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Corresponding author at: Department of Healthcare Policy & Research, Weill Cornell Medicine, 425 East 61st Street, Suite 301, New York, NY 10065, United States of America.
23% of treatment facilities had programs for pregnant/postpartum women (PPW).
•
PPW programs offered methadone 24% and buprenorphine 44%.
•
Childcare 16%, transportation 50%, and domestic violence 51% services were offered.
•
Service availability was even lower in outpatient PPW Programs & Other Programs.
•
There are significant gaps in the availability of treatment services benefiting PPW.
Abstract
The increasing prevalence of opioid use disorders among pregnant and postpartum women (PPW) has generated a need for greater availability of specialized programs offering evidence-based and comprehensive substance use disorder treatment services tailored to this population. In this study, we used data from the 2007 to 2018 National Survey of Substance Abuse Treatment Services to describe recent time trends and the geographic distribution of treatment facilities with specialized programs for PPW. We also compared differences in the availability of opioid agonist medication treatments (MT), key ancillary services, and health insurance acceptance between PPW Programs and Other Programs, overall and by residential and outpatient settings. We found that the prevalence of PPW Programs increased from 17% in 2007 to 23% in 2018, for a total of 3,429 PPW Programs and 11,230 Other Programs in 2018. The prevalence of PPW Programs was lowest in some states in the South and Midwest. Compared to Other Programs, PPW Programs were more likely to accept Medicaid (75% vs. 64%) and offer opioid agonist MTs methadone (24% vs. 6%), buprenorphine (44% vs. 30%), or both (18% vs. 4%). PPW Programs were also more likely to offer other key ancillary services such as childcare (16% vs. 3%), transportation (50% vs. 42%), and domestic violence assistance (51% vs. 35%). Compared to PPW Programs in outpatient settings, PPW Programs in residential settings were more likely to offer these key ancillary services but less likely to offer methadone or accept Medicaid. Our findings reflect considerable variation in the availability of PPW Programs over time and across states, as well as substantial gaps in key services offered in PPW Programs, let alone in Other Programs.
Opioid overdose deaths and rates of opioid misuse and opioid use disorder (OUD) have increased exponentially in the United States since the early 2000s (
). Rates of opioid misuse and OUD among pregnant women have also increased substantially during this time, leading to a marked growth in adverse maternal and neonatal outcomes (
Trends and disparities in receipt of pharmacotherapy among pregnant women in publicly funded treatment programs for opioid use disorder in the United States.
Journal of Substance Abuse Treatment.2018; 89: 67-74
Treatment services for pregnant women with OUD should have a level of comprehensiveness that matches the complexity and multifaceted nature of OUD and its correlates in this population (
). Pregnant women with OUD often face challenging circumstances, including polysubstance use, a history of sexual abuse and domestic violence, inadequate social supports, poor nutrition, unstable housing, and co-occurring mental health disorders (
). They also face unique challenges for initiating and remaining in treatment such as a lack of childcare and other accessibility issues, financial barriers, stigma, and even criminal prosecution (
). Several states have criminal justice focused prenatal substance use laws that discourage pregnant women from disclosing their substance use and entering treatment (
). Additionally, while more than 50% of pregnant women who enter OUD treatment have Medicaid and 5% have private insurance, about one third are uninsured (
). Even among those with insurance, financial barriers might remain since key services may not be covered, substance use disorder (SUD) treatment providers may not accept insurance, and many pregnant women in states that did not expand Medicaid under the Affordable Care Act will lose Medicaid 60 days postpartum (
). Another important challenge is that either due to a lack of training, experience, or other factors, some providers are unwilling to treat pregnant women with OUD (
For these reasons, treatment for pregnant women with OUD should be delivered in the context of specialized programs that include providers who are trained to care for this population and that offer comprehensive services along with opioid agonist MTs, including mental health care, prenatal care, childcare, housing assistance, domestic violence assistance, and other key ancillary services (
). Previous work shows that pregnant women receiving treatment in specialized programs exhibit higher rates of treatment retention, illicit drug abstinence, and report fewer barriers to care (
In spite of improved outcomes of opioid agonist MT delivered along with other specialized services, a large proportion of pregnant women with OUD do not receive these services, let alone any SUD treatment. According to the 2007 to 2017 National Survey on Drug Use and Health, an estimated 37% of pregnant women with OUD received any SUD treatment in the past year and 25% received OUD-specific treatment in the past year. About 50% of pregnant women in OUD-specific treatment did not receive opioid agonist MTs (
Trends and disparities in receipt of pharmacotherapy among pregnant women in publicly funded treatment programs for opioid use disorder in the United States.
