Background The 2016 Comprehensive Addiction and Recovery Act amended the Child Abuse Prevention and Treatment Act (CAPTA), expanding requirements for the development of state-specific Plans of Safe Care (POSC) for prenatal substance exposure. POSCs were intended to amplify existing efforts to include maternal referral to treatment and services in addition to infant safety planning. States were left to re-operationalize their own POSC procedures, including the extent to which the POSC process involved the child welfare system. We reviewed state statutes, regulations, and reports to create a taxonomy of state POSC approaches based on their relationship with child protective services (CPS) and healthcare systems. Methods We evaluated state POSC-related statutes, regulations, and federally mandated child welfare state reports (Annual Progress & Services Reports, Child & Family Services Plans, & CAPTA plans) for all 50 states and Washington, D.C. from 2012 to 2024. Using artificial intelligence-assisted text extraction and subject matter expert textual interpretation, we reviewed 634 documents and more than 123,000 pages of text. Through iterative categorization, we developed a five-domain POSC taxonomy, organizing POSC policies by their proximity to and engagement with CPS and healthcare systems. We then identified the number of states with POSC policies in each domain and the timing of implementation. Results Nearly all states had implemented their POSC by 2024. Our final taxonomy consisted of the following domains: (a) All CPS Referrals (26%), (b) Open Case Only (28%), (c) Alternative Response (26%), (d) Hospital-initiated (16%), and (e) Dual Pathways, that uses type of substance exposure to determine receipt of a Hospital-initiated POSC or traditional CPS response (14%). Eighty percent (80%) of states restrict POSC access to families already subject to CPS reporting or investigation. Conclusions Despite federal intent to broaden public health supports, state POSC policies largely reinforce existing CPS practices rather than offering proactive, non-punitive interventions. The proposed taxonomy offers a framework for future comparative research, policy evaluation, and reform efforts.

OBJECTIVE:Health insurance gaps are common among publicly insured children, undermining health care access and health. The Families First Coronavirus Response Act halted Medicaid disenrollments during the COVID-19 public health emergency (PHE), offering an opportunity to study the impact of continuous Medicaid eligibility on child health insurance coverage, health care access and use, and health. METHODS:Using 2016-2022 National Survey of Children's Health data (n = 182 910), we applied a difference-in-differences approach to compare changes in health insurance coverage gaps, health care access (unmet health care needs [any, mental health, and specialist]), health care use (preventive care, emergency department [ED]), and general health status before and during the PHE between publicly ("treated") and privately ("untreated") insured children. Adjusted models included child demographics, household characteristics, and state of residence. We also conducted subgroup analyses by child age and special health care need status. RESULTS:Continuous Medicaid eligibility was associated with a 3.1 percentage point (pp) decrease in health insurance coverage gaps (95% CI, -3.9 to -2.3) and a 3.9 pp decrease in ED use (95% CI, -5.7 to -2.0) among publicly insured children. Among children with special health care needs (CSHCN), continuous eligibility was associated with a larger decrease in ED use (-7.5 pp, 95% CI, -11.3 to -3.7) and was additionally associated with a 6.4 pp increase (95% CI, 2.7-10.1) in excellent general health status compared with children without special health care needs. No significant associations were observed with other indicators of health care access or use. CONCLUSION:Policies promoting continuous Medicaid eligibility may improve child health care use and health through improved coverage consistency, particularly among CSHCN.

Objective: To characterize the weight trajectories of infants exposed to opioids and evaluate the association between different exposures and risk of excessive neonatal weight loss. Study design: Using mother-baby linked electronic health records, vital records, and claims data, we identified a retrospective cohort of infants exposed to opioids born at a large, academic medical center (2010-2021). We characterized prenatal substance exposures 90 to 2 days before delivery, including medications for opioid use disorder (MOUD), non-MOUD opioids, selective serotonin reuptake inhibitors, benzodiazepines, gabapentin, cigarette smoking, and toxicology evidence of opioids and nonopioid exposures (eg, barbiturates, cannabinoids, amphetamines, cocaine). We parameterized neonatal weight loss as the maximum percentage decrease from birth weight in the first 14 days of life during birth hospitalization. We used multivariable linear regression to compare the association between prenatal exposures and maximum percentage weight loss. Results: Among 868 maternal-infant dyads exposed to opioids that were identified, 622 (71.7%) had prenatal exposure to at least 1 additional substance. Infants with additional prenatal exposures had a greater median weight loss and a later nadir in weight loss compared with those without additional exposures (P < .001). In analyses examining individual substances, MOUD prescriptions (coefficient 0.99; 95% CI 0.50-1.48) and positive toxicology for nonopioid drugs (coefficient 0.53; 95% CI 0.08-0.98) were associated with a greater maximum percentage weight loss. Conclusions: Exposure to MOUD and nonopioid exposures were associated with greater weight loss among infants exposed to opioids during the first 14 days of life. These findings inform the clinical management of infants exposed to opioids to mitigate weight loss during the neonatal hospitalization.

