Standard Treatment Falls Short for Privately Insured Pregnant Women with Opioid Use Disorder

Opioid use disorder during pregnancy remains a critical yet under-addressed public health issue in the U.S., according to a new study at Columbia University Mailman School of Public Health. Although effective, evidence-based treatments exist, many pregnant individuals face barriers to accessing timely and appropriate care. Despite clear clinical guidelines recommending medication for opioid use disorder for all pregnant women with OUD, fewer than half receive this treatment. The findings are published in the journal Drug and Alcohol Dependence.

“Gaps in screening, diagnosis, and treatment—along with stigma and structural challenges—continue to limit the use of medication for opioid use disorder (MOUD), the clinical standard for managing this condition,” said Silvia Martins, MD, PhD, professor of Epidemiology at Columbia Mailman School and co-lead author together with Yongmei Huang, MD, DrPH, assistant professor of Reproductive Science (in Obstetrics and Gynecology) at Columbia Vagelos College of Physicians and Surgeons.

From 2016 to 2020, approximately 0.3 percent of pregnant and postpartum women with commercial insurance in the United States were diagnosed with opioid use disorder (OUD). Among those diagnosed before or during pregnancy, fewer than half (43 percent) received medication for opioid use disorder, the standard of care.

“Less than half of pregnant women with OUD receive medication treatment, despite MOUD being the gold standard,” said Martins, who is also Director of the Substance Use Epidemiology Unit of the Department of Epidemiology.  “Our findings highlight substantial missed opportunities to provide evidence-based care during pregnancy and underscore the need for targeted interventions.”

Medication for opioid use disorder—including methadone, buprenorphine, and naltrexone—are recommended by the American College of Obstetricians and Gynecologists and other clinical guidelines. These treatments are associated with improved maternal and neonatal outcomes compared to untreated OUD or detoxification alone.

An important predictor of treatment receipt was the timing of diagnosis. Women diagnosed with OUD prior to pregnancy were more likely to receive MOUD than those diagnosed during pregnancy, emphasizing the importance of early identification and intervention.

“In one national survey, only 33 percent of obstetrician-gynecologists reported that they usually or always recommend MOUD for pregnant patients with OUD,” said Huang, who is also an adjunct assistant professor at the Department of Health Policy and Management at Columbia Mailman School of Public Health. “This points to a need for improved screening in a more timely fashion, and perfected provider education.”

Researchers analyzed data from the Merative MarketScan Commercial Claims and Encounters Database, which includes healthcare claims from over 300 payers across all 50 states and Washington, D.C.

The study included pregnant individuals aged 15–54 with continuous insurance enrollment from 90 days before pregnancy through 90 days postpartum between 2016 and 2020. OUD diagnoses and MOUD treatment were identified using diagnostic codes and pharmacy and procedure claims.

Among 909,241 pregnancies analyzed, 2,926 individuals (0.3 percent) were diagnosed with OUD. Of those diagnosed before or during pregnancy (n=2,346), only 40–43 percent received MOUD.

Key findings include:

• Half of OUD cases were diagnosed before pregnancy 
• 17 percent were diagnosed in the first trimester, 12 percent in the second, 10 percent in the third, and 11 percent postpartum 
• Buprenorphine was the most commonly used treatment (84 percent of those receiving MOUD) 
• Women in the South were 14 percent less likely to receive MOUD than those in the Northeast 
• Younger age and residence in non-metropolitan areas were associated with OUD diagnosis 
• Chronic pain and other substance use disorders were linked to lower MOUD use, while multiple mental health conditions were associated with higher treatment rates 

Untreated OUD during pregnancy is associated with serious risks, including poor prenatal care engagement, adverse mental health outcomes, and increased pregnancy complications. At the same time, opioid-related overdose deaths among pregnant and postpartum women have risen sharply in the past decade and are now a leading cause of pregnancy-associated death.

“MOUD is safe and effective during pregnancy and is associated with significantly better outcomes for both mothers and infants,” said Huang. “Yet treatment uptake remains persistently low.”

While methadone is highly effective, access is restricted to federally regulated clinics, which often require daily visits; and childcare can be an issue. Buprenorphine, which can be prescribed in office-based settings, may offer a more accessible alternative. Emerging evidence also supports the safety of buprenorphine/naloxone during pregnancy.

“Obstetricians, gynecologists, and primary care providers play a critical role in screening, diagnosis, and ensuring timely access to evidence-based treatment,” said Martins. “Improving care delivery during pregnancy is essential to addressing this ongoing public health challenge.”

Co-authors include W. Fan, L.E. Segura, E. Bruzelius, M.E. Marziali, and A. Khan, Columbia Mailman School; and M.M. Philbin, University of California San Francisco.

The study was supported by NIH-NIDA, grants R01DA05374, T32DA031099 and R36DA061635.

The authors have no competing financial disclosures to report.