Implementation of State Laws Giving Pregnant People Priority Access to Drug Treatment Programs in the Context of Coexisting Punitive Laws

Published:October 19, 2022DOI:



      In response to increased prenatal drug use since the 2000s, states have adopted treatment-oriented laws giving pregnant and postpartum people priority access to public drug treatment programs as well as multiple punitive policy responses. No prior studies have systematically characterized these state statutes or examined implementation of state priority access laws in the context of co-existing punitive laws.


      We conducted legal mapping to examine state priority access laws and their overlap with state laws deeming prenatal drug use to be child maltreatment, mandating reporting of prenatal drug use to child protective services, or criminalizing prenatal drug use. We also conducted interviews with 51 state leaders with expertise on their states’ prenatal drug use laws to understand how priority access laws were implemented.


      Thirty-three states and the District of Columbia have a priority access law, and more than 80% of these jurisdictions also have one of the punitive prenatal drug use laws described. Leaders reported major barriers to implementing state priority access laws, including the lack of drug treatment programs, stigma, and conflicts with punitive prenatal drug use laws.


      Our results suggest that state laws granting pregnant and postpartum people priority access to drug treatment programs are likely insufficient to significantly increase access to evidence-based drug treatment. Punitive state prenatal drug use laws may counteract priority access laws by impeding treatment seeking. Findings highlight the need to allocate additional resources to drug treatment for pregnant and postpartum people.
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        • Abraham A.J.
        • Andrews C.M.
        • Harris S.J.
        • Friedmann P.D.
        Availability of medications for the treatment of alcohol and opioid use disorder in the USA.
        Neurotherapeutics. 2020; 17: 55-69
        • Albrecht J.
        • Lindsay B.
        • Terplan M.
        Effect of waiting time on substance abuse treatment completion in pregnant women.
        Journal of Substance Abuse Treatment. 2011; 41: 71-77
        • American Academy of Family Physicians
        Substance use disorders.
        Date: 2019
        Date accessed: August 10, 2022
        • American College of Obstetricians and Gynecologists (ACOG)
        ACOG committee opinion no 473. Substance abuse reporting and pregnancy: the role of the obstetrician-gynecologist.
        Obstetrics and Gynecology. 2011; 117: 200-201
        • American College of Obstetricians and Gynecologists (ACOG)
        Opposition to criminalization of individuals during pregnancy and the postpartum period.
        • American College of Obstetricians and Gynecologists Committee on Obstetric Practice
        ACOG Committee Opinion No. 711: Opioid use and opioid use disorder in pregnancy.
        Obstetrics and Gynecology. 2017; 130: e81-e94
        • American Medical Association
        Legal interventions during pregnancy: Court-ordered medical treatments and legal penalties for potentially harmful behavior by pregnant women.
        Journal of the American Medical Association. 1990; 264: 2663-2670
        • American Nurses Association
        Non-punitive treatment for pregnant and breast-feeding women with substance use disorders.
        • American Psychiatric Association (APA)
        Position statement on the care of pregnant and newly delivered women addicts.
        American Journal of Psychiatry. 1992; 149: 724--7724
        • Angelotta C.
        • Weiss C.J.
        • Angelotta J.W.
        • Friedman R.A.
        A moral or medical problem? The relationship between legal penalties and treatment practices for opioid use disorders in pregnant women.
        Womens Health Issues. 2016; 26: 595-601
        • Armstrong M.A.
        • Gonzales Osejo V.
        • Lieberman L.
        • Carpenter D.M.
        • Pantoja P.M.
        • Escobar G.J.
        Perinatal substance abuse intervention in obstetric clinics decreases adverse neonatal outcomes.
        Journal of Perinatology. 2003; 23: 3-9
        • Atkins D.N.
        • Durrance C.P.
        State policies that treat prenatal substance use as child abuse or neglect fail to achieve their intended goals.
        Health Affairs (Millwood). 2020; 39: 756-763
        • Atwood E.C.
