Women with substance use disorders (SUDs) released from incarceration face a markedly elevated risk of fatal overdose during the first 2 weeks post-release compared with women with SUDs in the community. Prior research estimates that individuals leaving incarceration may be more than 100 times more likely to die from overdose during this period than the general population. This article describes a gender-responsive behavioral health reentry model, Engaging and Motivating to Prevent Overdose among Women via Effective Reentry (EMPOWER), implemented statewide in North Carolina. Among 359 self-referred women with SUDs, the program reported zero fatal overdoses during the 2-week post-release period. EMPOWER builds upon Jenna's Project: Preventing Overdose and Improving Recovery Outcomes for Women Leaving Incarcerated Settings During Pregnancy and Postpartum Periods, which served 132 perinatal women and reported zero fatal opioid overdoses at 6 months post-release. EMPOWER expanded the population to include women aged 18-44 years with a history of illicit substance use across three state prisons, regardless of pregnancy status. These findings suggest that evidence-based behavioral health interventions delivered during early reentry may reduce fatal overdose risk and demonstrate preliminary acceptability and feasibility. To our knowledge, this is among the first manuscripts to examine overdose outcomes during the critical 2-week post-release period among justice-involved women in North Carolina.

The Maternal Opioid Treatment: Human Experimental Research (MOTHER) study was a rigorous randomized controlled trial that compared methadone and buprenorphine for the treatment of pregnant women with opioid use disorder. Since the primary outcomes were published in 2010, this study has served as a cornerstone of the evidence base guiding both clinical practice and national and international health policy. This commentary examines MOTHER's contributions to the global policy landscape and also traces the scholarly advances it catalyzed, including advances in neonatal abstinence syndrome research, landmark pharmacoepidemiological studies, and innovations in medication delivery, among others. As such, MOTHER is among the most influential clinical trials in addiction medicine and perinatal research and an excellent example of the contributions of behavioral pharmacology, the field concerned with the physiological and behavioral mechanisms by which drugs operate, encompassing not only the effects of drugs on behavior but also how behavioral factors contribute to the actions of drugs and the ways in which they are used, to advancing addiction science.

OBJECTIVES:Although a dyadic approach to clinical care is recommended for opioid-exposed mothers and their infants, there is a lack of practice-based guidance on clinical implementation. To address this knowledge gap, a comparative evaluation of outpatient dyadic care practice models in the US was conducted. METHODS:This 2-phase qualitative study was designed to identify essential commonalities and distinctions in dyadic practice across 3 domains: clinical, administrative, and service wraparound. Five programs serving urban and rural communities participated from private, academic, and federally qualified health centers (FQHC) with business models spanning grant-funded, fee-for-service, and FQHC. Data were analyzed by applying descriptive statistics. RESULTS:Across programs (1 rural, 4 urban), dyadic care was consistently defined but variably operationalized across clinical, administrative, and service wraparound domains. Clinically, all programs treated the mother-infant dyad as a single unit, yet care delivery was typically fragmented across time and setting due to resource constraints. Administratively, billing practices were heterogeneous, with reliance on existing obstetric, pediatric, maternal mental health, and family therapy codes; no program used dyad-specific billing mechanisms. All programs incorporated wraparound services, including food, housing, transportation, lactation support, infant supplies, and parenting education, though the extent and integration of these services varied. CONCLUSIONS:Despite challenges, including funding, space, and coordination across clinicians/departments associated with providing dyadic care, key practice-based elements were identified that can facilitate the implementation of dyadic care across clinical, administrative, and service wraparound domains. Consideration should be given to address common resource limitations to significantly improve mother-infant dyad care across these domains.

