Minimize Substance Use During Pregnancy

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Introductory Paragraph

Pregnancy adds significant obstacles to an already complex condition of substance use disorder (SUD). Developing strategies to decrease substance use during pregnancy involves a multifaceted approach to address complex, overlapping issues, and extenuating circumstances.[1]

Pregnant women with substance abuse disorder face multiple social and situational challenges and obstacles, including social, mental health, legal, environmental, cultural, economic, and geographic. Lack of access to medical care, ineffective collaboration among social service systems, stigma, and fear of punishment further compound the issue.[2]

Current research suggests that a collaborative, integrated approach to managing SUD in pregnant women provides the best chance to counteract obstacles and minimize or eliminate substance use.  A wraparound, comprehensive approach based on evidential research including social, family, criminal justice, social service, medical, and mental health professionals.[3]


Women who are misusing opioids or who have opioid use disorder (OUD) may have many obstacles to getting treatment, family planning, or prenatal care. A strategy to minimize unintentional pregnancies for these women should include plans to help them overcome obstacles to receiving these services. The obstacles include:

⦁ Transportation

⦁ Childcare

⦁ Employment conflicts

⦁ Unsupportive living environments

⦁ Unstable living environments

⦁ Homelessness

⦁ Partner with a substance use disorder

⦁ Stigma and/or guilt

⦁ Fear of losing the child

⦁ Fear of incarceration

⦁ Fear of being discovered about misusing substances (by family, employer, etc.)

Key Information

According to recent data, women are at their highest risk for developing SUDs during reproductive years.  Polysubstance use is common among pregnant women with SUD, and the unintended pregnancy rate among women with SUD is ~80%. [4]

Studies suggest that pregnancy provides a unique opportunity for women to embrace recovery options.  [5]


Barriers to Seeking Treatment

Quitting substance use, especially when an individual has SUD, can be difficult. Pregnant women might find quitting more difficult due to fears of potential legal and social consequences if they ask for help. Lacking child care when receiving treatment also may deter mothers from seeking help. Women in treatment may need help with handling the burdens of work, home and child care, and other family responsibilities.[6]

Stigma 

A large barrier to treatment and recovery is stigma.  The societal stigma toward women who abuse substances tends to be greater than that toward men, and the stigma amplifies significantly for pregnant drug users.  Women's ascribed role and the expectations placed on them influences societal perceptions and reactions towards women with SUDs.  Women who use alcohol and illicit drugs regularly feel shame and guilt, and they also often suffer from low levels of self-esteem and self-efficacy. [7]

Culture

The intricate relationship between culture and health—and the influence of differing attitudes, definitions, and beliefs about health and substance use among cultural groups—affects the psychosocial development of women and their substance use and abuse, resulting in further stigmatization of substance use.

Gender

Gender differences in use and treatment approach women and men sometimes use drugs for different reasons and respond to them differently. Additionally, substance use disorders can manifest differently in women than in men. [8]  In the past, women were not included in most clinical research.[9]

Discrimination

Women may experience varying levels of discrimination in both healthcare and criminal justice —based on gender, race, ethnicity, religion, language, culture, socioeconomic status, sexual orientation, age, HIV status, and disability—that affect their substance use and may affect their recovery. Some women use substances to cope with the further stresses of discrimination. Pregnant women using substances, particularly women of color and women in lower socioeconomic brackets, deal with increased surveillance and may face consequences like but not limited to arrest and child removal.[10]

Environmental

Many women with SUDs have experienced trauma in the past that was perpetrated by someone close to them. This contributes to these women’s treatment needs.[11]

Geography

Rural women are 9% more likely than urban women to face severe maternal morbidity mortality. They are also 59% more likely than urban women to have an SUD diagnosis at the time of birth.[12]    

Rates of substance use during pregnancy are typically higher in rural communities than in urban ones.  Rural communities often have limited resources for prevention and treatment and lack the resources needed to provide services to parents dealing with substance use.  For instance, more opioids are prescribed in rural communities than in urban ones. This has led to prescription opioids being the most common type of drug abused by rural pregnant women. Despite being vulnerable, a majority of the research on the prevalence, prevention, and treatment of substance abuse during pregnancy has focused on urban areas. 

