Access to Care for Justice-Involved Pregnant People With a Substance Use Disorder

There is a critical need to increase access to evidence-based care for justice-involved pregnant people with a substance use disorder (SUD)—and connect them to continued coverage and care upon release—according to national physician and policy experts in a May 2023 webinar sponsored by the American Medical Association (AMA) and Manatt Health. Dr. Ruth Potee, Dr. Cara Poland and Dr. Josiah Rich¹ emphasized that regardless of a person’s involvement with the carceral system, medication for addiction treatment (MAT) remains the established medical standard of care for opioid use disorder (OUD) in all phases of pregnancy. “When you are pregnant, you should walk into any facility and receive the standard of care, and—quite honestly—you should be given options,” remarked Dr. Potee, who explained how critical it is to find alternative solutions that get pregnant individuals out of carceral settings as soon as possible. “We work really hard to get pregnant women out of our facility … we get people diverted to treatment—which is where most pregnant women belong.”

Many jails and prison systems do not provide MAT to pregnant people or others with OUD, despite clear guidance issued by the U.S. Department of Justice (DOJ). DOJ underscores that the Americans with Disabilities Act protects people who take medication to treat their OUD. Despite this, a recent survey of jails across the country found that medication to treat opioid use disorder (MOUD) was available during pregnancy at only 60 percent of jails, even though pregnant individuals with OUD often experience adverse obstetrical outcomes, including higher rates of preterm labor, stillbirth and neonatal abstinence syndrome, and OUD accounts for 10 percent of postpartum mortality.^2,3 Among the carceral systems that did provide MOUD to pregnant people, more than half (55 percent) discontinued treatment immediately following delivery through tapering practices or, in some cases, abrupt cessation.⁴ This abrupt cessation can trigger withdrawal, which is associated with painful physical and mental symptoms. Dr. Poland noted, “Withdrawal feels like the worst flu of your life, coupled with really bad insomnia ... and on top of that you just had a baby.”

Dr. Rich highlighted that some states and counties have begun to implement policies to ensure all individuals have access to MOUD in carceral settings. Rhode Island now guarantees access to all three forms of MOUD (methadone, buprenorphine and naltrexone) for incarcerated individuals. Similarly, the Massachusetts U.S. Attorney’s Office announced in April 2022 that it had partnered with law enforcement officials to ensure that all three forms of MAT are available to inmates within the commonwealth, regardless of whether they are held in a local, state or federal facility.⁵ This statewide achievement was built on the work of Dr. Potee, who has been providing MAT in a small county jail in Massachusetts for more than a decade. As she explained during the webinar, the policy contributes to safety and peace for inmates and staff alike: “A good jail is a healthy jail … there’s fewer fights, less diversion. It’s a safer place to work, and there is much less moral injury for all the staff—both security and medical.”

In other states, the efforts to improve care for incarcerated pregnant people are more piecemeal, depending on the energy and innovation of local law enforcement leaders and individual medical professionals. In Kent County, Michigan, for example, Dr. Poland works in partnership with local jails to deliver high-quality prenatal care and delivery services to pregnant people.⁶ Dr. Poland stated, “We have worked really hard in Kent County to ensure that people are screened for SUD as they enter jail regardless of gender or pregnancy status, and are offered medication for addiction treatment.” In reflecting on her experiences, Dr. Poland noted that it is challenging to provide effective care to any incarcerated individual, but especially those who are pregnant with SUD. Along with the complexity Dr. Poland faces of helping them secure appropriate medication, her patients must contend with the reality that security personnel are present during incredibly intimate, private exams. In some instances, they have provided unsolicited opinions and advice to Dr. Poland, prompting her to reach out to the jail’s administration to ensure accompanying staff are attuned to the need for privacy, confidentiality and discretion during obstetric and gynecologic exams.