Despite well-documented harms of prenatal alcohol exposure, evidence-based treatment guidelines for alcohol use disorder (AUD) during pregnancy remain limited. We systematically reviewed international clinical practice guidelines to examine how they address the full cascade of AUD care during pregnancy, including diagnosis, engagement, treatment initiation, and retention. We searched over 40 clinical practice guideline databases (including PubMed and Guidelines International Network) and gray literature sources globally, identifying 1045 records. Using the Population, Interventions, Comparators, Attributes, Recommendation Characteristics (PICAR) framework, we evaluated guidelines from medical organizations in English-speaking nations addressing alcohol use and AUD management in pregnancy. Our final analysis included 18 guidelines from the United States, Canada, the United Kingdom, Australia/New Zealand, and the World Health Organization published from 2014 to the present. Two reviewers independently assessed each guideline using the Appraisal of Guidelines Research and Evaluation-Recommendations Excellence (AGREE-REX) framework to evaluate quality and risk of bias. We used narrative synthesis to summarize findings across key concepts and care cascade stages. Nearly all guidelines (94%) described risks of alcohol exposure and recommended counseling on cessation (89%), yet few extended beyond these early cascade stages. Only 44% mentioned medications for AUD (MAUD), and merely 17% discussed specific psychosocial treatments. Among guidelines addressing MAUD, only one cautiously supported use, while three explicitly recommended against it. Most guidelines (61%) ended treatment recommendations at referral to specialty care, with half limiting guidance to acute alcohol withdrawal management. Taken together, our findings reveal a stark misalignment between screening emphasis and treatment guidance. While guidelines consistently recommend universal screening and brief intervention, they provide minimal actionable frameworks for managing AUD throughout pregnancy. This gap leaves clinicians without evidence-based pathways for comprehensive AUD treatment during the prenatal period, highlighting an urgent need to strengthen both the evidence base and clinical guidance for AUD management in pregnancy.

Objective To compare the incidence of neurodevelopmental disorders among children with prenatal exposure to buprenorphine versus methadone. Design Population based cohort study. Setting US nationwide Medicaid data on >2.5 million live births from 2000 to 2018. Participants 18 612 pregnancies exposed to buprenorphine or methadone, of which 587 were excluded from the analysis owing to exposure to the comparator drug. Main outcome measures The primary outcome was a composite of neurodevelopmental disorders (autism spectrum disorder, attention deficit/hyperactivity disorder, developmental speech or language disorder, developmental coordination disorder, behavioural disorder, learning difficulty, or intellectual disability). Individual neurodevelopmental disorders were considered secondary outcomes. Cumulative incidences were obtained using Kaplan-Meier analyses, and hazard ratios using Cox proportional hazards regression. Propensity score overlap weighting was applied to adjust for confounding, including personal characteristics, maternal medical and mental health comorbidities, exposure to medications and other substances, proxies for severity of opioid use disorder, healthcare utilisation, and adequacy of prenatal care utilisation. Results 12 635 children were exposed to buprenorphine and 5390 to methadone prenatally. The crude cumulative incidence of any neurodevelopmental disorder at age 8 years among those exposed to buprenorphine was 34% (95% confidence interval (CI) 30% to 38%) and among those exposed to methadone was 33% (29% to 37%). Adjusted analyses suggested slightly lower hazards of any neurodevelopmental disorder associated with exposure to buprenorphine versus methadone (adjusted hazard ratio 0.81, 95% CI 0.70 to 0.94). Similar results were obtained for the individual neurodevelopmental disorders such as attention deficit/hyperactivity disorder (0.89, 0.65 to 1.21) and autism spectrum disorder (0.74, 0.46 to 1.21). With prevalent use, prenatal exposure to buprenorphine was associated with lower hazards of any neurodevelopmental disorder compared with prenatal exposure to methadone (adjusted hazard ratio 0.62, 0.51 to 0.76). This association was not observed with treatment initiation during pregnancy (adjusted hazard ratio 1.13, 0.90 to 1.42). Further sensitivity analyses indicated results consistent with no increased risk of neurodevelopmental disorders among pregnancies exposed to buprenorphine versus methadone. Conclusions The findings of this study suggest no increased risk of long term adverse neurodevelopmental outcomes among children with prenatal exposure to buprenorphine versus methadone, further supporting buprenorphine as a safe treatment option for opioid use disorder during pregnancy.