Journal of Substance Abuse Treatment.2018; 89: 67-74
). Limited availability of providers may be one possible explanation for the treatment gap. The proportion of SUD treatment facilities with a specialized program for pregnant and postpartum women (PPW) has been arguably low and declined from 19% in 2002 to 15% in 2009 (
). The proportion of SUD treatment facilities offering methadone and buprenorphine has also been low and estimated at 10% and 25% in 2016, respectively (
In an effort to improve service availability and treatment outcomes for PPW with substance use disorders, the Federal government has historically funded treatment in residential settings through the Substance Abuse and Mental Health Services Administration's (SAMHSA) Services Grant Program for Residential Treatment for Pregnant and Postpartum Women. Only recently, did SAMHSA expand the grant program to fund treatment in outpatient settings. This shift may have important implications for treatment outcomes in the PPW population. Evidence suggests that residential settings result in better treatment outcomes than outpatient settings among individuals with OUD (
). These findings might be partially due to differences in service availability across treatment settings.
Neither the prevalence of PPW Programs over the last decade nor the availability of treatment services in these programs are known. It is also unknown whether service availability in these programs varies by treatment setting. In this study, we used data from the 2007 to 2018 National Survey of Substance Abuse Treatment Services to describe recent time trends in the prevalence of SUD treatment facilities with PPW Programs and MTs in these programs, overall and by treatment setting. The geographic distribution of treatment facilities with PPW Programs was also described. Additionally, we compared the prevalence of MTs and other key treatment services between PPW Programs and Other Programs, overall and by treatment setting. By characterizing the availability of SUD treatment services for pregnant and postpartum women, we provide policymakers with timely information that can help identify and overcome barriers to treatment in this vulnerable population.
2. Methods
2.1 Data
We analyzed data from the 2007 to 2018 National Survey of Substance Abuse Treatment Services (N-SSATS), an annual survey of substance use disorder (SUD) treatment facilities administered by the Substance Abuse and Mental Health Services Administration (SAMHSA) (N = 165,350). N-SSATS is designed to survey all specialty SUD treatment facilities in the United States, both public and private. Each year, approximately 90% of eligible facilities respond and are included in the sample. N-SSATS collects information on the services offered at these treatment facilities and the utilization of those services. Services include medication management for substance use disorder and mental health disorders, testing, and ancillary services, among others. Information on facility characteristics such as type of ownership, geographic location (i.e. state), and payer acceptance are also collected. The unit of observation in N-SSATS is a facility, defined as the physical location where treatment services are provided.
2.2 Sample
Pregnancy is defined as the period between conception and childbirth and the postpartum period is commonly defined as the six weeks after childbirth. While the N-SSATS questionnaire does not explicitly define pregnant and postpartum women (PPW), it asks SUD treatment facilities to report whether they “offer a substance abuse treatment program or group specifically tailored” to PPW and clarifies that if the “facility treats [PPW] clients but does not have a specifically tailored program or group for them” to not report offering such program or group. We used this information to identify and stratify facilities into those with specific programs or groups for pregnant and postpartum women (PPW Programs) and those without these programs or groups (Other Programs). We further stratified treatment facilities based on treatment setting, including residential and outpatient settings. Treatment setting was not mutually exclusive. In our sample, 73% of facilities offered services in outpatient settings only, 16% in residential settings only, 9% in both, and 2% in neither. When stratifying the sample by treatment setting, we identified residential settings and outpatient settings without residential services (i.e. non-residential).
2.3 Analysis
2.3.1 Time trends in PPW programs
Using the 2007 to 2018 N-SSATS, we examined time trends in the percentage of treatment facilities with PPW Programs, overall and by treatment setting. Time trends in the number of treatment facilities with PPW Programs and the total number of treatment facilities, overall and by treatment setting, were included in Appendix Fig. A1. We also examined time trends in the percentage of treatment facilities with PPW Programs offering opioid agonist MTs methadone -measured as the number of opioid treatment programs- and buprenorphine, overall and by treatment setting.
