Consensus guidelines and state policies: the gap between principle and practice at the intersection of substance use and pregnancy

The opioid crisis has had a substantial effect on pregnant and parenting women, focusing both public health and policymaker attention on opioids and on other substance use in pregnancy and postpartum. There is overwhelming consensus on the principle of a nonpunitive approach toward substance use in pregnancy. Experts universally endorse supportive policies, which reduce barriers to care, and oppose punitive policies, which can increase the fear of legal penalties, discouraging women from seeking prenatal care and addiction treatment during pregnancy. We review the changes over time in state-level policy environments around substance use in pregnancy and contrast the policy responses with the principles and guidance from professional societies and federal agencies. Between 2000 and 2015, more states adopted punitive policies than supportive policies, in direct contrast with guidance from professional societies and federal agencies. The increase in punitive policies over the past 2 decades suggests that the gap between principles and practices is widening. Furthermore, the increase in punitive policies is occurring in the context of considerable structural barriers to comprehensive healthcare across the woman’s entire life course, growing awareness of racial and ethnic inequities in maternal morbidity and mortality, and increasing restrictions at the state level on abortion access. Women with substance use disorder need comprehensive, coordinated, evidence-based, trauma-informed, and family-centered care. This care should be delivered in a compassionate and nonpunitive environment, and clinicians, policymakers, and public health officials all have a role to play in achieving this goal.