Substance Use Disorder in Pregnant Women: State of the Problem, Treatment, and Recommendations for Improving Interventions

This is Issue 12 of the On Women’s Health Series.

Executive Summary

• In addition to the adverse health effects substance use disorders have on pregnant mothers, they can also have a variety of dangerous, even lethal, effects on their unborn children, ranging from miscarriage, preterm birth, low birth weight, stillbirth, cognitive/behavioral impairments, to a host of other lasting medical problems.

• By some estimates, women constitute around 40% of those suffering from a drug use disorder and 26% of those suffering from both drug and alcohol abuse in the U.S, with many thousands of these women abusing drugs or alcohol during pregnancy. One of the most common drug use disorders in the U.S. is opioid use disorder (OUD).

• Depending on the particular indications of a pregnant woman suffering from OUD, interventions may involve Medication-Assisted Treatment (MAT) with opioid agonists, Medically Supervised Detoxification with the goal of tapering the woman off the drug entirely, and/or behavioral interventions such as counseling and group therapy.

• Babies born with withdrawal-related disorders such as Fetal Alcohol Syndrome or Neonatal Opioid Withdrawal Syndrome may either receive nonpharmacological interventions such as rooming-in with the mother, minimizing sensory stimulation, and ensuring adequate sleep and nutrition; pharmacological treatments if indicated, such as with opioid agonists; and/or a combination of both.

• Recommendations for improving treatment approaches include increasing access to MAT in primary care settings, ensuring informed consent regarding the benefits and potential risks of MAT, ensuring that MAT programs offer adequate mental health and other holistic support, and increasing state funding for research into best practices for treating SUD in pregnant women.

 

I. Introduction

Substance use disorder (SUD), or drug addiction, can have a uniquely devastating impact on pregnant women and their children. Common forms of SUD include alcoholism, opioid abuse, methamphetamine addiction, and other kinds of unhealthy dependence. In addition to the adverse health effects these disorders have on pregnant mothers suffering from SUD, they may also have a variety of dangerous, even lethal, effects on their unborn children, ranging (depending on the particular substance involved) from Fetal Alcohol Syndrome, Neonatal Opioid Withdrawal Syndrome, stillbirth, to a host of other developmental impairments and medical vulnerabilities that may follow such children throughout their lives.

This paper will begin by exploring the scope of the problem of various kinds of substance abuse in pregnant women and their impact on unborn children. It will then turn to an analysis of current treatment approaches, best practices, and promising models in order to provide some general recommendations for improving care.

II. Scope of the Problem

According to the National Center for Drug Abuse Statistics, as of 2023, 51.2% of Americans 12 years and older had used illicit drugs at least once, 47.7 million were currently using illegal drugs, and 38.6% of people using illegal drugs had a substance use disorder.^[1] As mentioned previously, the national problem of SUD extends to pregnant women and their unborn children. By some estimates, women constitute around 40% of those suffering from a drug use disorder and 26% of those suffering from both drug and alcohol abuse. Many of these women abuse drugs or alcohol during pregnancy.^[2] For example, a national study by the Substance Abuse and Mental Health Services Administration (SAMHSA) in 2020 found that 8.3% of surveyed pregnant women aged 15-44 had used illicit drugs in the past month. This was up 54% from 2018, though down 2.4% from 2017.^[3] Abusing multiple substances (“polysubstance use”) during pregnancy is also common. In a 2020 study conducted by the Centers for Disease Control and Prevention (CDC), 41.7% of pregnant survey respondents who reported drinking in the previous 12 months had also used at least one other substance during that same period, the most common of which were tobacco, marijuana, and opioids.^[4]

Neonatal Abstinence Syndrome (NAS), typically caused by maternal opioid abuse, was found in 2% of newborns encountered in a 2018 study of 136,762 neonates at 23 U.S. hospitals.^[5] The CDC estimates that these rates are even worse when it comes to Fetal Alcohol Spectrum Disorders (FASDs): “Up to 1 in 20 U.S. school-aged children,” says the CDC, “may have fetal alcohol spectrum disorders,” emphasizing that those with FASDs “can experience lifelong issues.”^[6]

In the following subsections, data related to some of the most common substances implicated in SUD for pregnant women and their unborn children will be unpacked in greater detail.

A. Opioids

Opioid addiction and deaths have increased substantially in recent decades.^[7] Between 2002 and 2022, the overall number of deaths from opioids increased by 586%, from 11,920 to 81,806. In that same period, the age-adjusted death rate from opioids rose from 4.1 per 100,000 to 25, an increase of 510%.^[8] In 2023, SAMHSA data from its National Survey of Drug Use and Health (NSDUH) showed that 4 million U.S. women aged 18+ had misused opioids in the past year, and 4.3 million aged 12+.^[9] It should be noted here and elsewhere where NSDUH data is mentioned, however, that these numbers are likely substantial undercounts, as the NSDUH survey results are based on self-reports and exclude two populations where drug abuse is most common: among those who are living “without a fixed household address (e.g., homeless and/or transient people not in shelters)” and “residents of institutional group quarters, such as jails or hospitals.”

Important for contextualizing this data is that, with the introduction of synthetic opioids such as fentanyl, the potency/lethality of opioids has increased. As Phil Skolnick writes in his 2022 paper Treatment of overdose in the synthetic opioid era, “Over the past 7–8 years, there has been an alarming increase in the misuse of synthetic opioids (‘synthetics’), primarily fentanyl and related piperidine-based analogs.”^[10] Citing CDC data from Ahmad et al. (2021),^[11] he goes on to point out that synthetics were involved in over 80% of fatal U.S. opioid overdoses in 2020. This is unsurprising, given that such synthetic opioids can have a potency as high as 50 times that of heroin.^[12]

There is evidence, moreover, that women are more at risk than men for developing opioid use disorder (OUD) and experiencing the worst of its effects,^[13] a problem only compounded by pregnancy. One study found that approximately 7% of women surveyed in 2019 reported using prescription opioid pain medications during pregnancy. Among these women, 20% reported misusing the opioids, where “misuse” was defined as either using the opioids for reasons other than pain alleviation or obtaining prescription opioid pain medications from a non-medical source.^[14] And, according to 2023 SAMHSA data, 4,000 women surveyed reported misusing opioids while pregnant in the past month (not including illegally made fentanyl).^[15]

Neonatal Consequences

Being pregnant while suffering from OUD can adversely impact the unborn child in the form of Neonatal Abstinence Syndrome (NAS), a condition in which the newborn baby experiences withdrawal from the opioids he or she was exposed to in utero. The type of NAS specific to opioid abuse is referred to as Neonatal Opioid Withdrawal Syndrome (NOWS), though the terms are often used interchangeably since NOWS is the most common type of NAS. A 2012 study by Patrick et al. found that, of infants exposed to opioids during pregnancy, around 60-80% will develop NOWS.^[16]

In NOWS, it is primarily the central nervous system and gastrointestinal tract that are impacted, where most opioid receptors are found. Although the clinical presentation of NOWS can vary according to factors like the kind of opioid abused, maternal metabolism, and maternal drug history, general symptoms of NOWS can include central nervous system irritability, tremors, seizures, difficulty feeding, fever, and excessive high-pitched crying.^[17] There is also some evidence to suggest longer-term effects on those born with NOWS well into their childhood, such as issues with motor development as well as cognitive and behavioral problems.^[18]

The number of babies in the U.S. born with NAS saw an 82% increase between 2010 and 2017,^[19] and the incidence of NOWS specifically rose from 1.2 to 8.8 per 1,000 hospital births between 2000 and 2016.^[20] However, it appears that rates of NAS began to improve in 2017 and have been steadily declining ever since: from 2017 to 2022, rates of NAS decreased from 7.3 to 5.4 per 1,000 newborn hospitalizations.^[21] The extent of this problem varies considerably by state.^[22] As of 2022, some of the worst rates of NAS among hospitalized newborns were in states like Maine, Vermont, New Mexico, and West Virgina. In a 2021 study of the West Virginia obstetric population between 2016-2019, Patel et al. found that, of 783 births, there was a shocking 20.9% positive screening rate for opioid use.^[23] As of 2022, West Virginia’s NAS rate was 33.4 per 1,000 newborn hospitalizations, the highest by far in the country. By contrast, in states like Iowa, Nebraska, and Hawaii, rates were far lower (2, 1.4, and 0.9, respectively).^[24] Despite the continuing serious rates of NAS in states like West Virginia, however, there have also been significant decreases reflecting the national downward trend: from 2017 to 2022, West Virginia’s NAS rate dropped to 33.4 from a peak of 56.2 in 2017.

Although there are signs of hope,^[25] the prevalence of OUD in pregnant women and consequent NOWS in their children remains unacceptably high and, as discussed below, the approach to treatment ought to be based on the best evidence-based recommendations.

B. Ecstasy/MDMA

Ecstasy, or 3,4-Methylenedioxymethamphetamine (MDMA), is a psychoactive drug that acts as a hallucinogen and stimulant, primarily used for recreational purposes. SAMHSA reported that, in 2023, 0.8% of people 12 and older in the U.S. had used ecstasy in the past year, or around 2.1 million.^[26],[27]  The same data showed that 3.7 million U.S. women aged 18+ had misused central nervous system stimulants (of which ecstasy is a sub-type) in the past year, ^[28] and 161,000 women 18+ had used hallucinogens (of which ecstasy is also a sub-type).^[29] Similar to OUD, some evidence suggests that women may be more susceptible than men to stimulant abuse and addiction.^[30]

In 2023, among 183,000 reproductive age women who had used ecstasy in the past month, 3,000 (1.6%) were pregnant.^[31] According to Marcela et al., “stimulants are the second most widely used and abused substances during pregnancy and pregnant women using stimulants in pregnancy are at increased risk of adverse perinatal, neonatal, and childhood outcomes.”^[32]

Whether or not ecstasy is addictive has not yet been settled by research. However, it is plausible that it can be given that it appears to impact the brain in a way similar to other addictive substances. There are some animal experiments, for example, in which MDMA elicited behaviors akin to those resulting from addictive drugs like opioids and cocaine, such as self-administration.^[33] The evidence, however, is inconclusive. Summarizing some of the literature on the subject in 2018, Lee et al. emphasized that “[i]nterpretation of self-administration studies using MDMA are complicated by a variety of factors such as dose, timing, and prior exposure of the test animals to other drugs of abuse.”^[34] Still, it is clear that ecstasy has detrimental effects on users. As Singer et al. explained, “Immediate feelings of energy, sociability, euphoria, enhanced sensory perception, and emotional connectedness frequently give way to depressive symptoms and executive function and memory impairments with chronic use.”^[35]

Neonatal Outcomes

Regardless of whether ecstasy is truly addictive like the other drugs discussed in this paper, there is evidence supporting the conclusion that exposure to MDMA during pregnancy can have adverse consequences for the unborn child.

A series of papers by Singer et al. were the first to provide evidence using a prospective, controlled study design for this conclusion. For the first 2012 paper, 96 U.K. women, 28 of which were ecstasy users and 68 of which were not, were studied. It was found that “MDMA exposed infants differed in sex ratio (more male births) and had poorer motor quality and lower milestone attainment at 4 months,” and these outcomes had a dose-response relationship to the amount of drug exposure.^[36] In the second 2012 study, the one-year outcomes of the same cohort were evaluated. The amount of exposure babies had to ecstasy in utero predicted “poorer mental and motor development at 12 months in a dose-dependent manner.”^[37] In 2016, Singer et al. followed up with the same cohort at two years of age, finding that prenatal MDMA exposure was again associated with motor delays for up to two years after birth.^[38]

Studies on humans are thus strongly suggestive but limited. Preclinical studies on rats, however, have also evidenced a variety of detrimental effects MDMA exposure may have on infants. These findings include that ecstasy can cross the placenta,^[39] that offspring can have growth retardation and reductions in bodyweight,^[40] and that learning and memory can be adversely impacted following ecstasy exposure.