        • Sollender G.
        • Hsu E.
        • Arsnow C.
        • Flanagan V.
        • Celenza J.
        • Holmes A.V.
        A qualitative study of family experience with hospitalization for neonatal abstinence syndrome.
        Hospital Pediatrics. 2016; 6: 626-632
        • Bakhireva L.N.
        • Shrestha S.
        • Garrison L.
        • Leeman L.
        • Rayburn W.F.
        • Stephen J.M.
        Prevalence of alcohol use in pregnant women with substance use disorder.
        Drug and Alcohol Dependence. 2018; 187: 305-310
        • Barnett E.R.
        • Knight E.
        • Herman R.J.
        • Amarakaran K.
        • Jankowski M.K.
        Difficult binds: A systematic review of facilitators and barriers to treatment among mothers with substance use disorders.
        Journal of Substance Abuse Treatment. 2021; 126: 108341
        • Barry C.L.
        • Kennedy-Hendricks A.
        • Gollust S.E.
        • Niederdeppe J.
        • Bachhuber M.A.
        • Webster D.W.
        • McGinty E.E.
        Understanding Americans' views on opioid pain reliever abuse.
        Addiction (Abingdon, England). 2016; 111: 85-93
        • Barry C.L.
        • McGinty E.E.
        • Pescosolido B.A.
        • Goldman H.H.
        Stigma, discrimination, treatment effectiveness, and policy: Public views about drug addiction and mental illness.
        Psychiatric Services (Washington, D.C.). 2014; 65: 1269-1272
        • Center for Behavioral Health Statistics and Quality
        Results from the 2020 National Survey on Drug Use and Health: Detailed tables. Rockville, MD.
        Date: 2021
        Date accessed: November 1, 2022
        • Clemans-Cope L.
        • Lynch V.
        • Epstein M.
        • Kenney G.M.
        Opioid and substance use disorder and receipt of treatment among parents living with children in the United States, 2015-2017.
        Annals of Family Medicine. 2019; 17: 207-211
        • Crane D.
        • Marcotte M.
        • Applegate M.
        • Massatti R.
        • Hurst M.
        • Menegay M.
        • Williams S.
        A statewide quality improvement (QI) initiative for better health outcomes and family stability among pregnant women with opioid use disorder (OUD) and their infants.
        Journal of Substance Abuse Treatment. 2019; 102: 53-59
        • Drabble L.
        • Thomas S.
        • O’Connor L.
        • Roberts S.C.M.
        State responses to alcohol use and pregnancy: Findings from the Alcohol Policy Information System.
        Journal of Social Work Practice in the Addictions. 2014; 14: 191-206
        • Faherty L.J.
        • Heins S.
        • Kranz A.M.
        • Patrick S.W.
        • Stein B.D.
        Association between punitive policies and neonatal abstinence syndrome among Medicaid-insured infants in complex policy environments.
        Addiction. 2021; 117: 162-171
        • Faherty L.J.
        • Kranz A.M.
        • Russell-Fritch J.
        • Patrick S.W.
        • Cantor J.
        • Stein B.D.
        Association of punitive and reporting state policies related to substance use in pregnancy with rates of neonatal abstinence syndrome.
        JAMA Network Open. 2019; 2: e1914078
        • Faherty L.J.
        • Heins S.
        • Kranz A.M.
        • Stein B.D.
        Postpartum treatment for substance use disorder among mothers of infants with neonatal abstinence syndrome and prenatal substance exposure.
        Women's Health Reports. 2021; 2: 163-172
        • Gartner K.
        • Elliot K.
        • Smith M.
        • Pearson H.
        • Hunt G.
        • Martin R.E.
        Participatory action research with women with substance use in pregnancy.
        Canadian Family Physician. 2018; 64: e309-e316
        • Goler N.C.
        • Armstrong M.A.
        • Taillac C.J.
        • Osejo V.M.
        Substance abuse treatment linked with prenatal visits improves perinatal outcomes: a new standard.
        Journal of Perinatology. 2008; 28: 597-603
        • Goodman D.J.
        • Saunders E.C.
        • Wolff K.B.
        In their own words: A qualitative study of factors promoting resilience and recovery among postpartum women with opioid use disorders.
        BMC Pregnancy and Childbirth. 2020; 20: 178
        • Gregoire K.A.
        • Schultz D.J.
        Substance-abusing child welfare parents: treatment and child placement outcomes.
        Child Welfare. 2001; 80: 433-453
        • Gressler L.E.
        • Shah S.
        • Shaya F.T.