Objective:The aim of the study was to examine the relationship between opioid use disorder (OUD)-related service trajectories during pregnancy and postpartum emergency department (ED) and hospitalizations.Methods:We used the Merative MarketScan Commercial Claims and Encounters Database (2013-2021) to identify a cohort of pregnant individuals with OUD. We used group-based multitrajectory modeling to identify opioid-related treatment and service trajectories during pregnancy and examined their association with postpartum ED and hospital utilization.Results:Seven opioid-related treatment and service trajectories were identified in our cohort of 2,531 pregnant individuals with OUD. Compared to individuals initiating medications for OUD (MOUD) halfway through pregnancy but maintaining high adherence without ancillary services, those receiving only services throughout pregnancy had a higher risk of postpartum ED visits (HRED = 1.34). This latter group also faced significantly higher risks of postpartum hospitalizations, compared to adherent MOUD use (proportion of days covered >= 80%) alone, both throughout or in the latter half of pregnancy (HRHOS = 1.93; HRHOS = 1.60), and patients without MOUD or services (HRHOS = 1.43). Individuals initiating MOUD late in pregnancy with poor adherence and infrequent service use faced significantly higher risks of postdelivery hospitalization compared to consistent MOUD users throughout pregnancy (HRHOS = 2.33), or in the latter half, with or without services (HRHOS = 2.02; HRHOS = 1.93), and those not receiving MOUD or services (HRHOS = 1.73).Conclusions:Adherent MOUD use either throughout pregnancy or the latter half of pregnancy, irrespective of other service use, was associated with better postpartum outcomes defined by fewer ED visits and hospitalizations.

OBJECTIVE:Since 2016, federal law has stipulated state child welfare agencies must maintain policies and procedures to address the needs of infants with prenatal substance exposure (PSE) and their caregivers through a plan of safe care (POSC) focused on health and substance use treatment. Research into the effects of POSC across states has been slow due to a lack of accounting of states' POSC policies. The current study documents the status and contents of states' POSC policies. METHODS:We used search terms related to POSC in Nexis Uni, a legal software, to identify state statutes and regulations in effect during spring or summer 2024. We used a mixed deductive-inductive content analysis approach to identify domains of interest of POSC policies. To overcome limits of the legal search, we additionally compiled states' reports to Congress that describe their POSC policies. We calculated an accessibility rating to characterize the extent to which each state's POSC policy was available for public inspection. RESULTS:Every state except Illinois maintains some type of POSC policy, primarily in the form of an administrative manual, while only 18 states had enacted POSC statutes or regulations. Administrative manuals are not easily accessible to the public or clinicians. While statutes and regulations are publicly accessible, they are inconsistent regarding parts of the POSC "process" are codified. Thirty-one states had very low levels of accessibility of POSC policies. CONCLUSIONS:Ensuring consistent and transparent intervention for families with PSE will require greater clarity in policies and additional policy implementation supports.

(Abstracted from JAMA Health Forum 2025;6(4.11):e251814) Between 1999 and 2017, the number of pregnant people with opioid use disorder (OUD) increased from 1.5 to 8.2 per 1000 delivery hospitalizations in the United States. The American College of Obstetrics and Gynecology and the Substance Abuse and Mental Health Administration endorse the use of either methadone, a full μ-opioid receptor agonist, or buprenorphine, a partial μ-opioid receptor agonist and full κ-receptor antagonist, to treat OUD in pregnancy.

