The American Society of Addiction Medicine (ASAM) is deeply committed to the health and well-being of pregnant and postpartum people, their families, and communities. This includes advocating for the prevention and treatment of substance use-related harms throughout the reproductive years, with a focus on the perinatal period. Substance use disorder (SUD) is a stigmatized medical condition, and poorly understood for pregnant and postpartum people, who face discrimination accessing care and treatment. In areas most affected by the opioid crisis, opioid-involved pregnancies may include as many as 6 percent of childbirths...

Recommendations (October 2022)

The American Society of Addiction Medicine recommends:

Prevention, Screening, and Toxicology Testing

• Addiction medicine professionals should screen all people of reproductive age for pregnancy intention, and either provide contraception if desired or refer for comprehensive family planning.
• Addiction medicine and reproductive health professionals should work toward co-location and integration of services, including services for trauma and IPV.
• All pregnant people should be screened with a validated instrument by their prenatal clinician to identify who may need an assessment for SUD.79 Prenatal providers should use motivational interviewing techniques, offer medication initiation, and/or discuss referral to licensed SUD treatment services if SUD is diagnosed.
• Toxicology testing during the perinatal period should be standardized in hospital policies, be used only when clinical indications suggest it is necessary, be part of a clear plan outlined by the clinician (e.g., how will the result change clinical care?), and—outside of emergency situations—obtained with informed, written32 consent to ensure risks and benefits have been reviewed given the unique legal and social consequences of testing for pregnant and postpartum people. Both clinician and patient should have clarity as to the goal of testing, who will have access to the results, and the possible ramifications of a positive test. Patients have the right of refusal and refusing a toxicology test should neither be seen as indication of use nor detract from clinical care.
• A positive screening toxicology test result should be discussed with the patient, and a definitive test should be utilized if the patient’s self-report is not consistent with the presumptive test.
• Clinicians should not interpret a positive toxicology test result as determinative of a SUD. A positive toxicology test should result in: a) an increase in the intensity of an addiction treatment plan for patients with a SUD, b) evidence-based early intervention, and c) implementation of service-needs matching41 programs.
• Parents should be made aware of toxicology testing of infants, and whenever possible, parental permission should be obtained. Infant meconium, umbilical cord, and cord blood testing often takes 5-7 days to result, lack clinical utility in guiding the management of hospitalized infants, and are not recommended.
• Health care systems and hospitals should rigorously evaluate their use and applications of toxicology testing in pregnant and postpartum persons, and neonates, and examine the consequences of sharing the results of such testing outside the health care system; evaluation of such policy should be stratified by race and ethnicity. Policies that result in inequities in practice should be removed; areas where a lack of policy exists and results in inequities in practice should be addressed and rectified.

Federal and State Policy Changes and Reimagining Support

• States with legislation defining in-utero substance exposure as child abuse or neglect should eliminate such language. This legislative effort should be informed by public health professionals, medical professional societies, substance use prevention services, child protection agencies, and people with lived experience in joint efforts with champion legislators.
• The federal government, through CAPTA revisions and strategic guidance from federal agencies, should incentivize states to implement non-punitive, evidence-based, public health-driven approaches for SUD in pregnant and postpartum people.A rigorous evaluation of CAPTA strategies should include linked parent-child health data to assess if the legislation is achieving its goal of improving child outcomes.
• Federal agencies should issue guidance with particular attention to how states should define the term “affected by,”80 with clarification that addiction medications, including medications for OUD, are neither considered “prenatal drug exposure” nor should be included under any perceived CAPTA requirements. Any reauthorization of CAPTA should also include such clarification.
• Jurisdictions and institutions should remove policies and statutes that may deter pregnant people from seeking care, including mandates to report pregnant or postpartum people to child protection systems or other governmental agencies on the sole basis of substance use or SUD.
• Child protection system agencies should not use evidence of substance use to implement sanctions on parents, especially child removal. Such sanctions should only be made when other risk factors or harms have been assessed or identified, and there is objective evidence of abuse, neglect, or other danger to the child.
• Jurisdictions should fund programs that focus on substance use prevention, treatment, perinatal care, and recovery supports that are culturally resonant, gender responsive, and trauma-informed, and include wrap around services for pregnant and postpartum people.
• Federal and state agencies should fund the provision of social services and financial support to families in need.Social service benefits and financial support should not be made contingent on toxicology testing of parents.
  Federal and state agencies should prioritize funding for programs with demonstrated effectiveness, such as harm reduction programs that provide doula or paraprofessional-delivered home-visiting interventions for parents and children that reduce health disparities and risk of substance use,54,55 and integrated services addressing trauma and IPV.81 New interventions should be rigorously evaluated to consider both intended and unintended outcomes.
• Federal and state policy should promote paid family and medical leave, thus allowing parents to fulfill caregiving responsibilities and engage in treatment services without having to forgo paid employment.

