(71) Healthcare Experiences of Pregnant Persons with Opioid Use Disorder: A Mixed-Methods Analysis

Background & Introduction: People who use drugs (PWUD) often face discrimination and stigma in healthcare settings. Moreover, pregnant persons with opioid use disorder (OUD) face unique barriers when seeking substance use treatment and supportive services. Studies show that pregnant people who use drugs fear legal repercussions, such as being reported to Child Protective Services (1). Stigmatization is a substantial barrier to care, not only externally from providers, but internally as well, which can lead to anxiety and isolation, further driving lack of access to prenatal services for pregnant patients (2).

The REACH Project, Inc. (REACH) is an innovative community-based organization providing integrated harm reduction and SUD treatment services. Located in Upstate New York, REACH is a 501(c)3 non-profit organization at the forefront of addiction medicine. REACH, an acronym for Respectful, Equitable Access to Compassionate Healthcare, has a mission to provide high-quality, non-stigmatizing, evidence-based healthcare to marginalized groups in a harm reduction setting. REACH promotes health equity through low threshold services such as Medication for Opioid Use Disorder (MOUD), primary care, behavioral health, outreach-based services, and telemedicine. REACH provides services to 5,273 patients residing in 55 counties across New York State. This research aimed to evaluate REACH’s services and the impact on patients.

Methods: Pregnant patients (n=84) were identified based on self-reported intake questionnaire responses, clinical encounters, and clinical ICD-10 diagnosis codes.
Descriptive statistics were performed for the sociodemographic variables (age, race/ethnicity, location), intimate partner violence, as well as proportion of overall appointments done via telemedicine vs. in-person, and retention time (<=90, 91-180, >180 days). A multinomial logistic regression was performed to assess predictors of retention time such as age, % using telemedicine, and experience of partner emotional abuse. Results were deemed significant if the 95% confidence intervals of the odds ratios did not include 0 (p < 0.05). Analysis was done using R 4.3.0.
A qualitative evaluation tool was developed and utilized for this assessment. Interviews were analyzed using qualitative content analysis. A text message invitation was sent to all patients who received buprenorphine to complete a screening assessment survey for recruitment to determine eligibility to participate. Participants were interviewed by phone or Zoom for approximately one hour using semi-structured interview guides about their overall experience with REACH and their health care utilization outside of REACH. Five people were identified who fit the pregnant or recently pregnant demographic and were interviewed. Participants received $30 Visa gift cards for their participation.

Results: The analytic sample consisted of 84 pregnant persons from REACH, aged 20 to 49 (median and mean=32, SD=4.6). The sample was predominantly White (88.1%) and from New York state (96.4%) with few from Pennsylvania (3.6%). About 29.8% came from Tompkins county where the clinic is located. The majority of patients (60.7%) receive 50% or more of their appointments via telemedicine, and most were retained after 180 days (82.5%). While more than a third (37%) did not answer questions on partner violence, among those who did, 30.2% indicated some form of emotional abuse, 21.2% were afraid of their partner, 18.9% indicated physical abuse, and 11.3% indicated sexual abuse. Retention time was not significantly associated with either patient age, partner emotional abuse, or % of telemed appointments (continuous).
Eligible REACH patients who had a pregnancy within the past two years recounted their experiences receiving healthcare as a pregnant person with OUD. When recalling experiences outside of REACH (which does not provide prenatal care services) participants noted that they faced discrimination throughout their pregnancy, and felt they were being treated differently during labor and delivery due to their substance use history. Providers were perceived to be rushed and harsh with sharing information about their substance use disorder, and were noted as not being empathetic when they did share information.
Most notably, providers did not offer adequate pain management throughout pregnancy. Participants stated there was no discussion regarding their pain tolerance, leaving them to feel mistreated as a result. Participants expressed a need for more supportive services including education around pregnancy and OUD. Reducing shame and stigma for pregnant persons with OUD were emerging themes.

Conclusion & Discussion: Descriptive statistics of the sample revealed a fairly homogenous sample by sociodemographic variables, with a high proportion utilizing telemedicine for their MOUD treatment. Retention in MOUD was not significantly different between pregnant persons who predominantly utilize telemedicine compared to those who primarily go to the clinic in-person. This indicates the high level of patient engagement in MOUD treatment regardless of the modality in medical service delivery.
Qualitative analyses showed that pregnant persons with OUD receive inadequate pain management throughout pregnancy from medical providers. Additionally, pregnant persons who use drugs face discrimination and note a lack of communication from providers regarding their pregnancy and substance use treatment, underscoring the lack of trauma-informed harm reduction medical education around OUD and pregnancy in healthcare. Communication, proper pain management, and reducing stigma are imperative to providing proper care to pregnant persons with OUD. This information is helpful for providing insight on supportive services REACH and other community-based practices could provide to fill in health care gaps for this population.

References: 1 Roberts, S.C.M., Pies, C. Complex Calculations: How Drug Use During Pregnancy Becomes a Barrier to Prenatal Care. Matern Child Health J 15, 333–341 (2011). https://doi.org/10.1007/s10995-010-0594-7
2 Andrea Weber, Benjamin Miskle, Alison Lynch, Stephan Arndt & Laura Acion (2022) Substance Use in Pregnancy: Identifying Stigma and Improving Care, Substance Abuse and Rehabilitation, 12:, 105-121, DOI: 10.2147/SAR.S319180
3 Stone, R. Pregnant women and substance use: fear, stigma, and barriers to care. Health Justice 3, 2 (2015). https://doi.org/10.1186/s40352-015-0015-5