Updating System Policies to Address Inequities and Support Families Impacted by Substance Use

As a part of our United Against Racism effort to achieve health equity for patients and communities across our system, we have prioritized health conditions with the greatest racial disparities in outcomes and are addressing policies that may unwittingly perpetuate structural racism. Substance use disorder (SUD) is a condition with significant racial and ethnic inequities, especially in the context of pregnancy, when more punitive approaches to substance use disproportionately affect Black individuals. Studies — including some within our system — have found that Black pregnant people are more likely to be drug tested and to be reported to child welfare systems than white pregnant people.

One way that Mass General Brigham is addressing inequities in SUD is by creating a systemwide policy to support pregnant people and their infants to ensure a standardized and equitable approach to toxicology testing and reporting for pregnant people and their infants, aligned with national practice guidelines. The goal is to reduce barriers to treatment that have disproportionately impacted patients of color, while prioritizing practices that support the safety and wellbeing of families impacted by SUD.

“Our new perinatal testing and reporting policy is the latest step in our efforts to address longstanding inequities in substance use disorder care and to provide compassionate, evidence-based support to families, while addressing substance use disorder as a treatable health condition,” said Sarah Wakeman, MD, senior medical director for Substance Use Disorder, Mass General Brigham. “This policy reflects an emerging consensus, based on sound science, that is being embraced by our peer institutions and was developed in coordination with a wide range of partners.”

Policymakers are increasingly modifying policies that create barriers to SUD treatment. For example, the Biden-Harris Administration recently issued a reported titled Substance Use Disorder in Pregnancy: Improving Outcomes for Families.

According to Dr. Wakeman, several values emerged from that report, notably the assertion that having substance use disorder during pregnancy is not, by itself, child abuse or neglect. Further, the report underscored that pregnant people who have SUD should be encouraged to access support and care systems, and that barriers to access should be addressed, mitigated, and eliminated where possible.

One important way to achieve this is to update policies that automatically trigger mandatory filings with child welfare agencies when a pregnant individual is engaged in treatment for substance use disorder, absent any other concerns for potential abuse or neglect. Health equity leaders note that these policies create undue risk that pregnant people might be separated from their newborn infants and discourage them from accessing treatment. These policies disproportionately impact patients from historically marginalized populations.

Across the U.S., policymakers have also worked to promote SUD treatment pathways for pregnant people. For example, New Mexico changed its law to specify that substance use on its own is not considered abuse or neglect. Connecticut has specified that in instances where there is substance exposure without concern for abuse or neglect, healthcare professionals complete what is known as a “Plan of Safe Care” and provide notification of the birth without reporting for child abuse or neglect.

In Massachusetts, state health officials recently released a report on access to maternal health services and noted that they would “update guidance for healthcare providers to share best practices and document the establishment of a dual reporting system whereby substance exposed newborns with no indication of neglect or abuse can be identified for support but not investigated for neglect or abuse.”

To that end, Mass General Brigham’s new policy, launching this month, makes several changes for providers: First, the new policy requires written consent for toxicology testing of any pregnant individual or infant outside of emergent situations. At the same time, it limits toxicology testing to circumstances where results will change the medical management of the pregnant person or infant.

The policy also notes that an abuse/neglect report to state child welfare agencies in Massachusetts and New Hampshire after delivery should be filed only if there is reasonable cause to believe that the infant is suffering or at imminent risk of suffering physical or emotional injury and that ‘substance exposure’ alone, including treatment with methadone or buprenorphine for opioid use disorder, does not require a report of abuse or neglect in the absence of protective concerns for the infant.

Clinical leaders say the new policy will help reduce stigma and improve access to SUD treatment and support the safety and well-being of families.

“The updated policy reflects our focus on providing safe and equitable care for all patients. The process allowed us to turn our lens inward to understand our own contributions to stigma and inequity and strive to fix them,” said Allison Bryant, MD, MPH, associate chief health equity officer, Mass General Brigham.

The new policy is also aligned with national practice recommendations. The American College of Obstetricians and Gynecologists (ACOG) opposes drug testing of individuals or infants without consent and discourages “the separation of parents from their children solely based on substance use disorder, either suspected or confirmed.”

The American Society of Addiction Medicine (ASAM) states that written consent should be required for any toxicology testing of pregnant and birthing people. In addition, ASAM clearly states that a positive toxicology test should not be equated with child abuse or neglect. ASAM also recommends that institutes should remove policies that mandate reporting birthing people to child welfare on the sole basis of substance use or substance use disorder.

Clinical leaders note that the policy is also one step toward enhancing treatment pathways, and that it will complement additional, ongoing efforts like the Bridge Clinics, to improve equity in SUD outcomes.

“It takes a multi-pronged approach to eliminate racial inequities and drop barriers to treatment, and we will continue to enhance access through our comprehensive SUD programming throughout our organization,” said Dr. Wakeman.