Noteworthy characteristics that make rural living more challenging are the lack of economic opportunity, transportation, and technological limitations.[13]

Financial/socioeconomic 

Women dealing with SUD who struggle financially may have to deal with low-income unstable housing, lack of access to transportation and medical care, as well as poor nutrition. Less access to health care, and difficulty in funding treatment due to a lack of health insurance, can result in later referral for substance abuse treatment.

Legal  

Pregnant women who misuse substances are situated at the intersection of public health and criminal justice intervention. Their substance use affects their health and the health of their fetuses. Public health professionals are concerned about this since the field is committed to improving maternal and infant health. In the last 30 years, prenatal substance use has become a criminal justice issue since the fetal protectionism movement encouraged greater use of criminal sanctions for mothers who use substances.

In addition to being a public health concern, substance use during pregnancy presents legal challenges and the threat of punishment

Reporting requirements and administrative policies prevent additional obstacles, including mandatory involvement with child protective services, loss of child custody, or other legal consequences, fear of criminal prosecution, and legal requirements for medical professionals to report them.

For women seeking help, there is often a fear of judgment. Many are afraid they will be arrested, forced to have an abortion, asked to leave a prenatal care program, and reported to child protective services.

Some states have broadened their civil child-welfare requirements to add prenatal substance use so that prenatal drug exposure can lead to the termination of parental rights due to claims of child abuse or neglect. Several states demand healthcare providers test for prenatal drug exposure, and if necessary report it. These findings can serve as evidence in child-welfare proceedings. To be awarded federal child abuse prevention funds, states must make providers notify child protective services if they look after an infant affected by illegal substance use. 

Public policy is catching up to this idea although there are many challenges with state legislature depending on geography and federal grants give states the power to decide how to implement key elements. Even though a number of states have adopted policies focused on the importance of treatment for pregnant women who are abusing drugs and of the accessibility of prenatal care, other States have approached this issue from a criminality standpoint (e.g., with child welfare and criminal laws) in the past few decades.

In one study, the pregnant participant’s stories demonstrated how they controlled the risk of health or criminal justice authorities detecting substance use, including isolating themselves from others, skipping treatment appointments, or avoiding treatment altogether. [14]

Co-occurring Conditions

Women with substance abuse issues often have high levels of comorbid psychopathology, personality problems, and mental health issues. SUDs and mental disorders have a bidirectional relationship. Having a mental disorder may contribute to the beginning or growth of an SUD. Correspondingly, the existence of an SUD may begin the beginning or growth of a mental disorder.[15]

Women are more prone to co-occurring disorders. In 2019, 34.3M adult women had a mental illness and/or SUD.[16]   There is also an increased risk for suicidality among women.[17]


Lack of Adequate Medical Resources 

In one study, the pregnant respondents reported several barriers to treatment and healthcare. Some of these were having insufficient treatment options and difficulty locating and entering treatment. Residential treatment facilities are limited.  In 2019[18], only 3,875 out of 15,961 facilities had treatment programs tailored to pregnant women, accounting for only 24.3% including private non-profit, private for-profit, local, county, or community government, state government, tribal government.[19]

Relapse Prevention/ Continuing Treatment Post-Partum

Despite pregnancy motivating some women to begin treatment, several studies indicate that pregnant women do not remain in treatment as long. Researchers have also linked retention to the stage of pregnancy and if the individual has co-occurring psychiatric disorders.

Transitional programs and aftercare services can offer educational programs, vocational training, relapse prevention programs, childcare services, and housing options for women and their newborns to support a sustained recovery as well.

