Medication-assisted treatment (MAT) is recommended by the American College of Obstetricians and Gynecologists for opioid use disorder among pregnant women. Four common punitive state policies are intended to curb pregnant opioid use by legislating (1) substance use as child abuse and (2) as grounds for civil commitment, (3) additional drug screening requirements, and (4) mandatory reporting by physicians. Integrating pregnancy services into opioid treatment programs (OTPs) may improve MAT outcomes, thereby reducing law violations. However, little is known about how these policies affect integrating pregnancy services into OTPs. The present study investigates whether states’ punitive severity, rurality, and criminal justice treatment referrals predict integration of tailored pregnancy services in OTPs.

Methods

We used the National Survey of Substance Abuse Treatment Services (2017) to identify OTPs in the US (n=1,165), a Guttmacher Institute report to create a weighted score of state legal severity, US Department of Agriculture estimates to create a state-level indicator of rurality, and the Treatment Episode Dataset-Discharges to create a state-level indicator of referrals to treatment by the criminal justice system. We used a moderated moderation framework and logistic regression to test associations between policy score and integrated pregnancy services.

Results

As policy scores increased and became more punitive, the likelihood of tailored pregnancy services in OTPs increased the most in urban states that also had high levels of criminal justice referrals (x²=8.14, p<0.0001). Within rural states, there was no change in pregnancy services as policy score increased, and no difference in the effect of policy score on pregnancy services between levels of criminal justice referrals (x²=0.34, p=0.56).

Conclusions

OTPs in urban states with high levels of criminal justice referrals may have responded to punitive legal policies by integrating pregnancy services into MAT treatment. More health service options in rural communities may further reduce undue legal involvement.