Contraceptive services in opioid use disorder programs reduce unintended pregnancies

Opioid treatment programs that also offer contraceptive services cost-effectively prevent unintended pregnancies, particularly if financial incentives for attending follow-up visits are included, researchers reported.

Women with opioid use disorder (OUD) are less likely to use effective contraception than women who do not use drugs, and more than 75% of women with OUD have had an unintended pregnancy, the researchers reported.

Also, the researchers noted that the number of babies born with neonatal abstinence syndrome (NAS) in the United States has almost doubled over the past decade due to increases in maternal opioid use.

The persistently high rate of unintended pregnancy suggests that current contraceptive services do not work for most of these women, said author Sarah H. Heil, PhD, professor of psychiatry at the Vermont Center on Behavior and Health at the University of Vermont’s Larner College of Medicine.

“In 2011, we published a study that found that 86% of a large sample of pregnant women using opioids (n = 946) reported that the pregnancy was unintended, a rate nearly double that of the general population,” Heil told Healio.

“This suggested substantial unmet contraceptive need among women with opioid use disorder, but there was very little in the scientific literature at that time about how to decrease this gap between women’s reproductive intentions and their contraceptive behavior. That inspired this line of research,” she continued.

The trial enrolled 138 women between the ages of 20 and 44 years (median age = 31 years) receiving medication for OUD between May 2015 and September 2018 at an opioid treatment program in Burlington, Vermont.

These women also were at high risk for unintended pregnancy, meaning they had no plans to become pregnant in the following 6 months, they were having vaginal sex, and they weren’t using an effective prescription contraception method, Heil said.

“Many were struggling with other co-occurring psychiatric conditions and wide-ranging psychosocial instability that made it difficult for them to take the necessary steps to start and continue prescription contraceptive use,” Heil said.

“Many also reported bad experiences with health care providers in the past, including discrimination and stigma related to their substance use,” she continued.

Participants were randomly assigned to usual care (n = 48), contraceptive services (n = 48), or contraceptive services plus financial incentives (n = 42). Most of the participants (n = 122; 88.4%) reported having had at least one prior unintended pregnancy.

Participants in the usual care group received a brochure with general information about contraception methods and contact information about community contraception service facilities.

The women in the contraceptive services group met with a member of the trial staff and discussed their values, preferences and goals in deciding whether and which contraception was right for them. Contraception then was provided immediately for free to those women who chose it.

Participants in the contraceptives plus incentives group received the same care as the contraceptives group, plus $15 for the first follow-up visit scheduled to assess their satisfaction with their contraception, with $2.50 added to the total for each subsequent visit. Incentives were awarded in the form of gift cards.

The incentives were awarded only for attending follow-up visits and did not depend on contraceptive use. Participants could attend up to 13 visits during the 6-month study period and earn up to $437.50 in gift cards.

The researchers found graded increases in verified prescription contraceptive use at the end of the 6-month period. Usual care saw a 10.4% increase, co-located contraceptive services saw a 29.2% increase, and services plus incentives saw a 54.8% increase.

These increases were sustained through the 12-month final assessment, with contraceptive adherence at 6.3% with usual care compared with 25% with services and 42.9% with services plus incentives.

There also was a graded decrease in unintended pregnancy rates through the 12-month trial, with usual care at 22.2%, contraceptive services at 16.7%, and services plus incentives at 4.9%.

According to an economic analysis considering the estimated costs of an unintended pregnancy for people with OUD, each dollar spent on the program had a societal cost benefit of $5.59 for contraceptive services vs. usual care, $6.14 for contraceptive services plus incentives vs. usual care, and $6.96 for combining incentives with contraceptive services vs. contraceptive services alone.

The study also had a positive impact on the lives of these women, Heil said, with one participant telling the researchers that the clinic was a genius asset to have so close to a medication-assisted treatment program. Participants reported that clinic staff were respectful, compassionate and supportive.

“Many participants also reported that the clinic staff was helpful and caring despite participants’ significant life challenges, with one saying, ‘Even when I couldn’t make my appointments, they were understanding and kind,’” said Heil.

Additionally, the researchers were surprised that approximately half of the participants randomly assigned to each study arm wanted a long-acting reversible contraceptive (LARC), such as an IUD or implant.

“Despite this, none of the participants in the usual care condition were using a LARC method at either of the trial assessments,” Heil said. “This underscores the need for interventions like the two we tested, which resulted in approximately 20% and 40% of the participants getting a LARC method.”

Heil further noted that the biggest challenge was the finite amount of time the researchers had to work with participants because it was a research study.

“While the data suggest we were able to help many participants meet their current family planning goal of avoiding an unintended pregnancy, we know that family planning goals change over time and we would have liked to continue helping participants meet their future goals, whatever they may have been, beyond the trial,” she said.

The study is defined by the NIH as a Stage II trial of pure efficacy done in a research setting with research-based providers, Heil said.

“The next step is likely an NIH Stage III trial of real world efficacy done in community settings with community-based providers and caregivers,” she added.

“We encourage interested facilities to reach out to us. We would be happy to answer any questions about the trial and offer advice to those that are interested in translating our research into practice,” she said.

Reference:

Heil S, et al. JAMA Psychiatry. 2021;doi:10.1001/jamapsychiatry.2021.1715.

For more information:

Sarah Heil, PhD, can be reached at sarah.heil@uvm.edu.