C. Methamphetamine

Methamphetamine is a sub-type of amphetamine, a class of drugs that stimulates the central nervous system.^[41] In the form the drug is typically sold on the street, it is often referred to as “crystal meth.”^[42] Adverse effects of methamphetamine can include irregular heartbeat, paranoia, anxiety, memory loss, and, in the worst case, death.^[43] In 2023, SAMHSA estimated that 2.6 million people aged 12 years and older used methamphetamine in the past year, and 1.8 million suffered from methamphetamine use disorder.^[44]

Although men appear to abuse methamphetamine at higher rates that women, the problem for women is still notable. Of women aged 12 and older in 2023, over 6.5 million reportedly used methamphetamine during their lifetime,^[45] and 984,000 used the drug in the past year.^[46] That same year, 2,000 of 369,000 reproductive age women who reportedly used methamphetamine in the past month were pregnant (or just over 0.5%).^[47] Use of this stimulant during pregnancy can have serious adverse consequences for maternal outcomes: In a 2024 retrospective cohort study of California women using data spanning 2008-2019, it was found that pregnant women who used methamphetamine were at increased risk for severe preeclampsia, cardiovascular morbidity, placental abruption, severe maternal morbidity, and other issues.^[48]

Neonatal Outcomes

Neonatal outcomes can be negatively impacted by methamphetamine use during pregnancy. The aforementioned 2024 study of California women by Sarena et al., for example, found increased risks of preterm birth, infant death, and neonatal intensive care unit admission among babies born of women who used methamphetamine.^[49]

“Methamphetamine use in pregnancy is associated with an increased risk of adverse maternal and neonatal outcomes that persists after adjustment for confounding variables and sociodemographic factors,” the authors concluded. Pham et al., in a 2020 retrospective cohort study of women who gave birth between January and December 2015, discovered similar results. In the study, the outcomes of a group of women who tested positive for methamphetamine prior to giving birth were compared to a group of women who did not test positive. The babies of those who used methamphetamine were at increased risk for preterm birth and perinatal demise.^[50]

Potential adverse effects of exposure to methamphetamine in utero, however, may not be limited to the period immediately after birth. There is evidence suggesting that a variety of physical and mental issues can result from such exposure and last into childhood, some of which may be due to the drug’s neurotoxic effects on the baby.^[51] One study by Linda et al. in 2012 found that prenatal exposure to methamphetamine was associated with problems with anxiety, depression, and emotional reactivity at ages three and five, and ADHD-related problems by age five.^[52] Similarly, research by Diaz et al. revealed that children exposed to methamphetamine “had significantly higher cognitive problems” which “may impact academic achievement and lead to increased negative behavioral outcomes.”^[53] A 2022 meta-analysis of the literature found associations between exposure to the drug in utero and poorer language development, intellectual functioning, and short-term memory in such children.^[54]

D. Benzodiazepines

Benzodiazepines (such as Xanax, Valium, and Klonopin/Clonazepam), or “benzos,” are indicated for the treatment of seizures and anxiety-related disorders, in addition to being used as pre-anesthetic sedatives. Classified as “nervous system depressants,” they work by slowing down brain and nervous system activity.^[55]

In 2023, over 3.6 million Americans 12 and older were found to have used benzodiazepines illicitly in the past year.^[56] Men are less likely than women to be prescribed benzodiazepines, though rates of misuse appear to be comparable. However, McHugh et al. found that women tend to misuse benzodiazepines to cope with anxiety or sleeping issues more often than men, who instead tend more often to use the drugs for “enhancement” (defined as “to feel high/euphoria” or “out of curiosity”).^[57] In 2023, 4,277 women died of benzodiazepine overdose.^[58]

Neonatal Outcomes

Between 2006 and 2011, benzodiazepines were the second most commonly used psychotropic medicine during pregnancy,^[59] and misuse of the drugs by pregnant women comes with a number of risks for neonatal outcomes. Potential risks include miscarriage,^[60] admission to the NICU,^[61] and preterm birth.^[62],[63] A 2017 study by Yonkers et al. also found associations between maternal benzodiazepine use and cesarean delivery, use of ventilatory support for the baby, and low birth weight.^[64] Additionally, there is a danger of infants developing NAS from intrauterine exposure to benzodiazepines, particularly in cases of polysubstance use.^[65],[66]

E. Barbiturates

Barbiturates are a type of central nervous system depressant historically used to treat a variety of conditions, including epilepsy, insomnia, and anxiety.^[67] The consequences of barbiturate abuse can be severe and may include hypotension, respiratory depression, apnea, and even coma.^[68] Among U.S. individuals 12 and older in in 2023, 19,000 reportedly misused barbiturates in the previous year.^[69] Abuse of this class of drug used to be more prevalent, but since the development of similar drugs with superior safety profiles in the 1970s, such as benzodiazepines, such abuse has decreased.^[70]

Neonatal Outcomes

Use or abuse of barbiturates by pregnant women may cause neonatal complications. There is some research suggesting that taking the common anti-seizure barbiturate phenobarbital during pregnancy, for example, carries risks (even if slight) of birth defects and withdrawal symptoms.^{[71],[72],[73],[74]} In this vein, a recent study by Battino et al. found that phenobarbital, along with several other anti-seizure medications, increased the risk of major congenital malformations in a dose-dependent manner.^[75]

F. Marijuana (delta-9-tetrahydrocannabinol (THC))

Marijuana is the most commonly used illicit drug during pregnancy.^[76] The primary active ingredient in marijuana is THC, which can cause a variety of adverse effects when used at intoxicating levels. These may include memory problems, anxiety, impaired thinking, elevated heart rate, dissociation, and (when smoked) lung damage.^[77]

According to SAMHSA’s 2023 NSDUH report, 61.8 million people 12 and older had used marijuana illicitly in the past year, and 43.6 million in the past month.^[78] Of the 61.8 million, 28.6 million were female.^[79] There were 12.7 million women of reproductive age who reported using marijuana in the past month, 85,000 of which (3%) were pregnant.^[80] Studies have also found marijuana use rates as high as 2-5% among pregnant women.^[81] West Virginia again serves as a case study in how severe this problem can become: in the WV obstetric population studied in Patel et al., 326 of 783 pregnant patients, or 41.64%, screened positive for THC.^[82]

As in the case of opioids, it is important to contextualize data on the potential harms to both women and unborn children from marijuana by noting that the potency of this drug has increased over time, with far higher concentrations of THC than was the case (say) in the 1970s or 80s. In a 2016 study, for example, ElSohly et al. found that “[o]verall, the potency of illicit cannabis plant material has consistently risen over time since 1995 from approximately 4% in 1995 to approximately 12% in 2014.”^[83] Writing on the health risks of rising THC concentrations in cannabis for Yale School of Medicine in 2023, Isabella Backman came to a similar conclusion:

Over the last several decades, the THC content of cannabis has changed substantially. In 1995, the average THC content in cannabis seized by the Drug Enforcement Administration was about 4%. By 2017, it had risen to 17% and continues to increase. Beyond the plant, a staggering array of other cannabis products with an even higher THC content like dabs, oils, and edibles are readily available—some as high as 90%. “The marijuana and cannabis products that your grandparents may have used are very different from what’s out there now,” says Deepak Cyril D’Souza, MD, Albert E Kent Professor of Psychiatry at Yale School of Medicine.”^[84]

A 2023 article in The New Scientist affirmed this conclusion, explaining that the cannabis now commonly used “contains more than 10 times as much THC, on average, than it did in the 1970s.”^[85]

Neonatal Outcomes

Prenatal exposure to THC may have a variety of negative consequences for the unborn child.^[86] A 2025 systematic review and meta-analysis of 51 studies by Lo et al. found that, even adjusting for simultaneous use of tobacco products, prenatal marijuana use was associated with increased risk of low birth weight, preterm birth, and being small for gestational age. The study also concluded that use of cannabis during pregnancy may carry a risk of perinatal mortality, though the evidence for this connection was weakest.^[87]

Congenital anomalies may also be a risk of prenatal marijuana use. In a 2022 analysis of several large data sets that sought to establish a causal connection between cannabis use and congenital anomalies, Reece and Hulse concluded that “[d]ata implicate cannabinoids including cannabidiol [CBD] in a diverse spectrum of heritable [congenital anomalies].”^[88] Some of the more notable anomalies associated with THC exposure specifically included cardiovascular defects, limb defects, spina bifida, and chromosomal abnormalities. Similar results were found by van Gelder et al.^[89]

Prenatal exposure to THC may also come with a moderate risk of stillbirth. In 2014, Varner et al. reported an increased stillbirth rate among THC users, both independently and in combination with other drugs.^[90] In a similar vein, a 2024 secondary-data analysis by Habersham, Hurd, and Nomura found a sevenfold increased risk of fetal death (miscarriage or stillbirth) among women who used marijuana during pregnancy. An elevated risk remained even after adjusting for potential confounders.^[91]

Although there are some studies suggesting a link between prenatal marijuana use and longer-term cognitive and behavioral difficulties,^[92] the evidence overall is mixed. A 2017 review of the extant literature by the National Academies of Sciences, Engineering, and Medicine concluded that “[t]here is insufficient evidence to support or refute a statistical association between maternal cannabis smoking and later outcomes in the offspring.”^[93]

G. Alcohol

Alcohol is by far the most commonly abused substance in the U.S. In 2023, 134.7 million Americans 12 years old and over reportedly used alcohol in the past month, of which 61.4 million (46%) binged alcohol and 16.4 million (12%) used alcohol heavily.^[94] That same year, an estimated 27.8 million women 12+ had binged alcohol in the past month,^[95] and 6.6 million engaged in heavy alcohol use.^[96] Further, 91,000 pregnant women, or 4.8% of women of reproductive age,^[97] reportedly binged alcohol in the past month, 1,000 of which engaged in heavy alcohol use.^[98]

Neonatal Outcomes

Because no amount of alcohol is considered safe for the fetus during pregnancy, total abstinence is recommended by the CDC, American College of Obstetricians and Gynecologists (ACOG), and other professional organizations.^[99] Conditions negatively impacting the fetus caused by prenatal alcohol consumption are collectively referred to as Fetal Alcohol Spectrum Disorders (FASDs),^[100] and it is estimated that as many as 1 in 20 school-aged children in the U.S. may have FASDs.^[101] Fetal Alcohol Syndrome (FAS) is the most severe of these disorders.

According to the CDC, children born with FASDs may suffer from a variety of physical, behavioral, and cognitive problems, including but not limited to attention issues, hyperactivity, learning disabilities, intellectual disabilities, cardiovascular and bone-related issues, problems with vision or hearing, and abnormal facial features.^[102] Babies whose mothers drank during pregnancy may also suffer from a variety of structural malformations impacting the kidneys, heart, or skull.^[103] Those with FAS specifically have central nervous system problems and stunted growth, and may also suffer from a combination of cognitive/behavioral issues, such as with attention, memory, learning, and/or communication.^[104]

Prenatal alcohol exposure also comes with an increased risk of miscarriage, and this risk appears to be dose related. It has been estimated that for pregnant women who have five alcoholic drinks or less per week (approximately one per day), there is a 6% increase in miscarriage risk per each additional drink.^[105] Moreover, risk of miscarriage has been found to increase for every additional week of alcohol consumption during the first trimester.^[106] Preterm birth, stillbirth, and sudden infant death syndrome can also result from prenatal alcohol use.^[107]

H. Cocaine

According to SAMHSA, 42,280,000 people aged 12 or older reported using cocaine at some point during their lifetime in 2023 (14.9% of those surveyed), and 1,814,000 had used cocaine in the past month (0.6% of those surveyed).^[108] Additionally, 17,915,000 of those 12+ who used cocaine at some point in their lifetime were women (12.4%), with 1,792,000 women having used cocaine in the past year and 631,000 in the past month. Beginning around 2012, the rate of drug overdose deaths from cocaine began steadily climbing: in 2010, the rate was 1.3 per 100,000 standard population and rose to 8.2 by 2022.^[109]

Fortunately, cocaine use during pregnancy does not appear as prevalent as abuse of other substances, with only 4,000 pregnant women aged 15 to 44 reporting use of cocaine in the past month in 2023.^[110]

Neonatal Outcomes

A variety of risks to the baby attend the use of cocaine during pregnancy. These can include preterm birth, impaired fetal growth, cognitive and neurodevelopmental issues, central and autonomic nervous system disturbances, and a variety of placenta-related syndromes including premature rupture of membranes.^[111] Elaborating on the mechanism of action for some of the detrimental cognitive effects, Bonthius et al. write, “In the fetal brain, cocaine interacts with monoaminergic receptors, whereby it alters the physiology, structure, and survival of neurons and leads to long-term learning and behavior problems in prenatally exposed children.”^[112]

Some authors caution, however, that a variety of independent factors may contribute to the presence or severity of cocaine-associated neonatal impacts. For example, Bonthius et al. observe that while “[i]t is now appreciated that cocaine can damage a fetus, sometimes with permanent consequences, … that damage is typically either circumscribed in nature or subtle in severity.”^[113] And Cressman et al. point out in a 2014 paper that “recent systematic reviews and meta-analyses suggest that sociodemographic, environmental, and other factors … may make a contribution to these adverse neurodevelopmental outcomes that is equal to or even greater than cocaine.”^[114]

Regardless, cocaine use during pregnancy comes with definite risks of harm to the nascent child, and should be taken seriously and treated accordingly.