Opioid Crisis

Recently, the number of pregnant people using opioids has rapidly increased.  This population’s growth rate is similar to the increase observed in the general population. [20]


Treatments & Best Practices


Offering holistic, integrated support for pregnant women with substance use concerns is an emerging best practice in how to support pregnant women with substance use concerns. These programs can be provided through various models including outreach, multi-service co-located agencies, or a network of community-based services. Research in this area has shown that integrated support models can improve maternal and fetal outcomes and successfully support women to reduce alcohol use in pregnancy.[21]


Approaches to SUD treatment for women should include:

  • Relational approaches that take into consideration positive and negative familial and partner influences and relationships, and promote a safe and caring treatment environment.
  • Treatment programs that integrate the whole person, including family and parenting responsibilities.
  • Trauma-informed approaches that include screening and assessing women for trauma history.
  • A focus on identifying and addressing co-occurring substance use and mental disorders, such as mood, anxiety, and eating disorders.
  • Consideration of appropriate medications for pregnant women; buprenorphine is safer than naltrexone or methadone to ensure better outcomes for newborn children.
  • Provider recognition of women’s cultural expectations to help improve engagement and retention in treatment programs

Medication-Assisted Treatment (MAT)

MAT is the combination of medications alongside counseling and behavioral therapies to provide a whole-patient approach when treating SUDs. The use of MAT during pregnancy is a recommended best practice for the care of pregnant women with opioid use disorders[22]. Research shows that a combination of medication and behavioral therapies is most successful for substance use disorder treatment. 

MAT is clinically driven and focuses on individualized patient care. Medications used to treat opioid use disorders include methadone and buprenorphine. Both of these medications stop and prevent opioid withdrawal and reduce opioid cravings, allowing the person to focus on other aspects of recovery.


Integrated Treatment Program Integrated/Coordinated Care

Integrated treatment for co-occurring disorders differs from traditional approaches. Services are organized in an integrated fashion. For example, this would mean that there are assessments provided that screen for both mental illness and substance use.[23]  

Integrated Programs for Mothers with Substance Abuse Issues Integrated treatment programs (those that include on-site pregnancy-, parenting-, or child-related services with addiction services) were developed to break the intergenerational cycle of addiction, potential child maltreatment, and poor outcomes for children.

Care Collaboration and Support Services

A significant suggestion is that women would benefit from comprehensive care and professional advocacy.

A multidisciplinary approach to clinical care and connection to psychosocial support services can improve the chances of treatment success for women with substance use disorders in general. Additionally, women can benefit from behavioral health referrals, services for addressing social determinants of health (eg, housing or food insecurity), and connection with peer and community supports. For more information read, Integrated programs for mothers with substance abuse issues: A systematic review of studies reporting on parenting outcomes.[24]


Evidence-Based

Evidence-based practice (EBP) is increasingly becoming more popular in many health care disciplines. One of its main characteristics is its focus on the interaction between hard scientific evidence, clinical expertise, and patient needs and choices. Evidence-based programs have discovered there are many different methods that are effective, including traditional programs (which center around the pregnancy period), comprehensive treatment and home visitation, and contemporary approaches. These newer methods include motivational interviewing and contingency management and they concentrate on the mother-infant relationship, collaboration among social service systems, including child protective services and family treatment drug court, and pharmacotherapy. [25]

Group/Peer Support

Mental healthcare is also an integral aspect of addiction treatment, and this includes both individual and group therapy sessions. Group sessions may take place with other pregnant women and focus on specific issues for this population. Women can work together during group skills sessions to learn parenting techniques and healthy stress coping mechanisms. 

Therapy

Behavioral therapies help to discover what may have prompted initial drug abuse, and they can teach participants new ways of thinking that will promote future healthy behaviors and habits. Another benefit for women is that counseling can help teach them how to manage childbirth and the pain and medical concerns that might occur during pregnancy and in childbirth. Creating a plan for these potential difficulties in combination with addiction treatment can be helpful. For example, after childbirth, pain medications may need to be monitored or switched for non-habit-forming ones.

