Substance Use Disorder Treatment in Pregnant Adults

Date of current publication: July 16, 2021
Lead authors: Kelly S. Ramsey, MD, MPH, MA, FACP
Writing group: Sharon Stancliff, MD; Lyn C. Stevens, MS, NP, ACRN; Christopher J. Hoffmann, MD, MPH; Charles J. Gonzalez, MD
Committee: Substance Use Guidelines Committee
Date of original publication: July 16, 2021

Goals: This guideline on the treatment of substance use disorders (SUDs) in pregnant adults (≥18 years old) was developed by the New York State (NYS) Department of Health (DOH) AIDS Institute (AI) to establish a New York State standard of care. The goal of this guideline is to ensure that healthcare providers in New York State are aware of and able to provide appropriate options for SUD treatment during pregnancy and to:

• Inform clinicians of available treatment options for SUDs to expand access to SUD treatment for pregnant individuals.
• Provide evidence-based recommendations to guide the management of substance use and SUDs during pregnancy.
• Promote a harm reduction approach to SUD treatment in pregnancy by providing practical strategies for reducing the negative consequences of drug and alcohol use during pregnancy.
• Increase awareness among healthcare providers about the stigma associated with drug and alcohol use during pregnancy.

Use of this guideline: This guideline is intended for clinicians with patients who have SUDs during pregnancy. SUD treatment during pregnancy can be managed in various inpatient and outpatient settings. Communication and coordination among healthcare providers are essential.

Many aspects of SUD treatment are the same for pregnant and nonpregnant patients. The recommendations in this guideline focus on aspects of SUD treatment that differ for pregnant individuals; where appropriate, clinicians are referred to the following NYSDOH AI guidelines for more information:

• Treatment of Opioid Use Disorder
• Treatment of Alcohol Use Disorder
• Substance Use Harm Reduction in Medical Care

The recommendations presented here address the treatment of SUD in pregnant patients; they do not address the management of pregnancy itself.

In 2018, the Centers for Disease Control and Prevention reported that in the United States, the number of pregnant individuals with opioid use disorder (OUD) at the time of labor and delivery more than quadrupled from 1999 to 2014 Haight, et al. 2018. In New York State, the rate of newborns with neonatal withdrawal syndrome (NOWS) per 1,000 delivery hospitalizations/newborn discharges increased from 2.6 in 2008 to 5.8 in 2014 NYSDOH 2023.

There are few data on the prevalence of other substance use disorders (SUDs) in pregnant individuals. A population-based study of deliveries in Massachusetts between 2003 and 2007 found that 5% of mothers had an SUD, but only 66% were taking treatment Kotelchuck, et al. 2017. Among a total of 76,799 deliveries between 2003 and 2013 in Korea, 1211 (1.6%) women had an alcohol use disorder preceding delivery (AUD) Oh, et al. 2020.

Estimates of substance use among pregnant individuals based on national surveys in the United States include:

• In 2018, approximately 4.7% of pregnant individuals reported cannabis use, 9.9% reported alcohol use, 0.9% reported opioid use, and 11.6% reported tobacco use in the last 30 days SAMHSA 2019.
• Alcohol: In 2018, 19.6% of respondents in their first trimester and 4.7% in their second or third trimesters reported alcohol use in the last 30 days England, et al. 2020. Overall, 38.2% of pregnant respondents who reported alcohol use in the previous 30 days also reported using 1 or more other substances in the same period, most commonly tobacco and cannabis England, et al. 2020.
• Tobacco: The overall prevalence of tobacco use during pregnancy in the United States continues to decline, but less significant declines have been reported among people of lower education levels and socioeconomic status Drake, et al. 2018.
• Cannabis: The estimated prevalence of cannabis use in the last 30 days increased from 3.4% in 2002 to 2003 to 4.7% in 2018; over the same period, the prevalence of daily or near-daily cannabis use in the last 30 days increased from 0.9% to 1.5% SAMHSA 2019; Volkow, et al. 2017.

However, these data are self-reported and, because of the stigma associated with substance use during pregnancy, may underestimate the extent of use.

Prenatal tobacco use and prenatal alcohol use have well-established obstetric, neonatal, and adverse developmental effects, and OUD often results in NOWS Guille and Aujla 2019. The data on most other substances suggest potential adverse effects, including low birthweight and premature birth, but the results are variable. For example, a population-based study of deliveries in Massachusetts between 2003 and 2007 found that women who received SUD treatment had lower odds of premature birth (AOR 0.61, 95% CI 0.55-0.68), low birthweight (AOR 0.54, 95% CI 0.49-0.61), and neonatal mortality (AOR=0.49, 95% CI: 0.31–0.74) than those who did not receive treatment Kotelchuck, et al. 2017.

In clinical studies, including those discussed below, it is difficult to quantify the degree to which the biological effects of the substance contribute to poor outcomes, compared with other health, socioeconomic, and environmental factors, such as polysubstance use, cigarette smoking, and lack of adequate prenatal care. Comprehensive prenatal care and appropriate SUD treatment are vital to promoting the health and well-being of the dyad.