Importance:Recent trends in drug-related overdoses among adolescents have highlighted the need for mental health and substance use disorder (SUD) treatment. However, the extent of these treatment gaps is understudied. Objective:To characterize the factors associated with the diagnosis of and treatment for mental health and SUD for adolescents. Design, Setting, and Participants:This cross-sectional study used survey-weighted descriptive statistics and χ2 tests to estimate differences in characteristics and treatment receipt and included US adolescents and young adults aged 12 to 20 years who participated in the National Survey on Drug Use and Health in 2021 and 2022. Data were analyzed from February 2024 to February 2025. Main Outcomes and Measures:Primary outcomes included the prevalence of depression and suicidality-related mental health diagnoses, SUDs, and treatment rates for both conditions. Additional measures included treatment setting, socioeconomic and demographic characteristics, and health insurance-related factors. Results:From 2021 to 2022, 13% of participants had SUD and 24% had a mental health diagnosis during the previous year (mean [SD] age, 16.0 [2.5] years; 48.4% female individuals; 6.1% Asian, 13.9% Black, 25.7% Hispanic, and 49.9% White individuals). Only 10% of participants with SUD and 51% of adolescents with mental health diagnoses received treatment for their conditions, with higher rates of treatment among adolescents with comorbid SUD and mental health diagnoses. When comparing adolescents (aged 12-17 years) and young adults (aged 18-20 years) with SUD for treatment receipt, reductions were found in any mental health treatment (63% vs 51%; P = .03) and any SUD treatment (11% vs 8%; P = .01). Moreover, these lower rates were also found in more resource-intensive treatment settings, such as inpatient mental health care (14% vs 9%; P = .02) and specialty mental health facilities (47% vs 33%; P = .003). However, adolescents with opioid use disorder were less likely to receive medication treatment (11% vs 28%; P = .02). Treatment differences were associated with socioeconomic and insurance coverage factors. Compared with adolescents, young adults with SUD experienced increased poverty rates (20% vs 26%; P = .02), uninsurance rates (5% vs 10%; P = .05), and private insurance rates (49% vs 56%; P = .02) while receiving decreased Medicaid coverage (47% vs 33%; P < .001) and government assistance (34% vs 25%; P = .001). Conclusions and Relevance:The results of this cross-sectional survey study suggest that adolescents and young adults with SUDs rarely received treatment. Adolescents are especially vulnerable to treatment gaps once reaching young adulthood, and medications for opioid use disorder are systematically underused, especially for adolescents.

Introduction: The opioid crisis is increasingly impacting women, and access to buprenorphine to treat opioid use disorder (OUD) is limited by the number of providers authorized to dispense it. Stigma can represent an additional barrier to accessing medication for OUD. Qualitative data were analyzed from a randomized simulated patient field experiment of calls to outpatient buprenorphine-waivered providers. Objectives: Our primary objective was to analyze descriptions of barriers women encountered when seeking buprenorphine to treat OUD to account for differential experiences based on pregnancy status, race/ethnicity, and insurance status. Our secondary objective was to identify potential intervention strategies to improve access to medications for OUD. Methods: The Health Stigma and Discrimination framework was applied to guide our study of barriers encountered by women seeking OUD treatment. Callers representing vocal features of white, Hispanic, and Black women and simulating ages 25-30 were randomized to represent combinations of public/private insurance and pregnant/not pregnant characteristics. Callers contacted 5,944 buprenorphine-waivered providers requesting to make an appointment to obtain medications to treat OUD. There were 15,358 free-text comments in response to the prompt "Please give an objective play-by-play of the description of what happened in this conversation." Data were coded and analyzed using an iterative inductive-deductive approach. We consulted six community experts, women who had sought treatment for OUD, to inform our study findings and identify patient-driven solutions to address barriers. Results: Findings revealed that experiences of interpersonal stigma were connected to systemic barriers such as stigmatizing behaviors within institutional cultures and normative practices. Key results indicate that race/ethnicity, pregnancy status, and insurance status influence experiences of stigma. For instance, Black and Hispanic callers reported experiencing race-based microaggressions, and pregnant women faced additional judgment and reduced access to treatment. Qualitative findings and community experts' insights underscored the necessity for the adoption of anti- stigma policies and practices that facilitate easier access to medications for OUD across socioecological levels. Conclusions: The findings demonstrate a need for multilevel interventions to improve women's access to medications for OUD. (c) 2024 Jacobs Institute of Women's Health, George Washington University. Published by Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

