A review of recent findings on substance abuse treatment for pregnant women

Recent years have brought an increased interest in the treatment needs of pregnant substance abusers. This article reviews the literature on this subject, providing an overview of what is known about the prevalence of substance abuse during pregnancy; the factors in women's lives, especially pregnant women, that lead to substance abuse and that facilitate and impede treatment success; and the components of successful treatment programs. The prevalence of prenatal illicit drug use is known to be about 5% of all pregnant women nationwide, with higher rates for selected subgroups. Local studies have shown much higher rates. Substance abuse is associated with poverty, with the substance abuse of significant others, and with family violence. Perinatal substance abusers experience poorer birth outcomes. The negative consequences for babies do not stop at birth; home environments may be chaotic and often children are removed from their mother's care if substance abuse continues after birth. While the literature on prevalence, correlates, and outcomes of perinatal substance abuse is plentiful, there continues to be sparse information on successful treatment approaches. Sample sizes are small and there are few studies with adequate comparison groups. The small number of outcome studies we review suggest that, as with the broader treatment literature for other populations, success (as measured by abstinence) is associated with retention. Retention is facilitated by the provision of support services, such as child care, parenting classes, and vocational training. There is no clear empirical basis for concluding that one type of treatment (for example, residential treatment) is more effective than another.     

Predictors of Treatment Outcomes for Substance-Abusing Women: A Retrospective Study

This study examined whether client characteristics at admission predict Retention, Abstinence, and utilization of Required Services and Specialized Services for pregnant women in outpatient and residential substance abuse treatment. Retrospective data were collected with the Psychosocial History (PSH), a structured clinical interview that is an expansion of the Addiction Severity Index, designed specifically to assess substance abusing women. The PSH was administered at intake for 183 pregnant women admitted to outpatient (n = 133) or residential (n = 50) treatment. Factor analysis reduced predictors to five factors with composite scores, and multiple regression procedures determined client characteristics that predict treatment outcomes. The findings suggest the complexity of predicting treatment outcomes for pregnant women. Significant predictors were composites of variables that encompassed all aspects of women's personal and family lives including medical and psychiatric needs, family and parenting issues, housing, victimization, and clients' perceived needs for treatment and assistance in all of these areas. The results suggest the need for a holistic approach to substance abuse treatment and continued exploration of a broad range of psychosocial assessments at intake in order to develop substance abuse treatment programs that effectively address multiple aspects of women's lives.     

Predictors of treatment outcomes for substance‐abusing women: A retrospective study

This study examined whether client characteristics at admission predict Retention, Abstinence, and utilization of Required Services and Specialized Services for pregnant women in outpatient and residential substance abuse treatment. Retrospective data were collected with the Psychosocial History (PSH), a structured clinical interview that is an expansion of the Addiction Severity Index, designed specifically to assess substance abusing women. The PSH was administered at intake for 183 pregnant women admitted to outpatient (n = 133) or residential (n = 50) treatment. Factor analysis reduced predictors to five factors with composite scores, and multiple regression procedures determined client characteristics that predict treatment outcomes. The findings suggest the complexity of predicting treatment outcomes for pregnant women. Significant predictors were composites of variables that encompassed all aspects of women's personal and family lives including medical and psychiatric needs, family and parenting issues, housing, victimization, and clients’ perceived needs for treatment and assistance in all of these areas. The results suggest the need for a holistic approach to substance abuse treatment and continued exploration of a broad range of psychosocial assessments at intake in order to develop substance abuse treatment programs that effectively address multiple aspects of women's lives.     