Opioids: Opioid use during pregnancy has been associated with an increased risk of preterm birth and stillbirth Kaltenbach, et al. 2018; Jones and Fielder 2015. However, individuals receiving OUD treatment during pregnancy, compared to no treatment, had lower odds of preterm birth (0.51 [0.43–0.61]) and low birthweight (0.46 [0.39–0.55]) Kotelchuck, et al. 2017.

Systematic reviews and meta-analyses have demonstrated that prenatal opioid exposure, compared with no exposure, is negatively associated with neurocognitive and physical development in children ≥6 months old Yeoh, et al. 2019; Baldacchino, et al. 2014. However, many of the studies included in the meta-analyses did not have control groups matched for familial, socioeconomic, and environmental risks, which may have contributed to observed cognitive differences. Another meta-analysis found no significant differences in developmental outcomes in children with prenatal exposure to buprenorphine or methadone compared with children who had no exposure to those substances when all studied had comparable levels of prenatal exposure to tobacco smoke Nelson, et al. 2020.

Alcohol: Approximately 1 in 3 infants born to individuals with AUD display symptoms of fetal alcohol spectrum disorder (FASD). Subtle manifestations of FASD include slight learning disabilities or slight physical abnormalities; severe manifestations include central nervous system dysfunction, low IQ, microcephaly, delayed growth, and facial abnormalities Miller 2018. A multisite study using active case ascertainment methods estimated an FASD prevalence rate of 1% to 5% among first graders exposed to alcohol in utero Muggli, et al. 2017. In a study that compared children aged 9 and 10 years with and without prenatal alcohol exposure, exposure was associated with increased psychopathology, attention deficits, and impulsiveness Lees, et al. 2020.

Alcohol use during pregnancy may increase the risk of miscarriage, stillbirth, and preterm delivery, and the risks may be more pronounced with heavy alcohol use Bailey and Sokol 2011. However, the role of sociodemographic and lifestyle factors that co-occur with alcohol use during pregnancy and the synergistic effects of these factors plus alcohol use is unclear. Most available studies evaluate the impact of alcohol use, not alcohol use disorder (AUD), before or during pregnancy. In a large cohort study from Korea, the diagnosis of AUD preceding birth was associated with an increased risk of intrauterine growth restriction but not associated with other birth complications Oh, et al. 2020. The increased risk was more marked in individuals diagnosed with AUD in the 12 months preceding birth.

Tobacco: Tobacco use during pregnancy has been linked to low birth weight, preterm birth, placental abruption, miscarriage, stillbirth, poor fetal neurodevelopment, sudden unexpected infant death, and various congenital disabilities Anderson, et al. 2019; Akerman, et al. 2015; Cressman, et al. 2012; Forinash, et al. 2010.

Cannabis: A systematic review and meta-analysis found that individuals who used cannabis during pregnancy had an increase in the odds of anemia (pooled OR =1.36: 95% CI 1.10 to 1.69) compared with women with no cannabis use Gunn, et al. 2016. In addition, the meta-analysis found that infants exposed to cannabis in utero had a decrease in birth weight (pOR=1.77: 95% CI 1.04 to 3.01) and an increased need for placement in the neonatal intensive care unit (pOR=2.02: 1.27 to 3.21) compared with infants whose mothers did not use cannabis Gunn, et al. 2016. In a large population-based, retrospective cohort study, the CUD rate among pregnant individuals increased from 2.8 to 6.9 per 1,000 deliveries from 2001 to 2012 Shi, et al. 2021. Prenatal CUD was associated with an increased likelihood that infants would be small-for-gestational-age (OR = 1.13, 95% CI = 1.08, 1.18), born preterm (OR = 1.06, 95% CI = 1.01, 1.12), of low birth weight (OR = 1.13, 95% CI = 1.07, 1.20), or would die within 1 year of birth (OR = 1.35, 95% CI = 1.12, 1.62). Infants born to a parent with CUD who also used tobacco had greater odds of preterm birth, low birth weight, hospitalization, and death associated with prenatal CUD than infants born to a parent who did not use tobacco Shi, et al. 2021.

Cocaine and methamphetamine: Meta-analyses indicated that cocaine and specifically crack use during pregnancy may be associated with significantly higher odds of preterm delivery, low birth weight, and small-for-gestational-age infants Dos Santos, et al. 2018; Gouin, et al. 2011. However, the authors note several limitations in the studies, including the difficulty of accurately measuring illicit substance use patterns among women throughout pregnancy and a pattern of polysubstance use in this population, and they emphasize the impact of adverse personal and social circumstances on study outcomes Gouin, et al. 2011.

The Maternal Lifestyle Study (MLS), a prospective, longitudinal study of infants with prenatal exposure to cocaine and other substances, found that after controlling for birth weight and indices of the caregiving environment, prenatal cocaine exposure was not associated with mental, psychomotor, or behavioral functioning through 3 years of age Messinger, et al. 2004. A similar longitudinal, controlled cohort study, the Infant Development, Environment, and Lifestyle (IDEAL) study, evaluated the effects of prenatal methamphetamine exposure on neonatal outcomes at birth and over time. Overall, investigators found no differences in maternal complications or newborn health outcomes Smith, et al. 2015; Shah, et al. 2012. Neonates exposed to methamphetamine in utero had smaller head circumferences and were shorter than neonates who were not exposed. Differences in height between the groups persisted through 3 years of age Shah, et al. 2012; Zabaneh, et al. 2012. An analysis through 7.5 years of age found no significant behavioral differences between infants/children with prenatal methamphetamine exposure and those with no exposure groups Chu, et al. 2020.