A Federal Opportunity to Connect Individuals With SUD to Care Upon Community Reentry

The AMA and Manatt Health webinar also highlighted the need to connect justice-involved individuals, particularly pregnant and postpartum people, to community care upon their departure from the carceral setting and reentry into the community. During the presentation, Kinda Serafi, a partner at Manatt Health, described a new opportunity for states to pursue a Medicaid Section 1115 demonstration, as California has recently done, to build bridges to community-based care for incarcerated individuals.⁷

As Serafi explained, the federal Centers for Medicare & Medicaid Services (CMS) issued a State Medicaid Director Letter (SMDL) in April 2023 that outlines an opportunity for states to waive the inmate exclusion (which prohibits Medicaid from covering services provided during incarceration) and receive federal financial participation for expenditures for certain prerelease health care services provided to individuals who are incarcerated.⁸ In the SMDL, CMS describes how states can secure a federal waiver to provide coverage for up to 90 days prior to release from state and/or local correctional facilities for the following services.

1. MAT for opioid use and alcohol use disorders, which includes all U.S. Food and Drug Administration (FDA)-approved medications for OUD, as well as acamprosate and naltrexone for alcohol use disorder.
2. Case management to assess and address physical and behavioral health needs and health-related social needs.
3. A 30-day supply of all prescription medications upon release.

The webinar panelists noted the SMDL’s promise to establish continuity of care beyond pregnancy during the postpartum period, also known as the “4th trimester.” “The 4th trimester is a terrible time to lose any kind of services because a patient’s needs are even greater during this time,” said Dr. Rich. Connecting incarcerated individuals to Medicaid coverage and prerelease services is instrumental in improving care transitions for individuals as they reenter the community and reducing post-release morbidity and mortality. Policy changes that allow for connections to care for pregnant and postpartum people during reentry help bridge the divide between carceral settings and the community by giving newly released individuals access to critically important resources.

As Dr. Poland sums up,“It’s hard for people post-incarceration to make transitions back to the community. Making a care plan with a provider and establishing strong reintegration plans are all things that we have purposefully worked on in our county. … Making sure that [individuals] have all the other social supports—housing, a job, child care—has been really integral to building success within our community to encourage family-centered, strengths-based support for these individuals, meeting them where they are.”

_{¹ Cara Poland, MD, MEd | Associate Professor, Michigan State University College of Human Medicine, and Principal Investigator, MICARES; Ruth Potee, MD | Medical Director, Franklin County House of Corrections; Director of Addiction Services, Behavioral Health Network; and Medical Director, Franklin Recovery Center; and Josiah Rich, MD, MPH | Professor of Medicine and Epidemiology, Brown University, and Attending Physician, the Miriam and Rhode Island Hospitals.}

_{² Sufrin CB, Knittel A. Health Care and Social Justice Implications of Incarceration for Pregnant People Who Use Drugs. International Review of Psychiatry. September 2021.}

_{³ Haight SC. Opioid Use Disorder Documented at Delivery Hospitalization — United States, 1999–2014. Centers for Disease Control & Prevention: Morbidity Mortality Weekly Report. August 2018.}

_{⁴ Sufrin C, Kramer CT, Terplan M, et al. Availability of Medications for the Treatment of Opioid Use Disorder Among Pregnant and Postpartum Individuals in U.S. Jails. JAMA Network Open. January 2022.}

_{⁵ U.S. Attorney’s Office, District of Massachusetts | U.S. Attorney Rollins Announces Correctional Facilities Statewide to Maintain All Medications for Opioid Use Disorder, Press Release. April 2022.}

_{⁶ Samples S. Kent County Jail Expands Program to Fight Opioid Abuse, Wood TV. January 2020.}

_{⁷ CMS. Approval of California Advancing and Innovation Medi-Cal Section 1115(a) Demonstration. 26 January 2023.}

_{⁸ CMS, SMDL# 23-003. Opportunities to Test Transition-Related Strategies to Support Community Reentry and Improve Care Transitions for Individuals Who Are Incarcerated. April 2023.}