Hospital Practices Related to Substance Use

• Hospitals should eliminate restrictive and inequitable policies that separate the parental-newborn dyad, limit the implementation of evidence-based practices, restrict patient movement or visitation, and allow for punitive room searches.
• Hospitals should implement policies that prioritize the shared interests of the parental-newborn dyad. This includes a) coordination and communication—prior to active labor—among anesthesiology, neonatology, labor, delivery, and pediatric staff, and b) facilitating extended hospital stays for birthing parent when a neonate is being monitored or treated for withdrawal symptoms.
• Hospitals should train staff that care for the parental-newborn dyad in the delivery of trauma-informed, respectful, comprehensive care that is patient-centered and tailored to whole person support. 

Approach to Treatment in Peripartum Period

• Pregnant and postpartum people who are stable on medication should be maintained on that medication unless there is a clear clinical rationale for discontinuation or due to patient preference.
• Treatment decisions should be made collaboratively between a patient and their healthcare provider. Neither child protective services nor judges should make specific treatment recommendations or mandate or prohibit any particular type of treatment or peer support, but instead should know how to help patients connect with local, licensed SUD treatment providers.
• Clinicians should make concerted efforts to communicate with social services professionals about the safety, efficacy, and importance of treatment with medications for pregnant and postpartum people with OUD.
• Clinical protocols that result in racial inequities in treatment delivery—such as methadone dosage and buprenorphine access—should be identified and rectified.
• Barriers to OUD treatment access and retention, including complex intake procedures, access to transportation, and childcare assistance, should be addressed.

Treatment, Harm Reduction, and Recovery Supports

• SUD treatment services, residential treatment facilities, clinicians, and harm reduction programs should include reproductive health services, including family planning, contraception services, and pregnancy testing.
  Peripartum people should be given priority access to SUD treatment.
• Payment models need to ensure that SUD treatment providers can meet the specific needs of pregnant and postpartum people and their families. Such services include but are not limited to: the management of co-occurring mental health conditions, childcare, transportation, housing, nutrition, parenting skills classes, IPV counseling, and encouragement of breast/chestfeeding.  
• States should expand Medicaid and the Children’s Health Insurance Program (CHIP) to provide 12 months of coverage for postpartum care under the American Rescue Plan Act.82 States that have not expanded Medicaid as offered under the Affordable Care Act should do so.
• State Medicaid programs should reimburse for the full range of prevention and treatment services during pregnancy, including screening, brief intervention, and referral to treatment (SBIRT), and IPV assessment and referral.
• Residential treatment and recovery housing facilities should provide affordable, family housing that permits children to live on the premises with a parent receiving treatment or who is in recovery.83
  Clinicians should provide counseling regarding harm reduction strategies during and after pregnancy, including approaches to continue breastfeeding safely.
• Clinics and hospitals should develop policies to ensure that overdose and suicide prevention is consistently offered, that naloxone kits are prescribed or dispensed, and SUD follow-up is arranged within 48 hours post-hospital discharge.
• Harm reduction programs that provide doula, peer support services, or paraprofessional-delivered home-visiting interventions for parents and children should be further studied and those with demonstrated effectiveness for improving health equity should be replicated.

Medical Education

• Medical education at all levels should include culturally appropriate education in the treatment and management of SUD during pregnancy and delivery, and the management of NAS; training in universal SUD screening methods, motivational interviewing, SBIRT, and training on responding to IPV. Concurrently, education on harm reduction approaches and the racist history of American drug policy should be taught.
• Prenatal providers should be trained to care for pregnant people with SUD, including the use of methadone and buprenorphine for OUD. The American College of Graduate Medical Education program requirements should be updated to state this explicitly.
• State perinatal collaboratives should train and disseminate information to prenatal and pediatric clinicians related to state and child protection system reporting/notification  laws and policies.

Pregnant and Postpartum People Who are Incarcerated

• The use of shackles during delivery should not be permitted; policies mandating the use of shackles or handcuffs should be eliminated.
• Policies should support rooming-in and breastfeeding while the birthing parent is in the hospital. Telephone privileges while in the hospital should be no more restrictive than while in jail or prison.
• Pregnant and postpartum people with SUD who are incarcerated should be able to access addiction medications, whether initiating or continuing a medication. Pregnant people with SUD who are incarcerated and in labor should be brought for appropriate medical care and permitted to continue addiction medications postpartum.
• Policies should permit breast/chestfeeding/breast-pumping for postpartum people who are incarcerated.

Protecting People’s Bodily Autonomy

• It is a critical time for advocates—including clinicians—to unite in opposition to legislative interference with the patient-clinician relationship, such as abortion bans,88 and policies that reduce or eliminate access to voluntary, evidence-based, and in many cases, life-saving medical treatment.