Online Health Communities

In a study using online health communities (OHC), there were five themes of self-management support needs identified. In the online communities, women looked for information regarding the potential adverse effects of gestational opioid use, protocols for self-managed withdrawal, pain management safety during pregnancy, hospital policies and legal procedures related to child protection, and strategies for navigating offline support systems. 58.5% of the pregnant women in the study expressed negative emotions, of whom only 10.2% wanted to address their emotional needs with the help of the OHC.[26]


Harm reduction should include:[27]

  • Public Health Strategies
  • Implementation of public health strategies (e.g., improving state prescription drug monitoring program use and enhancing provider training) can support the delivery of evidence-based care for pregnant women.
  • Group-based treatment
  • Training of service professionals
  • Collaborative Care Models
  • Evidence-based policy development

Relevant Research

CDC:[28]Substance Use During Pregnancy Alcohol Use and Co-Use of Other Substances Among Pregnant Females Aged 12–44 Years — the United States, 2015–2018

Co-Creating Evidence Evaluation Report: Stories and Outcomes of Wraparound Programs Reaching Pregnant and Parenting Women at Risk.[29]

National Center for Biotechnology Information (NCBI) 

● Pregnant women and substance use: fear, stigma, and barriers to care[30] ● Concurrent Opioid and Alcohol Use Among Women Who Become Pregnant: Historical, Current, and Future Perspectives[31]

Substance Abuse and Mental Health Services Administration (SAMHSA) 2019 National Survey on Drug Use and Health [45][32]

Healthcare Cost And Utilization Project (H-CUP) Obstetric Delivery Inpatient Stays Involving Substance Use Disorders and Related Clinical Outcomes, 2016[33]


● Treating Opioid Use Disorder During Pregnancy[34] 

● Substance Use While Pregnant and Breastfeeding[[35]

● Sex and gender differences in substance use[36] 

Impactful Federal, State, and Local Policies

Comprehensive Addiction and Recovery Act of 2016 (CARA)

The Comprehensive Addiction and Recovery Act (CARA) establishes a comprehensive, coordinated, balanced strategy through enhanced grant programs that would expand prevention and education efforts while also promoting treatment and recovery. 

Applicable sections:

Title V:  Addiction and Treatment Services for Women, Families, and Veterans 

Sec. 501 – Improving Treatment for Pregnant and Postpartum Women:  This section reauthorizes the Residential Treatment Program for Pregnant and Postpartum Women. It also authorizes the creation of grants within CSAT for a pilot program to enhance a State's services for women who are pregnant and postpartum while suffering from substance use disorder.

Sec. 503 – Infant Plan of Safe Care: Requires HHS to produce information concerning best practices on developing plans for the safe care of infants born with substance use disorders or showing withdrawal symptoms. This section also requires that a State plan addresses the health and SUD treatment needs of the infant, among others.[37]

Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act) [Public Law 115–271]  

Broadly, the legislation imposes tighter oversight of opioid production and distribution; imposes additional reporting and safeguards to address fraud; and limits coverage of prescription opioids, while expanding coverage of and access to opioid addiction treatment services. The bill also authorizes a number of programs that seek to expand consumer education on opioid use and train additional providers to treat individuals with opioid use disorders.[38]

State Child Welfare & Prenatal Substance Use

Several states have expanded their civil child-welfare requirements to include prenatal substance use so that prenatal drug exposure can provide grounds for terminating parental rights because of child abuse or neglect. Further, some states, under the rubric of protecting the fetus, authorize civil commitment (such as forced admission to an inpatient treatment program) of pregnant women who use drugs; these policies sometimes also apply to alcohol use or other behaviors. A number of states require health care professionals to report or test for prenatal drug exposure, which can be used as evidence in child-welfare proceedings. And in order to receive federal child abuse prevention funds, states must require health care providers to notify child protective services when the provider cares for an infant affected by illegal substance use.[39]

⦁ 23 states and the District of Columbia consider substance use during pregnancy to be child abuse under civil child-welfare statutes, and 3 consider it grounds for civil commitment.

⦁ 25 states and the District of Columbia require health care professionals to report suspected prenatal drug use, and 8 states require them to test for prenatal drug exposure if they suspect drug use.

⦁ 19 states have either created or funded drug treatment programs specifically targeted to pregnant women, and 17 states and the District of Columbia provide pregnant women with priority access to state-funded drug treatment programs.

⦁ 10 states prohibit publicly funded drug treatment programs from discriminating against pregnant women.