Even if substance use treatment is declined, reaching and engaging pregnant individuals who use substances may improve prenatal care and support harm reduction. In a retrospective cohort study, pregnant individuals who used drugs who obtained prenatal care delivered infants of greater weight and with larger head circumferences than did those who obtained no care (P < .05) Berenson, et al. 1996. In another retrospective cohort study that stratified results by the intensity of prenatal care received and current injection drug use, status among pregnant individuals, greater engagement in prenatal care (i.e., care utilization) improved outcomes El-Mohandes, et al. 2003. In addition, the risk for prematurity, low birth weight, and small-for-gestational-age infants decreased regardless of IDU status.

Efforts at the healthcare delivery level to increase engagement in care can involve collocating and coordinating prenatal, perinatal, substance use, mental health, and trauma and violence treatment, including social services. Integrating the different aspects of care helps pregnant individuals get to appointments, address multiple needs, and participate in clinic programming Rutman, et al. 2020.

For recommendations on substance use screening during pregnancy, see the NYSDOH AI guideline Substance Use Screening and Risk Assessment in Adults.

Pregnancy is not a contraindication for substance use disorder (SUD) treatment. Treatment can be managed in various settings by perinatal, primary care, or SUD specialty providers. SUD treatment and other aspects of care for pregnant patients should be coordinated among healthcare providers.

SUD treatment goals during pregnancy can include:

• Abstaining from or reducing substance use
• Preventing adverse effects of substance use or withdrawal for the pregnant individual and fetus
• Staying in care, which can also facilitate prevention, diagnosis, and treatment of other conditions
• Reducing high-risk behaviors, such as injection drug use and use or reuse of unsterile equipment and sharing injection equipment, and reducing related complications, such as infection and overdose
• Improving the quality of life and other social conditions, such as employment, stable housing, and risk of incarceration

Barriers to care: Engagement in substance use care is associated with better maternal and neonatal outcomes Minozzi, et al. 2020; Chamberlain, et al. 2017; Binder and Vavrinková 2008; O'Connor and Whaley 2007. However, pregnant individuals who use substances can face substantial obstacles to healthcare access, ranging from lack of transportation to fear of legal consequences, which may delay care until late in the pregnancy or the point of delivery Stone 2015. Pregnant Black women are more likely to be tested for drug use during pregnancy and referred to child protective services than their non-Black counterparts despite equivalent rates of positive drug tests between the 2 groups Kunins, et al. 2007. The influence of implicit care provider bias and institutional racism in the healthcare system on these different testing and reporting rates cannot be ignored. Most states have laws requiring the reporting of prenatal drug exposure Guttmacher Institute 2022. Fear of being reported, legal action, and child services involvement may lead to the avoidance of prenatal or substance use treatment and possible negative health consequences for the parent and infant Angelotta, et al. 2016; House, et al. 2016; Stone 2015.

Note: Many aspects of opioid use disorder (OUD) treatment in pregnant individuals are similar to treatment in nonpregnant individuals, including the preferred medications. The recommendations below focus on differences in treatment during pregnancy; consult the NYSDOH AI guidelines Treatment of Opioid Use Disorder and Substance Use Harm Reduction in Medical Care for additional recommendations.

Avoid opioid withdrawal: Abrupt discontinuation of opioids, including BUP or methadone, should be avoided during pregnancy to prevent or minimize withdrawal symptoms. Consultation with an experienced substance use treatment provider may be appropriate. Inconsistent opioid levels during pregnancy may precipitate withdrawal in the fetus, which can harm placental function and can increase the risks of NOWS, stunted growth, preterm labor, fetal convulsions, and fetal death Hudak and Tan 2012; Kaltenbach, et al. 1998.

Maternal and fetal risks and benefits of opioid use and treatment: Treatment with BUP or methadone is the standard of care for OUD in pregnant patients (see SAMHSA Clinical Guidance for Treating Pregnant and Parenting Women With Opioid Use Disorder and Their Infants). Treatment with BUP or methadone reduced use of opioids and decreased risk of preterm delivery, low infant birth weight, and transmission of HIV to the neonate Minozzi, et al. 2020; ACOG(a) 2017; Saia, et al. 2016; Wiegand, et al. 2015; Gawronski, et al. 2014; Mozurkewich and Rayburn 2014; Lund, et al. 2013; Wong, et al. 2011; Jones, et al. 2010; Binder and Vavrinková 2008. Table 1, below, summarizes the risks and benefits of BUP and methadone.

Although infants exposed to BUP or methadone can experience NOWS, the severity of symptoms is reduced when the mother is taking medication for OUD treatment Brogly, et al. 2014; Fajemirokun-Odudeyi, et al. 2006. The risk of NOWS does not differ based on treatment with BUP or methadone, but studies indicate that infants exposed to BUP/NLX in utero are less likely to require treatment for NOWS than those exposed to other opioid agonist medications, including BUP, methadone, or long-acting opioids Link, et al. 2020. In a study comparing BUP and methadone treatment during pregnancy, neonates exposed to BUP had significantly less severe NOWS, a shorter duration of treatment for NOWs, and shorter hospital stay than those exposed to methadone Jones, et al. 2010.