        Association of Criminal Statutes for Opioid Use Disorder With Prevalence and treatment among pregnant women with commercial insurance in the United States.
        JAMA Network Open. 2019; 2: e190338
        • Guttmacher Institute
        Substance use during pregnancy.
        • Haight S.C.
        • Ko J.Y.
        • Tong V.T.
        • Bohm M.K.
        • Callaghan W.M.
        Opioid use disorder documented at delivery hospitalization — United States, 1999–2014.
        Morbidity and Morality Weekly Reports. 2018; 67: 845-849
        • Haug N.A.
        • Duffy M.
        • McCaul M.E.
        Substance abuse treatment services for pregnant women: psychosocial and behavioral approaches.
        Obstetric and Gynecolocological Clinics of North America. 2014; 41: 267-296
        • Howard D.S.
        • Dhanraj D.N.
        • Devaiah C.G.
        • Lambers D.S.
        Cannabis use based on urine drug screens in pregnancy and its association with infant birth weight.
        Journal of Addiction Medicine. 2019; 13: 436-441
        • Jarlenski M.
        • Hogan C.
        • Bogen D.L.
        • Chang J.C.
        • Bodnar L.M.
        • Van Nostrand E.
        Characterization of U.S. state laws requiring health care provider reporting of perinatal substance use.
        Women's Health Issues. 2017; 27: 264-270
        • Jessup M.A.
        • Humphreys J.C.
        • Brindis C.D.
        • Lee K.A.
        Extrinsic barriers to substance abuse treatment among pregnant drug dependent women.
        Journal of Drug Issues. 2003; 33: 285-304
        • Jones H.E.
        • Heil S.H.
        • Baewert A.
        • Arria A.M.
        • Kaltenbach K.
        • Martin P.R.
        • Fischer G.
        Buprenorphine treatment of opioid-dependent pregnant women: A comprehensive review.
        Addiction. 2012; 107: 5-27
        • Kennedy-Hendricks A.
        • Barry C.L.
        • Gollust S.E.
        • Ensminger M.E.
        • Chisolm M.S.
        • McGinty E.E.
        Social stigma toward persons with prescription opioid use disorder: Associations with public support for punitive and public health–oriented policies.
        Psychiatric Services. 2017; 68: 462-469
        • Kozhimannil K.B.
        • Dowd W.N.
        • Ali M.M.
        • Novak P.
        • Chen J.
        Substance use disorder treatment admissions and state-level prenatal substance use policies: Evidence from a national treatment database.
        Addictive Behavior. 2019; 90: 272-277
        • Kozhimannil K.B.
        • Graves A.J.
        • Jarlenski M.
        • Kennedy-Hendricks A.
        • Gollust S.
        • Barry C.L.
        Non-medical opioid use and sources of opioids among pregnant and non-pregnant reproductive-aged women.
        Drug and Alcohol Dependence. 2017; 174: 201-208
        • Krans E.E.
        • Kim J.Y.
        • James 3rd, A.E.
        • Kelley D.
        • Jarlenski M.P.
        Medication-assisted treatment use among pregnant women with opioid use disorder.
        Obstetrics and Gynecology. 2019; 133: 943-951
        • Lieberman L.
        • Taillac C.
        • Goler N.
        Vision, research, innovation and influence: Early Start’s 15-year journey from pilot project to regional program.
        Permanente Journal. 2005; 9: 62-64
        • Madden E.F.
        Intervention stigma: How medication-assisted treatment marginalizes patients and providers.
        Social Science & Medicine. 2019; 232: 324-331
        • Maeda A.
        • Bateman B.T.
        • Clancy C.R.
        • Creanga A.A.
        • Leffert L.R.
        Opioid abuse and dependence during pregnancy: Temporal trends and obstetrical outcomes.
        Anesthesiology. 2014; 121: 1158-1165
        • March of Dimes
        Policies and programs to address drug-exposed newborns.
        • Martin C.E.
        • Longinaker N.
        • Terplan M.
        Recent trends in treatment admissions for prescription opioid abuse during pregnancy.
        Journal of Substance Abuse Treatment. 2015; 48: 37-42
        • Mattick R.P.
        • Breen C.
        • Kimber J.
        • Davoli M.
        Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence.
        Cochrane Database of Systematic Revoews. 2009; : CD002209
        • McGinty E.E.
        • Barry C.L.
        Stigma reduction to combat the addiction crisis—Developing an evidence base.
        New England Journal of Medicine. 2020; 382: 1291-1292
        • Minozzi S.
        • Amato L.
        • Jahanfar S.
        • Bellisario C.
        • Ferri M.
        • Davoli M.
        Maintenance agonist treatments for opiate-dependent pregnant women.
