2)
¶
1.1% (1.0–1.2)
13.9% (13.6–14.3)
7.6% 9.5% 5.5% 7.6% 3.3% 3.7% 1.2% 1.3%
11.3% (11.0–11.6) 4.6% (4.3–4.8) 1.4% (1.2–1.6)
(6.7–8.6) (7.8–11.2) (4.7–6.3) (6.0–9.3) (2.7–3.9) (2.7–4.8) (0.8–1.5) (0.7–1.9)
2nd trimester
3rd trimester
7.7% (6.0–9.4)
5.7% (4.2–7.2)
5.0% (3.7–6.3)
4.0% (2.8–5.2)
3.4% (2.2–4.5)
2.8% (1.9–3.6)
1.2% (0.6–1.8)
1.0% (0.3–1.7)
Parenting
P values‡
5.8% (5.5–6.1)
< 0.001 0.006 < 0.001 0.002 < 0.001 0.396 < 0.001 0.766
4.5% (4.2–4.8) 1.8% (1.6–1.9) 0.8% (0.7–0.9)
a
Row data indicate column percentages. 61 observations are missing trimester data. ‡ Top P values are those comparing groups by pregnancy/parenting status and bottom P values are by trimester. § Data includes those receiving addiction treatment who met criteria for substance use disorder and/or expressed past year need for treatment. ǁ Data include those meeting criteria for use disorder using cannabis, cocaine, hallucinogens, inhalants, methamphetamines, heroin, or prescription psychotherapeutic drugs. ¶ Data include those meeting criteria for use disorder using heroin or pain relievers. †
did not express a treatment need (8.7 %; 95 % CI 7.8–9.6 %; p < 0.0001; data not shown). More women with illicit drug use disorder (17.1 %; 95 % CI 6.6–8.3 %) received treatment than those with an alcohol use disorder (7.4 %; 95 % CI 6.6–8.3 %). Among women with alcohol use disorder, a significantly smaller proportion of neither pregnant nor parenting women received treatment than those for pregnant or parenting women (p = 0.02). A quarter (23.6 %; 95 % CI 18.9–28.2 %) of women with opioid use disorder received treatment with significantly fewer parenting women receiving treatment (p = 0.03). Among pregnant women, treatment receipt did not differ by trimester for any substance (p = 0.2), including illicit drugs (p = 0.2), alcohol (p = 0.5) and opioids (p = 0.2; Table 3). In the multivariable analysis, both pregnant (AOR 0.6; 95 % CI 0.40.9) and parenting (AOR 0.6; 95 % CI 0.5-0.7) women had lower odds of needing SUD treatment than neither pregnant nor parenting women when adjusting for race, age, marital status, health status, and arrest in past year. Similarly, Black women had half the odds of needing treatment (AOR 0.5; 95 % CI 0.4-0.6) compared to White women. Married (AOR 0.6; 95 % CI 0.5-0.8), older (AOR 0.7; 95 % CI 0.5-0.8 for > 35 years) and employed women (AOR 0.8; 95 % CI 0.6–1.0) had lower odds of needing treatment (Table 4).
