Pregnant People Who Use Drugs Deserve Supportive Policies and Treatment, Not Punishment

(Jamie Grill / Getty Images)

It is an unarguable fact: Pregnant people use opioids and other drugs. The stigma and discrimination they face, including when seeking prenatal care, can lead to worse outcomes for them and their babies. 

Addiction is a medical issue, not a moral one, and persistent stigma is a continued barrier to care. As Dr. Nora Volkow, the director of the National Institute on Drug Abuse (NIDA), wrote, “Fifty years after founding, NIDA urges following science to move beyond stigma.” 

The opioid and overdose crisis disproportionately affects women of childbearing ageOne-fifth of U.S. pregnant people are prescribed opioids, of whom 20 percent report non-prescribed opioid use. Since the late 1990s, the prevalence of opioid use disorder during pregnancy has more than quadrupled. 

Prenatal opioid use can impact maternal and newborn health. But, we have evidence-based treatments. The American College of Obstetricians and Gynecologists and the American Society of Addiction Medicine recommend that pregnant people with opioid use disorder receive medication for opioid use disorder (MOUD).

Pregnant people face unique barriers in accessing gold-standard treatments, chief among them stigma and discrimination. In some states, women have even been arrested for taking MOUD prescribed by a physician.

Stigma and discrimination are also deep-rooted in our legal and child protection systems. These systems often focus on punishing people who use drugs rather than helping them to access treatment.

Widespread fears of severe and irreversible developmental damage has now been largely debunked, yet the punitive response remains.

While punitive policies affect nearly all people who use drugs, pregnant people face unique penalties. In some states, this includes criminal charges that can only be applied to people who are pregnant.

In 2020, nearly half of U.S. states defined substance use during pregnancy as child abuse; 26 states mandate reporting by providers who suspect substance use during pregnancy. Pregnant people who screen positive for drugs not prescribed by a provider can lose their children to foster care, or have their parental rights terminated, regardless of circumstance.

Not all pregnant people are screened equally for potential drug use. Who gets tested and reported by providers depends on a person’s race and ethnicity, education, and poverty level. Contemporary, punitive policies are historically rooted in approaches that emerged out of the crack epidemic in the 1980s, with the media labeling infants as ‘crack babies.’ Widespread fears of severe and irreversible developmental damage has now been largely debunked, yet the punitive response remains.

Some policy makers argue that criminalization reduces drug use and give infants a “fighting chance.” But, punitive policies limit pregnant people’s ability to be honest about drug use and to seek help from their medical providers.

Providing prenatal care is advantageous to all, regardless of whether the pregnant person wants to access substance use treatment. To be sure, we all want healthy babies, but these destructive policies risk worsening the exact problems they promised to solve.

Babies born in states with punitive policies often have worse outcomes than states without these laws. Punitive policies may, in fact, increase the risk of infant mortality, along with numerous other adverse outcomes.

In more than three decades experience working with people who use drugs, we have yet to meet a pregnant person who does not want the best for their child. To achieve this, pregnant people must be able to speak frankly and freely with healthcare providers, and access the services they need.

Punitive policies are out of sync with existing science, which can ensure healthy pregnancies and deliveries for infants whose mother used opioids. Following examples such as Horizons at the University of North Carolina and HOPE Clinic at Massachusetts General Hospital, we must create systems that facilitate holistic pregnancy care.

Pregnant people who use drugs often avoid healthcare because they fear discrimination, criminalization and loss of their child. Infants who are immediately removed and placed in the NICU miss out on the vital benefits of skin-to-skin contact and bonding, and may be placed into foster care. States with the most punitive policies—and the highest levels of mandated reporting and infant removal—fund their social systems that support infants at astonishingly low levels.

We must roll back punitive policies and create non-stigmatizing medical environments that can support pregnant people who use drugs. In Volkow’s words, we must move “beyond stigma toward compassion and with it, improved care.” 

All stakeholders—healthcare providers and policymakers—must bring compassion to innovative drug policies that are fueled by science instead of stigma.

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About and

Morgan Philbin is an associate professor in the UCSF Department of Medicine, and a public voices fellow with the OpEd Project in partnership with the UCSF Benioff Homelessness and Housing Initiative.
Emilie Bruzelius is a postdoctoral fellow at Columbia University in the Department of Epidemiology.