A long-term study of infants exposed to BUP or methadone in utero reported healthy growth and cognitive and psychological development at 36 months of age for both groups Kaltenbach, et al. 2018. In addition, a recent meta-analysis found no significant differences in cognitive development scores in children up to 5 years old with and without prenatal exposure to methadone or BUP Nelson, et al. 2020.

Buprenorphine monoformulation or buprenorphine/naloxone: A recent systematic review of 5 studies with 6 study groups found no significant differences in adverse maternal and neonatal outcomes when comparing BUP/naloxone (NLX) or methadone treatment in pregnancy. Outcomes included admission to the neonatal intensive care unit, full-term delivery, vaginal delivery, neonatal length of stay, gestational age at delivery, neonatal length, birthweight, and neonatal head circumference Link, et al. 2020; Mullins, et al. 2020; Nechanská, et al. 2018; Jumah, et al. 2016; Wiegand, et al. 2015; Gawronski, et al. 2014. Pregnant patients who are initiating or continuing BUP maintenance can choose either the monoformulation or BUP/NLX.

Naltrexone: The NYSDOH AI guideline Treatment of Opioid Use Disorder > Treatment Considerations recommends naltrexone as an alternative to be offered if patients cannot take BUP or methadone or prefer naltrexone.

If a pregnant individual is currently using opioids, initiation of naltrexone is not recommended because withdrawal from opioids is required Towers, et al. 2020; ACOG(a) 2017; Jones, et al. 2013; FDA 2010; Hulse, et al. 2004. If a patient taking naltrexone becomes pregnant, clinicians should inform the patient of the risks and benefits of naltrexone and the preferred pharmacologic treatment options to support informed and shared decision-making about treatment (see Table 2, below). If the patient opts to discontinue naltrexone and initiate methadone or BUP, clinicians should educate the patient about the risk of NOWS.

Initiating buprenorphine: In pregnant patients, BUP should be initiated when a patient is experiencing mild opioid withdrawal symptoms (see the Clinical Opiate Withdrawal Scale and Subjective Opiate Withdrawal Scale) Wesson and Ling 2003; Handelsman, et al. 1987. For nonpregnant patients, clinicians are advised to initiate treatment when the patient is experiencing moderate withdrawal symptoms. However, if a pregnant individual is experiencing physiological withdrawal, it affects the fetus, too, so medication is initiated earlier in withdrawal to avoid the increased risk to the fetus.

One emerging strategy for BUP/NLX induction is “microdosing,” which does not require opioid withdrawal Randhawa, et al. 2020; Klaire, et al. 2019; Hämmig, et al. 2016. A small initial dose (e.g., 0.5 mg/0.125 mg) is followed by small incremental increases over 7 to 10 days; patients can continue to use other opioids until the therapeutic level of BUP/NLX is reached. Case reports on nonpregnant adults indicate that BUP/NLX microdosing is well tolerated and may reduce opioid cravings and withdrawal symptoms during induction Klaire, et al. 2019; Hämmig, et al. 2016. Microdosing is an emerging strategy for BUP/NLX induction, and studies are needed to guide clinical care. To date, BUP/NLX microdosing has not been studied in pregnant individuals. Because of the lack of data, this committee does not take a position on microdosing during BUP/NLX induction in pregnant patients.

Although there is little published evidence, clinical experience supports a cautious approach to BUP induction in pregnant individuals, with slow titration to the optimal dose for a pregnant patient. For example, clinicians can advise patients to take an initial dose of BUP 2 mg, followed 30 to 60 minutes later by an additional 2 mg Jones, et al. 2008. If the patient experiences any worsening of opioid withdrawal symptoms within 30 to 60 minutes after a dose of BUP, the interval between doses can be decreased. The pattern of increasing BUP in 2 mg increments and waiting 30 to 60 minutes before the next increase continues until the dose is sufficient to control opioid cravings and prevent withdrawal.

Continuing opioid use disorder treatment through pregnancy, labor, delivery, and postpartum: Patients with OUD who initiate BUP or methadone during pregnancy or who become pregnant while taking either medication should continue treatment with the same medication throughout the intra- and postpartum periods Meyer, et al. 2015; Lund, et al. 2013; Jones, et al. 2010.

If treatment goals are not being met with BUP treatment during the pregnancy, clinicians should refer the patient to an OTP for methadone treatment if available ACOG(a) 2017. However, during pregnancy, a switch from methadone to BUP is not recommended because the transition could cause precipitated opioid withdrawal symptoms and may require inpatient care and monitoring to decrease the risk of miscarriage or premature delivery. If a patient requests a change from methadone to BUP, clinicians are advised to consult with an expert in OUD treatment during pregnancy.