The use and misuse of opioids has surged in the past decade, with nearly half of the users being female. Although opioid use is lower among pregnant women, trends mirror the general population. While pediatric exposures largely occur through prescriptions. This review presents a novel landscape analysis of pharmacology knowledge gaps in opioids in the maternal and pediatric populations. We queried PubMed for studies on 27 opioids, focusing on pharmacokinetics (PK), and pharmacoepidemiology (PE) or clinical trials (CT) in maternal and pediatric populations. English-language publications were included, and data were synthesized to identify gaps. Additionally, MarketScan claims data and United States Food and Drug Administration (FDA) drug labels were analyzed to compare scientific evidence, opioid prescriptions/orders, and FDA recommendations. Morphine, fentanyl, methadone, and buprenorphine are the most researched opioids in PK and PE/CT literature in both populations, but hydrocodone, oxycodone, and codeine are the most prescribed. Nine opioids lack FDA labels, and four of the 18 labeled drugs lack any human data. Hydrocodone, oxycodone, and codeine labels include lactation-focused PK information, with some pediatric clinical data for the latter two. Seven opioids lack PK and PE/CT studies in the maternal population, and PK research is absent for seven opioids, and PE/CT data is lacking for eight opioids in the pediatric population. PK studies often focus on labor, delivery, and lactation accompanied by neonatal data, whereas pregnancy research mainly occurs in PE studies. In pediatric populations, study types are evenly distributed among children, but PE studies focus more on adolescents. Drug concentration is the most reported parameter in PK studies, and neonatal opioid withdrawal syndrome (NOWS) is a key outcome in both PK and PE studies. NOWS is also researched more using real-world data, whereas neurodevelopmental outcomes are often captured in prospective observational studies. There is substantial disparity between the most commonly researched and prescribed opioids. In particular, the opioid pharmacology knowledge gaps are larger in pregnant women and for the highly prescribed opioids hydrocodone and oxycodone. The limited human data in FDA labels underscores the need for additional studies. Studies using real-world data can potentially help address these gaps.

Importance:For the first time in nearly 2 decades, the US infant mortality rate has increased, coinciding with a rise in overdose-related deaths as a leading cause of pregnancy-associated mortality in some states. Prematurity and low birth weight-often linked to opioid use in pregnancy-are major contributors. Objective:To assess the health and economic impact of perinatal opioid use disorder (OUD) treatment on maternal and postpartum health, infant health in the first year of life, and infant long-term health. Design, Setting, and Participants:This was a cost-effectiveness, population-based analysis using a stochastic time-to-event discrete-event simulation model to simulate the clinical progression and outcomes for hypothetical pregnant individuals with OUD who initiate treatment during pregnancy. In addition, a scenario analysis was conducted assuming that individuals were stable taking OUD treatment before pregnancy and continued treatment during pregnancy. Data were analyzed from May to September 2024. Exposures:Study exposures included outpatient methadone, buprenorphine monotherapy, and buprenorphine-naloxone; outpatient methadone, buprenorphine, and naltrexone after inpatient-managed withdrawal; and inpatient-managed withdrawal with and without an intensive behavioral component. Main Outcomes and Measures:Outcomes included return to illicit use; fatal and nonfatal overdose; incremental discounted costs; quality-adjusted life-years (QALYs), which are a combined measure of mortality and morbidity; net health benefit; infant mortality within the first year of life; preterm birth; low birth weight; and neonatal opioid withdrawal syndrome (NOWS). Results:In this economic evaluation of a hypothetical cohort of 100 000 pregnant individuals (mean [SD] starting age, 29 [5.6] years), in the pregnancy and postpartum simulation, buprenorphine dominated all strategies, yet methadone was a viable alternative. In the combined infant lifetime model, compared with methadone, buprenorphine showed an incremental effect of 0.262 QALYs per person, totaling 20 960 QALYs for 80 000 Medicaid-affected mother-infant dyads (IQR uncertainty interval [UI] 25th to 75th percentiles, 14 880-27 040 QALYs); mean cost savings of $21 512 per person, totaling $1.72 billion (IQR UI, $1.46-1.98 billion). Compared with naltrexone, buprenorphine showed an incremental effect ranging from 0.228 to 0.229 QALYs per person; 18 240 of 18 320 total QALYs for 80 000 mother-infant dyads (IQR UI, 13 840-22 720 QALYs; naltrexone-oral; IQR UI, 13 760-22 880 QALYs; naltrexone-extended release [XR]). Mean cost savings ranged from $25 316 per person ($2.03 billion; IQR UI, $1.83-$2.21 billion; naltrexone-oral) to $46 437 per person ($3.71 billion; IQR UI, $3.47-$3.96 billion; naltrexone-XR). Conclusions and Relevance:Results of this analysis suggest that both methadone and buprenorphine remained viable options for managing OUD during pregnancy and post partum; however, buprenorphine offered the greatest benefits in the lifetime models that account for infant outcomes.

