The costs and effectiveness of substance abuse treatment programs for pregnant women

Marilyn Daley, Ph.D.Conference on Harm Reduction Strategies in UzbekistanBrandeis UniversityAugust 18, 2004

MOTHERS Project was funded through HCFA Cooperative Agreement #HC-05-111-PC/004

Background: Drug, alcohol and tobacco use among pregnant women is a serious public health problem in the United States

According to national epidemiological studies: 5% of U.S. women use illicit drugs during

pregnancy 20% use alcohol 20% use tobacco

In 1996, 647 pregnant women were admitted to publicly funded drug treatment programs in Massachusetts

About 40% of these women are heroin users

Background Drug and alcohol use among pregnant

women is associated with adverse birth outcomes and is very expensive to society Leading preventable cause of low birth weight HIV transmission/pediatric AIDS Hepatitis C and other infections Neonatal abstinence syndrome Growth, learning and behavioral problems which

can persist into adulthood Increased use of neonatal intensive care units,

lengthy hospital stays, abandoned infants Cost Medicaid program over $1 Billion in 1991

Expansion of treatment programs during the 1990s – 2000s

Reports of a shortage of treatment slots that could accommodate the physiological needs of pregnant women, particularly those under Medicaid

Led to increased federal, state and private funding for specialized treatment for pregnant women

NIDA, NIAAA, CSAP, CSAT and HCFA all funded demonstration projects

Led to 250% increase in publicly funded treatment services available for pregnant women in Massachusetts between 1989 and 1995

Description of the MOTHERS Project

Funded by the Health Care Financing Administration between 1992-1996

Part of a five site research and demonstration project to explore new ways to increase access to prenatal care and substance abuse treatment for pregnant women

Interviewed 627 pregnant women who were receiving treatment in Massachusetts publicly funded detoxification programs

Followed these women for a year and a half using face to face follow-up interviews at 3, 6, 9 and months, birth records, Medicaid claims and substance abuse treatment records

Compared the costs and effectiveness of the following treatment programs:

Methadone (n=56) Residential (n=63) Outpatient (n=79) Residential/outpatient (n=77) Detoxification only (used as a no

treatment comparison group) (n=170)

Methadone programs

Accepted protocol was to maintain pregnant women on methadone and withdraw the child after delivery

12 methadone programs in Massachusetts Transportation provided to and from the

programs Total cost: $20 day plus transportation Pregnant women on methadone were accepted

at a few of the residential treatment programs Numbers of pregnant women served by

methadone programs remained stable between 1992 and 1996 at 72

Outpatient programs

Day treatment programs Linkages to prenatal care, WIC, early

intervention, local welfare offices Individual and group counseling Case management 4 hours per day for six days per week Total cost: $55/day The number of pregnant women in day

treatment programs increased from 46 in 1988 100 in 1996

Detoxification programs

8 specialized detoxification programs that could serve pregnant women up to their 3rd trimester

Needed to be associated with a hospital, a prenatal care provider, an early intervention program, DPW, WIC

Had a full time OB/GYN nurse on staff to provide medical care and case management

Total cost: $160/day Number of women using these services increased

from 10 in 1988 to 377 in 1996

Residential programs

200 residential beds 11 recovery homes 4 therapeutic communities 9 family shelters

Many allowed other children to live on site Individual & group counseling, parenting skills training,

housing assistance, etc. Needed to be affiliated with a physician, a hospital, a

prenatal care provider, WIC, early intervention, local welfare office

Total cost: $80/day Admissions increased from

18 in 1988 to 115 in 1996

Emerson House in Falmouth, Massachusetts10 beds for pregnant women

Steppingstone women’s program in Fall River: 6 beds for pregnant women

MOTHERS Project clients

Average age = 28 41% black, 41% white, 18% hispanic 83% had other children, but 77% did not have

custody of their children 33% said heroin was their drug of choice, 26%

cocaine, 26% crack, 8% alcohol 90% were unmarried 45% had been homeless in the last 3 years 60% had been physically abused 50% had not graduated from high school

Costs of treatment and health care during pregnancy to six months postpartum

$0

$5

$10

$15

$20

Thousands

Treatment 2723 4009 6812 9882 17720

Health care 12850 13059 16717 19563 15163

detox out meth res r&o

Birth weight for 445 infants(singleton live births)

2864

2955 2963

3026

3072

2750

2800

2850

2900

2950

3000

3050

3100

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Percent low birth weight (445 singleton live births)

26

18 18 1613

0

5

10

15

20

25

30

dtx meth op res r&o

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According to regression analysis, the following variables were also associated with higher or lower birth weight

Mothers age (-13 g year) Male infants (+ 115 g) Previous preterm delivery (-142 g) Gravidity (+127 g) Weight gain (+110 g) Readmissions to detoxification during pregnancy (-121 )

The following variables increased costs: Previous preterm delivery (+ $2,140) Age (-$168) Infections (+ $5,001)

#Cigarettes per day, polydrug use, race, #prenatal care visits, #grades completed had no effect

Discussion: cost-effectiveness There was a near linear relationship between the amount of

treatment received and birth outcomes Mothers who received the most treatment (130 days) in

residential/outpatient delivered infants who weighed 190 grams more than the women who received only detoxification, who spent only 17 days in treatment

The infants whose mothers received detox only had twice the rate of low birth weight (13% vs. 26%) compared to women in residential/outpatient

However, the residential/outpatient programs also cost $16,323 more than the detoxification programs

Outpatient programs were the most efficient option. Infants weighed 139 g more than in detox for a cost of only $1788 or $13 gram

Methadone programs cost $7,920 more than detox and increased birth weight by 107 grams, or $75 per gram

Treatment programs for pregnant women benefit society

Produce healthier children Improve health and quality of life for mothers Decrease drug use for mothers Reduce crime to society Reduce health care expenditures Reduce criminal activity and attendant costs Promote family reunification Reduce the spread of HIV and other infections Since they produce more benefits than costs, an

investment in treatment programs for pregnant women produces a net return to society

Reductions in the cost of crime High rate of criminal involvement in

mothers project sample: 68% had been arrested 40% had spent time in jail

Women commit different crimes from men Shoplifting Prostitution Drug sales

Did treatment reduce the costs of crime?

Background Since crack epidemic more women have

entered retail drug trade Between 1986 and 1991 there was a 433%

increase in the number of women in state prisons for drug offenses

All treatment programs reduced the costs of criminal activity even after accounting for treatment costs, representing a net gain to society

Annualized savings due to reductions in crime (net gain to society)

Detoxification ($3,072) Methadone ($7,884) Outpatient ($8,508) Residential/Outpatient ($18,060) Residential ($32,772)

Benefits (net of costs) of treatment programs due to reductions in crime

$3,072

$7,884$8,508

$18,060

$32,772

0

5000

10000

15000

20000

25000

30000

35000

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For every dollar spent on treatment programs for pregnant women, society receives a return of :

$1.14

$1.54$1.72

$2.10 $2.11

$0.00

$0.50

$1.00

$1.50

$2.00

$2.50

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