I. Polysubstance Use

Abuse of multiple drugs, or “polysubstance use,” is common among those struggling with a substance use disorder. SAMHSA’s 2023 survey found that 7,549,000 people 12 and older had both alcohol and a drug use disorder in the past year (2.7% of respondents),^[115] and according to the CDC, nearly half of drug overdose deaths in 2022 involved multiple drugs.^[116] Reviewing some of the literature on this question in 2021, Ellis et al. concluded that “recent research suggests that for many individuals living with addiction, particularly those with opioid use disorder, polysubstance use is the norm rather than the exception.”^[117]

Polysubstance use is also not uncommon among pregnant women struggling with addiction. A 2020 study by England et al., for example, found that, among the 10% of pregnant women reporting that they were currently using alcohol, around 40% reported also using other substances.^[118] Similarly, Tran et al. concluded in a 2023 systematic review that “[p]olysubstance use during pregnancy is common, especially with alcohol, marijuana, and/or tobacco/nicotine.”^[119]

Unfortunately, as noted by the CDC,^[120] the cumulative impact of polysubstance use specifically during pregnancy is not well known, in part because studies typically examine abuse of a single substance while not accounting for the potential presence of other substances. It stands to reason, however, that many of the same detrimental effects attributable to the individual substances involved would only compound harms to children in combination. Additionally, the possible presence of polysubstance use needs to be taken into consideration when considering Medication Assisted Treatment for OUD (more on which below) and inform the nature of the treatment approach taken.

III. Treating SUD: Best Practices and Professional Recommendations

Having surveyed the scope of the problem of women suffering from SUD in the United States, and potential impacts on their unborn children, we can now turn to a consideration of best practices and professional recommendations for treating substance abuse in pregnant women and treating NAS in their children. Because best practices for treating opioid abuse in pregnant women are in many ways the most researched and best developed, the following will focus on Opioid Use Disorder (OUD) treatment. However, a brief word about research related to recommended treatments for pregnant women with some of the other forms of SUD mentioned above may be helpful before proceeding to focus in on OUD.

Research on best practices for treating pregnant women with SUD involving methamphetamine, benzodiazepines, or marijuana is especially scant. However, broad interventions such as counseling and cognitive-behavioral therapy may improve outcomes.^[121] The ideal for pregnant women struggling with alcohol abuse is of course to achieve abstinence, especially since there is insufficient evidence of the prenatal safety of medications typically recommended for alcohol use disorder (AUD) pharmacotherapy.^[122],[123] However, given the potential risks of severe withdrawal for both mother and child, a cautious use of certain medications during pregnancy to manage withdrawal, such as benzodiazepines, may be recommended when the cost-benefit analysis for an individual’s situation calls for such an approach.^[124] Psychological interventions, such as counseling and cognitive-behavioral therapy, are also recommended to help women achieve abstinence or reduce harm from alcohol use during pregnancy.^[125]

Though the following material relates only to the treatment of OUD, some of the basic principles involved, such as the provision of holistic behavioral support in the form of counseling and related interventions, as well as ensuring interventions are evidence-based and take seriously the equal interests of all involved (mothers, families, and children born and unborn), may be generalized to treatment approaches for other forms of substance abuse.

A. Medication-Assisted Treatment (MAT)

Medication-assisted treatment (MAT) is the most commonly recommended approach to OUD, both in general and for pregnant women specifically. It is the default treatment endorsed, for example, by the CDC,^[126] SAMHSA,^[127] and ACOG.^[128] In MAT, an alternative opioid agonist is used as a safer substitute for the opioids to which the patient is addicted, typically either buprenorphine (a partial opioid agonist)^[129] or methadone (a full opioid agonist).^[130] Unlike the illicit opioids the patient had been using, these medications are long-acting and so not as dangerous, lessen the intensity of euphoria and respiratory depression, and act to reduce withdrawal symptoms and opioid cravings. A less frequently used MAT is naltrexone (a competitive opioid antagonist).^[131] This is typically not recommended as the ideal medication for use during pregnancy due to a lack of robust evidence supporting its effectiveness, risks of relapse and lowered tolerance to opioids, and consequent risk of overdose.^[132] Patients may either be on MAT for a specific period of time or indefinitely, depending on the nature and severity of OUD.

Taking all factors into consideration, MAT with buprenorphine or methadone is generally considered the safest and most effective treatment for both mother and child.^[133] For the pregnant mother, it has been shown to help prevent relapse and overdose.^[134] For the unborn child, there is evidence that MAT may help to reduce the incidence of preterm delivery and low birth weight.^[135] However, it is still expected that babies born of women underdoing MAT will suffer from NAS. This consequence is generally accepted as worth the risk, given the perceived greater risks of the mother relapsing or overdosing, which of course may prove lethal for the unborn child.

It’s important to note that continuation of MAT postpartum may be crucial for many women struggling with OUD. In a 2015 systematic review of literature on MAT discontinuation in pregnant and postpartum women (where “discontinuation” was defined as “stopping treatment with no plan for continued medication assisted treatment”), Wilder et al. found up to 33% of women discontinue MAT. Because of this reality, even if a child avoids NAS, women should be followed up with postpartum regarding treatment status.^[136]

Although both buprenorphine and methadone are approved for use in MAT, buprenorphine seems to be the preferred treatment as it has a number of advantages over methadone. As Chokshi et al. summarized, “Studies have shown efficacy, safety and improved neonatal outcomes [of buprenorphine] when compared to methadone.”^[137] A large cohort study published in 2022 by Suarez et al., for example, found that 52% of infants exposed to buprenorphine had NAS, whereas 69% exposed to methadone had NAS.^[138] The risks of preterm birth and low birth weight were also less relative to methadone.

Additionally, though the evidence is limited in this area, the research that does exist appears to suggest that use of MAT with methadone or buprenorphine is generally safe for the baby during breastfeeding. According to a 2015 systematic review by Holbrook and Nguyen, “there is minimal transmission of either methadone or buprenorphine to the neonate in breastmilk.”^[139]

However, MAT, like any other approach, does come with potential risks. “[I]ncreased access to MAT is not a silver bullet for the addiction crisis,” Font et al. emphasize. “At present, there is no approved MAT for addiction to stimulants such as cocaine and methamphetamine, and MAT may itself be abused, sold, or taken in combination with other illicit substances. Due to diversion of MAT prescriptions and improper storage, thousands of children have been poisoned by methadone and buprenorphine” (citations omitted).^[140] Because of these risks, implementation of MAT should always come with rigorous and evidence-based protocols and monitoring.

There are a variety of ways MAT can be implemented, which can broadly be divided into program-based and office-based approaches.^[141] One such model for MAT implementation is the “Hub and Spoke” model, in which, depending upon individual needs, patients receive MAT through specialized opioid treatment programs (“hubs”) and/or community clinics that provide more holistic care for patients with less complex cases (“spokes”).^[142] Another is Office-Based Opioid Treatment (or “OBOT”), in which trained and approved physicians prescribe naloxone and/or buprenorphine in a primary care setting, often with the assistant of a nurse or social worker who helps to coordinate more holistic, such as psychosocial, services.^[143] According to Lagisetty et al. (2018), “Primary care-based models for [MAT] have been shown to reduce mortality for [OUD] and have equivalent efficacy to MAT in specialty substance treatment facilities.”^[144] In a similar vein, Korthuis et al. (2016) found that treatment retention and positive outcomes for opioid use with OBOT were comparable to those found for methadone treatment programs.^[145]

Other models include emergency department initiation of OBOT; inpatient initiation of MAT, wherein OUD is identified in the hospital and MAT is initiated during the hospital stay; and integrated prenatal care and MAT, in which prenatal care is provided to pregnant women receiving buprenorphine treatment in a primary care setting.^[146] The latter is particularly relevant to the subject of this paper because, as Chou et al. (2016) explain, “this model can identify women with limited or no access to care who come into contact with the medical system for prenatal care and might benefit from MAT.”^[147]

To summarize, MAT continues to be the primary recommended treatment for pregnant women suffering from OUD, and research supports the notion that its known benefits will often outweigh the potential costs. Despite this, there is also evidence that in some cases and for some pregnant women, given the right supports, a detoxification approach may prove safe and effective.

 B. Medically Supervised Detoxification

Medically supervised detoxification (MSD) is an approach to SUD that seeks to achieve abstinence for the pregnant woman during her pregnancy and can be pursued either with or without the aid of MAT (though typically it is with the aid of MAT, given the more significant risks of severe withdrawal from acute detoxification). Although it is usually not recommended by professional organizations, in recent years a growing number of studies have begun to suggest that, when properly utilized, MSD can be a safe and effective option for some women.

In particular, this may be an option some women wish to pursue in order to avoid the NAS-related risks to their baby from continuing MAT throughout pregnancy. We have already seen that NAS is simply expected when women are treated with MAT throughout all of pregnancy. Moreover, some have suggested that the substitute opioids used for MAT, such as buprenorphine or methadone, may adversely impact the fetal brain long-term.^[148] As mentioned previously, there is always a cost-benefit analysis to be considered by women in consultation with their doctors in making such decisions, since there are also risks of detoxification. However, it cannot be ruled out in advance that in some cases and for some women, that cost-benefit analysis may end up favoring MSD.

Medically supervised detoxification can take place either in an inpatient or outpatient setting (or a mix of both—such as inpatient tapering followed by outpatient behavioral health support),^[149] and is usually used in conjunction with some form of pharmacotherapy (such as buprenorphine or methadone).^[150] However, unlike the standard uses of MAT during pregnancy explored above that do not have abstinence as the goal, in MSD pharmacotherapy is used in order to try to taper pregnant patients off of opioids completely. To support pregnant women in this difficult process, counseling or other behavioral and mental health supports may also be involved.

Data from a number of studies have supported the safety and efficacy of certain kinds of MSD for some women and their unborn children. In a 2016 retrospective analysis of women who underwent four different kinds of detoxification protocol (one of which was “acute” detox in a prison setting without opiate agonist support, two of which involved buprenorphine-supported inpatient detox, and the fourth of which involved slow buprenorphine-supported detox in an outpatient setting), Bell et al. found that the 301 pregnant women who fully detoxified experienced “no adverse fetal outcomes related to detoxification.”^[151] Additionally, among the four groups of detoxified women, the rate of relapse was 36%, and the rate of NAS was only 31%. The authors concluded that “detoxification of opiate-addicted pregnant women does not appear to be harmful” and that the rate of relapse and NAS “can also be reduced if continued long-term behavioral health follow-up occurs once a patient is drug free.”