Monitor for dose increase later in pregnancy: An increased dose of BUP or methadone may be required late in the second and third trimesters because of increased blood volume and metabolism later in pregnancy Bastian, et al. 2017; Albright, et al. 2011; Cleary, et al. 2010. Patients may opt to split their BUP dose during the day if it suits their comfort level. Clinicians should assess withdrawal symptoms and opioid cravings at every visit. If a pregnant patient is experiencing any opioid withdrawal symptoms or opioid cravings, the dose of medication should be increased, typically in increments of 5 mg to 10 mg per day for methadone (every 3 to 5 days as needed) and 2 mg to 4 mg per day for BUP. The medication dose should be reassessed at each visit. Patient education is essential to ensure that the patient understands that increasing the dose of either BUP or methadone will not increase the risk of NOWS Wong, et al. 2018; Cleary, et al. 2010; Jones, et al. 2010.

If a pregnant patient taking methadone has withdrawal symptoms or cravings that are not relieved by a dose increase, the OTP should perform testing for the patient’s serum peak and trough levels of methadone. If the peak-to-trough level ratio is higher than 3:1, the methadone dosage should be divided and administered twice daily, ideally every 12 hours.

Pain management: At a minimum, the maintenance OUD treatment dose of methadone or BUP is maintained ASAM(b) 2020. Nonopioid medications are the first-line option. The addition of a short-acting full-agonist opioid can be considered to manage moderate to severe acute pain. When adding a full-agonist opioid analgesic, patients will likely need a higher dose than opioid-naive patients to achieve adequate analgesia ASAM(b) 2020.

Breastfeeding: Breastfeeding is safe when a patient takes methadone, BUP, or naltrexone LactMed(b) 2022; LactMed(e) 2022; LactMed(a) 2021. In addition, breastfeeding has been shown to decrease the risk of NOWS and, when NOWS does occur, decrease the need for pharmacologic treatment Reece-Stremtan and Marinelli 2015; Welle-Strand, et al. 2013; McQueen, et al. 2011; Jansson, et al. 2008. This benefit is likely due to the skin-to-skin contact inherent in breastfeeding rather than the minuscule amount of BUP or methadone in breast milk. The only contraindication to breastfeeding is HIV infection. Hepatitis C virus infection is not a contraindication to breastfeeding as long as the skin of the nipple is intact.

Postpartum considerations: Following birth, a patient who is taking medications to treat OUD will require continued treatment and support. The postpartum period can be stressful for new parents, particularly if they lack social support and have comorbidities, such as mental health diagnoses or chronic medical conditions; during this period, individuals who use opioids are at increased risk for recurrence of use and unintentional overdoses Schiff, et al. 2018. One study found that individuals who gave birth to infants with NOWS had a significantly higher incidence of major depression, postpartum depression, and anxiety in the 12 months postpartum than matched controls Corr, et al. 2020. A population-based study in Massachusetts found that overdose events decreased with progression through the pregnancy and were lowest in the third trimester (3/100,000 person-days); the highest risk of overdose occurred 7 to 12 months after delivery (12.3/100,000 person-days) Schiff, et al. 2018.

In the postpartum period, the mother should continue taking BUP or methadone for as long as a benefit is derived. If the patient’s dose of BUP or methadone was increased during pregnancy, clinicians should not decrease the dose to the prepregnancy level immediately postpartum; dose decreases should be individualized.

Clinicians should inform pregnant patients who are taking opioids, buprenorphine (BUP), or methadone, that NOWS is an expected and treatable neonatal outcome. Patient education about NOWS may reduce stress after delivery.

Risk of neonatal opioid withdrawal syndrome: A fetus that is exposed to opioids, methadone, or BUP during pregnancy is at risk of developing NOWS ACOG(a) 2017; Kraft, et al. 2016; McQueen and Murphy-Oikonen 2016; Saia, et al. 2016; Gawronski, et al. 2014; Hall, et al. 2014; Kocherlakota 2014; Wong, et al. 2011; Jones, et al. 2010; Bakstad, et al. 2009.

Harm reduction: Strategies to reduce the severity of NOWS include treatment with BUP or methadone and preventing opioid withdrawal in pregnant patients who use opioids Brogly, et al. 2014; Fajemirokun-Odudeyi, et al. 2006. There is no association between BUP or methadone dose and the likelihood of NOWS; therefore, dose reductions to avoid NOWS are not advised Kaltenbach, et al. 1998. Reducing the dose of BUP or methadone may increase illicit drug use and increase the risk to the fetus.

Symptoms: Signs of opioid withdrawal generally occur within the first 48 hours of life for neonates exposed to BUP in utero and within 5 days for those exposed to methadone. Symptoms include tremors, hypertonicity, irritability, vomiting, and respiratory distress, and the number, severity, and duration of symptoms vary in individual neonates Zelson, et al. 1973. Multiple factors affect the expression of symptoms: neonatal gestational age, sex, and genetics; maternal substance use factors, exposure to medications (selective serotonin reuptake inhibitors, benzodiazepines, gabapentinoids), smoking, and metabolism Kraft, et al. 2016. Diagnosis of NOWS is based on maternal history and neonatal clinical features, with or without biological testing Anbalagan and Mendez 2022.