Three percent (95 % CI 2.9–3.2%) of women were in need of treatment for an illicit drug use disorder, and 1.1 % (95 % CI 1.0–1.2%) were in need of treatment for opioid use disorder. Overall, SUD treatment need differed by parenting status (Fig. 1) with less pregnant and parenting women needing treatment than neither pregnant nor parenting (p < 0.001). Among pregnant women, the proportion needing treatment decreased by gestational trimester (p = 0.006). The direction of these trends persisted regardless of substance (Table 2). Few women with a current past year SUD treatment need received treatment (9.3 %; 95 % CI 8.4–10.2%; Fig. 1). Throughout study years, treatment need among reproductive age women remained stable varying between 8.8 % (in 2007 and 2014) and 9.9 % (in 2008). Treatment receipt did not increase significantly during this timeframe with only 2.8 % more women in need of SUD treatment receiving in 2014 (10.2 %) compared to 2007 (7.5 %; data not shown). Slightly more pregnant (12.8 %; 95 % CI 8.7–16.9 %) than parenting (9.9 %; 95 % CI 8.5–11.4 %) or neither pregnant nor parenting women (8.8 %; 95 % CI 7.7–9.8 %) received treatment (Fig. 1), but this was not statistically significant (p = 0.06; Table 3). A greater proportion of women who expressed a need for SUD treatment received it (18.7 %; 95 % CI 14.6–22.9 %) than women who met SUD criteria but
Table 3 Past year substance use disorder treatment receipt among reproductive age women in need of treatment. Substance use disorder diagnosis
Totala
Any past year substance use disorder treatment need§
9.3% (8.4–10.2)
Alcohol use disorder
7.4% (6.6–8.3)
Illicit drug use disorderǁ
Opioid use disorder¶
17.1% (15.5–18.7)
23.6% (18.9–28.2)
Not pregnant nor parenting
8.8% (7.7–9.8)
6.8% (5.9–7.7)
17.0% (14.8–19.2)
31.1% (27.0–35.1)
Pregnant† 1st trimester
2nd trimester
3rd trimester
12.8% (8.7–16.9) 12.5% (7.3–17.7)
9.4% (4.7–14.0)
18.7% (5.5–32.0)
11.8% (7.2–16.5) 11.7% (5.8–17.6)
9.0% (3.3–14.7)
16.2% (2.6–29.9)
13.2% (5.1–21.3)
29.2% (8.5–49.9)
20.0% (3.5–36.5)
31.1% (0.0–63.7)
21.8% (13.9–29.6) 26.0% (15.1–36.8) 34.7% (20.7–48.7) 54.2% (30.2–78.1)
a
Parenting
P values‡
9.9% (8.5–11.4)
0.063 0.246
8.2% (6.6–9.9)
0.021 0.505
16.5% (13.7–19.3)
0.439 0.187
23.6% (18.9–28.2)
0.033 0.152
Row data indicate column percentages. 61 observations are missing trimester data. ‡ Top P values are those comparing groups by pregnancy/parenting status and bottom P values are by trimester. § Data includes those receiving addiction treatment who met criteria for substance use disorder and/or expressed past year need for treatment. ǁ Data include those meeting criteria for use disorder using cannabis, cocaine, hallucinogens, inhalants, methamphetamines, heroin, or prescription psychotherapeutic drugs. ¶ Data include those meeting criteria for use disorder using heroin or pain relievers. †
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Table 4 Characteristics associated with having past year substance use disorder treatment need among all reproductive age womena – Multivariable analysis. Demographic characteristic Reproductive Status Not pregnant, not parenting Pregnant Parenting Race/Ethnicity White Black Hispanic Other Age ≤20 21-25 26-34 ≥35 High school diploma or equivalent† Government Assistance Employed Insurance† Private Public None Married Arrested in past year† Health Status† Excellent Very Good Good Fair Poor
Crude OR (95% CI)
Adjusted OR (95% CI)
ref 0.5 (0.45–0.58) 0.4 (0.36–0.40)
Ref 0.6 (0.42–0.86) 0.6 (0.49–0.69)
Ref 0.7 (0.63–0.76) 0.6 (0.58–0.71) 0.6 (0.51–0.68)
Ref 0.5 (0.38–0.59) 0.7 (0.61 – 0.91) 0.9 (0.65 – 1.20)
Ref 1.0 (0.91–1.03) 0.5 (0.50–0.59) 0.3 (0.30–0.35) 0.9 (0.93–0.99) 1.2 (1.13–1.28) 0.6 (0.58–0.70)
Ref 1.1 (0.89 0.9 (0.71 0.7 (0.53 1.0 (0.85 0.9 (0.81 0.8 (0.64
Ref 1.3 (1.18–1.35) 1.2 (1.15–1.34) 0.3 (0.27–0.31) 3.3 (2.93–3.74)
————————————————————————————— ————————————————————————————— ————————————————————————————— 0.6 (0.50 – 0.75) —————————————————————————————
Ref 1.4 (1.31- 1.53) 1.6 (1.47–1.73) 1.8 (1.62–2.09) 2.2 (1.73–2.82)
————————————————————————————— ————————————————————————————— ————————————————————————————— ————————————————————————————— —————————————————————————————
– – – – – –
1.25) 1.09) 0.82) 1.18) 1.10) 0.95)
a Data are for women with past year addiction treatment need which included those meeting criteria for substance use disorder and/or expressing need for substance use treatment in past year. † Removed from multivariable logistic regression based on a priori determination of analysis.