Housing insecurity is a critical social driver of health, strongly associated with increased risk of substance use, adverse medical and psychiatric outcomes, and legal and employment instability. These risks are particularly acute during pregnancy and parenting times of life, where housing instability exacerbates maternal stress and adversely affects infant and early childhood health. Patients who have completed residential substance use disorder treatment often have limited options regarding housing as they are often reintroduced to low-income environments and experience discrimination associated with their substance use problems. This pilot project evaluated the impact of a structured housing voucher intervention on housing stability and substance use–related outcomes among perinatal patients and mothers following discharge from residential substance use disorder treatment. Participants (n = 12) were enrolled in a voucher-based housing payment program for up to 12 months that provided rental assistance alongside integrated medical, psychiatric, substance use disorder treatment, and case management services. Monthly assessments were conducted to evaluate housing status, mental and physical health, legal and employment outcomes, and substance use outcomes. Our results indicated that participants showed reductions in housing insecurity and little substance use over the course of their participation in the study. Improvements were also observed in legal and employment domains, as well as in self-reported mental health indicators. These findings underscore the critical role of housing interventions in promoting sustained recovery and maternal–child well-being. Further investigation in larger, randomized samples is warranted to establish generalizability and inform policy implementation.

There is a growing and urgent worldwide need to reduce the number of children under 12 years of age using drugs. The Child Intervention for Living Drug-Free (CHILD) curriculum has been developed and implemented around the world to help clinicians treat children between the ages of 4-12 for drug use problems. The aim of the present study is to determine the barriers and benefits of the Child Intervention for Living Drug-Free for children enrolled in residential treatment for drug problems, for their parents/caregivers, and for the staff providing care to the children. Within two treatment programs operated by the Society for the Promotion of Youth and Masses (SPYM) in New Delhi, India, six focus groups were conducted. Focus group 1 had n=15 children, focus group 2 had n=8 children, focus group 3 had n=12 parents/caregivers, focus group 4 had n=6 parents/caregivers, focus group 5 had n= 7 parents/caregivers and focus group 8 had n=8 staff. Findings revealed that children valued interactive, expressive activities that promoted personal growth and emotional well-being. Caregivers reported improvements in their child’s behavior but voiced concerns about their child’s possible future return to substance use, the impact of stigma on their families, and the lack of educational and vocational support in their communities. Staff praised the Child Intervention for Living Drug-Free curriculum’s engagement strategies but suggested simplifying content and increasing the use of visual and activity-based tools. Common themes across groups emphasized the importance of emotional resilience, decision-making skills, family support, and life skills linked to future employment. This qualitative evaluation underscores the importance of developmentally appropriate, family-centered, and community-supported approaches to child substance use treatment. While these findings are rooted in the Indian context, the challenges and solutions resonate globally. Given similar risk factors in the U.S., including lack of community support and peer pressure, the Child Intervention for Living Drug-Free curriculum offers a promising, adaptable model for early intervention especially for illicit drugs like fentanyl. Broader implementation and further research are recommended to support its effectiveness across diverse cultural settings.

Introduction: The rise in fentanyl use during pregnancy has created new challenges in caring for women with opioid use disorders (OUD) and their infants with neonatal abstinence syndrome or neonatal opioid withdrawal syndrome (NAS/NOWS). Despite complexities in treating opioid-affected dyads, little research exists on healthcare workers' perspectives regarding fentanyl's impact on perinatal and neonatal care. Objectives: Explore dynamic challenges fentanyl has brought to the care of perinatal women with OUD and their infants experiencing NAS/NOWS from healthcare providers' perspectives. Methods: Fifteen healthcare providers (neonatologists, OBGYNs, nurse practitioners, registered nurses, and pediatricians) from the Pacific Northwest completed an online qualitative survey with a mixture of Likert-type and open-ended questions. Reflexive thematic analysis was used to analyze open-ended responses. Results: Three themes emerged from provider data that reflect systemic failures in addressing the complex needs of perinatal women and their families and highlight challenges in implementation of evidence-based care: 1) Systemic Barriers to Perinatal and Infant Care, 2) Impact of Increasing Polysubstance Use on Neonates and Mothers, and 3) Stigma and Judgment from Healthcare Providers toward Perinatal Women with Substance Use Disorders. Conclusions: Themes reflected how broad and interconnected systemic issues contribute to inadequate care and support for mothers and newborns in the context of rising fentanyl and polysubstance use. Themes echoed the root of the problems lies in systemic failures-issues within the healthcare system, societal attitudes, and policy frameworks that collectively fail to meet the complex and evolving needs of families affected by the everchanging landscape of substance use.