Available Tools and Resources

Pregnancy Planning for Women Being Treated for Opioid Use Disorder[40] 


National Advocates for Pregnant Women (NAPW) NAPW works to secure the human and civil rights, health, and welfare of all people, focusing particularly on pregnant and parenting women, and those who are most likely to be targeted for state control and punishment — low-income women, women of color, and drug-using women.[41]


American Addictions Centers  (AAC)[42]  Treatment centers and resources for pregnant substance-using women and girls 

 

Promising Practices

Center for Addiction and Pregnancy (CAP) - The Johns Hopkins Bayview Medical Center-CAP offers an innovative approach to help mothers and infants deal with the physical, emotional, and social problems caused by addiction. CAP, an outpatient program with an available overnight housing unit for patients requiring a recovery-oriented domicile, provides a comprehensive, coordinated, and multidisciplinary approach to one of our greatest problems today: drug-dependent mothers and their drug-affected babies.  [43]

Her Way Home provides non-judgmental health care and social supports for pregnant and parenting women who have a history of substance use and may also be affected by mental health issues, violence, and trauma.[44]

Project Nurture provides prenatal care, inpatient maternity care, and postpartum care for women who struggle with addictions, as well as pediatric care for their infants. Nurture integrates maternity care with substance use treatment and features coordination between the health care and human services sectors. The model provides pregnant women with peer support, clinical care, and links to social services with the goal of safe and healthy parenting in an environment that patients view as respectful and nonjudgmental.  Project Nurture Integrates Care And Services To Improve Outcomes For Opioid-Dependent Mothers And Their Children.[45]

Project Respect  (Recovery, Empowerment, Social Services, Prenatal care, Education, Community and Treatment), is a high-risk obstetrical and addiction recovery medical home at Boston Medical Center and Boston University School of Medicine. Project RESPECT provides a unique service of comprehensive obstetric and substance use disorder treatment for pregnant women and their newborns in Massachusetts.[46] 

Project CARA 

Project CARA, housed at MAHEC Ob/Gyn Specialists, has supported over 800 women with substance use disorders since 2014. MAHEC first offered integrated substance use treatment services with obstetrical visits in the late 1990s. Our Project CARA team has built on this early foundation to provide comprehensive substance use care using current evidence-based practices.[47]

Drug treatment services linkage and referral

  • National Partnership for Women and Families: Maternity Care in the United States: We Can – and Must – Do Better[48]
  • Maternal, Infant and Early Childhood Home Visiting Program Funding[49]
  • Healthy Safe Children[50]
  • Obstetric-Fetal Pharmacology Research Centers[51]
  • Alliance for Innovation on Maternal Health (AIM)[52]
  • Recovery Research Institute[78][53]


Child Welfare System[54]