In 2019, Connecticut became the first state to implement a deidentified notification policy for infants with prenatal substance exposure in response to updated provisions contained in the federal Child Abuse Prevention and Treatment Act (CAPTA) of 1974. Our study aimed to test whether Connecticut's notification policy was associated with an increase in Child Protective Services (CPS) interactions for this population. We analyzed child welfare and vital records over the course of a sixty-six-month time frame starting two years before the policy took effect. We used interrupted time series models to estimate monthly reports to CPS and foster care placements for infants with prenatal substance exposure in Connecticut's eight counties between March 2017 and July 2022. Reports and foster placements decreased for newborns with prenatal substance exposure after policy implementation. After covariates were controlled for, the adjusted rate of reports per birth decreased by 7 percent per month after the policy's implementation. The proportion of prenatal substance exposure reports resulting in foster care placement decreased by 4 percent per month. These findings suggest that Connecticut's approach to CAPTA was associated with a reduction in child welfare encounters among infants with prenatal substance exposure.

BACKGROUND:The majority of opioid analgesics prescribed for pain after ambulatory pediatric surgery remain unused. Most parents do not dispose of these leftover opioids or dispose of them in an unsafe manner. We aimed to evaluate the association of optimal opioid disposal with a multidisciplinary quality improvement (QI) initiative that proactively educated parents about the importance of optimal opioid disposal practices and provided a home opioid disposal kit before discharge after pediatric ambulatory surgery. METHODS:Opioid disposal behaviors were assessed during a brief telephone interview pre- (Phase I) and post-implementation (Phase II) after surgery. For each phase, we aimed to contact the parents of 300 pediatric patients ages 0 to 17 years who were prescribed an opioid after an ambulatory surgery. The QI initiative included enhanced education and a home opioid disposal kit including DisposeRX ® , a medication disposal packet that renders medications inert within a polymeric gel when mixed with water. Weighted segmented regression models evaluated the association between the QI initiative and outcomes. We considered the association between the QI initiative and outcome significant if the beta coefficient for the change in intercept between the end of Phase I and the beginning of Phase II was significant. Safe opioid disposal and any opioid disposal were evaluated as secondary outcomes. RESULTS:The analyzed sample contained 161 pediatric patients in Phase I and 190 pediatric patients in Phase II. Phase II (post-QI initiative) cohort compared to Phase I cohort reported higher rates of optimal (58%, n = 111/190 vs 11%, n = 18/161) and safe (66%, n = 125/190 vs 34%, n = 55/161) opioid disposal. Weighted segmented regression analyses demonstrated significant increases in the odds of optimal (odds ratio [OR], 26.5, 95% confidence interval [CI], 4.0-177.0) and safe (OR, 4.4, 95% CI, 1.1-18.4) opioid disposal at the beginning of Phase II compared to the end of Phase I. The trends over time (slopes) within phases were nonsignificant and close to 0. The numbers needed to be exposed to achieve one new disposal event were 2.2 (95% CI, 1.4-3.7]), 3.1 (95% CI, 1.6-7.4), and 4.3 (95% CI, 1.7-13.6) for optimal, safe, and any disposal, respectively. CONCLUSIONS:A multidisciplinary approach to educating parents on the importance of safe disposal of leftover opioids paired with dispensing a convenient opioid disposal kit was associated with increased odds of optimal opioid disposal.