Tools such as the Finnegan Neonatal Abstinence Scoring System Finnegan and Kaltenbach 1997 and the MOTHERS score Jones, et al. 2010 are used to assess central nervous system, metabolic, vasomotor, respiratory, and gastrointestinal symptoms. The score is used to guide treatment decisions, including the initiation of pharmacologic treatment. A diagnosis of NOWS can require individually tailored supportive care strategies because presenting symptoms can vary Wiles, et al. 2014; Velez and Jansson 2008

Treatment: The treatment goals are to minimize the severity and duration of withdrawal symptoms in the infant and reduce the length of hospital stay and the need for adjunctive therapies. Current practice encourages nonpharmacologic management of NOWS and infant-family contact Ryan, et al. 2019; Grossman, et al. 2018.

Because many NOWS symptoms are associated with infant overstimulation, nonpharmacologic care focuses on controlling environmental factors to maximize infant comfort. Methods include swaddling, quiet and dimly lit rooms, skin-to-skin contact, breastfeeding, and infant positioning Ryan, et al. 2019. Several studies have found that rooming-in, or keeping an infant with the parent instead of a neonatal intensive care unit, is associated with decreased need for NOWS pharmacologic treatment and reduced length of hospital stay Lembeck, et al. 2019; Holmes, et al. 2016; Saiki, et al. 2010; Abrahams, et al. 2007. In the “eating/sleeping/consoling” (ESC) approach, if infants can be consoled in less than 10 minutes, eat an ounce or more of formula or breastfeed well, and sleep for an hour or longer at a time with nonpharmacologic strategies, no medication is indicated for the treatment of NOWS Grossman, et al. 2018.

Mild cases of NOWS (Finnegan Score <8) can often be managed with nonpharmacologic treatment; more severe cases may require adjunctive medication Ryan, et al. 2019. Medication, generally morphine and, less commonly, methadone, is the first-line pharmacologic treatment for NOWS Kocherlakota 2014; Hudak and Tan 2012; Jansson and Velez 2012; Osborn(a), et al. 2010; Osborn(b), et al. 2010.

Buprenorphine is safe for the treatment of NOWS, and sublingual dosing has been demonstrated to be feasible in the neonatal population Kraft, et al. 2008. BUP has been shown to have an efficacy advantage over standard opioid therapy for NOWS in controlled clinical trials and treatment settings Kraft 2018; however, its use is not yet widespread.

There is significant variability in treatment approaches to NOWS, and an optimal protocol has not been established Kraft, et al. 2016; Tolia, et al. 2015; Patrick, et al. 2014; O'Grady, et al. 2009; Sarkar and Donn 2006. Despite significant effort in the medical community to find the most effective medication and dosing regimen for treatment of NOWS, the use of a standardized institutional protocol based on best practices is more effective than a specific medication (morphine or methadone) in reducing the total length of hospital stay and duration of pharmacologic treatment Kraft, et al. 2016. The most effective treatment approaches employ a systematic, multidisciplinary, and multimodal approach.

Note: This section of the guideline addresses alcohol use in general, rather than alcohol use disorder (AUD), because the risk of harm to the fetus is greater with nondependent alcohol use than with nondependent use of other substances. Some aspects of treatment for pregnant individuals with AUD are similar to those for nonpregnant individuals.

The recommendations below focus on differences in treatment during pregnancy; consult the NYSDOH AI guidelines Treatment of Alcohol Use Disorder and Substance Use Harm Reduction in Medical Care for additional recommendations.

Alcohol withdrawal: Pregnancy is considered a relative indication for inpatient management of alcohol withdrawal and may be indicated for any pregnant patient who requires symptom management. For pregnant patients with a score of 10 or higher on the CIWA-Ar scale or at risk for moderate, severe, or complicated alcohol withdrawal, a referral for inpatient withdrawal management is recommended ASAM(a) 2020; VA/DoD 2015. Clinicians should consult with an OB/GYN during withdrawal management ASAM(a) 2020.

Symptoms of alcohol withdrawal syndrome include autonomic hyperactivity (sweating, fast pulse); increased hand tremors; insomnia; nausea; vomiting; transient hallucinations or perceptual disturbances of the auditory, visual, or tactile type; psychomotor agitation; anxiety; and generalized seizures Kattimani and Bharadwaj 2013. Physiologic and psychological stress during pregnancy can adversely affect the pregnant individual and the fetus and result in preterm birth and low birth weight DeVido, et al. 2015; Enlow, et al. 2009; Hobel, et al. 2008.

Benzodiazepines are commonly used in treating alcohol withdrawal in nonpregnant adults, but data on the safety of benzodiazepines during pregnancy are unclear DeVido, et al. 2015. Fetal exposure to benzodiazepines in the first trimester has not been associated with an increased risk of congenital disabilities in limited studies Bellantuono, et al. 2013. The World Health Organization and the American Society of Addiction Medicine recommend short-term, limited use of benzodiazepines in pregnant patients who develop alcohol withdrawal and note that the risk of fetal adverse events has to be balanced with the potential harm of complications of severe alcohol withdrawal ASAM(a) 2020; WHO 2014.