Other studies have corroborated that detoxification using opioid agonist tapering is safe for some women with minimal risk for the baby,^[152] as well as the importance of mental health and behavioral support for improving the outcomes of women and their children undergoing detoxification.^[153]

A 2014 study of women undergoing detoxification in an inpatient, residential setting in Norway by Haabrekke et al. similarly found that “no miscarriages, complications, or morbidities were associated with the residential detoxification treatment.”^[154] Women receiving this residential treatment were also provided opiate agonists and pain relief medications as needed, from which they steadily tapered off. The authors of this study questioned whether the risks of relapse and overdose found in other studies of detoxification during pregnancy weren’t partly the result of not studying pregnant women receiving detox in a more supportive, residential setting such as the one they studied in Norway. In that setting, mothers received ongoing guidance, medical support, and better nutritional and living conditions during the detox process. The authors concluded that “residential care with controlled detoxification and psychological support can build or strengthen the motivation for expecting mothers to become drug free” and a residential care setting during detoxification “dramatically reduces the much-dreaded possibility of relapse and overdose.” Additional research has suggested the importance of supportive inpatient treatment for protecting pregnant patients from relapse.^[155]

Although inpatient treatment is arguably the ideal form of MSD for pregnant women in terms of consistency of support and monitoring in a way that minimizes the risk of relapse, some women may also succeed in detoxifying through a well-developed outpatient protocol. Such an outpatient protocol was developed and studied at a clinic in West Virginia, for example, and the results were published in a 2021 prospective observational study by Patel et al.^[156] This outpatient protocol, a type of “Office-Based Medication Assisted Treatment” (OBMAT), involved weekly random screening for illicit drug use, consultation with a maternal-fetal medicine physician, professional addiction counseling and therapy (both individual and group), and slow buprenorphine tapering, all with the goal of achieving patient abstinence. Participation in all aspects of the protocol was entirely voluntary, though patients received vouchers and other prizes for changed behaviors to incentivize compliance.

Of the 94 women who participated at some point in the program, only 14.9% (14/94) successfully completed the program and achieved abstinence by birth, 23.4% were still enrolled and continuing the tapering process, and 60.6% were either lost to follow-up, were terminated due to non-compliance, or relapsed into opioid use. Although only a small number of those who participated at some point in the program ended up completing it by birth, it is noteworthy that none of the babies born to these women had NAS. What these mixed results appear to indicate is that, on the one hand, it does seem that a more closely monitored inpatient approach to detoxification is superior to an outpatient approach in terms of effectiveness, but also that, should women choose to comply with an outpatient detoxification protocol, their babies have less risk of being born with NAS.

C. Treating Neonatal Abstinence Syndrome

Depending on circumstances and severity, NAS may be treated either with or without medication. In milder cases, nonpharmacological modes of treatment are recommended, whereas when NAS is considered moderate to severe, both pharmacological and nonpharmacological interventions are recommended. A period of several or more days of postnatal observation helps to determine which of these approaches should be taken.^[157] According to SAMHSA’s 2018 clinical guidance for treating mothers suffering from OUD and their infants, “An infant exhibiting mild signs of NAS should be managed with nonpharmacological interventions … and monitored for progression to more severe symptoms according to a formal NAS protocol.”^[158]

Nonpharmacological treatment includes ensuring the baby has adequate sleep and nutrition, rooming-in with the mother (keeping the mother and infant together instead of having the infant in a nursery or NICU), skin-to-skin contact, swaddling, minimizing sensory stimulation (such as bright lights and loud noises), frequent feeding, and temperature stabilization.^[159] The CDC, for example, recommends “[p]lacing the infant in a dark, quiet area to lessen both light and sound,” as well as “[g]ently rocking the infant” and “[a]llowing the infant to stay in the same hospital room as the mother.”^[160] Although it may be determined that pharmacological interventions are also needed, the American Academy of Pediatrics emphasizes that “[n]onpharmacologic interventions should be used for all infants with opioid exposure and should be considered the foundation of care.”^[161]

According to UCSF Benioff Children’s Hospitals, some of the indications that pharmacological treatment should be initiated include “[i]nability to eat, sleep, [and] console,” and when the infant is “unresponsive to non-pharmacologic interventions.”^[162] As is the case with pregnant women suffering from OUD, the goal of pharmacological treatment of infants with NAS is to put them on an opioid agonist and then slowly wean them off of that agonist in order to manage withdrawal. According to some estimates, around 60-80% of infants suffering from NAS are treated with medication, and this inpatient treatment may last from several weeks to several months.^[163] (As noted in footnote 24 above, however, it is important to keep in mind the potential impact of changing diagnostic criteria on statistics such as these.

Historically, the primary medication used to treat NAS in infants has been morphine. Although morphine continues to be the most common treatment approach, the previously mentioned opioid agonists methadone and buprenorphine have also shown promise as alternative effective treatments.^[164] Methadone and buprenorphine may have certain advantages over morphine, such as a shorter treatment duration.^[165] Regardless of which medication is used, however, the dosage is titrated until symptoms begin to substantially improve, after which the infant is slowly weaned off the medication.^[166] If needed, treatment with opioid agonists may also be supplemented by use of another medication such as phenobarbital or clonidine.^[167]

D. Involuntary Commitment

A more controversial practice related to treating women suffering from SUD is involuntary commitment, or compelling a person through a judicial procedure to undergo treatment for substance abuse. There are reasonable considerations both for and against the practice of involuntary commitment, and it seems likely that if and when it may be justified will vary on a case-by-case basis and depend on the nature and strength of the support a committed woman receives. Currently, some form of involuntary commitment law exists in all 50 states and the District of Columbia, as well as in all U.S. territories. The precise conditions under which a person can be involuntarily committed, however, vary, as do the types of treatment judges can order (such as inpatient, outpatient, or both) and length of treatment.^[168]

The basic argument in favor of involuntary commitment is straightforward: In general, those for whom involuntary commitment is deemed appropriate will be at significant risk of overdose, harming themselves, or harming others.^[169] The immediate need in such situations, then, is to ensure that these harms do not take place, and it is unreasonable in such cases of imminent danger to wait until the person suffering from SUD voluntarily chooses to receive treatment. If we can save their life by these extraordinary means in the short term, we can then make it possible for the person to receive more sustained treatment in the long term. Also relevant in this context is the fact that, according to 2022 NSDUH data, more than 95% of individuals suffering from a substance use disorder and not receiving treatment at that time did not believe that they needed treatment. Additionally, a majority of the people who did acknowledge that they needed treatment did not report any attempts to access treatment.^[170] Because of this and related data, Font et al. conclude, “There has never been evidence that a fully voluntary response to a drug epidemic – with no CPS and no other civil or criminal enforcement – is effective.”^[171]

There are two main arguments advanced by those who are against or otherwise skeptical of involuntary commitment. The first is that involuntary commitment threatens to undermine the liberty or autonomy of those who are committed.^[172] The second is that involuntary commitment may not be effective, and may even be counterproductive, in the long term. Some may be made worse off, for example, by having their risk of overdose increased once they leave treatment due to decreased tolerance caused by a period of abstinence.^[173]

The limited research on this topic does not appear to support either unqualified endorsement or wholesale rejection of involuntary commitment—though more and higher quality research needs to be done. As Abhishek et al. wrote in a 2018 review of the literature,

With limited empirical evidence about these [involuntary commitment] laws, arguments for or against them have generally been extrapolated from studies in other countries, derived from criminal justice system interventions (such as drug courts), or based on civil commitment of individuals with substance use and co-occurring disorders, such as schizophrenia. In short, whether civil commitment improves or worsens the outcomes of those who abuse opioids or other substances is unclear.^[174]

One study of opioid-related deaths in Massachusetts from 2013-2014 by the state’s Department of Public Health found that individuals with a history of involuntary commitment were a little over twice as likely to die of opioid-related overdoses than those who only had a history of voluntary commitment.^[175] In itself, this statistic would seem to lend some credence to the anti-involuntary commitment position. It’s unclear, however, to what extent the history of involuntary commitment itself was a causal factor, or the decisive causal factor, in this difference. There were, for example, other differences between the two groups that may have independently impacted the likelihood of overdose: 83% of those with a history of involuntary commitment also had prior mental health treatment, compared to just 58% of those with only a history of voluntary commitment; and 44% of those with a history of involuntary commitment also had a prior overdose, compared to just 18% of those with only a history of voluntary commitment.^[176]

Presumably both mental health issues and prior overdose are independent risk factors for future overdose, so it’s possible the difference between the two groups is at least partly attributable to these factors. Indeed, the study itself acknowledged that “[t]he differences in history of prior mental health treatment and nonfatal overdoses may indicate that these clients [those who were involuntarily committed] have complex co‐morbid conditions and are at a higher risk of fatal overdose.”^[177]

A 2016 systematic review of the literature on outcomes of compulsory drug treatment by Werb et al. found mixed results. Of the nine quantitative studies that met their inclusion criteria, “[t]hree studies (33%) reported no significant impacts of compulsory treatment compared with control interventions. Two studies (22%) found equivocal results but did not compare against a control condition. Two studies (22%) observed negative impacts of compulsory treatment on criminal recidivism. Two studies (22%) observed positive impacts of compulsory inpatient treatment on criminal recidivism and drug use.”^[178] The authors concluded that the evidence “does not, on the whole, suggest improved outcomes related to compulsory treatment.”

This accords with earlier research, such as a 2005 literature review by Klag et al., who concluded that “three decades of research into the effectiveness of compulsory treatment have yielded a mixed, inconsistent, and inconclusive pattern of results, calling into question the evidence-based claims made by numerous researchers that compulsory treatment is effective in the rehabilitation of substance users.”^[179]

However, some have suggested that one reason involuntary commitment may often not be that effective is due to many facilities lacking necessary resources and best practices to make involuntary treatment safe and effective. A qualitative review of the literature by the Harm Reduction Research & Treatment Center (HaRRT) at University of Washington Medicine, for example, stated the following:

[I]nstitutions who provide civil commitment are rarely set up to provide state-of-the-science care for people with opioid or other substance use disorder (e.g., opioid agonist therapy; Evans et al., 2021). This has resulted in overdose when people leave civil commitment (Rafful et al., 2018), and is especially salient when considering that one study showed 34% of people relapse the day they are released (Christopher et al., 2018).^[180]

HaRRT therefore concluded that “we need to be sure this is an evidence-based practice before it is a recommended treatment or intervention for people who use substances” and “[i]f citizens would like to see involuntary civil commitment as a more widely available intervention practice, they should demand funding an effort to have states collect data on their current programs and/or submit existing data for rigorous analysis.”

E. Family and Drug Courts

Although family and drug courts cannot directly mandate that people take medications^[181] such as those involved in MAT, they can serve an important role in incentivizing pregnant women or women with young children involved in these courts to engage in various forms of treatment, some of which may offer MAT, as a condition for probation, retaining child custody, or satisfying other court requirements.

For example, drug courts (a sub-type of “problem-solving court,” or “PSC”) can help “facilitate[] access to behavioral substance use therapies for people with non-violent, and/or involvement in, drug-related crimes,” which can include “authorizing supervised treatment programming, conducting drug testing to monitor abstinence, using frequent court check-ins for judicial monitoring, and using incentives and sanctions to ensure compliance of participants.”^[182] Regarding how MAT may sometimes enter into this picture, Farago et al. (2023) summarize as follows:

Traditional behavioral therapy is an expected service in PSCs, but judges and PSC staff can also allow participants with alcohol and opioid disorders to be referred to treatment providers that provide medications for SUDs. That is, a PSC can recognize the value of medications as a treatment option by allowing PSC participants to take the medications while involved in the PSC or refer participants to qualified providers and/or clinics that offer medications. Since courts do not deliver treatment per se (i.e., run treatment groups, administer medications, etc.), a PSC cannot mandate that individuals take treatment medications. Rather the question is whether the PSC supports the use of medications as a tool to address substance and alcohol use disorders given the effectiveness of the medications in reducing drug use, cravings for illicit drugs and/or alcohol, and improving recidivism outcomes.^[183]

For pregnant or parenting women caught up in the child welfare system, involvement with the Sobriety Treatment and Recovery Teams (START) program may also be helpful. START is geared towards those diagnosed with a substance use disorder who have at least one child five years old or younger, and is “designed to recruit, engage, and retain parents in SUD treatment while keeping children safe.”^[184] People are referred to START by Child Protective Services (CPS). Once referred, parents must complete a SUD assessment as well as at least four treatment sessions, in addition to home check-ins from their family peer mentors and CPS caseworkers, among other requirements. Typically, a START program lasts about 14 months.^[185]

Another option in this vein is Family Drug Treatment Courts (FDTCs).^[186] Like START, FDTCs are for those involved in the child welfare system who may lose custody of their children for various reasons. If it’s determined that substance abuse is impacting the parent’s ability to care for their children, they may be referred to an FDTC by a social worker, family court judge, or attorney. While participation is voluntary, these courts “provide intensive judicial monitoring, timely and integrated treatment and wraparound services, frequent drug testing, weekly or biweekly court hearings, and rewards and sanctions associated with treatment compliance.”^[187]

For certain women, such interventions may constitute a beneficial “middle way” between involuntary commitment and an entirely voluntary decision, absent strong incentive structures, to enter into a treatment program.