        Cochrane Database of Systematic Reviews. 2020; 11: CD006318
        • Mojtabai R.
        • Mauro C.
        • Wall M.M.
        • Barry C.L.
        • Olfson M.
        Medication treatment for opioid use disorders in substance use treatment facilities.
        Health affairs (Project Hope). 2019; 38: 14-23
        • National Academies of Sciences Engineering Medicine
        Medications for opioid use disorder save lives.
        The National Academies Press, Washington, DC2019
        • National Institute on Drug Abuse
        Available treatments for marijuana use disorders.
        • Nishimoto R.H.
        • Roberts A.C.
        Coercion and drug treatment for postpartum women.
        American Journal of Drug and Alcohol Abuse. 2001; 27: 161-181
        • O'Rourke-Suchoff D.
        • Sobel L.
        • Holland E.
        • Perkins R.
        • Saia K.
        • Bell S.
        The labor and birth experience of women with opioid use disorder: A qualitative study.
        Women and Birth. 2020; 33: 592-597
        • Olsen Y.
        • Sharfstein J.M.
        Confronting the stigma of opioid use disorder—And its treatment.
        JAMA. 2014; 311: 1393-1394
        • Ostrach B.
        • Leiner C.
        “I didn't want to be on suboxone at first…” - Ambivalence in perinatal substance use treatment.
        Journal of Addiction Medicine. 2019; 13: 264-271
        • Patrick S.W.
        • Buntin M.B.
        • Martin P.R.
        • Scott T.A.
        • Dupont W.
        • Richards M.
        • Cooper W.O.
        Barriers to accessing treatment for pregnant women with opioid use disorder in Appalachian states.
        Substance Abuse. 2019; 40: 356-362
        • Patrick S.W.
        • Davis M.M.
        • Lehmann C.U.
        • Cooper W.O.
        Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012.
        Journal of Perinatology. 2015; 35: 650-655
        • Patrick S.W.
        • Richards M.R.
        • Dupont W.D.
        • McNeer E.
        • Buntin M.B.
        • Martin P.R.
        • Cooper W.O.
        Association of pregnancy and insurance status with treatment access for opioid use disorder.
        JAMA Network Open. 2020; 3: e2013456
        • Patrick S.W.
        • Schiff D.M.
        • Committee On Substance Use and Prevention
        A public health response to opioid use in pregnancy.
        Pediatrics. 2017; 139: e20164070
        • Petrangelo A.
        • Czuzoj-Shulman N.
        • Balayla J.
        • Abenhaim H.A.
        Cannabis abuse or dependence during pregnancy: A population-based cohort study on 12 million births.
        Journal of Obstetrics and Gynaecology Canada. 2019; 41: 623-630
        • Roberts S.C.
        • Pies C.
        Complex calculations: How drug use during pregnancy becomes a barrier to prenatal care.
        Maternal and Child Health Journal. 2011; 15: 333-341
        • Roberts S.C.M.
        • Thomas S.
        • Treffers R.
        • Drabble L.
        Forty years of state alcohol and pregnancy policies in the USA: Best practices for public health or efforts to restrict women's reproductive rights?.
        Alcohol and Alcoholism. 2017; 52: 715-721
        • Roberts S.C.M.
        • Thompson T.-A.
        • Taylor K.J.
        Dismantling the legacy of failed policy approaches to pregnant people’s use of alcohol and drugs.
        International Review of Psychiatry. 2021; 33: 502-513
        • Shi Y.
        • Zhong S.
        Trends in cannabis use disorder among pregnant women in the U.S., 1993-2014.
        Journal of General Internal Medicine. 2018; 33: 245-246
        • Short V.L.
        • Hand D.J.
        • MacAfee L.
        • Abatemarco D.J.
        • Terplan M.
        Trends and disparities in receipt of pharmacotherapy among pregnant women in publically funded treatment programs for opioid use disorder in the United States.
        Journal of Substance Abuse Treatment. 2018; 89: 67-74
        • Substance Abuse and Mental Health Services Administration
        Treatment of stimulant use disorders.
        National Mental Health and Substance Use Policy Laboratory. Substance Abuse and Mental Health Services Administration, Rockville, MD2020
        • Substance Abuse Mental Health Services Administration
        National household survey on drug abuse 2002, 2003, and 2004.
        National Mental Health and Substance Use Policy Laboratory. Substance Abuse and Mental Health Services Administration, Rockville, MD2004
        • Terplan M.
        • Longinaker N.
        • Appel L.