The costs of crime and the benefits of substance abuse treatment for pregnant women

Although many pregnant, drug-dependent women report extensive criminal justice involvement, few studies have examined reductions in crime as an outcome of substance abuse treatment programs for pregnant women. This is unfortunate, because maternal criminal involvement can have serious health and cost implications for the unborn child, the mother and society. Using the Addiction Severity Index, differences in pre- and posttreatment criminal involvement were measured for a sample of 439 pregnant women who entered publicly funded treatment programs in Massachusetts between 1992 and 1997. Accepted cost of illness methods were supplemented with information from the Bureau of Justice Statistics to estimate the costs and benefits of five treatment modalities: detoxification only (used as a minimal treatment comparison group), methadone only, residential only, outpatient only, and residential/outpatient combined. Projected to a year, the net benefits (avoided costs of crime net of treatment costs) ranged from US$32,772 for residential only to US$3,072 for detoxification. Although all five modalities paid for themselves by reducing criminal activities, multivariate regressions controlling for baseline differences between the groups showed that reductions in crime and related costs were significantly greater for women in the two residential programs. The study provides economic justification for the continuation and possible expansion of residential substance abuse treatment programs for criminally involved pregnant women.     

The influence of distance on utilization of outpatient mental health aftercare following inpatient substance abuse treatment

This study examined whether substance abuse patients who live farther from their source of outpatient mental health care were less likely to obtain aftercare following an inpatient treatment episode. For those patients who did receive aftercare, distance was evaluated as a predictor of the volume of care received. A national sample of 33,952 veterans discharged from Department of Veterans Affairs (VA) inpatient substance abuse treatment programs was analyzed using a two-part choice model utilizing logistic and linear regression. Patients living farther from their source of outpatient mental health care were less likely to obtain aftercare following inpatient substance abuse treatment. Patients who traveled 10 miles or less were 2.6 times more likely to obtain aftercare than those who traveled more than 50 miles. Only 40% of patients who lived more than 25 miles from the nearest aftercare facility obtained any aftercare services. Patients who received aftercare services had fewer visits if they lived farther from their source of aftercare. Lack of geographic access (distance) is a barrier to outpatient mental health care following inpatient substance abuse treatment, and influences the volume of care received once the decision to obtain aftercare is made. Aftercare services must be geographically accessible to ensure satisfactory utilization.     

Birth outcomes for infants born to women participating in integrated substance abuse treatment programs: A meta-analytic review

Background: Infants born to women with substance abuse issues are at increased risk for prematurity, low birth weight, and impaired physical development. Integrated programs (programs that integrate on-site pregnancy-, parenting-, or child-related services with substance use treatment) have been developed to address these risks, barriers to accessing care, and the unique needs of pregnant women who abuse substances.

Method: To examine the effects of integrated programs on birth outcomes, we compiled a database of 10 studies (N?=?2471) of integrated programs published between 1990 and 2009 with birth outcome data. Data were summarized and meta-analyses were performed.

Results: Compared to women with substance abuse issues not in treatment, women in integrated programs had infants with significantly higher birth weights, larger head circumferences, fewer birth complications, positive toxicology screens, and low birth weight classifications (d's?=?0.42–0.87). Women in integrated programs attended significantly more prenatal visits (d?=?2.20) and had significantly fewer pre-term births (d?=?0.35) than women in non-integrated programs.

Conclusions: This is the first systematic quantitative review of studies evaluating the impact of integrated programs on birth outcomes. Findings suggest that integrated programs may be associated with advantages over non-integrated programs in increasing women's participation in prenatal care and decreasing premature delivery. This review highlights the need for further research with improved methodology, study quality, and reporting to improve our understanding of how best to meet the needs of pregnant women with substance abuse issues.     

Sexual abuse, parental bonding, social support, and program retention for women in substance abuse treatment

Residential programs that provide safe environments and child care can attract perinatal women into treatment. Other factors, however, may prevent some women from benefiting from these programs. Attachment theory suggests that one's early history determines the effectiveness with which one can utilize available social supports. Lower levels of program retention were predicted for women who had been sexually abused and for those who had poor early bonding. Eighty-four women in residential substance abuse treatment programs were studied. Clients who reported sexual abuse also reported lower parental care. Parental care and overprotection were inversely related, and related, in predicted directions, to perceptions of social supports. Sexual abuse alone was associated with time in treatment and the likelihood of graduation. Implications for developing effective counseling programs for women in substance abuse treatment are discussed.     

