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Comment & Response
July 2017

Treatment of Opioid Use Disorder During Pregnancy May Increase Cases of Neonatal Abstinence Syndrome—Reply

Author Affiliations
  • 1Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville
  • 2Institute for Pharmaceutical Outcomes and Policy, University of Kentucky College of Pharmacy, Lexington
JAMA Pediatr. 2017;171(7):707-708. doi:10.1001/jamapediatrics.2017.0863

In Reply Schiff and Patrick bring up 3 related points regarding our prior work in neonatal abstinence syndrome (NAS) rates nationally and in Kentucky.1 The first is a limitation of the study, which was omitted owing to space limitations but acknowledged through reference to a study by Patrick et al.2 In using administrative data with International Classification of Diseases, Ninth Revision codes to identify NAS cases, the possibility of misclassifying licit or illicit maternal opioid use will always exist.2 This limitation can be overcome by using more detailed clinical data or by combining data sources to include measures of maternal medication use that were not available for our or similar studies. Second, the authors point out that if medication-assisted treatment (MAT) of substance abuse disorders has increased over time, ie, using buprenorphine or methadone, then NAS rates may correlate with this “licit” use of opioids. While true, this viewpoint ignores the fact there is an already established maternal addiction, which is likely to have developed into NAS regardless of whether MAT was used. Lastly, we hope to distinguish public policies that focus on supply and demand of opioids and how these 2 facets have contributed to the substance abuse epidemic. Contemporary supply-focused policies include those seeking to limit the amounts of opioids dispensed and diverted through prescription drug monitoring programs, abuse-deterrent formulations of opioids, “pill mill” regulations, and the rescheduling of hydrocodone.3 Analysis of these supply policies shows a slowing effect in opioid use that was correlated with a similar fall in deaths3 but no decrease in NAS during the same time.1 Those are the policies that we refer to that occur within the study period, which would not have an effect on licit use of opioids as Schiff and Patrick suggest. Demand-side policies would be those policies that seek to treat the underlying substance use disorder and include increasing access to MAT and other treatment. Provisions in the Affordable Care Act implemented payment systems for substance abuse disorders in 2012. In Kentucky, these federal provisions along with state grants providing direct funding to substance use treatment centers, including funding for pregnancy-specific residential centers, likely have increased the use of MAT in pregnant women. However, this would not increase the NAS cases because these substance use disorders must precede use of MAT. Further, for Kentucky in particular, MAT did not see a large uptake until approximately 2014 and has increased greatly since.4 Newer policies, specifically federal legislation, including the Protecting Our Infants Act of 2015 and the 21st Century Cures Act of 2016, should be championed for providing specific funding to combat the demand aspect of the substance abuse epidemic, whereas older policies have focused on the supply aspect and seem to have not affected NAS rates.5,6 We agree with Schiff and Patrick that future research should seek to understand the role of maternal treatment on the severity of NAS and suggest more work to evaluate these new policies and their effects.

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