2.3.2 Geographic distribution of PPW programs
Using the 2018 N-SSATS and the 2016 to 2017 National Survey on Drug Use and Health through SAMHSA's Restricted-use Data Analysis System, we examined the geographic distribution of treatment facilities with PPW Programs across states. We did this by calculating and mapping quintiles based on the number of PPW Programs per 1000 reproductive age women (ages 15 to 44) with a substance use disorder in the past year. This rate and the percentage of treatment facilities with PPW Programs in each state as well as underlying numerators, denominators, and other information were included in Appendix Table A1.
2.3.3 Treatment services and payer acceptance at PPW programs
Using the 2018 N-SSATS, we calculated the number and percentage of treatment facilities with PPW Programs offering key services, including medications, testing, and ancillary services, overall and by treatment setting. Since financial barriers are often reported as a reason for not seeking treatment, we also considered payer acceptance, including cash, free treatment, and different types of health insurance. Services offered and payer acceptance at Other Programs were reported for comparison.
We used Chi-square tests to compare services at PPW Programs to services at Other Programs and to compare services at residential settings to services at outpatient settings separately for PPW Programs and for Other Programs. Given the large sample size and number of hypotheses tested per comparison groups (
), we implemented a Bonferroni correction that considered a P-value lower than 0.05/33 = 0.002 evidence against the null.
3. Results
3.1 Time trends in PPW programs
The top panel of Fig. 1 shows that the percentage of facilities with PPW Programs increased from 17% in 2007 to 23% in 2018. The bottom panel of Fig. 1 shows that while initially the percentage of residential facilities with PPW Programs was slightly higher than the percentage of outpatient facilities with PPW Programs, these differences became nearly identical after 2013.
Fig. 1Substance use disorder treatment facilities with specialized programs for pregnant and postpartum women, overall and by treatment setting.
The top panel of Fig. 2 shows that PPW Programs offered methadone and buprenorphine at higher rates than Other Programs and that buprenorphine availability in PPW Programs increased at a faster rate than in Other Programs over the sample period. However, the proportion of PPW Programs offering methadone declined from 29% in 2013 to 24% in 2018. The bottom panel stratifies the PPW Program sample by treatment setting and shows that residential PPW Programs offered methadone at a substantially lower rate than outpatient PPW Programs. However, buprenorphine prevalence and growth was similar regardless of setting.
Fig. 2Opioid agonist medication treatment availability in facilities with specialized programs for pregnant and postpartum women, overall and by treatment setting.
There was considerable variation in the number of PPW Programs per 1000 reproductive age women with SUD across states, ranging from 0.09 in the District of Columbia to 1.83 in Maine (see Fig. 3 and Appendix Table A1). Fig. 3 shows that the rate of PPW Programs was highest in Maine, Kentucky, Alaska, Idaho, Delaware, Vermont, Wyoming, West Virginia, New Mexico and New Hampshire, but lowest in many states in the South (District of Columbia, Texas, South Carolina, Arkansas, Tennessee, Louisiana, Alabama) and the Midwest (Illinois, Ohio, Missouri, Iowa, Wisconsin).
Fig. 3Geographic distribution of substance use disorder treatment facilities with specialized programs for pregnant and postpartum women per 1000 reproductive age women with substance use disorders, by state.
Notes: National Survey of Substance Abuse Treatment Services, 2018. PPW Programs per 1000 reproductive age women with substance use disorders in a given state were classified into quintiles (Q1 to Q5).
3.3 Treatment services and payer acceptance at PPW programs
In Table 1, we compared the availability of treatment services in PPW Programs and Other Programs. Across medications, PPW Programs were more likely to offer methadone (24% vs. 6%, 18 percentage point difference), buprenorphine (44% vs. 30%, 14 percentage point difference) or both methadone and buprenorphine (18% vs. 4%, 14 percentage point difference), but less likely to offer medications for psychiatric disorders (41% vs. 46%, −5 percentage point difference) even when PPW have a high burden of mental health conditions. PPW Programs were more likely to test for Hepatitis C (40% vs. 26%, 14 percentage point difference), HIV (39% vs. 26%, 13 percentage point difference) and STDs (31% vs. 20%, 11 percentage point difference). Likewise, PPW Programs offered several key ancillary services at substantially higher rates than Other Programs, child care (16% vs. 3%, 13 percentage point difference) and assistance with social services (72% vs. 57%, 15 percentage point difference), employment assistance (49% vs. 36%, 13 percentage point difference), housing assistance (69% vs. 50%, 19 percentage point difference), and domestic violence services (51% vs. 35%, 16 percentage point difference). Lastly, there were few meaningful differences in payer acceptance although notably, PPW Programs accepted Medicaid more often than Other Programs (75% vs. 64%, 11 percentage point difference).