Background: Policy changes during the COVID-19 pandemic allowed buprenorphine to be prescribed for opioid use disorder via telemedicine without an in-person visit. A recently proposed change will limit buprenorphine access to 30 days without an in-person visit. Given that people living in rural areas may be disproportionally impacted by this change, we sought to better understand how buprenorphine adherence may be impacted by requiring in-person visits. Objective: Compare buprenorphine adherence after telemedicine to adherence after in-person visits for patients who live in rural and urban areas. Methods: In this retrospective cohort study, we used electronic health record data from a large medical center. The cohort included all adult patients prescribed buprenorphine for opioid use disorder during 2017-2022. The primary outcome was adherence, characterized by the Medication Possession Ratio (MPR) and gaps in buprenorphine treatment at 30 and 180 days. We conducted a longitudinal analysis at visit level, stratified by patient urbanicity, and controlled for patient, prescriber, prescription, and setting characteristics. Results: From 511 patients, we followed 3302 in-person and 519 telemedicine visits. Compared to in-person visits we observed no difference in the adherence following telemedicine visits overall. However, telemedicine was associated with higher MPR for rural patients (30 days: adjusted marginal effects FAME], 3.7%; 95% CI, 2.0-5.5; P < 0.001 and 180 days: AME, 8.5%; 95% CI 5.7-11.3; P < 0.001) and fewer gaps (30 days: AME, -6.7%; 95% CI, -9.9 to -0.1; P < 0.001 and 180 days: AME, -9.4%; -14.0 to -4.5; P < 0.001) compared to in-person visits. Conclusion: These findings suggest that telemedicine is a viable alternative to in-person visits, especially for patients living in rural areas, which should help guide future policies that preserve or increase access to buprenorphine in a manner that can reduce barriers for patients.

This survey study evaluates whether the wording of questions regarding mature minor doctrines is associated with parental opinions about adolescent consent for medical services overall and for specific care types.

OBJECTIVE:Parents of children born preterm are at risk of neglecting their own medical needs following the birth of a medically complex child. This study examines the self-reported health of parents of preterm children born with low birthweight (LBW; 1500-2499 g) or very low birthweight (VLBW; <1500 g) compared with parents of term children of normal weight (term; ≥2500 g). METHODS:We examined self-reported health among parents with children 0 to 3 years of age using the National Survey of Children's Health (2016-2022), a cross-sectional dataset. We used multivariable logistic regression to analyze parent's self-reported health by gestational age-birthweight categories, adjusting for child and household sociodemographics. RESULTS:Parents of children born VLBW had higher rates of fair/poor physical health versus parents of term children (10.9% vs. 3.9%, odds ratio [aOR] 2.92; 95% confidence interval [CI] 1.55-5.49). Parents of VLBW children had higher rates of poor/fair mental health compared to parents of term children (8.5% vs. 5.1%), but the differences were not significant in adjusted analyses. While parents of children born LBW trended toward higher odds of fair/poor health, the differences were not significant in adjusted analyses. CONCLUSIONS:We found important differences in reported physical health among parents of children born VLBW compared to parents of children born at term with normal birthweight. This elevated health burden is critical to address, as self-reported poor health is linked to long-term negative health consequences and increased parental mortality risk. Pediatricians should consider screening for caregiver health concerns during neonatal intensive care unit (NICU) discharge and well-child visits.

