REVIEW OF: Heil SH et al, JAMA Psychiatry 2021;78(10):1071–1078

STUDY TYPE: Randomized controlled trial

Among women with opioid use disorder, nearly eight out of every 10 pregnancies are unintended (Fischbein RL et al, Contracept Reprod Med 2018;3:4). The complications and potential adverse outcomes of these pregnancies include neonatal opioid withdrawal syndrome (NOWS), microcephaly, and miscarriage, with many newborns suffering future developmental delay and disability. The economic impact is profound, costing Medicaid an estimated $600 million annually in additional healthcare expenses for NOWS-related postnatal care alone.

This new study, funded by the National Institutes of Health, examined the efficacy and cost benefit of co-locating contraceptive services and addiction treatment for patients with OUD. Over a three-year period, researchers enrolled 138 women who were receiving medication for OUD and were at high risk for unintended pregnancy. Participants had a mean age of 30.6 years (range 20–44), and 92% were white. Participants were randomized to receive one of three interventions: usual care (education and referral to community health care facilities); on-site contraceptive services (located in the same building as substance use treatment) plus six months of follow-up visits; or the same on-site contraceptive services plus financial incentives for attending follow-up visits. Each participant was followed for one year, and the primary outcome was verified contraceptive use at six-month follow-up. Secondary outcomes included contraceptive use at 12 months, use of a long-acting contraceptive such as an intrauterine device or an implant, and unintended pregnancy.

The analysis showed that co-located contraceptive and addiction services outperformed usual care, and that the group receiving financial incentives did the best. Verified contraceptive use was highest in the combined services with financial incentives group (40.5%), second highest in the non-incentivized combined services group (25%), and lowest in the usual care group (6.3%). Following on logically, the rate of unintended pregnancies was lowest in the incentivized group (4.9%), higher in the non-incentivized group (16.7%), and highest in usual care (22.2%). A cost-benefit analysis showed that the incentivized intervention was the most cost effective as well, with $6.96 saved for every dollar spent.

The authors point out that the study’s skewed demographics, small sample size, and high intensity of intervention could limit its generalizability. They also acknowledge the debate about tying financial incentives to contraceptive services and that this could potentially be seen as coercive, especially given the history of reproductive injustice among marginalized groups.

CATR’s Take
Combining contraceptive care and addiction treatment decreased rates of unintended pregnancy and saved health care dollars, showing the potential benefits of co-located health care services. Though still a relatively new care model, refer your OUD patents at risk of unintentional pregnancy to such clinics if they are available in your area. If your patients wish to become pregnant, be sure to make a referral to an obstetrician.