Table 5 Characteristics associated with receiving substance use disorder treatment among reproductive age women with past year treatment needa – Multivariable analysis. Demographic characteristic Reproductive Status Not pregnant, not parenting Pregnant Parenting Race/Ethnicity White Black Hispanic Other Age ≤20 21-25 26-34 ≥35 High school diploma or equivalent Government Assistance Employed† Insurance Private Public None Married Arrested in past year Health Status† Excellent Very Good Good Fair Poor
Crude OR (95% CI)
Adjusted OR (95% CI)
ref 1.5 (1.02–2.29) 1.1 (0.95–1.40)
ref 0.9 (0.48 –1.82) 0.7 (0.47 – 0.91)
ref 0.7 (0.51–0.94) 0.7 (0.52–0.95) 0.7 (0.47–0.97)
ref 0.3 (0.23 – 0.49) 0.6 (0.39 – 0.90) 0.7 (0.47 – 1.19)
ref 1.0 1.6 1.7 0.6 2.8 0.4
(0.82–1.21) (1.26–2.02) (1.30–2.31) (0.45–0.68) (2.30–3.44) (0.29–0.52)
ref 1.1 (0.76 – 1.63) 1.9 (1.21 – 3.08) 1.9 (1.16 – 3.21) 1.1 (0.79–1.41) 1.9 (1.36 – 2.62) —————————————————————————————
ref 3.2 1.9 0.8 2.7
(2.6–4.0) (1.54–2.37) (0.63–1.05) (2.12–3.43)
ref 2.1 1.2 0.9 2.8
(1.47 (0.86 (0.60 (2.13
– – – –
2.96) 1.71) 1.30) 3.65)
————————————————————————————— ————————————————————————————— ————————————————————————————— ————————————————————————————— —————————————————————————————
Ref 1.1 (0.76–1.53) 2.4 (1.72–3.41) 3.4 (2.48–4.74) 3.6 (2.0–6.54)
a Data are for women receiving past year addiction treatment among those with treatment need (i.e., meeting criteria for substance use disorder and/or expressing need for substance use treatment in past year). † Removed from multivariable logistic regression based on a priori determination of analysis.
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Care Act (ACA) narrowed gaps in racial disparities in insurance coverage, race continues to influence disparities in addiction care (Hansen et al., 2013; Kaiser, 2019). Our finding of a lower prevalence of SUD among pregnant than nonpregnant women is consistent with prior studies (Muhuri and Gfroerer, 2009; Terplan et al., 2012), as is increasing abstinence rates with greater gestational age (Ebrahim and Gfroerer, 2003; Terplan et al., 2009). These consistent findings highlight the unique opportunity pregnancy brings to many women who use substances with regards to motivation for behavioral change. Women who continue to use substances during pregnancy likely have a use disorder, and therefore linkage with timely treatment is vital (ASAM, 2017). Women’s health providers, including obstetrician-gynecologists, are primed to play a key role in closing this treatment gap through universal, directed screening and referral to treatment as well as integration of SUD treatment into reproductive/sexual health (e.g., X buprenorphine waiver to manage opioid use disorder pharmacotherapy during prenatal care visits). Notably, the burden of alcohol use disorder among US women exceeded that of other SUD, including opioids and other illicit drugs. Historically, alcohol use disorder has been more common among men than women, although this gender gap is shrinking (Erol and Karpyak, 2015). Women experience more alcohol related medical problems such as liver (Becker et al., 1996) and cardiovascular disease (Corrao et al., 2000), and women die at younger ages from these causes than men (Haberman and Natarajan, 1989; Holman et al., 1996). These co-morbidities compound the well-known teratogenic effects of alcohol exposure (Easey et al., 2019). With the attention to the opioid crisis, it is important that efforts targeting other substances, especially alcohol and tobacco, not be compromised as their health effects remain substantial and treatment needs high. NSDUH data does not query postpartum status. We were therefore unable to investigate treatment need and receipt in the year following delivery. Postpartum is a period of increased vulnerabilities for women with SUD (Metz et al., 2016; Smid et al., 2019) especially for disease recurrence (Ebrahim and Gfroerer, 2003). Most notably, overdose has become a significant contributor to maternal deaths in the US, with the majority occurring after delivery (CDC-Foundation, 2018; Schiff et al., 2018; Smid et al., 2019). To better characterize the relationship between SUD and maternal mortality, it would be helpful if national-level data more clearly captured the year following delivery. All people with addiction face barriers to treatment such as workforce shortage, cost of care and discrimination (SAMHSA, 2018). In our study, we found that only 9 % of reproductive age women in need of SUD treatment received it. This is slightly lower than the most recently reported 12 % treatment receipt within the general population (SAMHSA, 2018). This difference may reflect the additional unique barriers women face such as childcare responsibilities and co-morbid mood disorders (Greenfield et al., 2007) as well as the national shortage of women centered services (Terplan et al., 2015). Additionally, for pregnant and parenting women, fear of child protective service reporting and consequence is a barrier to care commonly described by women with addiction (Elms et al., 2018). A better understanding of the role of the child welfare system in SUD treatment seeking, entry and retention is much needed. Lastly, only 5.1 % of women with a SUD treatment need also expressed a past year need for treatment, and this finding did not differ by pregnancy/parenting groups. This low prevalence of perceived treatment need is consistent with prior work using NSDUH data which has identified ‘not being ready to stop using’ as the most common barrier closely followed by financial reasons (Chen et al., 2013). Nonetheless, the absence of comprehensive treatment availability in many parts of the US may influence treatment need disclosure. Further, we know that pregnant people who use drugs and alcohol experience great prejudice and discrimination which may also affect disclosure of need for treatment.
Among women with treatment need, those who were pregnant (AOR 0.9; 95 % CI 0.5–1.8) or parenting (AOR 0.7; 95 % CI 0.5–0.9) had a similar odds of treatment receipt compared to neither pregnant nor parenting women adjusting for race, age, marital status, health status, insurance, government assistance, arrested in past year, and employment. Compared to White women, Black (AOR 0.3; 95 % CI 0.2–0.5) and Hispanic (AOR 0.6; 95 % CI 0.4-0.9) women had much lower odds of receiving addiction treatment. Even though older women had a greater odds of treatment receipt (AOR 1.9; 95 % CI 1.1–3.2 for > 35 years), women with at least a high school education (AOR 1.1; 95 % CI 0.8–1.4) did not. Those receiving government assistance (AOR 1.9; 95 % CI 1.4–2.6) or with public insurance (AOR 2.1; 95 % CI 1.5–3.0) had greater odds of receiving treatment compared to those not receiving such services or with private insurance, respectively. Lastly, women who had been arrested within the year had 3 times the odds of receiving treatment than women who had not been arrested (AOR 2.8; 95 % CI 2.1–3.7; Table 5). 4. Discussion 4.1. Key findings Among reproductive age women in the US with a substance use disorder (SUD) treatment need, only 9.3 % received past year treatment. Although pregnant women are considered a priority population by the Substance Abuse and Mental Health Services Administration (SAMHSA) and should receive preferential access to addiction treatment (ASAM, 2017), our results do not indicate that pregnant women receive priority services. In addition, we identify marked racial disparities in addiction treatment receipt with Black and Hispanic women being especially less likely to receive care. Previous reports have described a large addiction treatment gap in the US (Bernstein et al., 2015; Creedon and Cook, 2016). Still, our finding of the current unmet SUD treatment need among reproductive age women is striking. Less than 1 in 10 women with a need for addiction treatment received it during the study timeframe. Further, as was found from 2002 to 2006 (Terplan et al., 2012), only a minority of pregnant women received any SUD treatment and were not more likely to receive treatment than non-pregnant women. The prevalence of treatment receipt did not increase by trimester, again suggesting that treatment engagement does not increase as pregnancy progresses. With the opioid crisis, we have subjectively witnessed an increased attention to substance use in pregnancy (Haight et al., 2018), but our data are consistent with other sources that this increased attention has not translated into improved treatment utilization (Short et al., 2018). In the multivariable analysis, socioeconomic status factors were associated with treatment receipt rather than pregnancy/parenting status. Women who had been arrested in the past year had 3 times the odds of receiving treatment. Addiction treatment received through the