Encourage abstinence or minimal alcohol use: Clinicians should encourage pregnant individuals who use alcohol or have AUD to abstain from or minimize use during pregnancy to decrease the risk of fetal alcohol spectrum disorder (FASD) Reece-Stremtan and Marinelli 2015; WHO 2014. Expert consultation or inpatient management of alcohol withdrawal may be needed with patients who are physically dependent on alcohol (see discussion of alcohol withdrawal, above). During pregnancy, heavy alcohol use may lead to various congenital disabilities and alterations in neonatal growth and development Lees, et al. 2020; Miller 2018. FASD, which is characterized by congenital abnormalities associated with exposure to alcohol in utero, may cause mild or subtle problems, such as a slight learning disability or physical abnormality, or it may cause more severe problems, such as central nervous system dysfunction, low IQ, microcephaly, delayed growth, and facial abnormalities Miller 2018.

There is no known safe amount of alcohol use during pregnancy, and there is clear evidence that binge drinking and heavy drinking during pregnancy are associated with adverse fetal effects Carson, et al. 2017; Flak, et al. 2014; O'Leary and Bower 2012. Because of the linear dose-response of alcohol on the fetus and the potentially serious and irreversible consequences in the fetus and neonate of in utero exposure, abstaining from or minimizing use is recommended Chang 2022; May, et al. 2016.

Behavioral treatment: Clinicians should provide or refer pregnant patients who use alcohol for counseling or other psychosocial treatment. A meta-analysis of alcohol screening and brief intervention studies in pregnant patients found that abstinence during pregnancy was consistently higher in the intervention groups (counseling on alcohol use) than the control groups (odds ratio, 2.26; 95% CI, 1.43 to 3.56; 5 studies [n = 796]) after 6 to 12 months [O’Connor, et al. 2018]. Among trials reporting abstinence before delivery, abstinence ranged from 72% to 90% among intervention participants and 55% to 74% among control participants [O’Connor, et al. 2018].

Referral options may include intensive outpatient substance use treatment, mental health treatment, peer support groups (e.g., 12-step, SMART Recovery), electronic apps (e.g., SMART Recovery, In the Rooms), public health, and other community-based recovery coaching, and other available psychosocial interventions. Cognitive-behavioral therapy, motivational interviewing, and contingency management may also help a pregnant patient minimize substance use WHO 2014. There is wide variability in the efficacy of these interventions, and recommendations and referrals should be tailored to the individual patient’s needs and preferences.

Harm reduction counseling: Pregnant patients who cannot abstain from alcohol use may be able to decrease use or address other treatment goals. Harm reduction approaches during pregnancy have been shown to decrease alcohol use, reduce healthcare costs, improve engagement and retention in prenatal services and substance use treatment, and improve health outcomes for parents and their children Racine, et al. 2009; Poole and Greaves 2007. Clinicians should discuss and encourage harm reduction strategies.

Focusing health messages on abstinence and improving fetal health, although pertinent given the low threshold at which fetal harm can occur, can fail to consider a patient’s social context and address the root causes of alcohol use during pregnancy [O’Leary and Bower 2012]. Studies have shown that trauma, interpersonal violence, and structural inequities may impact alcohol use in pregnancy Varcoe, et al. 2014; Poole and Greaves 2007. Patient counseling recommending abstinence can be presented in a rational, nonjudgmental manner, with the treatment goal being to reduce harm to the pregnant individual and the fetus [O’Leary and Bower 2012].

An abstinence-based approach can also perpetuate the social stigmatization of those who use alcohol and inadvertently discourage engagement in care, which contributes to long-term harm to both parents and children. Individuals who use alcohol during pregnancy may avoid accessing prenatal and other medical and social care for fear of judgment or punitive measures, such as child welfare authorities removing their child Varcoe, et al. 2014; Poole and Greaves 2007.

Pharmacologic treatment: Acamprosate and naltrexone are the preferred agents for pharmacologic treatment of AUD in nonpregnant individuals. However, few data are available from well-controlled studies of acamprosate or naltrexone in pregnant individuals, and the potential carcinogenic, mutagenic, or fertility effects in humans are unknown. In a small study among pregnant individuals treated with naltrexone, outcomes for neonates exposed to naltrexone in utero did not appear to differ from other neonates Hulse, et al. 2004. Gabapentin may be considered, but caution should be taken with its use during the third trimester Patorno, et al. 2020. Treatment with disulfiram is not advised during pregnancy.

If a patient becomes pregnant while taking medication for AUD, continuing treatment during pregnancy requires informed decision-making after weighing the risks to the fetus and the benefits to the pregnant patient Kelty, et al. 2019. With effective pharmacologic treatment, a pregnant patient may be able to reduce or abstain from alcohol use, which may improve maternal health and will minimize fetal exposure to alcohol and the risk of associated harms, such as FASD Reece-Stremtan and Marinelli 2015; WHO 2014.

Breastfeeding: The effects of alcohol use during lactation are complex, and there is conflicting evidence on the effects of infant exposure to alcohol in breast milk May, et al. 2016; Haastrup, et al. 2014. Alcohol is excreted into breast milk in concentrations similar to those in parental blood, which means that the amount of alcohol ingested by an infant through breast milk is a fraction of the amount consumed by the parent. Alcohol can disrupt breastfeeding by decreasing milk production and let down LactMed(a) 2022. However, the effect of occasional alcohol consumption on milk production appears small, temporary, and clinically irrelevant Haastrup, et al. 2014.

