In 2017, nearly 48 000 Americans died of opioid-related overdoses—a 6-fold increase since 1999.1 The unprecedented increase in opioid-related harms is not limited to adults. The last 2 decades also saw surges in infants receiving diagnoses of neonatal opioid withdrawal syndrome2 and foster care placements of young children because of parental substance misuse.3 Numerous states and municipalities have recently sued opioid manufacturers and distributors, seeking to hold them accountable for lives lost and communities harmed by the crisis, including costs associated with infants receiving of diagnosis of neonatal opioid withdrawal syndrome. If these suits are successful, settlements and jury verdicts may stretch to hundreds of millions or even billions of dollars, ultimately resulting in one of the largest legal recoveries since the tobacco settlement in the 1990s. Unfortunately, most tobacco settlement funds have not funded tobacco cessation activities specifically or even public health initiatives generally.4 It is essential that this mistake is not repeated and that funds from opioid litigation are equitably and responsibly allocated in a way that benefits those most affected and reduces the risk of future harm.
Mothers and Infants
While there is a substantial need to enhance efforts to prevent opioid misuse and increase harm reduction efforts for and treatment of individuals with opioid use disorder, the rise of the opioid crisis has also stressed an already fragmented and underfunded public system for maternal-child health, and many mothers and infants have fallen through the cracks. Recent federal efforts to improve opioid use disorder prevention and treatment are not commonly targeted to pregnant women and infants, and the few that are have limited scope or duration. For example, the US Substance Use Disorder Prevention That Promotes Opioid Recovery and Treatment for Patient and Communities Act included time-limited funding of $29 million for residential treatment programs for pregnant and postpartum women through 2023. Long-term structural investments beginning in pregnancy and extending through early childhood will pay societal dividends for generations to come. Settlements from the lawsuits filed against opioid manufacturers, distributors, and prescribers should preferentially invest in pregnant women and infants prenatally, at birth, and throughout the first year.
Prenatal
Connecting pregnant women with opioid use disorder to effective treatment is essential to reduce adverse pregnancy outcomes, including preterm birth and death. Most Americans with opioid use disorder, including pregnant women, do not receive evidence-based treatment. As the National Academies of Medicine recently highlighted,5 for pregnant women, these benefits extend to the fetus. Compared with untreated opioid use disorder, women who receive medications for opioid use disorder are less likely to overdose and more likely to deliver at term and have higher-birth-weight infants. Despite these benefits, fewer than half of pregnant women participating in treatment programs receive medications for opioid use disorder.5 Settlement dollars could be used to fund programs that connect pregnant women to treatment that offers medications for opioid use disorder, prenatal care, and wrap-around services. Programs should include a focus on training and incentivizing maternal community clinicians (eg, federally qualified health centers, family medicine physicians, and obstetricians) to prescribe buprenorphine and provide related supportive services. Focusing on federally qualified health centers and primary care clinicians, including nonphysician clinicians, could also mitigate disparities in access to treatment in rural communities where it is lacking most.
Birth
At birth, pregnant women and infants affected by the opioid crisis are faced with inconsistent care, and new mothers and infants are often separated by hospital transfer and care processes that place the infant in a neonatal intensive care unit. Recently, the Substance Abuse and Mental Health Administration released guidelines for the care of pregnant women and infants affected by the opioid crisis (https://store.samhsa.gov/system/files/sma18-5054.pdf), including effective screening for opioid use disorder, peripartum pain relief, and infant assessment; however, it is not clear if they are being followed. In addition, infants often do not need complex care in a neonatal intensive care unit and keeping new mothers with their infants likely improves breastfeeding and shortens length of hospital stay.6 The challenge is particularly acute for women and infants affected by the crisis in rural communities,7 which are often the hardest hit and have the fewest resources to support families struggling with opioid addiction. Lawsuit funds should target supporting care in local community hospitals, ensuring the consistency of care and support for hospitals and clinicians and social support for families, including fathers.
First Year
The immediate postpartum period is particularly high-risk for mothers with opioid use disorder and their families who face myriad challenges, including a heightened risk of relapse for mothers and developmental risks for infants. These risks are exacerbated by the lack of services and support focused on postpartum women and infants, as well problems accessing available services. Better coordinating posthospital care for the infant and mother, including ensuring enrollment in public systems, can help address these challenges. For example, many pregnant and parenting women who are eligible for assistance through the Women, Infants, and Children program are not enrolled, and while many infants exposed to opioids are eligible for early intervention services (eg, publicly funded developmental supports through the Program for Infants and Toddlers with Disabilities) to support healthy development, it remains unclear how frequently infants receive such services.
Continued maternal access to necessary health care for at least the first year of life is critical to ensure the infant has a healthy mother. Unfortunately, for some new mothers, even basic health insurance needs are unmet. For example, at 60 days post partum, Medicaid-enrolled women in non–Medicaid expansion states are at risk of losing health insurance coverage and, as a result, their access to opioid use disorder treatment and basic preventive health services, including contraception. States that have not expanded Medicaid could use settlement funds for such an expansion or to expand the pool of parenting women who are eligible for the program.
Further, our already overburdened child welfare system has struggled under an increased burden as the opioid crisis expanded. From 2011 to 2017, the number of infants in foster care grew by 10 000, mostly because of parental substance use. In West Virginia, more than 4% of the state’s infants are in the foster care system.3 While the last several years have heralded unprecedented federal action to improve the child welfare system (eg, using state child welfare funding for prevention and connection to substance use treatment), states, local governments, and judges are struggling to implement these changes.3 The changes, coupled with the influx of families, are a challenge for a system with a history of continual underfunding and staff turnover. Settlement dollars could target communities where child welfare systems have been disproportionately affected by the crisis to aid in implementing new federal laws, improve staff training and retention, and target training for family and drug court judges.
Conclusions
An effective community response to improve care for pregnant women and families affected by the opioid crisis will take a well-funded, coordinated effort. Funding should focus on immediate treatment needs as well as long-term strategies to improve the outcomes of those currently affected and should aim to reduce the number and severity of future effects. Doing so may be one of the best uses of opioid lawsuit funds, generating returns for affected individuals and communities for decades to come.