criminal justice system is commonly mandatory. Patients with this lack of autonomy commonly do not feel like these treatment avenues meet their needs (Rosenberg et al., 2018). Overall treatment outcomes appear to be as good as those receiving non-mandated treatment but vary by setting (Longinaker and Terplan, 2014). This issue is especially pertinent given the continued criminalization of pregnant women who use drugs (AI, 2017), a stark contrast to the call for provision of compassionate, person centered addiction care (Martin et al., 2018). Next, women with public insurance were more likely than women with private insurance to receive treatment. This finding highlights two important points. First, addressing the structural barriers to accessing SUD treatment across socioeconomic groups through Medicaid expansion, for example, is an important step to increase service utilization. Second, some barriers to addiction treatment utilization, such as stigma, do cross traditional socio-economic boundaries and should also be addressed. Lastly, we found a higher unmet addiction treatment need among Black and Hispanic than white women. Although the Affordable 6
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4.2. Strengths and weaknesses
References
The main strength and weakness of the study are the data. NSDUH is considered the gold standard for reporting substance use and SUD treatment nationally for the US. However, NSDUH is not completely comprehensive as it excludes certain relevant populations such as incarcerated and homeless peoples. We also did not include women less than 18 years old in our analysis, a highly vulnerable population when considering the burden of SUD across the lifecourse. Despite the large sample size, our current study only evaluated treatment need and receipt of a specific age group of women with further analysis across pregnancy/parenting status with smaller sample sizes which could have limited our power to detect true associations. In addition, NSDUH data is completely from self-report, including pregnancy, demographics, and substance use. This could have led to misclassification bias. For example, this could have resulted in under-reporting of SUD treatment need and receipt with SUD treatment need likely more affected than treatment receipt. Such a differential misclassification could have led our results to indicate a smaller SUD treatment gap than what truly exists. Also, we may have misclassified some parenting women as not parenting as women with children < 18 years old may not have had their children currently living with them at the time of the survey administration (e.g., without current custody). Lastly, another limitation to our study is the lack of prospective data to describe changes in SUD and treatment utilization across reproductive life stages such as the preconception and postpartum periods as well as pregnancy gestational age.
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5. Conclusions Addiction, like other chronic conditions, merits early and long-term treatment to reduce adverse consequences. Nationally, few women in need of substance use disorder treatment are receiving it. This high unmet treatment need highlights the role of behavioral health in both observed decreases in life expectancy (Evans et al., 2015) and increases in maternal deaths (Gemmill et al., 2019; Metz et al., 2016; Schiff et al., 2018; Smid et al., 2019). Untreated addiction has lasting impacts on families that go beyond the risk of its neonatal effects (Klaman et al., 2017) to include others such as those associated with postpartum depression (Chapman and Wu, 2013), violence (Koch and Geller, 2017) and children entering foster care (Simkiss et al., 2013). Assessment for substance use must be integrated into all domains of women’s health (ACOG, 2017), treatment capacity expanded (Clemans-Cope et al., 2019) and gender focused substance use research prioritized (Meyer et al., 2019). Contributors MT conceived the study. CEM and MT participated in study design. AS designed and performed the statistical analysis. All authors participated in manuscript drafting. All authors read and approved the final manuscript. Role of funding source This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of Competing Interest The authors report no conflict of interest. Acknowledgements None. 7
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