1. The costs and effectiveness of substance abuse treatment programs for pregnant women Marilyn Daley, Ph.D. Conference on Harm Reduction Strategies in Uzbekistan Brandeis University August 18, 2004 MOTHERS Project was funded through HCFA Cooperative Agreement #HC-05-111-PC/004

2. 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

3. 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

4. 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

5. 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

6. 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)

7. 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

8. 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

9. Detoxification programs  8 specialized detoxification programs that could serve pregnant women up to their 3 rd 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

10. 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

11. Emerson House in Falmouth, Massachusetts 10 beds for pregnant women

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

13. 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

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

15. Birth weight for 445 infants (singleton live births)

16. Percent low birth weight (445 singleton live births)

17. 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

18. 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

19. 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

20. 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?

21. 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

22. 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)

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

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