        Women-centered drug treatment services and need in the United States, 2002-2009.
        American Journal of Public Health. 2015; 105: e50-e54
        • Terplan M.
        • Smith E.J.
        • Kozloski M.J.
        • Pollack H.A.
        Methamphetamine use among pregnant women.
        American College of Obstetricians and Gynecologists. 2009; 113: 1285-1291
        • The Medicaid Outcomes Distributed Research Network
        Use of medications for treatment of opioid use disorder among US Medicaid enrollees in 11 states, 2014-2018.
        JAMA. 2021; 326: 154-164
        • Thomas S.
        • Treffers R.
        • Berglas N.F.
        • Drabble L.
        • Roberts S.C.M.
        Drug use during pregnancy policies in the United States from 1970 to 2016.
        Contemporary Drug Problems. 2018; 45: 441-459
        • Tolia V.N.
        • Patrick S.W.
        • Bennett M.M.
        • Murthy K.
        • Sousa J.
        • Smith P.B.
        • Spitzer A.R.
        Increasing incidence of the neonatal abstinence syndrome in U.S. neonatal ICUs.
        New England Journal of Medicine. 2015; 372: 2118-2126
        • Volkow N.D.
        • Frieden T.R.
        • Hyde P.S.
        • Cha S.S.
        Medication-assisted therapies—Tackling the opioid-overdose epidemic.
        New England Journal of Medicine. 2014; 370: 2063-2066
        • Volkow N.D.
        • Han B.
        • Compton W.M.
        • McCance-Katz E.F.
        Self-reported medical and nonmedical cannabis use among pregnant women in the United States.
        JAMA. 2019; 322: 167-169
        • Wagenaar A.C.B.
        • Scott C.
        Public health law reserach: Theory and methods.
        Jossey-Bass, San Francisco, CA2013
        • Weber A.
        • Miskle B.
        • Lynch A.
        • Arndt S.
        • Acion L.
        Substance use in pregnancy: Identifying stigma and improving care.
        Substance Abuse and Rehabilitation. 2021; 12: 105-121
        • Whittaker A.
        • Chandler A.
        • Cunningham-Burley S.
        • Midgley P.
        • Elliott L.
        • Cooper S.
        Problematisation and regulation: Bodies, risk, and recovery within the context of neonatal abstinence syndrome.
        International Journal of Drug Policy. 2019; 68: 139-146
        • Winkelman T.N.A.
        • Villapiano N.
        • Kozhimannil K.B.
        • Davis M.M.
        • Patrick S.W.
        Incidence and costs of neonatal abstinence syndrome among infants with Medicaid: 2004-2014.
        Pediatrics. 2018; 141: e20173520
        • Wolfson L.
        • Schmidt R.A.
        • Stinson J.
        • Poole N.
        Examining barriers to harm reduction and child welfare services for pregnant women and mothers who use substances using a stigma action framework.
        Health & Social Care in the Community. 2021; 29: 589-601
        • Yonkers K.A.
        • Howell H.B.
        • Allen A.E.
        • Ball S.A.
        • Pantalon M.V.
        • Rounsaville B.J.
        A treatment for substance abusing pregnant women.
        Archives of Womens Mental Health. 2009; 12: 221-227


      Sarah A. White, MSPH, conducts research on public policies related to mental health and substance use disorders within the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health.


      Alexander McCourt, JD, PhD, examines firearm policy, opioid policy, and other areas affected by the relationships between law and the public's health within the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health.


      Sachini Bandara, PhD, studies how public health policies can improve wellbeing for people who use drugs, have mental illness, or are involved in the carceral system within the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health.


      Daisy J. Goodman, CND, MPH, CNM, is a practicing nurse midwife, caring for women whose pregnancies are complicated by drug and alcohol use. She directs women's health services in Dartmouth-Hitchcock's perinatal addiction treatment program and works in their Department of Obstetrics and Gynecology.


      Esita Patel, PhD, RN, conducts real-world and timely health policy evaluation, with a special interest in issues at the intersection of health policy and the health workforce within the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health.


      Emma E. McGinty, PhD, conducts mixed-methods research on mental health and substance use disorder policy by integrating approaches from public policy and implementation science in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health.