Stability of Outcomes Following Residential Drug Treatment For Patients with Co-occurring Disorders

OBJECTIVE: Few studies have examined the stability of both substance use and mental health outcomes following residential drug abuse treatment for individuals with co-occurring disorders (COD). This study examines outcomes at 6 and 12 months for individuals with COD, in relationship to services received over the follow-up period. METHODS: Participants with COD (N=310) were sampled from 11 residential drug abuse treatment programs and completed in-depth assessments within 30 days of intake and at 6- and 12-month follow-ups. A path model was developed testing the relationships among treatment participation and services received, psychological status, and substance use outcomes across the two follow-up points. RESULTS: Retention for at least 90 days in residential drug treatment was associated with less inpatient mental health treatment and more mental health services received at 6 months; outpatient mental health treatment was associated with reduced substance use at 6 months. Substance use at 6 months was associated with more psychological distress at both 6 and 12 months and more inpatient mental health treatment at 12 months. CONCLUSIONS: Findings suggest that receipt of mental health services following residential drug abuse treatment for patients with COD is critical to improving their longer-term outcomes.     

Pregnant adolescents in chemical dependency treatment. Description and outcomes

This study examines the treatment, maternal and infant outcomes of pregnant adolescents (16-19 years) enrolled in an adult perinatal chemical dependency treatment program. Twenty-one adolescent subjects were compared to 323 adult women (mean age, 27.4 years) after enrollment into a randomized treatment trial consisting of intensive outpatient or short-term residential conditions. The results show a similar treatment retention rate. Adolescents differed from adult women on marital status, drugs of choice (alcohol, marijuana vs. opiates and cocaine) and method of administration, with no injection drug users in the adolescent cohort. Tobacco use was high (> 85%) in both groups. Obstetric, maternal, and infant outcomes to 1 year were comparable. Older adolescents who are chemically dependent and pregnant have treatment needs similar to adult women and can benefit from programs designed to treat older women. Recruitment difficulties for adolescents in need of treatment is discussed.     

Behavioral Strategies to Improve Treatment Participation and Retention by Pregnant Drug-Dependent Women

The present study examined the utility of behavioral incentives for improving early treatment participation and retention in a sample of 91 pregnant opiate and/or cocaine dependent women enrolled in an urban, university-based drug user treatment program between 1996 and 1997. An escalating voucher incentive system was compared to standard care. The relationship between treatment participation and retention and maternal and infant outcomes were examined using logistic regression, chi-square analyses, and t-tests. Behavioral incentives did not decrease rates of very early dropout from residential treatment, although improved outpatient treatment participation and retention during the transition from residential care was noted. Behavioral strategies demonstrate utility as adjuncts to counseling for high-risk substance dependent patients. They appear ineffective, however, for improving early residential treatment participation and retention, suggesting other variables (e.g., psychiatric comorbidity) may be operating during the first 24–48 hours post treatment admission.     

Behavioral strategies to improve treatment participation and retention by pregnant drug-dependent women

The present study examined the utility of behavioral incentives for improving early treatment participation and retention in a sample of 91 pregnant opiate and/or cocaine dependent women enrolled in an urban, university-based drug user treatment program between 1996 and 1997. An escalating voucher incentive system was compared to standard care. The relationship between treatment participation and retention and maternal and infant outcomes were examined using logistic regression, chi-square analyses, and t-tests. Behavioral incentives did not decrease rates of very early dropout from residential treatment, although improved outpatient treatment participation and retention during the transition from residential care was noted. Behavioral strategies demonstrate utility as adjuncts to counseling for high-risk substance dependent patients. They appear ineffective, however, for improving early residential treatment participation and retention, suggesting other variables (e.g., psychiatric comorbidity) may be operating during the first 24-48 hours post treatment admission.     