Objectives: Naltrexone may be utilized for the treatment of opioid and/or alcohol use disorder during pregnancy. However, limited information is available on the pharmacokinetics of naltrexone during pregnancy and lactation. The objective of this study was to evaluate maternal and infant concentrations of naltrexone and its major metabolite 6β-naltrexol in relevant matrices across pregnancy and the immediate postpartum period. Methods: Pregnant individuals receiving naltrexone were enrolled in this prospective cohort study. Maternal plasma and urine samples were collected serially during pregnancy at up to 6 time points. At delivery, cord blood, maternal plasma, infant plasma, and infant urine were collected. Four weeks after delivery, breastmilk, maternal plasma, and infant plasma samples were collected. All samples were analyzed for naltrexone and 6β-naltrexol using a validated liquid chromatography tandem mass spectrometry assay. Results: A total of 7 pregnant individuals were enrolled: 4 receiving extended-release and 3 receiving oral naltrexone. Concentrations of naltrexone in maternal plasma in pregnancy remained detectable across the dosing interval for both formulations. The ratio of median cord blood to maternal plasma concentration was 1.11 in the extended-release and 0.74 in the oral group. Of the 7 infants, 1 remained breastfed at 4 weeks. The relative infant naltrexone dose via breastmilk at 31 days after delivery from the 1 infant was 0.83%. Conclusions: While limited due to sample size, these data provide valuable information about the pharmacokinetics of prenatal use of naltrexone and perinatal transfer, guiding counseling and clinical management of the parent-infant dyad.

Objectives: National and international guidance recommends verbal screening to identify perinatal patients with substance use problems. However, perinatal patients report negative medical experiences and a rational fear of disclosing substance use due to negative consequences for disclosure. To improve screening experiences and accuracy, this study focused on the input of patients and staff with substance use disorders. Methods: Participants were perinatal patients with substance use histories in a gender-specific treatment program (n=6) or staff (peer support specialists, paraprofessionals, or Qualified Providers) working with perinatal patients (n=14) in a gender-specific substance use disorder treatment program. Qualitative information was gathered in three ways: 1) focus groups with perinatal patients, 2) focus groups with paraprofessionals and QPs, and 3) three individual interviews were conducted. A descriptive phenomenological approach was used for analysis. Results: The three themes that emerged from the perinatal patients with substance use histories group were provider fear of Child Protective Services (CPS), provider competency, and provider compassion. Three themes also emerged from the staff: methods to improve the assessment, concerns related to CPS, and challenges when working with healthcare professionals. Both groups recommended that (1) the screener’s introduction needs to provide information about CPS reporting, (2) patients receive a list of treatment resources, and (3) healthcare providers are trained in compassionate screening. Discussion: Participants recommended that pregnant patients with substance use histories are more likely to share their substance use history if there is a sense of safety through compassionate care. Before screening, healthcare providers should be committed to seeking training to treat perinatal substance use, adopt stigma-free language, support autonomy to disclose substance use history due to previous encounters, and be transparent about the use of the information and outcome, and have treatment resources readily available to reduce the harms of mandatory reporting to CPS.

BACKGROUND:The degree of alcohol use disorder (AUD) treatment utilization during the perinatal period is unknown. We report the prevalence of preconception receipt of medications for AUD (MAUD) and psychosocial interventions (PSY), discontinuation during pregnancy, and postpartum resumption in a multi-state sample, comparing pregnant and nonpregnant people with AUD. METHODS:Using MarketScan combined commercial and Medicaid claims (2016-2019), we identified individuals with AUD who had continuous insurance coverage throughout pregnancy, classifying those with a live birth as pregnant, and compared their MAUD and PSY patterns to nonpregnant peers matched by age, insurance type, and calendar time. All individuals had ≥1 claim for: (a) AUD diagnosis and (b) MAUD or PSY in the year preceding the study. Outcomes-filled MAUD prescriptions (naltrexone, acamprosate, and disulfiram) and receipt of PSY-were identified via claims. We computed rates of MAUD and PSY receipt, stratifying by five observation windows for pregnant individuals (12-week preconception; first, second, and third trimesters; 12 weeks postpartum) and nonpregnant peers (by corresponding windows). We assessed time to treatment discontinuation using multivariable Cox regression, adjusting for sociodemographics and comorbidities. RESULTS:Our sample consisted of 2080 pregnant persons with AUD and 7564 matched nonpregnant AUD peers. During pregnancy, MAUD receipt declined from 12.1% (preconception) to 0.3% (third trimester) among pregnant people and from 13.5% to 8.1% in nonpregnant peers during the equivalent time period (p < 0.001). Postpartum resumption of MAUD was uncommon in the pregnant cohort (pregnant = 1.9%; nonpregnant = 7.8%, p < 0.001). PSY declined for both the pregnant and nonpregnant cohorts yet remained modestly higher in the nonpregnant cohort (postpartum 10.3% vs. 13.8%, p < 0.001). In adjusted analyses, pregnant people were more likely to discontinue MAUD than nonpregnant peers (HR = 2.11 [1.71-2.60]) yet not more likely to discontinue PSY (HR = 1.01 [0.87-1.17]). CONCLUSIONS:Among pregnant people with preconception AUD receiving treatment, MAUD utilization is low and discontinuation is widespread, persisting postpartum.