Sources

  1. ↑ https://www.recoveryanswers.org/resource/women-in-recovery
  2. ↑ https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4426.pdf
  3. ↑ http://www.fasd-evaluation.ca/wp-content/uploads/2021/03/FINAL-CCE_Executive-Summary_Mar-10-for-web.pdf
  4. ↑ https://www.ndsu.edu/fileadmin/centers/americanindianhealth/files/Maternal_Health_Learning_Collaborative_Session_2.pdf
  5. ↑ https://www.cdc.gov/mmwr/volumes/69/wr/mm6931a1.htm?s_cid=mm6931a1_w
  6. ↑ https://www.hcup-us.ahrq.gov/reports/statbriefs/sb254-Delivery-Hospitalizations-Substance-Use-Clinical-Outcomes-2016.pdf
  7. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/
  8. ↑ https://www.drugabuse.gov/publications/drugfacts/substance-use-in-women
  9. ↑ https://www.drugabuse.gov/publications/research-reports/substance-use-in-women/importance-including-women-in-research
  10. ↑ https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=23
  11. ↑ https://www.sciencedirect.com/science/article/abs/pii/S0091743520303273
  12. ↑ https://www.nationalpartnership.org/our-work/resources/health-care/maternity-care-in-the-united.pdf
  13. ↑ https://www.hcup-us.ahrq.gov/reports/statbriefs/sb254-Delivery-Hospitalizations-Substance-Use-Clinical-Outcomes-2016.pdf
  14. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/
  15. ↑ https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-07-01-001-PDF.pdf
  16. ↑ https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health
  17. ↑ https://www.ndsu.edu/fileadmin/centers/americanindianhealth/files/Maternal_Health_Learning_Collaborative_Session_2.pdf
  18. ↑ https://www.samhsa.gov/data/quick-statisticsresults?qs_type=nssats&state=United%20States&year=2019
  19. ↑ https://ncsacw.samhsa.gov/topics/pregnant-postpartum-women.aspx#sup-1-bottom
  20. ↑ https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy
  21. ↑ https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4426.pdf
  22. ↑ https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy
  23. ↑ https://store.samhsa.gov/sites/default/files/d7/priv/ebp-kit-building-your-program-10112019.pdf
  24. ↑ https://harmreductionjournal.biomedcentral.com/articles/10.1186/1477-7517-9-14
  25. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC226388/
  26. ↑ https://onlinelibrary.wiley.com/doi/epdf/10.1111/hsc.13335
  27. ↑ https://www.nashp.org/wp-content/uploads/2018/10/NOSLO-Opioids-and-Women-Final.pdf
  28. ↑ https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6931a1-H.pdf
  29. ↑ http://www.fasd-evaluation.ca/wp-content/uploads/2021/03/FINAL-CCE_Report_Mar-8-for-web.pdf
  30. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/
  31. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6545650/
  32. ↑ https://www.samhsa.gov/data/sites/default/files/reports/rpt31102/2019NSDUH-Women/Women%202019%20NSDUH.pdf
  33. ↑ https://hcup-us.ahrq.gov/reports/statbriefs/sb254-Delivery-Hospitalizations-Substance-Use-Clinical-Outcomes-2016.pdf
  34. ↑ https://www.drugabuse.gov/publications/treating-opioid-use-disorder-during-pregnancy
  35. ↑ https://www.drugabuse.gov/publications/research-reports/substance-use-in-women/substance-use-while-https://www.drugabuse.gov/publications/drugfacts/substance-use-in-womenpregnant-breastfeeding
  36. ↑ https://www.drugabuse.gov/publications/drugfacts/substance-use-in-women
  37. ↑ https://www.cadca.org/comprehensive-addiction-and-recovery-act-cara
  38. ↑ https://fas.org/sgp/crs/misc/R45405.pdf
  39. ↑ https://fas.org/sgp/crs/misc/R45405.pdf
  40. ↑ https://store.samhsa.gov/sites/default/files/d7/priv/pre_pregnancy_factsheet_041919_508.pdf
  41. ↑ https://www.nationaladvocatesforpregnantwomen.org/issues/pregnancy-and-drug-and-alcohol-use/
  42. ↑ https://www.apa.org/pi/women/resources/treatment-resources-pregnant-women.pdf
  43. ↑ https://www.hopkinsmedicine.org/psychiatry/patient_information/bayview/medical_services/substance_abuse/center_addiction_pregnancy.html
  44. ↑ https://www.islandhealth.ca/learn-about-health/pregnancy-birth-babies/herway-home
  45. ↑ https://www.healthshareoregon.org/health-equity/project-nurture
  46. ↑ https://www.bmc.org/obstetrics/pregnancy/addiction
  47. ↑ https://mahec.net/patient-information/ob-gyn-care/project-cara-welcome
  48. ↑ https://www.nationalpartnership.org/our-work/resources/health-care/maternity-care-in-the-united.pdf
  49. ↑ https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting-overview
  50. ↑ https://healthysafechildren.org/trending-topics
  51. ↑ https://www.utmb.edu/nichd-oprc/
  52. ↑ https://www.acog.org/practice-management/patient-safety-and-quality/partnerships/alliance-for-innovation-on-maternal-health-aim
  53. ↑ https://www.recoveryanswers.org/research-post/ob-gyns-say-opioid-use-disorders-pregnancy-provide-opportunities-life-changing-interventions/
  54. ↑ https://www.recoveryanswers.org/research-post/using-the-child-welfare-system-to-engage-parents-with-substance-use-disorders/
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