As the opioid crisis continues to cause significant harm to individuals in every demographic group across the United States, treatment providers, policymakers, and research scientists continue to explore every possible method they can to support people with opioid use disorder (OUD). This article will address another issue that needs attention: the role of race and racism and how it impacts treatment for addiction during pregnancy.
One way to understand how to mitigate the harm caused by the opioid crisis is by examining which groups have the highest rates of opioid use disorder, which groups have the highest rates of engaging in treatment for opioid use disorder, and which groups have the highest success rates in recovery from opioid use disorder.
The opposite is also true. Scientists, policymakers, and treatment providers also need to know which demographic groups have the lowest rates of opioid use disorder, which have the lowest rates of engaging in treatment for opioid use disorder, and which groups have the lowest success rates in recovery from opioid use disorder.
It’s important to look at the problem from both perspectives. Identifying these factors helps us target support where it’s needed most and allocate resources appropriately. For instance, we can use information presented in articles like these on the blog section of our website to target care:
The Opioid Crisis: Overdose Among Non-Hispanic Black Residents of Kentucky
The Effect of Race and Stigma on SUD Treatment
Research Report: Increase in SUD Treatment Among Older Adults
Opioid Crisis Report: COVID-19 Increased Overdose Risk in Rural Communities
Those articles address issues that impact the fair and equitable support of people with opioid use disorder or other substance use disorders. They help us understand where and how we can best support the people who need support the most.
As we mention above, this piece will address a subject that needs attention: opioids and pregnant women. Specifically, we’ll examine the role of race in the treatment of pregnant women with opioid use disorder and pregnant women who report opioid use.
Race, Addiction, Pregnancy: Studying Treatment for OUD Among Pregnant Women
In March 2022, a group of researchers published a meta-analysis called “Perinatal Opioid Use Disorder Research, Race, and Racism: A Scoping Review” in the reputable medical journal Pediatrics. Here’s the goal of the meta-analysis, according to the research team:
“To systematically review research on maternal-infant dyads affected by opioid use disorder (OUD) to evaluate for racial/ethnic disparities in health utilization or outcomes and critically assess the reporting and inclusion of race/ethnicity data.”
To achieve this goal, researchers included 152 quantitative and 17 qualitative studies in the study. Among those studies, 111 examined infant outcomes, 112 mentioned race/ethnicity, 63 assessed differences between groups, and 27 identified differences base on race or ethnicity. They collected data on maternal outcomes during and after pregnancy, fetal outcomes during pregnancy, and infant outcomes after delivery.
Before we present the results of this meta-analysis, however, we’ll offer a quick overview of the latest data on pregnant women and opioid use.
Facts and Figures: Pregnant Women and Opioid Use
Here’s the latest data on the rates of opioid use disorder among pregnant women and rates of neonatal abstinence syndrome among infants, published in 2021 in a study called “Neonatal Abstinence Syndrome and Maternal Opioid-Related Diagnoses in the US, 2010-2017.”
Opioid Use Disorder (OUD) and Pregnancy
- Maternal opioid use disorder (OUD):
- 2010: 3.5 cases per 1000 deliveries
- 2017: 8.3 cases per 1000 deliveries
- Neonatal abstinence syndrome (NAS):
- 2010: 4.0 cases per 1000 births
- 2017: 7.3 cases per 1000 births
Those figures tell us that over seven years during the opioid crisis, rates of NAS increased by 82 percent and rates of maternal OUD increased by 131 percent. That means more pregnant women report opioid use than ever before. Those are significant increases, which become more disturbing when we understand that untreated OUD during pregnancy is associated with a host of negative consequences, which we list below.
The Impact of Untreated OUD During Pregnancy
- Inadequate prenatal care
- Increased emergency health care utilization
- Low birth weight
- Fetal death
- Preterm labor
- NAS
- Increased rate of birth defects, including:
- Heart problems
- Gastrointestinal issues
- Spina bifida
- Maternal mortality
That’s the big picture situation. During the opioid crisis, opioid use among pregnant women increase. Rates of maternal OUD and NAS increased dramatically, which indicates an increased need for SUD and OUD care designed for pregnant women who use opioids. That information also details the consequences of perinatal exposure to opioids for a developing fetus: the consequences are extreme, and can impact health and wellbeing over the entire lifespan, not only during infancy.
SUD and OUD Treatment During Pregnancy: Facts and Figures
In addition to the facts above, the researchers who conducted the meta-analysis identified race-based inequalities in maternal-infant morbidity/mortality and treatment for substance use disorder (SUD).