OBJECTIVE:Treatment of pregnant patients with opioid use disorder with methadone or buprenorphine is crucial for maternal and neonatal safety. While several clinical trials have demonstrated higher treatment discontinuation rates for buprenorphine compared with methadone outside of pregnancy, evidence during pregnancy and the postpartum period is limited. The authors compared treatment discontinuation between buprenorphine and methadone during pregnancy and over follow-up through 1 year postpartum. METHODS:This was a cohort study, using nationwide Medicaid data, of pregnant patients who initiated methadone or transmucosal buprenorphine (with or without naloxone) for opioid use disorder during the first trimester. The primary outcome was treatment discontinuation, defined as a treatment gap ≥60 days; alternative definitions for discontinuation were explored in sensitivity analyses. Hazard ratios were estimated using Cox proportional hazards regression with propensity score overlap weighting to control for confounding. Subgroup analyses were conducted, stratified by buprenorphine alone versus the buprenorphine/naloxone combination, each compared to methadone. RESULTS:Overall, 696 pregnant patients were identified who initiated methadone treatment and 1,538 who initiated buprenorphine treatment in the first trimester. Compared to methadone initiators, buprenorphine initiators were more likely to discontinue treatment during pregnancy (32.8% for buprenorphine vs. 25.6% for methadone; weighted hazard ratio=1.41, 95% CI=1.15, 1.72) and through 1 year postpartum (58.8% vs. 49.0%; hazard ratio=1.37, 95% CI=1.19, 1.57). For patients initiating the buprenorphine/naloxone combination, the hazard ratio was 1.73 (95% CI=1.36, 2.19) during pregnancy and 1.56 (95% CI=1.30, 1.86) through 1 year postpartum. For patients initiating buprenorphine alone, the hazard ratios were 1.14 (95% CI=0.90, 1.46) and 1.23 (95% CI=1.04, 1.46), respectively. Varying the treatment gap used to define discontinuation in sensitivity analyses yielded consistent results. CONCLUSION:Pregnant patients initiating transmucosal buprenorphine during early pregnancy were more likely to discontinue treatment than those initiating methadone, but treatment discontinuation was high for both treatments. The study findings highlight the importance of identifying and addressing barriers to treatment retention among pregnant patients with opioid use disorder.

OBJECTIVES:The primary objective of this study is to conduct a systematic review of the scientific literature on the practice of methadone split-dosing, where the total daily dose is divided into 2 or more doses taken 10-12 hours apart rather than administered as a single daily dose. The review aims to evaluate the perinatal effects of this dosing regimen on maternal, fetal, and neonatal outcomes. METHODS:A systematic review was conducted by searching 6 databases, including APA PsycInfo, the Cochrane Library, CINAHL, Embase, PubMed, and Scopus, through the last search date of June 13, 2023. We included studies that reported maternal, fetal, or neonatal outcomes. Multiple researchers screened references. Data were extracted using a standardized spreadsheet, including study details and outcomes, and included studies were assessed for bias independently by 2 researchers using JBI Critical Appraisal Tools. RESULTS:The systematic search yielded 612 unique references, of which 8 studies met the criteria. These studies focused on investigating the pharmacokinetics of methadone during pregnancy, fetal responses to maternal methadone administration, variables related to maternal substance use disorder treatment, and outcomes related to birth or neonatal health. The findings demonstrated significant alterations in methadone metabolism during pregnancy due to increased methadone metabolism as a result of enhanced hepatic enzyme activity (CYP3A4 and CYP2B6), resulting in lower plasma methadone levels and requiring dose adjustments. Neonatal outcomes were favorable, including higher birth weights, reduced preterm birth risk, improved intrauterine growth, and reduced neonatal abstinence syndrome (NAS). CONCLUSION:The evidence suggests that pregnancy significantly alters methadone metabolism, subsequently impacting both maternal and neonatal outcomes. These findings demonstrate that split-dosing of methadone is associated with more favorable outcomes compared with once-daily dosing.