IV. Interventions to Help Infants Born to Parents Struggling with SUD

Having explored treatment approaches to the medical issues of SUD and NAS, it is also worth briefly touching on the related issue of interventions intended to protect infants and other young children from abuse or neglect who are born to parents struggling with SUD.

Like the issue of involuntary commitment, how, when, and whether to intervene to protect children from potential or actual abuse/neglect resulting from parental substance abuse is complex and controversial. Indeed, many of the same moral questions are at stake, such as how to balance the privacy and autonomy of parents with mitigating risks to children, when and to what extent the intervention of authorities (in this case, CPS) is justified, and so on. A thorough exploration of these issues is beyond the scope of this paper; nevertheless, a few general remarks can be made.

There are a variety of potential consequences for infants and children living with parents suffering from SUD, including neglect resulting from decreased attention and executive functioning, the development of attachment issues, physical or mental health problems due to financial instability, increased risk for dangerous accidents, and physical or sexual abuse caused or made worse by intoxication. In light of these risks, it is imperative to have workable and evidence-based practices and procedures in place.

Under the federal Child Abuse Prevention and Treatment Act (CAPTA),^[188] states have an obligation to have a “Plan of Safe Care” (POSC) in place when it is known that an infant’s parents are “substance-affected.”^[189] (However, because the delivery and implementation of services is not tracked, and the plans are in the main voluntary, usually the implementation of these plans cannot in practice be enforced.) A POSC is defined as a plan “to ensure the safety and well-being of such [an] infant following release from the care of healthcare providers, including through … addressing the health and substance use disorder treatment needs of the infant and affected family or caregiver; and … the development and implementation by the State of monitoring systems regarding the implementation of such plans to determine whether and in what manner local entities are providing, in accordance with State requirements, referrals to and delivery of appropriate services for the infant and affected family or caregiver.”^[190]

Although the involvement of CPS has been the primary way a state’s POSC has been practically enforced, many activists and policymakers have sought to move away from or prevent CPS involvement. A number of policy strategies have been used to diminish CPS’s involvement. According to Font et al. in their 2025 paper exploring policies that limit the role of child protective services, this has included “preventing toxicology testing of pregnant women or newborns without the woman’s consent,” “defin[ing] ‘substance-affected’ newborns narrowly to exclude most substance-exposed infants from falling under CPS notification and POSC requirements,” enacting legislation according to which “substance abuse does not merit a CPS report in the absence of concurrent evidence of abuse or neglect,” and finally, “create[ing] ‘deidentified’ notification pathways that fulfill the CAPTA requirement but inhibit CPS from conducting an assessment or being responsible for the POSC.”^[191]

When, due to such barriers, CPS is unable to become involved in cases of infants living in substance-affected households, compliance with a POSC is entirely voluntary. Font et al. explain that this has the drawback that “a parent who has an active substance use disorder (SUD) is free to reject any offers of treatment and support without the potential ongoing supervision that could invoke court involvement should problematic use continue.”^[192] Moreover, even when CPS does get involved, existing procedures and training related to implementing a POSC may be inadequate. For example, social workers and OBGYNs often do not receive sufficient training regarding how to properly manage substance abuse in parents and its impact on their children.^[193]

Because of the foregoing, Font et al. insist that any policies seeking to properly address the issue of parental SUD and its impact on children must account for three realities. Their observations in this regard are worth quoting at length:

First, young children’s needs are immediate and ongoing. Harms will accumulate between the onset of a parent’s substance use problems and recovery, and they and their children may experience irreparable harm before reaching recovery. Thus, there is a social benefit to reducing time to treatment initiation or other means of entering recovery. Second, the longstanding reliance on the criminal legal system as the primary response to substance use was undoubtedly harmful; so too is the removal of social and legal pressure to address substance use problems. CPS could be helpful or harmful in responding to substance use problems depending on how it is deployed and resourced. Some version of the Portugal model – strong social pressure in support of treatment and recovery, accessible and affordable treatment, and use of civil procedures to encourage treatment – seems preferable to either a criminal-justice-led approach or a laissez-faire approach. Civil procedures should prioritize careful monitoring of the least intrusive option, with involuntary civil commitment used as a last resort for individuals at imminent risk of harm to self or others and in the context of due process (legal representation and evidentiary standards). Lastly, children, as non-autonomous persons, can neither consent to the risks imposed by their parent’s substance use nor impose any changes to their environments. The government, through CPS — the only entity with legal authority and primary mandate to address familial threats to child safety — must make a choice on their behalf. The decision can be to wait – hoping that the parent is able and willing to voluntarily address their substance use problems – unless or until another CPS or police report is filed, identifying the child as endangered or harmed. Or the decision can be to implement some sort of treatment or sobriety mandate with follow-up or monitoring, which may require court orders or other mechanisms of coercion.^[194]

Thus, as in the case of involuntary commitment, protecting children from the adverse effects of living in a substance-affected household must take seriously both the autonomy and privacy of parents, but equally the well-being and safety of children. How precisely to balance these considerations, or how to know when one consideration reasonably takes precedence over the other, is a delicate and complex question for policymakers. Regardless, evidence-based and effective solutions ought to take precedence over one-sided approaches, and it is arguable that an overemphasis on autonomy and fear of any and all coercive measures has prevented the implementation of a number of sensible policy proposals that could have, and may still, protect vulnerable children.

V. Recommendations

Based on the research reviewed above on what is working well, what is not, and what could be improved, the following are some recommendations for ensuring pregnant women suffering from SUD and their babies receive the best support available moving forward:

• In light of the fact that research shows offering MAT in primary care settings can reduce costs, enhance treatment access, and improve patient outcomes, as well as the fact that many low-resource patients find it difficult to enter or remain in more formal treatment programs, more primary physicians should be trained on how to integrate MAT into their practices.^[195]
• To ensure informed consent, MAT programs and individual prescribers of MAT should provide patients with information on the risks of NAS from taking opioid agonists throughout pregnancy and the alternative option of medically assisted detoxification with MAT.
• MAT programs and primary care providers should offer or help coordinate consistent group counseling and other mental health support, and attending counseling sessions should be a condition for remaining in MAT programs.
• Both weekly and random drug testing for a variety of substances (e.g., not just for opioids in cases of OUD) should be utilized by MAT programs in order to properly monitor patients for compliance, in addition to being tested for STDs. Staff should also be educated on false positives.
• Whenever possible, MAT programs should be affiliated with universities, since they tend to have strong competence, training, and a wider range of resources/services available for participants to take advantage of.
• If medically supervised detoxification is used (with or without MAT), there should be protocols in place to guarantee strict adherence to program requirements and provision of wrap-around services (such as help with housing, co-located mental health services, and vouchers/free transportation), in order to mitigate the risks of relapse and overdose.
• MAT clinics should accept insurance or have other means of providing buprenorphine and methadone instead of being cash-only, due to issues of affordability and the potential diversion of these drugs to those for whom they were not intended as patients try to come up with the cash needed for weekly visits.^[196]
• If involuntary commitment is utilized, evidence-based practices and wrap-around services, such as mental health support and the option of MAT, should always be part of care. Women involved in treatment through drug courts or the child welfare system should similarly receive these evidence-based practices and wrap-around services during their time in START programs, FDTCs, or related programs.
• In order to improve our knowledge base of which protocols and kinds of care are truly effective, state funding for research in this area should be increased and states should collect data on their current programs and/or submit existing data to help evaluate what is working and what isn’t.

 

Ben Cook, Ph.D., is Deputy Editor and Research Associate at the Charlotte Lozier Institute.

Additional research and organizational assistance for this paper were provided by former CLI Associate Scholar Byron C. Calhoun, M.D. Informal peer-review and essential feedback were provided by Sarah Font, Ph.D.

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[15] SAMHSA, “2023 NSDUH Detailed Tables.”

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[18] Andrew E. Weller, Richard C. Crist, Benjamin C. Reiner, et al., “Neonatal Opioid Withdrawal Syndrome (NOWS): A Transgenerational Echo of the Opioid Crisis,” Cold Spring Harbor Perspectives in Medicine 11, no. 3 (2021), doi:10.1101/cshperspect.a039669.

[19] “About Opioid Use During Pregnancy,” CDC, May 7, 2025, accessed September 16, 2025, https://www.cdc.gov/opioid-use-during-pregnancy/about/index.html.

[20] Weller et al. “Neonatal Opioid Withdrawal Syndrome (NOWS).”

[21] “Healthcare Cost and Utilization Project (HCUP) Fast Stats,” AHRQ, December 2024, accessed September 16, 2025, https://datatools.ahrq.gov/hcup-fast-stats/?tab=special-emphasis&dash=83.

[22] Ibid.

[23] Akhil Patel, Paul Dietz, Angela Castro, et al., “Autonomous Care Pathway to Patient Opioid Abstinence: Should All Programs Offer This Approach? Issues in Law and Medicine 36, no. 2 (2021):193-211, https://issuesinlawandmedicine.com/wp-content/uploads/2023/09/Calhoun_36n2.pdf.

[24] AHRQ, “Healthcare Cost and Utilization Project (HCUP) Fast Stats.”

[25] This should be tempered, however, by a recognition that some of the decline may be due to a shift in diagnostic criteria—for example, certain areas switching to the “eat, sleep, and console” method instead of the Finnegan scoring method (see Johnson K, Berkwitt A, Yankova L, Osborn R. “Comparisons of management approaches in neonatal opioid withdrawal syndrome: The eat, sleep, console approach vs. the Finnegan approach.” Semin Perinatol. 2025 Feb; 49(1):152021. doi: 10.1016/j.semperi.2024.152021). In many cases, a diagnosis of NAS will only be made if the child is admitted to the NICU or requires opioid-replacement therapy.

[26] SAMHSA, Key Substance Use and Mental Health Indicators in the United States: Results from the 2023 National Survey on Drug Use and Health (Rockville: SAMHSA, 2024), https://www.samhsa.gov/data/sites/default/files/reports/rpt47095/National%20Report/National%20Report/2023-nsduh-annual-national.pdf.

[27] SAMHSA, “2023 NSDUH Detailed Tables.”

[28] Ibid., Table 1.65A

[29] Ibid., Table 1.36C.

[30] Marcela C Smid, Torri D. Metz, Adam J. Gordon, “Stimulant Use in Pregnancy – an Under-Recognized Epidemic Among Pregnant Women,” Clinical Obstetrics and Gynecology 62, no. 1 (2019): 168-184, doi: 10.1097/GRF.0000000000000418.

[31] SAMHSA, “2023 NSDUH Detailed Tables,” Table 8.26A

[32] Smid et al., “Stimulant Use in Pregnancy.”

[33] Lee E. Dunlap, Anne M. Andrews, David E. Olson, “Dark Classics in Chemical Neuroscience: 3,4-Methylenedioxymethamphetamine,” ACS Chemical Neuroscience 9, no. 10 (2018): 2408-2427, doi:https://pubmed.ncbi.nlm.nih.gov/30001118/.

[34] Ibid.

[35] Lynn T. Singer, Derek G. Moore, Meeyoung O. Min, et al., “Motor Delays in MDMA (Ecstasy) Exposed Infants Persist to 2 Years,” Neurotoxicology and Teratology 54 (2016): 22-28, doi:10.1016/j.ntt.2016.01.003.

[36] Lynn T. Singer, Derek G. Moore, Sarah Fulton, et al., “Neurobehavioral Outcomes of Infants Exposed to MDMA (Ecstasy) and Other Recreational Drugs During Pregnancy,” Neurotoxicology and Teratology 34, no. 3 (2012): 303-310, doi:10.1016/j.ntt.2012.02.001.