Importance Opioid use disorder (OUD) in pregnancy has grown in the US. Buprenorphine, a medication to treat OUD, may improve pregnancy outcomes; however, most pregnant individuals do not receive it. Research evaluating buprenorphine use in pregnancy, its effects on the maternal-infant dyad, and in comparison to no treatment is limited. Objective To determine if treatment with buprenorphine for opioid use disorder in pregnancy is associated with improved maternal and infant outcomes compared to no treatment among mothers with OUD. Design, Setting, and Participants This retrospective cohort study included maternal-infant dyads continuously enrolled in the Tennessee Medicaid program from 20 weeks’ estimated gestational age to 6 weeks post partum between 2010 and 2021. Medicaid administrative was linked to birth and death certificates. Data analysis was conducted from April to October 2024. Exposure Buprenorphine use during pregnancy. Main Outcomes and Measures Adverse pregnancy outcomes included preterm birth, neonatal intensive care unit (NICU) admission, infant death, severe maternal morbidity (SMM), intensive care unit admission, and maternal death. Logistic regression and propensity scores with overlap weighting were used to calculate adjusted predicted probabilities for adverse outcomes. Results Among 14 463 maternal-infant dyads, 7469 (51.6%) received buprenorphine treatment (median [IQR] maternal age, 27 [24-31] years). There was a statistically significant lower rate of adverse pregnancy outcomes among dyads treated with buprenorphine compared to untreated dyads (25.4% vs 30.8%; P < .001); the treatment group also had a lower rate of SMM events (5.4% vs 6.9%; P < .001), preterm births (14.1% vs 20.0%; P < .001), and NICU admissions (15.2% vs 17.2%; P = .001). In adjusted analyses, those with buprenorphine treatment had a 5.1 percentage point (pp; 95% CI, 3.5-6.7 pp) lower probability of any adverse outcomes, including a 1.2 pp (95% CI, 0.4-2.1 pp) lower probability of SMM, 1.7 pp (95% CI, 0.4-2.9 pp) lower probability of NICU admission, and 5.3 pp (95% CI, 4.0-6.6 pp) lower probability of preterm birth. The number needed to treat to avoid an adverse pregnancy outcome was 20. Conclusions and Relevance In this cohort study of pregnant individuals with OUD, buprenorphine treatment was associated with improved outcomes for the mother and infant, underscoring the need to improve access to treatment nationwide.

State policies requiring clinicians to review prescription drug monitoring program (PDMP) databases have proliferated. However, patient advocates suggest these policies may adversely affect patients with chronic pain. This study aimed to quantify the effect of must-access PDMP implementation on pain and physical impairment. Using panel data on 34,431 older adults from the Health and Retirement Study (2002-2021), we conducted a heterogeneity-robust difference-in-differences analysis. Must-access PDMPs were associated with a 1.65 (95% CI: 0.43 to 2.87) percentage point increase in frequent pain during the two-year window surrounding policy implementation and a peak 3.52 (95% CI: 0.88 to 6.16) percentage point increase in the second post-policy period, after which the effect dissipated. Effects on impairment outcomes were positive but statistically insignificant. Findings suggest that must-access PDMP policies may increase numbers of older adults reporting frequent pain in the early policy implementation years, though they were not associated with statistically detectable changes in physical impairment.

BACKGROUND:The American Academy of Pediatrics recommends up to 7 days of observation for neonatal opioid withdrawal syndrome (NOWS) in infants with chronic opioid exposure. However, many of these infants will not develop NOWS, and infants with seemingly less exposure to opioids may develop severe NOWS that requires in-hospital pharmacotherapy. We adapted and validated a prediction model to help clinicians identify infants at birth who will develop severe NOWS. METHODS:This prognostic study included 33 991 births. Severe NOWS was defined as administration of oral morphine. We applied logistic regression with a least absolute shrinkage selection operator approach to develop a severe NOWS prediction model using 37 predictors. To contrast the model with guideline screening criteria, we conducted a decision curve analysis with chronic opioid exposure defined as the mother receiving a diagnosis for opioid use disorder (OUD) or a prescription for long-acting opioids before delivery. RESULTS:A total of 108 infants were treated with oral morphine for NOWS, and 1243 infants had chronic opioid exposure. The model was highly discriminative, with an area under the receiver operating curve of 0.959 (95% CI, 0.940-0.976). The strongest predictor was mothers' diagnoses of OUD (adjusted odds ratio, 47.0; 95% CI, 26.7-82.7). The decision curve analysis shows a higher benefit with the model across all levels of risk, compared with using the guideline criteria. CONCLUSION:Risk prediction for severe NOWS at birth may better support clinicians in tailoring nonpharmacologic measures and deciding whether to extend birth hospitalization than screening for chronic opioid exposure alone.

With fatal opioid overdoses rising steadily between 1999 and 2022, researchers have tried to identify effective policy approaches that can stem the tide and mitigate associated harms. However, policy evaluations intended to inform policy choices may muddy the waters, particularly when they generate inconsistent findings. In this article, we discuss a unifying framework and language for presenting analyses using quasi-experimental methods evaluating opioid policies to facilitate greater understanding of similarities and differences across studies. We discuss key data, methods, and design issues that confront researchers in this space, with the goal of increasing the pace of good science.