INTRODUCTION:Opioid exposure during pregnancy may significantly alter gene expression in the placenta, potentially disrupting its function and influencing fetal brain development. These alterations may contribute to adverse outcomes such as neonatal opioid withdrawal syndrome (NOWS). In this study, we aim to systematically investigate the changes in placental gene expression associated with maternal opioid exposure to better understand the underlying molecular mechanisms and their implications for fetal health. METHODS:Fresh placental tissue samples were collected from 18 opioid-exposed pregnancies and 26 non-opioid-exposed control pregnancies. Transcriptomic changes related to opioid exposure were assessed using RNA sequencing (RNA-seq). RESULTS:Among the 16,172 genes detected, 55 showed differential expression (Padjusted < 0.25 or Punadjusted < 0.001) in opioid-exposed placentas. Gene Set Enrichment Analysis (GSEA) revealed that the differentially expressed genes were primarily associated with immune responses, neuronal development and function, as well as cell replication and division. Computational deconvolution using the PlacentaCellEnrich program identified significant enrichment of upregulated genes in decidual NK cells. Furthermore, integrative analysis of DNA methylation and gene expression showed an enrichment of differentially methylated genes among downregulated genes in opioid-exposed placentas. DISCUSSION:Our findings suggest that opioid exposure during pregnancy may disrupt critical placental pathways, particularly those involved in immune responses. Future studies focusing on transcriptomic changes in specific placental cell types will be essential for fully understanding the structural and functional alterations in the placenta due to opioid exposure during pregnancy.

Incarceration during pregnancy is a pressing public health issue, but interventions to minimize harms for this population are not frequently described in the literature. We developed Justice Core, a pretrial diversion intervention for pregnant people with substance use disorders (SUDs), to minimize exposure to incarceration during pregnancy and increase access to SUD treatment. The intervention was feasible and acceptable to referring jail staff. In parallel, we conducted a needs assessment and identified an estimated 1,220 to 1,461 annual incarcerations during pregnancy among 77 responding jails (80% of North Carolina jails), and an estimated prevalence of perinatal SUDs of 66%. The Justice Core model of diversion into SUD treatment holds promise as a means to limit the duration and extent of incarceration, with a potential concomitant reduction in the harms experienced by pregnant people with SUD in jails and prisons.

Background: Perinatal opioid use disorder (OUD) and neonatal abstinence syndrome (NAS) require targeted interventions to address gaps in maternal education and support. Maternal involvement in non-pharmacological NAS care is essential for improving neonatal outcomes, yet many mothers lack accessible resources to manage NAS symptoms and to navigate social and healthcare challenges. Mobile health applications offer a promising solution, but few cater specifically to the needs of perinatal women with OUD. Objective: We assessed the usability, acceptability, and feasibility of a new mobile educational tool for pregnant women with OUD, focusing on the perinatal period and NAS care. Results: Six perinatal women with OUD (n = 1 pregnant, n = 5 postpartum; mean age 31) found the tool highly acceptable (modified CSQ-8 mean=28.8 out of 32) and usable (modified SUS mean=45.0 out of 50). Most were likely to use the tool during pregnancy and postpartum, citing improved preparedness for advocating for themselves, managing NAS, and navigating CPS. Feedback suggested expanding content on infant withdrawal medications. Conclusions: This mobile tool shows promise in empowering perinatal women with OUD. Further research is needed to evaluate its impact on clinical and neonatal outcomes.