Table 1Service availability at SUD treatment facilities with specialized programs for pregnant and postpartum women, N-SSATS 2018.
PPW programs
Other programs
Chi-2
N = 3429
N = 11,230
No.
%
No.
%
P-value
Medications
Methadone
833
24
677
6
0.000
Buprenorphine
1508
44
3382
30
0.000
Meth. or Bup.
1713
50
3594
32
0.000
Meth. and Bup.
628
18
465
4
0.000
Naltrexone
1058
31
3210
29
0.010
Disulfiram
677
20
2180
19
0.668
Acamprosate
692
20
2324
21
0.515
Nicotine replacement
968
28
3151
28
0.845
Psychiatric disorders
1415
41
5150
46
0.000
Testing
HCV
1383
40
2937
26
0.000
HIV
1351
39
2897
26
0.000
STD
1052
31
2276
20
0.000
Ancillary services
Case management
3075
90
9109
81
0.000
Social skills
2832
83
8316
74
0.000
Mentoring/peer support
2230
65
6263
56
0.000
Child care
564
16
287
3
0.000
Beds for clients' children
300
9
73
1
0.000
Assist. social services
2485
72
6354
57
0.000
Employment
1673
49
4031
36
0.000
Housing assist
2365
69
5646
50
0.000
Domestic violence
1761
51
3881
35
0.000
Intervention HIV
1198
35
2067
18
0.000
HIV/AIDS edu
2315
68
5456
49
0.000
Hepatitis edu
2177
63
4755
42
0.000
Health edu
2259
66
5332
47
0.000
Transportation assistance
1714
50
4694
42
0.000
Mental health svcs
2339
68
7653
68
0.943
Self-help groups
1758
51
4953
44
0.000
Smoking cessation
2007
59
5300
47
0.000
Payer acceptance
Cash/self-payment
3182
93
10,048
90
0.000
Free Tx
66
2
320
3
0.003
Medicaid
2536
75
7127
64
0.000
Other public
2244
65
7053
63
0.005
Private insurance
2432
72
8080
73
0.219
Notes: National Survey of Substance Abuse Treatment Services, 2018.
In Table 2, we further stratified PPW and Other Programs by residential and outpatient settings. Across medications, residential PPW Programs were more likely than outpatient PPW Programs to offer naltrexone (39% vs. 28%, 11 percentage point difference), acamprosate (26% vs. 18%, 8 percentage point difference), nicotine replacement (52% vs. 20%, 32 percentage point difference) and medication management for psychiatric disorders (55% vs. 36%, 19 percentage point difference). There was no statistically significant difference in buprenorphine between residential and outpatient PPW Programs, and methadone was offered in 30% of outpatient settings but only in 5% of residential settings (−25 percentage point difference).
Table 2Services offered in treatment facilities with specialized programs for pregnant and postpartum women by treatment setting, N-SSATS 2018.
PPW programs
Other programs
Residential
Outpatient
Chi-2
Residential
Outpatient
Chi-2
N = 775
N = 2609
N = 2663
N = 8340
N
%
N
%
P-value
N
%
N
%
P-value
Medications
Methadone
37
5
788
30
0.000
95
4
541
6
0.000
Buprenorphine
336
43
1142
44
0.837
1025
38
2219
27
0.000
Meth. or Bup.
341
44
1340
51
0.000
1037
39
2413
29
0.000
Meth. and Bup.
