Using a “secret shopper” design, Patrick et al1 investigated the association that pregnancy and insurance status had with a woman’s ability to obtain an appointment for medication-based treatment for opioid use disorder (OUD). The study found that pregnant women were less likely than nonpregnant women to receive an appointment when seeking one from buprenorphine-waivered prescribers but not from opioid treatment programs (OTPs). In addition, many clinicians did not accept insurance and accepted appointments only when patients agreed to pay cash.
Access to evidence-based treatment for OUD during pregnancy is a public health priority. The prevalence of OUD among pregnant women increased more than 4-fold from 1999 to 2014.2 Opioid use disorder during pregnancy is associated with considerable morbidity and mortality, including maternal death during hospitalization, cardiac arrest, placental abruption, neonatal abstinence syndrome, and intrauterine growth restriction, among others.3 However, while pregnant women receiving medication treatment for OUD have better maternal and infant health outcomes than those who are not receiving treatment4 or those who go through opioid withdrawal, the study by Patrick et al1 highlights that significant barriers exist for pregnant women to access appropriate OUD care.
The study by Patrick et al1 makes 3 critical contributions to our understanding of access to OUD treatment during pregnancy. First, the secret shopper design offers important methodological innovations that deepen our understanding of access to treatment for pregnant women. Prior studies used administrative data to document the limited availability of specialized OUD treatment services for pregnant women in the United States.5,6 However, to our knowledge, the study by Patrick et al1 is one of the first, through the use of a study design that randomized study participants into different pregnancy and insurance conditions, to identify the association that pregnancy status itself has with treatment access. The design also emulated the real-world scenarios faced by geographically, economically, and racially/ethnically diverse women seeking services and thus offered a view of the barriers encountered by women in the process of seeking care in a way that would not have been possible with administrative data. This design also exposed significant limitations in the reliability of public data sources, given the substantial proportion of listed clinicians who were either not in service or did not actively serve patients with OUD.
Second, the study included 10 states selected to represent a broad range of opioid-related complications and state policies. By choosing such a design, the study was able to document substantial disparities across states in access to treatment among pregnant and nonpregnant women. This finding raises important questions about the roles that state policies mandating priority access to substance use disorder treatment for pregnant women, state policies on Medicaid coverage for OUD treatment, and state and local investment in treatment facilities that provide specialized services for pregnant women play in shaping access to care for this vulnerable group. One way to pursue this research might be to investigate what relevant policies differ between the states where no disparity by pregnancy status was found among buprenorphine prescribers (eg, Virginia and Washington) and the states where such disparities existed (eg, Kentucky, Florida, and Massachusetts), as well as how such policies are associated with the types of payment accepted.
Third, the differences in access for pregnant women when seeking care from buprenorphine prescribers vs OTPs is particularly noteworthy. The study found no difference in access by pregnancy status among OTPs but did find a difference among buprenorphine prescribers. This finding highlights a clear need to invest in training and empowerment of general practitioners to treat pregnant women with OUD with buprenorphine. Existing buprenorphine prescribers may not think that they have the expertise to treat this population and to address the specific dosing needs and risks that arise during pregnancy. At the same time, women’s health physicians rarely prescribe buprenorphine7 and must therefore be trained and encouraged to offer treatment of OUD for pregnant patients. The lack of disparity in treatment access among OTPs could indicate that such facilities may be more experienced in treating pregnant women and could potentially serve as resources to expand the training and support of independent buprenorphine prescribers.
Although the design of this study1 offers clear advantages, there are also some unavoidable limitations that arise with this design. To increase internal validity, all secret shoppers had to meet the same profile. In this case, that constrained the study to represent healthy women who did not inject opioids, mostly used oxycodone hydrochloride, had no mental health issues, and were married. Concerns about overall access to treatment (regardless of pregnancy status) might be even more severe for women who, for example, have a history of injection drug use and mental illness. Future research should investigate how the intersection of pregnancy status with comorbidities such as mental illness is associated with access to treatment for OUD. Furthermore, the study1 characterized limited access to medication treatments for OUD among treatment-seeking women. Many obstacles, including stigma and criminalization, continue to deter many pregnant women from seeking OUD care in the first place. Thus, more work is needed to identify and address barriers to ongoing life-saving treatment among this important population.
The results of this study1 highlight the importance of policies that require payers, including Medicaid, to cover medications for OUD for all patients and particularly for vulnerable groups such as pregnant women. Policies can also be implemented to require and/or incentivize medical professionals to accept insurance as payment for OUD treatment among this population to ensure affordable access for women in need. Finally, medical societies and licensing institutions should require that medical education and residency training in women’s health include training in the provision of buprenorphine as a treatment for OUD. Such measures will expand the reach of physicians able and willing to treat this population.
Published: August 14, 2020. doi:10.1001/jamanetworkopen.2020.13899
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Cerdá M et al. JAMA Network Open.
Corresponding Author: Magdalena Cerdá, DrPH, MPH, Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, 180 Madison Ave, 4-16, New York, NY 10016 (email@example.com).
Conflict of Interest Disclosures: None reported.
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