Abstract Background The postpartum period provides an opportunity for birthing people with opioid use disorder (OUD) to consider their future reproductive health goals. However, the relationship between the use of medication for opioid use disorder (MOUD) and contraception utilization is not well understood. We used multistate administrative claims data to compare contraception utilization rates among postpartum people with OUD initiating buprenorphine (BUP) versus no medication (psychosocial services receipt without MOUD (PSY)) in the United States (US). Methods In this retrospective cohort study, we analyzed data from the Merative™ MarketScan® Multi-State Medicaid Databases 2016–2021 among postpartum women with OUD who did and did not initiate BUP during pregnancy. Our primary outcome was the receipt of prescribed highly-effective or effective contraception by 90 days postpartum. Highly-effective contraception was defined as female sterilization and long-acting reversible contraception [LARC]). Effective contraception was defined as oral contraceptive pills [OCPs], the contraceptive patch, ring, or injection. We used multivariable Poisson regression models, adjusting for sociodemographic and clinical characteristics, to measure the association of BUP (vs. PSY) on postpartum contraception utilization. Results Our sample consisted of 11,118 postpartum people with OUD. Among those, 3,443 initiated BUP and 7,675 received PSY. By 90 days postpartum, 22.4% (n = 2,487) of the cohort were prescribed contraception (21.5% PSY vs. 24.3% BUP). Among these participants, most received LARC (41.0%), followed by female sterilization (27.3%), the contraceptive injection (17.3%), pills (8.6%), ring (4.7%), and patch (1.0%), Compared to people engaged in PSY, BUP receipt was associated with a greater use of prescribed contraceptive use by 90 days postpartum (adjusted relative risk [aRR] = 1.17[1.07–1.28]), including a modestly greater use of the patch, ring, and pills, (aRR = 1.13[1.08–1.18]), but a modestly lesser use of injection contraception (aRR = 0.95[0.91–0.99]). There was no relationship observed between BUP and LARC use (aRR = 1.00[0.95–1.04]) and female sterilization (aRR = 1.01[0.98–1.06]). Conclusions Only 22% of pregnant people with OUD in our cohort used effective or highly-effective postpartum contraception. BUP receipt during pregnancy, relative to PSY, was associated with modestly greater use of prescribed effective contraceptive methods but was not associated with greater use of provider-administered contraceptive methods, such as the contraceptive injection, LARC and female sterilization.

Importance: Despite increased initiatives and funding to improve access to evidence-based treatments for opioid use disorder (OUD), including medications for OUD (mOUD), pregnant/postpartum individuals have significant obstacles to accessing these life-saving medications.Observations: Current legislation, specifically the Comprehensive Addiction and Recovery Act (CARA), mandates that the Governor of each state has systems in place to identify and address the needs of substance-exposed infants. However, this legislation removed the word "illegal" when defining substance use and left other important words in the law up to each individual state to define. These changes resulted in pregnant/postpartum individuals with OUD who were receiving legally prescribed mOUD, being subject to legal actions. In many states, such notifications result in investigation and punitive actions, which may include the removal of children from the care of postpartum individuals. These state policies have created additional barriers to accessing mOUD for pregnant and/or postpartum individuals. Research has demonstrated that pregnant individuals delay and/or avoid recommended prenatal care or decide to stop taking mOUD altogether, to prevent potential legal and child welfare-related consequences. This situation is problematic as it places individuals at risk of overdose and death and infants at risk of health complications. Importantly, such policies are subject to bias and disproportionately impact individuals of color and those from lower socioeconomic backgrounds.Conclusions and Relevance: The need to address and change the criminalization of pregnant/postpartum substance use laws to not penalize individuals adhering to the recommended standard of evidence-based care is urgent. Specific recommendations include: not relying on toxicology testing, reinstating "illegal/non-prescribed" language in legislation, implementing Plans of Safe Care, use of a two "track" reporting system, and federal support for states complying with Child Abuse Prevention and Treatment Act Reauthorization of 2010 (CAPTA) laws, increasing resources to improve outcomes for infants/postpartum individuals with OUD, and additional mandated training to educate key individuals, such as hospital/outpatient clinic providers and child-welfare workers.