32
4
590
23
0.000
83
3
347
4
0.000
Naltrexone
303
39
727
28
0.000
1002
38
2091
25
0.000
Disulfiram
159
21
495
19
0.339
587
22
1495
18
0.000
Acamprosate
201
26
464
18
0.000
678
25
1544
19
0.000
Nicotine Replacement
403
52
523
20
0.000
1268
48
1672
20
0.000
Psychiatric Disorders
428
55
946
36
0.000
1437
54
3510
42
0.000
Testing
HCV
332
43
1013
39
0.045
1018
38
1728
21
0.000
HIV
376
49
935
36
0.000
1106
42
1603
19
0.000
STD
268
35
746
29
0.001
886
33
1207
14
0.000
Ancillary services
Case management
730
94
2311
89
0.000
2378
89
6551
79
0.000
Social skills
730
94
2071
79
0.000
2306
87
5873
70
0.000
Mentoring/peer support
658
85
1555
60
0.000
2099
79
4069
49
0.000
Child care
281
36
281
11
0.000
69
3
216
3
0.997
Beds for clients' children
300
39
0
0
0.000
73
3
0
0
0.000
Assist. social services
679
88
1770
68
0.000
1817
68
4381
53
0.000
Employment
496
64
1172
45
0.000
1386
52
2623
31
0.000
Housing assist
684
88
1654
63
0.000
1908
72
3638
44
0.000
Domestic violence
477
62
1266
49
0.000
859
32
2971
36
0.001
Intervention HIV
334
43
845
32
0.000
785
29
1221
15
0.000
HIV/AIDS edu
616
79
1663
64
0.000
1764
66
3550
43
0.000
Hepatitis edu
581
75
1560
60
0.000
1620
61
2989
36
0.000
Health edu
620
80
1601
61
0.000
1795
67
3377
40
0.000
Transportation assistance
591
76
1098
42
0.000
1698
64
2908
35
0.000
Mental health svcs
575
74
1725
66
0.000
1678
63
5803
70
0.000
Self-help groups
679
88
1047
40
0.000
2207
83
2580
31
0.000
Smoking cessation
526
68
1445
55
0.000
1531
57
3602
43
0.000
Payer acceptance
Cash/self-payment
669
87
2472
95
0.000
2317
88
7521
91
0.000
Free Tx
32
4
34
1
0.000
106
4
211
3
0.000
Medicaid
523
69
1971
76
0.000
1269
49
5657
69
0.000
Other public
469
61
1733
66
0.002
1338
50
5505
66
0.000
Private insurance
521
69
1867
72
0.067
1736
67
6131
74
0.000
Notes: National Survey of Substance Abuse Treatment Services, 2018.
Residential PPW Programs dominated among most categories of testing and ancillary services relative to outpatient PPW Programs. Notably, residential PPW Programs offered the highest rates of assistance with child care (36% vs. 11%, 25 percentage point difference), social services (88% vs. 68%, 20 percentage point difference), employment (64% vs. 45%, 19 percentage point difference), domestic violence (62% vs. 49%, 13 percentage point difference), housing (88% vs. 63%, 25 percentage point difference), and transportation (76% vs. 42%, 34 percentage point difference). Across payers, residential facilities were less likely to accept health insurance than outpatient facilities, including Medicaid, both in PPW and Other Programs.
4. Discussion
The increasing prevalence of opioid use disorders among pregnant and postpartum women has generated a need for identifying and overcoming barriers to SUD treatment in this population. Our study estimated the availability of SUD treatment services for pregnant and postpartum women, focusing on specialized PPW Programs, MTs, key ancillary services, and payer acceptance. Service availability and payer acceptance across residential and outpatient settings was also considered.
Overall, we found a higher and growing prevalence of treatment facilities with PPW Programs since 2009 estimates in
and an increasing prevalence in buprenorphine availability, especially in PPW Programs. Despite the growing prevalence of PPW Programs, there was considerable variation in the availability of these Programs across states. In particular, the availability of PPW Programs was most limited in some Southern and Midwestern states. This is concerning because previous work has shown that the rates of neonatal drug withdrawal syndrome are high in many Southern and Midwestern states (
Substance use, treatment, and demographic characteristics of pregnant women entering treatment for opioid use disorder differ by United States census region.
Journal of Substance Abuse Treatment.2017; 76: 58-63
PPW Programs offered most medications, key ancillary services, and Medicaid acceptance at a higher rate than Other Programs. Nonetheless, there was still a considerable gap in MT availability in PPW Programs. Less than 45% of PPW Programs offered buprenorphine, less than 25% offered methadone, and less than 50% offered any of these MTs, both of which are considered the gold standard of care for treating pregnant women with OUD. This service gap extended to key ancillary services for the PPW population. Most notably, childcare was offered in less than 20% of PPW Programs. The low availability of childcare services may be an important barrier to PPW with OUD seeking treatment. Less than half of PPW Programs offered testing for Hepatitis C, HIV, and STDs and 25% did not accept Medicaid, the main insurer of pregnant women with OUD. Gaps in MTs and other key services for the PPW population were even more critical in Other Programs, which is concerning since Other Programs represented 77% of all specialty SUD treatment facilities in 2018 while PPW Programs only represented 23%.
