Women who receive treatment for a substance use disorder (SUD) would welcome services that integrate their treatment with family planning and contraceptive services, the authors of a recent study found.1

“Historically, both reproductive health and substance use have been siloed,” says Lauren MacAfee, MD, MSc, FACOG, OB/GYN and assistant professor at the University of Vermont Medical Center. “That creates big disparities for patients who may need multiple models of care and domains of care.”

Integrated care models for SUD and reproductive healthcare are a method of increasing access to both types of care. Investigators interviewed women of reproductive age who were in residential treatment. They found that 85% of the women expressed a desire to prevent pregnancy in the next year, although only one-third were using a form of contraception. Nearly 70% of the women said they preferred the integration of contraceptive care and treatment for SUD, and about 29% said they preferred a long-acting reversible contraceptive (LARC) if cost was not an issue.1

“It was a descriptive study,” says David Phillippi, PhD, a lecturer at Belmont University in Nashville, TN.

The data show that women in an SUD clinic are interested in integrated contraceptive care. “The primary purpose of the study was to measure the interest in integrative contraceptive care at an integrated substance use disorder treatment facility, and to assess which providers were likely to be well-received by the women in terms of who they could have that conversation with,” Phillippi says.

Researchers identified many barriers to reproductive health services among women in SUD treatment programs. These included women not being asked about family planning, or being unable to fill prescriptions for birth control. They also had difficulty making and getting to appointments.

“It’s important to develop bi-directional relationships between reproductive health providers and substance use services,” says Mishka Terplan, MD, MPH, FACOG, associate medical director at Friends Research Institute in Baltimore. Terplan also serves as adjunct faculty at the University of California, San Francisco, where he is a Substance Use Warmline clinician at its Clinical Consultation Center.

This relationship begins with reproductive health providers giving universal assessment for behavioral health and substance use disorders. “I’m working with Los Angeles County in a pilot project to integrate reproductive health assessment, referral, and treatment for people in the publicly funded drug treatment system,” Terplan explains. “It’s already started, and there’s a strong educational component to it.” The COVID-19 pandemic has slowed the program, although it is still underway, he notes.

One model for integrating contraceptive services with SUD treatment is to create a reproductive health office in or adjacent to a methadone clinic. With grant funding, researchers incorporated a contraceptive clinic at a methadone clinic for research purposes. The reproductive health clinic was one floor above the methadone clinic so women could receive treatment and head upstairs for contraceptive counseling and services, MacAfee says.

The study has not been published, but some early data, published in 2019, revealed increases in contraceptive use among women with opioid use disorder when they had access to integrated family planning and SUD services.2

Researchers found some positive results in preliminary data for a new study comparing several ways of providing contraceptives to women with SUD. This unpublished research suggests that free, onsite contraceptive care with counseling can result in a higher rate of contraceptive uptake than in the usual care group, says MacAfee, one of the study’s investigators. (More information is available at: https://clinicaltrials.gov/ct2/show/NCT01425060.)

“If you add vouchers to incentivize women to return to their reproductive health provider after initial counseling and contraceptive services, it worked even better,” she adds.

Investigators theorized that women with SUD often lack the skills and motivation to call their physicians if their first contraceptive choice does not work out. Instead, they might just stop using the contraceptive. Providing the women with an incentive to seek a follow-up appointment may make them more likely to return to their provider and sort out any problems, which would lead to higher rates of contraception use. The data show this to be true, MacAfee says.

“Having those visits allowed them to transition to new methods if they were having problems, and the highest uptake was in the group with a clinic on site and vouchers,” she adds.

The pragmatic challenge is funding this level of integration and the vouchers. “The big issue with healthcare vouchers is sustainability,” MacAfee says. “Who pays for the vouchers? Health insurance companies?”

Integrating reproductive healthcare and SUD treatment begins with staff training. “Step one is training the staff; step two is integrating some form of reproductive health needs at the patient level,” Terplan explains. “Step three is forming referral relationships with people who want LARC so they can go to the reproductive health clinic to get it.”

The program’s reproductive health clinicians visit drug treatment facilities to provide education and referral services. But that is only one model for collaboration.

“There are many different ways you can achieve integration,” Terplan says. “These range from comprehensive co-located services to physically separated services with tight connections and warm handoffs within those domains.”

Family planning clinicians should think about how to incorporate addiction treatment into the reproductive health setting, Terplan says.

“There might be Title X providers that are waived to provide drugs [buprenorphine] for opioid use disorder, and some do prescribe it,” he says. “There is a need not just for a relationship between a reproductive health center and a specialty addiction service, but also for integrating addiction treatment in the reproductive health center.”

One reason integration between contraceptive services and SUD treatment works so well is because women want the warm handoff between one clinic and another. They do not want separate appointments, and they do not want to explain to their physician that they are taking methadone, MacAfee says.

“Any opportunities you can take to bridge the gaps and minimize the barriers to patients will make a big difference,” she says. “We know transportation is a problem, so anytime you can have services on site, even a [reproductive health bus] in a parking lot, or have a soft handoff, it helps.”

Family planning clinics could create mutually beneficial agreements with SUD treatment centers and other providers. “There is no one-size-fits-all model for any clinic or setting,” MacAfee says. “It’s thinking about, ‘Here are the barriers to care, and how can we reduce any of those barriers and make it easier for patients to access these services?’”

Integrated services also give both reproductive health and SUD treatment providers confidence in handling health needs outside their comfort zone. For instance, a collaboration or integrated program allows family planning clinicians to send patients back to the SUD treatment center if there are recurring issues related to substance use. When the patient is stabilized, the treatment center can send her back to the family planning center, MacAfee explains.

“My pie in the sky hope is having a nurse practitioner who goes to all the [SUD] clinics on a rotating basis and provides contraceptive services on site,” she adds. “That would be great to incorporate these services.”

Robert A. Hatcher, MD, MPH, chairman of the Contraceptive Technology Update editorial board, says “The American Academy of Pediatrics could not be more clear about alcohol use in pregnant women. Here is their summary statement: ‘There is no point during pregnancy when drinking alcohol is considered safe.’”

REFERENCES

  1. Bhakta J, Morse E, Phillippi D. Reproductive health needs among women in treatment for substance use disorder. DNP Scholarly Projects 2020. https://repository.belmont.edu/cgi/viewcontent.cgi?article=1024&context=dnpscholarlyprojects
  2. Heil SH, Melbostad HS, Rey CN. Innovative approaches to reduce unintended pregnancy and improve access to contraception among women who use opioids. Prev Med 2019;128:105794.