[37] Lynn T. Singer, Derek G. Moore, Meeyoung O. Min, et al., “One-Year Outcomes of Prenatal Exposure to MDMA and Other Recreational Drugs,” Pediatrics 130, no. 3 (2012): 407-413, doi:10.1542/peds.2012-0666.

[38] Singer et al., “Motor Delays in MDMA (Ecstasy) Exposed Infants Persist to 2 Years.”

[39] Nicholas G. Campbell, James B. Koprich, Nicholas M. Kanaan, et al., “MDMA Administration to Pregnant Sprague-Dawley Rats Results in its Passage to the Fetal Compartment,” Neurotoxicoloy and Teratology 28, no. 4 (2006): 459-465, doi:10.1016/j.ntt.2006.05.006.

[40] Csaba Adori, Dora Zelena, Julia Timar, et al., “Intermittent Prenatal MDMA Exposure Alters Physiological but not Mood Related Parameters in Adult Rat Offspring,” Behavioural Brain Research 206, no. 2 (2010): 299-309, doi:10.1016/j.bbr.2009.09.031.

[41] “Amphetamines,” Cleveland Clinic, last reviewed March 24, 2025, accessed September 16, 2025, https://my.clevelandclinic.org/health/drugs/23039-amphetamines.

[42] “Methamphetamine,” National Institute on Drug Abuse, November 2024, accessed September 16, 2025, https://nida.nih.gov/research-topics/methamphetamine.

[43] Ibid.

[44] SAMHSA, Key Substance Use and Mental Health Indicators in the United States, 2023.

[45]SAMHSA, “2023 NSDUH Detailed Tables,” Table 1.41A.

[46] Ibid., Table 1.42A.

[47] Ibid., Table 8.26A.

[48] Sarena Hayer, Bharti Garg, Jessica Wallace, et al., “Prenatal Methamphetamine Use Increases Risk of Adverse Maternal and Neonatal Outcomes,” AJOG 231, no. 3 (2024): 356.e1-356.e15, doi: 10.1016/j.ajog.2024.05.033.

[49] Ibid.

[50] Tiffany Pham, Yolanda Tinajero, Lihong Mo, et al., “Obstetrical and Perinatal Outcomes of Patients with Methamphetamine-positive Drug Screen on Labor and Delivery,” AJOG MFM 2, no. 4 (2020), doi: 10.1016/j.ajogmf.2020.100195.

[51] Jia-Hao Li, Jia-Li Liu, Kai-Kai Zhang, et al., “The Adverse Effects of Prenatal METH Exposure on the Offspring: A Review,” Frontiers in Pharmacology 12 (2021), doi:10.3389/fphar.2021.715176.

[52] Linda L. LaGasse, Chris Derauf, Lynne M. Smith, et al., “Prenatal Methamphetamine Exposure and Childhood Behavior Problems at 3 and 5 Years of Age,” Pediatrics 129, no. 4 (2012): 681-688, https://pubmed.ncbi.nlm.nih.gov/22430455/.

[53] Sabrina D. Diaz, Lynne M. Smith, Linda L. LaGasse, et al., “Effects of Prenatal Methamphetamine Exposure on Behavioral and Cognitive Findings at 7.5 Years,” The Journal of Pediatrics 164, no. 6 (2014): 1333-1338, doi:10.1016/j.jpeds.2014.01.053.

[54] Chelsea Kunkler, Andrew J. Lewis, Renita Almeida, “Methamphetamine Exposure During Pregnancy: A Meta-Analysis of Child Developmental Outcomes,” Neuroscience and Biobehavioral Reviews 138 (2022), doi: 10.1016/j.neubiorev.2022.104714.

[55] “Benzodiazepines (Benzos),” Cleveland Clinic, last reviewed January 3, 2023, accessed September 16, 2025, https://my.clevelandclinic.org/health/treatments/24570-benzodiazepines-benzos.

[56] SAMHSA, “2023 NSDUH Detailed Tables,” Table 1.1A.

[57] R. Kathryn McHugh, Rachel B. Geyer, Alexandra R. Chase, et al., “Sex Differences in Benzodiazepine Misuse Among Adults with Substance Use Disorders,” Addictive Behaviors 112 (2021), doi:10.1016/j.addbeh.2020.106608.

[58] https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates#Download, excel file titled “Overdose_data_1999-2023 1.16.25.xlsx”.

[59] Gillian E. Hanley and Barbara Mintzes, “Patterns of Psychotropic Medicine Use in Pregnancy in the United States from 2006 to 2011 Among Women with Private Insurance,” BMC Pregnancy Childbirth 14, no. 242 (2014), https://pubmed.ncbi.nlm.nih.gov/25048574/.

[60] Odile Sheehy, Jin-Ping Zhao, Anick Berard, “Association Between Incident Exposure to Benzodiazepines in Early Pregnancy and Risk of Spontaneous Birth,” JAMA Psychiatry 76, no. 9 (2019): 948-957, doi:10.1001/jamapsychiatry.2019.0963.

[61] Marlene P. Freeman, Lina Goez-Mogollon, Kathryn A. McInerney, et al., “Obstetrical and Neonatal Outcomes After Benzodiazepine Exposure During Pregnancy: Results from a Prospective Registry of Women with Psychiatric Disorders,” General Hospital Psychiatry 53 (2018): 73-79, doi:10.1016/j.genhosppsych.2018.05.010.

[62] Michele L. Okun, Rebecca Ebert, Bandana Saini, “A Review of Sleep-Promoting Medications Used in Pregnancy,” AJOG 212, no. 4 (2015): 428-441, doi:10.1016/j.ajog.2014.10.1106.

[63] Yusuke Ogawa, Nozomi Takeshima, Toshi A. Furukawa, “Maternal Exposure to Benzodiazepine and Risk of Preterm Birth and Low Birth Weight: A Case-Control Study Using a Claims Database in Japan,” Asia-Pacific Psychiatry 10, no. 3 (2018), doi:10.1111/appy.12309.

[64] Kimberly Ann Yonkers, Kathryn Gilstad-Hayden, Ariadna Forray, et al., “Association of Panic Disorder, Generalized Anxiety Disorder, and Benzodiazepine Treatment During Pregnancy with Risk of Adverse Birth Outcomes,” JAMA Psychiatry 74, no. 11 (2017): 1145-1152, doi:10.1001/jamapsychiatry.2017.2733.

[65] Lauren A. Sanlorenzo, William O. Cooper, Judith A. Dudley, et al., “Increased Severity of Neonatal Abstinence Syndrome Associated with Concomitant Antenatal Opioid and Benzodiazepine Exposure,” Hospital Pediatrics 9, no. 8 (2019): 569-575, https://pmc.ncbi.nlm.nih.gov/articles/PMC6663519/.

[66] M. Levy and M. Spino, “Neonatal Withdrawal Syndrome: Associated Drugs and Pharmacologic Management,” Pharmacotherapy 13, no. 3 (1993): 202-211, https://pubmed.ncbi.nlm.nih.gov/8321734/.

[67] “Barbiturates,” DEA, accessed September 16, 2025, https://www.dea.gov/factsheets/barbiturates.

[68] Jolee T. Suddock, Kristen J. Kent, Angela C. Regina, et al., Barbiturate Toxicity (Treasure Island, FL: StatPearls Publishing, updated 2024), https://www.ncbi.nlm.nih.gov/books/NBK499875/.

[69] “2023 NSDUH Detailed Tables,” Table 1.125A.

[70] Suddock, et al., Barbiturate Toxicity.

[71] “Phenobarbital,” Epilepsy Foundation, accessed September 16, 2025, https://www.epilepsy.com/tools-resources/seizure-medication-list/phenobarbital.

[72] “Yusuf Cem Kaplan and Omer Demir, “Use of Phenytoin, Phenobarbital Carbamazepine, Levetiracetam Lamotrigine and Valproate in Pregnancy and Breastfeeding: Risk of Major Malformations, Dose-dependency, Monotherapy vs. Polytherapy, Pharmacokinetics and Clinical Implications,” Current Neuropharmacology 19, no. 11 (2021): 1805-1824, https://pmc.ncbi.nlm.nih.gov/articles/PMC9185784/.

[73] Antonio A. Zuppa, Chiara Carducci, Antonio Scorrano, et al., “Infants Born to Mothers Under Phenobarbital Treatment: Correlation Between Serum Levels and Clinical Features of Neonates,” European Journal of Obstetrics and Gynecology and Reproductive Biology 159, no. 1 (2011): 53-56, doi: 10.1016/j.ejogrb.2011.06.035.

[74]  Murdina M. Desmond, Rebecca P. Schwanecke, Geraldine S. Wilson, et al., “Maternal Barbiturate Utilization and Neonatal Withdrawal Symptomatology,” The Journal of Pediatrics 80, no. 2 (1972): 190-197, doi:10.1016/s0022-3476(72)80577-8.

[75] Dina Battino, Torbjorn Tomson, Erminio Bonizzoni, et al., “Risk of Major Congenital Malformations and Exposure to Antiseizure Medication Monotherapy,” JAMA Neurology 81, no. 5 (2024): 481-489, doi: 10.1001/jamaneurol.2024.0258.

[76] Jamie O. Lo, Chelsea K. Ayers, Snehapriya Yeddala, et al., “Prenatal Cannabis Use and Neonatal Outcomes: A Systematic Review and Meta-Analysis,” JAMA Pediatrics 179, no. 7 (2025): 738-746, doi:10.1001/jamapediatrics.2025.0689.

[77] “Cannabis (Marijuana),” National Institute on Drug Abuse, accessed September 16, 2025, https://nida.nih.gov/research-topics/cannabis-marijuana.

[78] “2023 NSDUH Detailed Tables,” Table 1.1A, Table 1.7A.

[79] Ibid., Table 1.27A.

[80] Ibid., Table 8.26A.

[81] “Committee Opinion No. 722 Summary: Marijuana Use During Pregnancy and Lactation,” Obstetrics and Gynecology 130, no. 4 (2017): 931-932, doi:10.1097/AOG.0000000000002354.

[82] Patel et al., “Autonomous Care Pathway to Patient Opioid Abstinence.”

[83] ElSohly MA, Mehmedic Z, Foster S, Gon C, Chandra S, Church JC. “Changes in Cannabis Potency Over the Last 2 Decades (1995-2014): Analysis of Current Data in the United States.” Biol Psychiatry. 2016 Apr 1;79(7):613-9. doi: 10.1016/j.biopsych.2016.01.004.

[84] Isabella Backman. “Marijuana: Rising THC Concentrations in Cannabis Can Pose Health Risks.” Yale School of Medicine, August 30, 2023, https://medicine.yale.edu/news-article/not-your-grandmothers-marijuana-rising-thc-concentrations-in-cannabis-can-pose-devastating-health-risks/.

[85] Alexis Wnuk, “Is cannabis today really much more potent than 50 years ago?” New Scientist, October 11, 2023. https://www.newscientist.com/article/2396976-is-cannabis-today-really-much-more-potent-than-50-years-ago/.

[86]  Torri D. Metz, Amanda A. Allshouse, Gwendolyn A. McMillin, et al., “Cannabis Exposure and Adverse Pregnancy Outcomes Related to Placental Function,” JAMA 330, no. 22 (2023): 2191-2199, doi: 10.1001/jama.2023.21146.

[87] Lo et al., “Prenatal Cannabis Use and Neonatal Outcomes: A Systematic Review and Meta-Analysis.”

[88] Albert Stuart Reece and Gary Kenneth Hulse, “Geotemporospatial and Causal Inference Epidemiological Analysis of US Survey and Overview of Cannabis, Cannabidiol and Cannabinoid Genotoxicity in Relation to Congenital Anomalies 2001-2015,” BMC Pediatrics 22, no. 47 (2022), doi:10.1186/s12887-021-02996-3.

[89] Marleen M.H.J. van Gelder, A. Rogier T. Donders, Owen Devine, et al., “Using Bayesian Models to Assess the Effects of Under-reporting of Cannabis Use on the Association with Birth Defects, National Birth Defects Prevention Study, 1997-2005,” Paediatric and Perinatal Epidemiology 28, no. 5 (2014): 424-433, doi: 10.1111/ppe.12140.