Here’s what they report from the existing scholarship on those two topics:
- Maternal mortality/morbidity:
- 4-5 times higher among BIPOC mothers than among white mothers/infants
- Infant mortality/morbidity:
- Twice as high among BIPOC infants than among White infants
- SUD treatment:
- BIPOC people less likely to initiate SUD treatment
- BIPOC people less likely to complete SUD treatment
- Access to medications for opioid use disorder (MOUD) for medication-assisted treatment (MAT) programs:
- BIPOC report less access than to MOUD and MAT than non-BIPOC people
- BIPOC report lower levels of adherence to treatment with MOUD and MAT
The information on inequities in rates of treatment reveal the disadvantage pregnant black women with OUD experience, as compared to pregnant white women with OUD.
The disparities created disadvantages because full engagement in properly supervised and managed MAT during pregnancy can:
- Prevent withdrawal symptoms
- Decrease likelihood of relapse
- Decrease infectious disease transmission
- Improve adherence to prenatal care
- Improve adherence to addiction treatment
- Reduce risk of miscarriage
- Reduce risk of premature birth
- Increase birthweight
- Decrease pregnancy related death for mothers
- Decrease severe OUD-related morbidity (disease/illness)
The evidence tells us that for pregnant mothers with OUD, MAT programs improve outcome across the board for both the mother and the developing fetus. That’s why the meta-analysis we discuss today is important: racial inequities in OUD care for pregnant women are something we can correct.
Let’s take a look at the results of that meta-analysis.
Race, Racism, and Addiction Treatment During Pregnancy: The Results
As we mention above, researchers gathered and analyzed data on maternal outcomes during and after pregnancy, fetal outcomes during pregnancy, and infant outcomes after delivery. They found race-associated differences in maternal care and outcome before and after pregnancy, and race-associated differences in infant care after delivery.
Here’s what they report.
Race and Addiction Treatment During Pregnancy, and Opioid Use Disorder
Maternal Metrics/Outcomes
- Black and Latinx patients had significantly lower likelihood of receiving MOUD and engaging in MAT, compared to white patients
- Among Black and Latinx patients who engaged in any MAT (methadone or buprenorphine):
- Treatment retention was lower
- Methadone was more common than buprenorphine
- Among Black and Latinx patients who engaged in MAT with buprenorphine specifically:
- Early discontinuation was more common than for non-Black/Latinx patients
- Black and Latinx mothers with OUD were more likely to receive sterilization than other contraceptive methods, compared to non-Black/Latinx mothers
- Non-Latinx Black women with OUD were more likely to utilize postpartum healthcare, compared to non-Latinx White women
Infant Metrics/Outcomes
- Black infants were less likely than white infants to receive pharmacotherapy for NAS
- Black infants were more likely than white infants to have a longer post-partum length of stay in hospital for NAS
This data teaches us at least two critical things that we must consider as we move forward and work toward offering equitable care for everyone who experiences the negative consequences of the opioid crisis.
First, although most of the studies in the meta-analysis focused on neonatal and/or infant outcomes, very few included data on race or ethnicity on the subjects in the studies. When the issue of race or ethnicity was addressed, various authors explained the absence of the mention of race by indicating the homogenous nature of their study subject: most studies either included almost all White women or almost all Black/Latinx women.
Very few had a diverse patient population.
That brings us to our second critical observation of this data, which the study authors address: the role of race in biomedical research.
Towards Inclusion in Treatment and Research
Here’s how the study authors describe this issue:
“The way in which research participants are recruited and data are collected may reflect a long history of biomedical research that excluded marginalized groups from research and/or resulted in harm to groups of Black, Indigenous, and people of color (BIPOC) without proper consent for research. The challenges of recruiting a diverse sample are real, but the historic impact of scientific racism can be overcome with careful attention to trust and accurate information about the goals of research.”
That’s an important and relevant insight. Not only might treatment and support for pregnant women with OUD be affected by issues of race and ethnicity, but the scientific data itself – which we use to make most of our public policy decisions – might also be affected by issues of race and ethnicity. The implication is that if we rethink and re-envision our entire care system through the lens of race and ethnicity, we may be better able to address and correct any inequities in care based on race and ethnicity.
How can we do this?
The study authors make the following suggestions for researchers, based on work published in the paper “How to Embed a Racial and Ethnic Equity Perspective in Research.” Here’s how researchers can move forward, and work toward a more inclusive paradigm:
- Researchers should examine their own backgrounds and biases
- Researchers should commit to digging deeper into the data to identify factors associated with race and ethnicity
- All researchers need to understand that the research process itself has an impact on communities, and they need to ensure their research benefits the communities they study
- Researchers should engage communities in research, and give credit to community members who contribute to the research
- Researchers should guard against making results associated with white race/whiteness the normative, standard, or default results by which to analyze data
When we read this list, we realize something important. In order to create a more inclusive paradigm of care, we can simply replace the words researchers and research in the list above with the phrase treatment providers and the word treatment. If we do that, we can interrogate our own biases, and ensure they don’t impact the support we offer to anyone – including pregnant BIPOC with opioid use disorder.