Treatment for substance use disorders in a privately insured population under managed care: costs and services use

The study investigated the relationship of substance use disorders, concurrent psychiatric disorders, and patient demographics to patterns of treatment use and spending in behavioral health and medical treatment sectors. We examined claims data for individuals covered by the same organization. Services spending and use were examined for 1899 individuals who received substance use disorder treatment in 1997. Medical and pharmacy spending was assessed for 590 individuals (31.1%). The most prevalent services were outpatient, intensive outpatient, residential, and detoxification. Average mental health/substance abuse (MHSA) care spending conditional on use was highest for those with concurrent alcohol and drug disorders ($5235) compared to those with alcohol ($2507) or drugs ($3360) alone; other psychiatric illness ($4463) compared to those without ($1837); and employees’ dependents ($4138) compared to employees ($2875) or their spouses ($2744). A significant minority also sought MHSA services in the medical sector. Understanding services use and associated costs can best be achieved by examining services use across treatment sectors.     

A performance measure for continuity of care after detoxification: Relationship with outcomes

Administrative data from five states were used to examine whether continuity of specialty substance abuse treatment after detoxification predicts outcomes. We examined the influence of a 14-day continuity of care process measure on readmissions. Across multiple states, there was support that clients who received treatment for substance use disorders within 14-days after discharge from detoxification were less likely to be readmitted to detoxification. This was particularly true for reducing readmissions to another detoxification that was not followed with treatment and when continuity of care was in residential treatment. Continuity of care in outpatient treatment was related to a reduction in readmissions in some states, but not as often as when continuity of care occurred in residential treatment. A performance measure for continuity of care after detoxification is a useful tool to help providers monitor quality of care delivered and to alert them when improvement is needed.     

Service-Level Costing of Drug Abuse Treatment

This paper presents a methodology for estimating costs of delivering specific substance abuse treatment services. Data collected from 13 programs indicate that the mean cost of residential treatment is $2,773 per patient per month, and outpatient treatment costs average $636 per patient per month. Data are presented on the cost per patient per month for individual treatment and nontreatment services, average number of services, cost per unit of service, and intensity of services. In addition to their application to insurance benefit cost estimation, these data illustrate the costing of best-practice adolescent treatment consistent with a Center for Substance Abuse Treatment (CSAT) Treatment Improvement Protocol. In the emerging policy environment, detailed cost estimates like these will aid the design of cost-effective treatment programs, and serve the development of the substance abuse benefit in a health care reform insurance package.     

Prenatal care utilization and foetal outcomes at Harare Maternity Hospital, Zimbabwe

OBJECTIVES: To examine the association between adverse infant outcomes and maternal under utilization of prenatal care, among women delivering at Harare Maternity Hospital. DESIGN: Hospital based, cross sectional study. SETTING: Harare Maternity Hospital, Harare, Zimbabwe. SUBJECTS: A random sample of 3,864 pregnant women. MAIN OUTCOME MEASURES: Prenatal care utilization, maternal socio-demographic information, as well as birth weight and other neonatal outcome characteristics. RESULTS: Of the total number of women who participated in this study 3,491 (90%) had at least one prenatal care visit. Women receiving no prenatal care, were more likely to be younger, unmarried and to have been transferred for delivery as compared with women receiving prenatal care. Women receiving no prenatal care were seven times more likely to deliver an infant weighing less than 1,500 grams, adjusted odd ratio (OR) = 7.22; 95% confidence interval (CI) 4.58 to 11.39 as compared with those who booked for care. Newborns of unbooked mothers were more likely to have a low apgar score at birth, adjusted OR = 1.71; to have been admitted to the neonatal intensive care unit, adjusted OR = 2.14, and to require intubation, adjusted OR = 3.35. A large proportion of women (31.4%) initiated prenatal care after 30 weeks gestation. CONCLUSIONS: There were significant differences between maternal characteristics and foetal outcomes in relation to booking status. Under utilization of prenatal care was associated with sub-optimal foetal outcomes. Improving the socio-economic status of women, their education and access to health care, and family planning methods are all strategies that should contribute to the reduction of adverse foetal outcomes.     