[90] Michael W. Varner, Robert M. Silver, Carol J. Rowland Hogue, et al., “Association Between Stillbirth and Illicit Drug Use and Smoking During Pregnancy,” Obstetrics and Gynecology 123, no. 1 (2015): 113-125, https://pmc.ncbi.nlm.nih.gov/articles/PMC3931517/.

[91] Leah L. Habersham, Yasmin L. Hurd, Yoko Nomura, “The Longitudinal Assessment of Prenatal Cannabis Use on Neonatal Outcomes,” Journal of Perinatology 44 (2024): 1152-1156, doi:10.1038/s41372-024-02027-w.

[92] See, for ex., Lidush Goldschmidt, Nancy L. Day, Gale A. Richardson, “Effects of Prenatal Marijuana Exposure on Child Behavior Problems at Age 10,” Neurotoxicology and Teratology 22, no. 3 (2000): 325-336, doi:10.1016/s0892-0362(00)00066-0; Lidush Goldschmidt, Gale A. Richardson, Marie D. Cornelius, et al., “Prenatal Marijuana and Alcohol and Academic Achievement at Age 10,” Neurotoxicology and Teratology 26, no. 4 (2004): 521-532, doi:10.1016/j.ntt.2004.04.003.

[93] National Academy of Sciences, “Prenatal, Perinatal, and Neonatal Exposure to Cannabis,” in The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research (Washington: National Academies Press, 2017), https://www.ncbi.nlm.nih.gov/books/NBK425751/.

[94] “2023 NSDUH Detailed Tables,” Table 2.1A; note that “heavy alcohol use” was defined as a subset of “binge alcohol use.”

[95] Ibid., Table 2.28A.

[96] Ibid., Table 2.29A.

[97] Ibid., Table 8.26B.

[98] Ibid., Table 8.26A.

[99] Katherine DeJong, Amy Olyaei, Jamie O. Lo, “Alcohol Use in Pregnancy,” Clinical Obstetrics and Gynecology 62, no. 1 (2019):142-155, https://pmc.ncbi.nlm.nih.gov/articles/PMC7061927/.

[100] “About Fetal Alcohol Spectrum Disorders (FASDs),” CDC, May 8, 2025, accessed September 16, 2025, https://www.cdc.gov/fasd/about/index.html.

[101] CDC, “Data and Statistics on FASDs.”

[102] Ibid.

[103] DeJong et al., “Alcohol Use in Pregnancy.”

[104] Ibid.

[105] Alexandra C. Sundermann, Sifang Zhao, Chantay L. Young, et al., “Alcohol Use in Pregnancy and Miscarriage: A Systematic Review and Meta-Analysis,” Alcohol Clinical and Experimental Research 43, no. 8 (2019): 1606-1616, https://pubmed.ncbi.nlm.nih.gov/31194258/.

[106] Alexandra C. Sundermann, Digna R. Velez Edwards, James C. Slaughter, “Week-by-Week Alcohol Consumption in Early Pregnancy and Spontaneous Abortion Risk: A Prospective Cohort Study,” AJOG 224, no. 1 (2021): 97.e1-97.e16, doi:10.1016/j.ajog.2020.07.012.

[107] “About Alcohol Use During Pregnancy,” CDC, May 16, 2024, accessed September 16, 2025, https://www.cdc.gov/alcohol-pregnancy/about/index.html.

[108] SAMHSA 2023 National Survey on Drug Use and Health: Detailed Tables.

[109] Merianne R. Spencer, Matthew F. Garnett, Arialdi M. Minino, “Drug Overdose Deaths in the United States, 2002-2022.” NCHS Data Brief, no. 491 (2024), https://www.cdc.gov/nchs/products/databriefs/db491.htm, Fig. 5.

[110] SAMHSA 2023 National Survey on Drug Use and Health: Detailed Tables.

[111] Cressman AM, Natekar A, Kim E, Koren G, Bozzo P. “Cocaine abuse during pregnancy.” J Obstet Gynaecol Can. 2014 Jul;36(7):628-631. doi: 10.1016/S1701-2163(15)30543-0; Bauer CR, Langer JC, Shankaran S, et al. “Acute Neonatal Effects of Cocaine Exposure During Pregnancy.” Arch Pediatr Adolesc Med. 2005;159(9):824–834. Doi:10.1001/archpedi.159.9.824.

[112] Daniel J Bonthius, Hana Cayton. “Congenital cocaine syndrome.” In: Lewis SL, Editor-in-Chief. MedLink Neurology. San Diego: MedLink, LLC. (Updated: June 23, 2025.)

[113] Ibid.

[114] Cressman AM, Natekar A, Kim E, Koren G, Bozzo P. “Cocaine abuse during pregnancy.” J Obstet Gynaecol Can. 2014 Jul;36(7):628-631. doi: 10.1016/S1701-2163(15)30543-0.

[115] SAMHSA 2023 National Survey on Drug Use and Health: Detailed Tables.

[116] “Polysubstance Use Facts.” CDC. https://www.cdc.gov/stop-overdose/caring/polysubstance-use.html.

[117] Ellis MS, Kasper ZA, Cicero TJ. “Polysubstance use trends and variability among individuals with opioid use disorder in rural versus urban settings.” Prev Med. 2021 Nov;152(Pt 2):106729. doi: 10.1016/j.ypmed.2021.

[118] England LJ, Bennett C, Denny CH, et al. “Alcohol use and co-use of other substances among pregnant females aged 12–44 years – United States, 2015–2018.” MMWR Morb Mortal Wkly Rep 2020; 69(31): 1009-1014.

[119] Tran EL, England LJ, Park Y, Denny CH, Kim SY. “Systematic Review: Polysubstance Prevalence Estimates Reported during Pregnancy, US, 2009-2020.” Matern Child Health J. 2023 Mar;27(3):426-458. doi: 10.1007/s10995-023-03592-w.

[120] “Polysubstance Use During Pregnancy.” CDC. May 8, 2025, https://www.cdc.gov/pregnancy/during/polysubstance-use.html.

[121] Cecily May Barber and Mishka Terplan, “Principles of Care for Pregnant and Parenting People with Substance Use Disorder: the Obstetrician Gynecologist Perspective,” Frontiers in Pediatrics 11 (2023), doi: 10.3389/fped.2023.1045745.

[122] Kelly S. Ramsey (lead author), Sharon Stancliff, Lyn C. Stevens, et al., Substance Use Disorder Treatment in Pregnant Adults (Baltimore, MD: John Hopkins University, 2021), https://www.ncbi.nlm.nih.gov/books/NBK572854/.

[123] Ibid.

[124] Barber and Terplan, “Principles of Care for Pregnant and Parenting People with Substance Use Disorder.”

[125] Ibid.

[126] “Treatment of Opioid Use Disorder Before, During, and After Pregnancy,” CDC, May 7, 2025, accessed September 16, 2025, https://www.cdc.gov/opioid-use-during-pregnancy/treatment/index.html.

[127] SAMHSA, Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants (SAMHSA, 2018), https://library.samhsa.gov/sites/default/files/sma18-5054.pdf.

[128] “Opioid Use and Opioid Use Disorder in Pregnancy,” ACOG, no. 711 (2017), https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy.

[129] “Buprenorphine,” SAMHSA, last updated March 28, 2024, accessed September 16, 2025, https://www.samhsa.gov/substance-use/treatment/options/buprenorphine.

[130] “Methadone,” SAMHSA, last updated March 29, 2024, accessed September 16, 2025, https://www.samhsa.gov/substance-use/treatment/options/methadone.

[131] “Naltrexone,” SAMHSA, last updated March 29, 2024, accessed September 16, 2025, https://www.samhsa.gov/substance-use/treatment/options/naltrexone.

[132] Ravi Chokshi, Samuel Parish, Nanyaly Santiago-Aponte, et al., “Current Research on Opioid Use Disorder (OUD) in Pregnancy with Emphasis on Medication Assisted Treatment (MAT),” Medical Research Archives 12, no. 8 (2024), https://esmed.org/MRA/mra/article/view/5736; CDC, “Treatment of Opioid Use Disorder Before, During, and After Pregnancy”; SAMHSA, Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants.

[133] Laura R. Lander, Patrick Marshalek, Carl R. Sullivan, “Medication-Assisted Treatment for Pregnant Women: An Interdisciplinary Group Based Model,” Journal of Groups in Addiction and Recovery 11, no. 3 (2016): 182–193, doi:10.1080/1556035X.2016.1185987; Chokshi et al., “Current Research on Opioid Use Disorder (OUD) in Pregnancy with Emphasis on Medication Assisted Treatment (MAT).”

[134] Ibid.; Jenny Macfie, Craig V. Towers, Kimberly B. Fortner, et al., “Medication-Assisted Treatment vs. Detoxification for Women who Misuse Opioids in Pregnancy: Associations with Dropout, Relapse, Neonatal Opioid Withdrawal Syndrome (NOWS), and Childhood Sexual Abuse,” Addictive Behaviors Reports 12 (2020), doi:10.1016/j.abrep.2020.100315; SAMHSA, Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants.

[135] Chokshi et al., “Current Research on Opioid Use Disorder (OUD) in Pregnancy with Emphasis on Medication Assisted Treatment (MAT).”

[136] Wilder C., Lewis D., Winhusen T. 2015. “Medication Assisted Treatment Discontinuation in Pregnant and Postpartum Women with Opioid Use Disorder.” Drug and Alcohol Dependence 149: 225–31. doi:10.1016/j.drugalcdep.2015.02.012.

[137] Ibid.

[138] Elizabeth A. Suarez, Krista F. Huybrechts, Loreen Straub, et al., “Buprenorphine versus Methadone for Opioid Use Disorder in Pregnancy,” NEJM 387, no. 22 (2022): 2033-2044, doi:0.1056/NEJMoa2203318.

[139] Amber M. Holbrook and Viba H. Nguyen, “Medication-Assisted Treatment for Pregnant Women: A Systematic Review of the Evidence and Implications for Social Work Practice,” Journal of the Society for Social Work and Research 6, no. 1 (2015), https://www.journals.uchicago.edu/doi/full/10.1086/680232.

[140] Sarah Font et al., “Who Should Respond to Substance-Exposed Infants? Reflections on U.S. Policies Limiting the Role of Child Protective Services,” Child Protection and Practice 5 (July 2025): 100137, https://doi.org/10.1016/j.chipro.2025.100137.

[141] “Medication Assisted Treatment (MAT) Explained.” SafeProject. https://www.safeproject.us/resource/medication-assisted-treatment-explained/.

[142] Medication-Assisted Treatment Models of Care for Opioid Use Disorder in Primary Care Settings [Internet], Technical Briefs, No. 28, Chou R, Korthuis PT, Weimer M, et al., 2016, https://www.ncbi.nlm.nih.gov/books/NBK402343/.

[143] Ibid.

[144] Lagisetty P, Klasa K, Bush C, Heisler M, Chopra V, Bohnert A. “Primary care models for treating opioid use disorders: What actually works? A systematic review.” PLoS One. 2017 Oct 17;12(10):e0186315. doi: 10.1371/journal.pone.0186315.

[145] Korthuis PT, McCarty D, Weimer M, Bougatsos C, Blazina I, Zakher B, Grusing S, Devine B, Chou R. “Primary Care-Based Models for the Treatment of Opioid Use Disorder: A Scoping Review.” Ann Intern Med. 2017 Feb 21;166(4):268-278. doi: 10.7326/M16-2149.

[146] Ibid.

[147] Ibid.

[148] Steve N. Caritis and Ashok Panigraphy, “Opioids Affect the Fetal Brain: Reframing the Detoxification Debate,” AJOG 221, no. 6 (2019): 602-608, doi:10.1016/j.ajog.2019.07.022.

[149] Jennifer Bell, Craig V. Towers, Mark D. Hennessy, et al., “Detoxification from Opioid Drugs During Pregnancy,” AJOG 215, no. 3 (2016): 374.e1-374.e6, doi:10.1016/j.ajog.2016.03.015; Patel et al., “Autonomous Care Pathway to Patient Opioid Abstinence: Should All Programs Offer this Approach?”