When stratifying PPW Programs by residential and outpatient settings, we found substantial heterogeneity in the availability of treatment services. Residential PPW Programs tended to offer ancillary services, such as child care, employment, housing, and domestic violence assistance at significantly higher rates than outpatient PPW Programs. Perhaps most notably, only 11% of outpatient PPW Programs offered childcare services versus 36% of residential PPW Programs. However, residential PPW Programs were less likely to accept Medicaid or offer methadone than outpatient PPW Programs. The low prevalence of methadone in residential PPW Programs plausibly stems from the fact that opioid treatment programs (OTPs), the only providers licensed to administer methadone for OUD treatment, are more likely to offer both outpatient services and PPW Programs. By law, OTPs must maintain current policies and procedures that reflect the special needs of patients who are pregnant. Prenatal care and other gender specific services for pregnant patients must be provided either by the OTP or by referral to appropriate healthcare providers (
). Buprenorphine prevalence was not significantly different between outpatient and residential PPW Programs. There was substantial heterogeneity in the availability of treatment services by setting in Other Programs as well.
Taken together, our results suggested that while the prevalence of treatment facilities with specialized PPW Programs has increased and that these Programs offered more comprehensive services relative to Other Programs, in absolute terms there were critical gaps in the availability of key services for PPW. Increasing capacity, funding, insurance coverage, and reimbursement of key services for PPW may be one way to ensure sufficient availability of such services at PPW and Other Programs. Since 2017, the State Targeted Response Grants and the State Opioid Response Grants by SAMHSA have offered opportunities to states for innovations in the area of OUD treatment among the PPW population and a number of states have used this funding to design programs for reproductive-aged women. With the passage of the FY 2019 appropriations law and the 2018 SUPPORT Act, Congress has shown commitment and support for the continuation of these grants, which would give more states opportunities to expand treatment availability for reproductive age women with OUD. Our results also suggested there were significant differences in service availability and payer acceptance between outpatient and residential PPW Programs. These differences may have important implications for treatment utilization, retention and downstream outcomes in the PPW population, especially in light of increasing federal funding for PPW treatment in outpatient settings through the State Pilot Grant Program for Treatment for Pregnant and Postpartum Women, which historically has been funded in residential settings through the Services Grant Program for Residential Treatment for Pregnant and Postpartum Women.
This study has several limitations. First, since N-SSATS does not specifically define postpartum women and assumes it to be whatever each facility considers postpartum women, there might be some inconsistencies in the definition PPW Programs across facilities. Second, our definition of PPW Programs measures whether services are offered but does not capture capacity. It is possible that facilities may have expanded the number of beds or treatment slots for PPW during 2007 to 2018. Finally, there is heterogeneity in how organizations respond to N-SSATS. Some organizations respond for individual programs within a facility, some report at the facility level, and some for multiple facilities. This may create some measurement error in our prevalence rates.
5. Conclusion
Pregnant and postpartum women with OUD face many social, structural and economic barriers to accessing treatment and recovery services. Specialized programs that offer comprehensive, integrated approaches to treatment combining clinical and social services with care coordination and trauma-informed care have been found to be most effective. Our study shows that the prevalence of such specialized programs and the availability of key services within these programs remains low. States that want to improve treatment outcomes among pregnant and postpartum women should consider designing programs especially for this population.
Funding sources
This work was supported by the National Institute of Mental Health T32MH073553.
Disclaimer
The content is solely the responsibility of the authors and does not necessarily represent the official views of the Office of the Assistant Secretary for Planning and Evaluation or the Department of Health and Human Services.
Declaration of competing interest
None.
Appendix A.
Fig. A1Treatment facilities with specialized programs for pregnant and postpartum women, overall and by treatment setting.
Substance use, treatment, and demographic characteristics of pregnant women entering treatment for opioid use disorder differ by United States census region.
Journal of Substance Abuse Treatment.2017; 76: 58-63
Trends and disparities in receipt of pharmacotherapy among pregnant women in publicly funded treatment programs for opioid use disorder in the United States.
Journal of Substance Abuse Treatment.2018; 89: 67-74
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