Outcomes at 1 and 5 years for older patients with alcohol use disorders

Older patients with alcohol use disorders who had gone through residential treatment were compared with matched groups of young and middle-aged patients (N = 432 in each age group) on their 1- and 5-year outcomes, use of continuing care services, and outcome predictors. Older patients had better outcomes than did young and middle-aged patients but had comparable levels of continuing substance abuse care and 12-step self-help group involvement. Similar factors predicted outcomes across the age groups. Longer duration of continuing substance abuse care and greater self-help group involvement were related to better outcomes, as were patients' attitudes and coping strategies at program discharge. The findings indicate that older patients with alcohol use disorders respond to age-integrated substance abuse treatment programs at least as well as do younger patients and are equally involved in formal and informal continuing substance abuse care.     

The influence of legal coercion on dropout from substance abuse treatment: results from a national survey

Legal coercion is frequently used to leverage substance abuse treatment upon persons who would otherwise not seek it voluntarily. Various methodological and conceptual problems of the existing research have prevented a clear understanding of its effectiveness. The influence of legal coercion on retention in substance abuse treatment was examined using a national survey of programs in the public sector of care and three different treatment modalities including short-term residential (N=756), long-term residential (N=757), and outpatient treatment (N=1181). Legal coercion was found to reduce the risk of dropout across all three treatment modalities. The greatest effect was among persons in short-term residential treatment. The smallest effect was observed in outpatient treatment. This study shows that legal coercion significantly reduces the risk of dropout in substance abuse treatment. However, the differential effects across treatment conditions must be carefully considered when using coercion to involve individuals in treatment.     

The Perinatal Outcome of Children Born to Women With Substance Dependence Detoxified in Residential Treatment During Pregnancy

There is growing documentation that infants exposed to opioids and poly-substances prenatally have an increased risk of aberrant development. In Norway, there are several in-patient clinics that specialize in medically supervised detoxification for pregnant women with substance dependence in a therapeutic setting. Because there is virtually no documentation on the perinatal outcome of the infants born to mothers receiving such treatment, this study aims to investigate the perinatal outcome of children born to mothers with opioid and poly-substance dependence detoxified in a residential setting during pregnancy compared with infants born to women with substance dependence at a time when no such treatment was available. Pregnant women from two time cohorts were followed from pregnancy to birth. Birth weight, head circumference, gestational age, and neonatal abstinence syndrome (NAS) were measured in infants born to mothers detoxified in a residential setting during pregnancy and compared with infants born to mothers receiving no treatment. Both study groups had concurrent comparison groups. Infants born to mothers in residential detoxification treatment experience less prenatal drug exposure and show better perinatal outcomes on gestational age and head circumference, as well as no NAS, compared to the infants in the earlier cohort whose mothers did not receive residential treatment. No miscarriages, complications, or morbidities were associated with residential detoxification treatment. Detoxification in residential treatment can be a preferred treatment form for many pregnant women struggling with drug abuse problems and should possibly be applied to a larger extent to ensure the best possible perinatal outcome for these children.     

Specialized substance abuse treatment for women and their children: an analysis of program design

In the present study, 36 specialized substance abuse treatment programs for women and their children were identified and chosen for review. These programs provide a wide range of services including substance abuse, mental health and medical treatment, life skills training (i.e. vocational and parenting training), and social services (i.e. child care and transportation). A cluster analysis was conducted, and three distinct patterns of program design were identified. Results suggest that programs vary considerably regarding the extent to which comprehensive services are provided and to whom they are offered. Many programs that appear to be comprehensive fail to provide the full range of services to all those who need them. In particular, many programs for pregnant women seem to focus almost exclusively on pregnancy-related issues. As such, specialized substance abuse treatment for women may be at risk for becoming too specialized. Recommendations are made for future substance-related program planning for women and their children.