[150] Mishka Terplan, Hollis J. Laird, Dennis J. Hand, et al., “Opioid Detoxification During Pregnancy: A Systematic Review,” Obstetrics and Gynecology 131, no. 5 (2018): 803-814, https://pmc.ncbi.nlm.nih.gov/articles/PMC6034119/.

[151] Bell et al., “Detoxification from Opioid Drugs During Pregnancy.”

[152] Ibid.; Ingunn O. Lund, Heather Fitzsimons, Michelle Tuten, et al., “Comparing Methadone and Buprenorphine Maintenance with Methadone-Assisted Withdrawal for the Treatment of Opioid Dependence During Pregnancy: Maternal and Neonatal Outcomes,” Substance Abuse and Rehabilitation 3 (2012): 17-25, doi:10.2147/SAR.S26288.

[153] Caritis and Panigrahy, “Opioids Affect the Fetal Brain: Reframing the Detoxification Debate.”

[154] Kristin Johanne Haabrekke, Kari Slinning, Kristine Beate Walhovd, et al., “Perinatal Outcome of Children Born to Women with Substance Dependence Detoxified in Residential Treatment During Pregnancy,” Journal of Addictive Disease 33, no. 2 (2014): 114-123, doi:10.1080/10550887.2014.909698.

[155] Jason Luty, Vasilis Nikolaou, Jenny Bearn, “Is Opiate Detoxification Unsafe in Pregnancy?,” Journal of Substance Abuse Treatment 24, no. 4 (2003): 363- 367, doi:10.1016/s0740-5472(03)00035-7; Robert D. Stewart, David B. Nelson, Emily H. Adhikari, et al., “The Obstetrical and Neonatal Impact of Maternal Opioid Detoxification in Pregnancy,” AJOG 209, no. 3 (2013): 267.e1-5, doi:10.1016/j.ajog.2013.05.026.

[156] Patel et al., “Autonomous Care Pathway to Patient Opioid Abstinence: Should All Programs Offer this Approach?”

[157] Patrick et al., “Neonatal Opioid Withdrawal Syndrome.”; “Consensus Guidelines for Management of Neonatal Opioid Withdrawal Syndrome (NOWS) & Drug-Exposed Infants,” UCSF Benioff Children’s Hospitals, June 12, 2024, accessed September 16, 2025, https://medconnection.ucsfbenioffchildrens.org/news/consensus-guidelines-for-management-of-neonatal-opioid-withdrawal-syndrome-nows-and-drug-exposed-infants.

[158] SAMHSA, Clinical Guidance for Treating Pregnant and Parenting Women with Opioid Use Disorder and Their Infants.

[159] “Neonatal Opioid Withdrawal Syndrome (formerly known as Neonatal Abstinence Syndrome),” Cleveland Clinic, last reviewed June 12, 2022, accessed September 16, 2025, https://my.clevelandclinic.org/health/diseases/23226-neonatal-abstinence-syndrome; Anita Siu and Christine A. Robinson, “Neonatal Abstinence Syndrome: Essentials for the Practitioner,” The Journal of Pediatric Pharmacology and Therapeutics 19, no. 3 (2014): 147-155, doi:10.5863/1551-6776-19.3.147; Maria Paula Castaneda Sandoval, Daniel Fernando Gonzalez Gonzalez, Kelly Johanna Pena Suarez, et al., “Neonatal Abstinence Syndrome and Non-Pharmacological Nursing Care. A Scoping Review,” Journal of Neonatal Nursing 30, no. 1(2024): 5-10, doi:10.1016/j.jnn.2023.07.015.

[160] “Treat and Manage Infants Affected by Prenatal Opioid Exposure,” CDC, May 7, 2025, accessed September 16, 2025, https://www.cdc.gov/opioid-use-during-pregnancy/treatment/infants-opioid.html.

[161] Patrick et al., “Neonatal Opioid Withdrawal Syndrome.”

[162] UCSF Benioff Children’s Hospitals, “Consensus Guidelines for Management of Neonatal Opioid Withdrawal Syndrome (NOWS) & Drug-Exposed Infants.”

[163]  Cleveland Clinic, “Neonatal Opioid Withdrawal Syndrome (formerly known as Neonatal Abstinence Syndrome)”; Siu and Robinson, “Neonatal Abstinence Syndrome.”

[164] Chokshi et al., “Current Research on Opioid Use Disorder (OUD) in Pregnancy with Emphasis on Medication Assisted Treatment (MAT).”

[165] Holbrook and Nguyen, “Medication-Assisted Treatment for Pregnant Women: A Systematic Review of the Evidence and Implications for Social Work Practice”; Ashraf H. Hamdan, “Neonatal Abstinence Syndrome Treatment & Management,” Medscape, last updated May 17, 2023, accessed September 16, 2025, https://emedicine.medscape.com/article/978763-treatment; Walter K. Kraft, Susan C. Adeniyi-Jones, Inna Chervoneva, et al., “The Buprenorphine for the Treatment of the Neonatal Abstinence Syndrome,” New England Journal of Medicine 376, no. 24 (2017): 2341-2348, doi:10.1056/NEJMoa1614835.

[166] Kathryn Dee Lizcano MacMillan, “Neonatal Abstinence Syndrome: Review of Epidemiology, Care Models, and Current Understanding of Outcomes,” Clinics in Perinatology 46, no. 4 (2019): 817-832, doi: 10.1016/j.clp.2019.08.012.

[167] Elisha M. Wachman and Marha M. Werler, “Pharmacologic Treatment for Neonatal Abstinence Syndrome: Which Medication Is Best?”, JAMA Pediatrics 173, no. 3 (2019): 221–223, doi:10.1001/jamapediatrics.2018.5029.

[168] Legislative Analysis and Public Policy Association, Involuntary Commitment of Those with Substance Use Disorders: Summary of State Laws (LAPPA, 2024), https://legislativeanalysis.org/wp-content/uploads/2024/12/Involuntary-Commitment-of-Those-with-Substance-Use-Disorders.pdf.

[169] Legislative Analysis and Public Policy Association, Involuntary Commitment of Those with Substance Use Disorders: Summary of State Laws.

[170] See Font et al., “Who Should Respond to Substance-Exposed Infants?”, citing SAMHSA, Key Substance Use and Mental Health Indicators in the United States: Results from the 2021 National Survey on Drug Use and Health (Rockville: SAMHSA, 2024), https://www.samhsa.gov/data/sites/default/files/reports/rpt39443/2021NSDUHFFRRev010323.pdf.

[171] Font et al., “Who Should Respond to Substance-Exposed Infants?”

[172] Leo Beletsky, Elisabeth J. Ryan, Wendy E. Parmet, “Involuntary Treatment for Substance Use Disorder: A Misguided Response to the Opioid Crisis,” Harvard Health Publishing, January 28, 2018, accessed September 16, 2025, https://www.health.harvard.edu/blog/involuntary-treatment-sud-misguided-response-2018012413180; Elizabeth A. Evans, Calla Harrington, Robert Roose, et al., “Perceived Benefits and Harms of Involuntary Civil Commitment for Opioid Use Disorder,” Journal of Law, Medicine, and Ethics 48, no. 4 (2021): 718-734, doi:10.1177/1073110520979382; Abhishek Jain, Paul Christopher, Paul S. Applebaum, “Civil Commitment for Opioid and Other Substance Use Disorders: Does it Work?,” Psychiatric Services 69, no. 4 (2018): 374-376, doi:10.1176/appi.ps.201800066.

[173] Kenneth Minkoff, “Civil Commitment for People With Substance Use Disorders: Balancing Benefits and Harms,” Psychiatric Services 75, no.12 (2024): 1279-1284, doi: 10.1176/appi.ps.20240115; Jain et al., “Civil Commitment for Opioid and Other Substance Use Disorders”; “Involuntary Commitment for Substance Use Disorders: Emerging Drug Trends—July 2017,” Hazelden Betty Ford Foundation, accessed September 16, 2025, https://www.hazeldenbettyford.org/research-studies/addiction-research/involuntary-commitment.

[174] Jain et al., “Civil Commitment for Opioid and Other Substance Use Disorders.”

[175]  Massachusetts Department of Health, An Assessment of Opioid-Related Deaths in Massachusetts (2013-2014) (Massachusetts DPH, 2016), https://www.mass.gov/doc/legislative-report-chapter-55-opioid-overdose-study-september-2016/download, p. 48.

[176] Ibid., p. 49.

[177] Ibid.

[178] D. Werb, A. Kamarulzaman, M.C. Meacham, et al., “The Effectiveness of Compulsory Drug Treatment: A Systematic Review,” International Journal of Drug Policy 28 (2016): 1-9, doi:10.1016/j.drugpo.2015.12.005.

[179] Stefanie Klag, Frances O’Callaghan, Peter Creed, “The Use of Legal Coercion in the Treatment of Substance Abusers: An Overview and Critical Analysis of Thirty Years of Research,” Substance Use & Misuse 40, no. 12 (2005): 1777–1795, doi:10.1080/10826080500260891.

[180] Susan Collins, “HaRRT Center Qualitative Review of the Literature on Involuntary Treatment,” UW Medicine Department of Psychiatry and Behavioral Sciences, July 29, 2022, accessed September 16, 2025, https://depts.washington.edu/harrtlab/1109/involutary_treatment/.

[181] SAMHSA, “Medication-assisted Treatment (MAT) in Drug Courts: Addressing Barriers to Effective Implementation.” April 14, 2020. YouTube. https://youtu.be/3aw42vn09SE?si=bnmaJFgfNwndjhFi&t=3552; See also Farago F, Blue TR, Smith LR, Witte JC, Gordon M, Taxman FS. “Medication-Assisted Treatment in Problem-solving Courts: A National Survey of State and Local Court Coordinators.” J Drug Issues. 2023 Apr;53(2):296-320. doi: 10.1177/00220426221109948: “Since courts do not deliver treatment per se (i.e., run treatment groups, administer medications, etc.), a [problem-solving court] cannot mandate that individuals take treatment medications. Rather the question is whether the PSC supports the use of medications as a tool to address substance and alcohol use disorders given the effectiveness of the medications in reducing drug use, cravings for illicit drugs and/or alcohol, and improving recidivism outcomes.”

[182] Farago F et al. “Medication-Assisted Treatment in Problem-solving Courts: A National Survey of State and Local Court Coordinators.”

[183] Ibid.

[184] “Sobriety Treatment and Recovery Teams.” Title IV-E Prevention Services Clearinghouse, https://preventionservices.acf.hhs.gov/programs/941/show.

[185] Ibid.

[186] Bomi Kim Hirsch, Ben Case. “Family treatment drug courts.” County Health Rankings & Roadmaps. https://www.countyhealthrankings.org/strategies-and-solutions/what-works-for-health/strategies/family-treatment-drug-courts.

[187] Gifford EJ, Eldred LM, Vernerey A, Sloan FA. “How does family drug treatment court participation affect child welfare outcomes?” Child Abuse Negl. 2014 Oct;38(10):1659-70, https://pmc.ncbi.nlm.nih.gov/articles/PMC4194264/.

[188] “Child Abuse Prevention and Treatment Act,” The Administration for Children & Families (ACF), n.d., https://acf.gov/sites/default/files/documents/cb/capta.pdf.

[189]  Font et al., “Who Should Respond to Substance-Exposed Infants?”

[190] “Child Abuse Prevention and Treatment Act,” p. 26.

[191] Font et al., “Who Should Respond to Substance-Exposed Infants?”

[192] Ibid.

[193] Ibid.

[194] Ibid.

[195] Brooks EM, Tong S. “Implementing Office-Based Opioid Treatment Models in Primary Care.” J Am Board Fam Med. 2020 Jul-Aug;33(4):512-520. doi: 10.3122/jabfm.2020.04.190240.

[196] See for ex. Art Van Zee and David A. Fiellin, “Proliferation of Cash-Only Buprenorphine Treatment Clinics: A Threat to the Nation’s Response to the Opioid Crisis,” American Journal of Public Health 109, no. 3 (2019): 393–94, https://doi.org/10.2105/AJPH.2018.304899.