Women with opioid use disorder benefit from incentives-based contraceptive services
Women with opioid use disorder at high risk for unintended pregnancy had better outcomes with onsite contraceptive service interventions vs. usual care, according to results of a randomized clinical trial published in JAMA Psychiatry.
Combining contraceptive services with incentives led to the most efficacious, cost-beneficial outcomes.
“The Centers for Disease Control and Prevention and the American Academy of Pediatrics have called for increased efforts to reduce opioid use during pregnancy and [neonatal abstinence syndrome], including ensuring access to contraception to prevent unintended pregnancy among women who use opioids,” Sarah H. Heil, PhD, of the department of psychiatry at the University of Vermont, and colleagues wrote. “More than 75% of women with opioid use disorder (OUD) report having had an unintended pregnancy, but they are less likely to use any contraception and more likely to use less effective nonprescription methods such as condoms compared with women who do not use drugs. They also report wanting easier access to contraception.”
The researchers aimed to assess the efficacy and cost-benefit profile of onsite contraceptive services with and without incentives for increasing prescription contraceptive use among this patient population compared with usual care. They included 138 women aged 20 to 44 years (median age, 31 years) who received medication for OUD and who had high risk for an unintended pregnancy at trial enrollment between May 2015 and September 2018. The researchers finished the final assessment in September 2019. A clinic co-located with an opioid treatment program administered contraceptive services to the participants. A total of 48 participants were randomly assigned to usual care, which consisted of information about contraceptive methods and community health care facilities; 48 to onsite contraceptive services adapted from the WHO that included 6 months of follow-up visits to evaluate method satisfaction; and 42 to those same onsite contraceptive services in conjunction with financial incentives for attending follow-up visits. Verified prescription contraceptive use at 6 months with a cost-benefit analysis conducted via a societal perspective served as the main outcome.
At the 6-month end-of-treatment assessment, results showed greater verified prescription contraceptive use among participants in the contraceptive services plus incentives group (54.8%; 95% CI, 38.7-70.2) compared with the contraceptive serviced alone group (29.2%; 95% CI, 17-44.1). Both interventions led to greater verified contraceptive use than usual care 10.4%; 95% CI, 3.5-22.7). These effects remained at the 12-month final assessment and were linked to graded reductions in unintended pregnancy rates across the 12-month trial. The researchers noted an estimated $5.59 (95% CI, 2.73-7.91) in societal cost-benefits for contraceptive services compared with usual care for each dollar invested. This benefit was $6.14 (95% CI, 3.57-7.08) for contraceptive services plus incentives vs. usual care and $6.96 (95% CI, 0.62-10.09) for the combination of incentives with contraceptive services vs. contraceptive services alone.
“The findings of this randomized clinical trial provide treatment programs with [two] rigorously evaluated, efficacious and cost-beneficial interventions, with the best outcomes achieved by combining co-located contraceptive services with incentives,” Heil and colleagues wrote. “These results provide sorely needed information that will help address the growing public health problems of opioid use during pregnancy and [neonatal abstinence syndrome].”
In a related editorial, Anne Drapkin Lyerly, MD, MA, of the department of social medicine at the University of North Carolina at Chapel Hill, highlighted the ethical dimension of using incentives among this patient population.
“Ultimately the use of incentives to shape behavior is not merely a question of outcome or cost, but of ethics: whether in promoting a voluntary choice they undermine robust respect for autonomy; whether they can be fairly used in a context of structural injustices such as stratified reproduction; and whether their purpose aligns with a patient-centered ethic of care,” Lyerly wrote. “As a tool to facilitate contraceptive use, it is unlikely that incentives will clear the bar.”