The American Society of Addiction Medicine recommends that patients who use alcohol and are breastfeeding wait for 2 hours per drink after drinking Miller 2018. For example, after 2 drinks, the individual should wait for at least 4 hours before breastfeeding. Breast milk can also be pumped and discarded after alcohol consumption. However, there is little clinical evidence to suggest that breastfed children are adversely affected by occasional alcohol use Haastrup, et al. 2014. Over-the-counter test strips are available to measure alcohol in breastmilk, but there are no clinical studies currently available on the use of the test strips.

Breastfeeding while taking acamprosate is not recommended. It is unknown if breastfed infants are exposed to acamprosate through breast milk FDA 2004. Naltrexone use is not contraindicated during breastfeeding; limited data indicate that naltrexone is minimally excreted into breast milk LactMed(a) 2021.

Clinicians should advise pregnant patients who use tobacco to abstain from or minimize use during pregnancy. Tobacco and nicotine use during pregnancy has been linked to low birth weight, preterm birth, placental abruption, miscarriage, stillbirth, sudden infant death syndrome, poor fetal neurodevelopment, and a variety of congenital disabilities Akerman, et al. 2015; Cressman, et al. 2012; Forinash, et al. 2010.

Nicotine replacement therapy: Clinicians should provide information about available pharmacologic treatment and offer NRT (patch, gum, lozenge, nasal spray, or inhaler), bupropion, or a combination of these medications. The choice is guided by patient preference. Of note, due to sex-based differences in the cytochrome P450 system and the number of beta-2 nicotinic acetylcholine receptors and hormonal and mood modulation effects of nicotine, NRT may be less effective in women than men Terplan, et al. 2020. Data regarding the efficacy of NRT is limited Terplan, et al. 2020. To potentially minimize NRT exposure to the fetus and a breastfeeding infant, patients may choose to take an immediate-release form of NRT, such as gum or an inhaler, instead of a slow-release form, such as the patch Dempsey, et al. 2002. The patch releases medication continuously, but the user controls dosing with lozenges, chewing gum, and inhalers. If the patient is wearing a nicotine patch, removing it at night may minimize fetal exposure to nicotine.

NRT medications are taken according to instructions for nonpregnant patients (see agent prescribing information). However, it is important to inform patients that the rate of nicotine metabolism increases in pregnant individuals, which could impair the effectiveness of NRT Dempsey, et al. 2002. A dose increase in NRT may be warranted.

There are conflicting data on NRT use during pregnancy, with limited evidence of efficacy in smoking cessation or reduction but mixed evidence regarding harm Claire, et al. 2020; Terplan, et al. 2020; Coleman, et al. 2012. In a systematic review and meta-analysis, NRT was associated with a 40% increase in smoking cessation rate measured in late pregnancy Coleman, et al. 2012. However, evidence suggests that if potentially biased, non-placebo-controlled, randomized trials are excluded from the meta-analysis, NRT was no more effective than placebo Claire, et al. 2020. Furthermore, there is little evidence that NRT during pregnancy has positive or negative effects on birth outcomes. One study that followed infants after birth found an association between maternal NRT and healthy developmental outcomes Cooper, et al. 2014.

Bupropion and varenicline: Bupropion, an antidepressant with dopaminergic and noradrenergic activity, can be prescribed concurrently with NRT for pregnant individuals Cressman, et al. 2012. In a pooled analysis from 2 bupropion studies, there was no clear effect on smoking cessation during later pregnancy (relative risk, 0.74), but the lack of effect may have been due to small sample sizes Claire, et al. 2020. There are limited and conflicting data on the fetal effects due to bupropion use. The estimated prevalence rate of congenital heart defects among infants with in utero exposure to bupropion is higher than in the general population but remains relatively low (2.1/1000 births) Byatt, et al. 2013; Alwan, et al. 2010; Reller, et al. 2008; Chun-Fai-Chan, et al. 2005.

There is insufficient evidence to support a recommendation for varenicline, a partial agonist of α4β2 nicotinic receptors, during pregnancy and postpartum. In a population-based cohort study among individuals in the first trimester of pregnancy, researchers found a significant reduction in the risk of any adverse perinatal event and no increased risk of major congenital anomalies in infants exposed to varenicline compared with those exposed to NRT Tran, et al. 2020.

Breastfeeding: Animal data suggest that exposure to nicotine may interfere with lung development or may be associated with sudden infant death syndrome, but the risks are not well established for exposure to nicotine in human infants. As a result, some experts recommend that while a patient is breastfeeding, an alternative to NRT may be preferred for tobacco cessation treatment LactMed 2020. One option is bupropion. At doses of up to 300 mg daily, this medication produces low levels in breastmilk that are not expected to cause adverse effects in infants. Though data in breastfed infants are scant, bupropion treatment in a nursing parent is not a contraindication to breastfeeding LactMed(c) 2022.

The National Institutes of Health LactMed database notes that no information is available on the use of varenicline during breastfeeding, and an alternate medication is preferred, especially while nursing a newborn or preterm infant LactMed(b) 2021. If an individual chooses to breastfeed while taking varenicline, the infant should be monitored for seizures and excessive vomiting LactMed(b) 2021; McAllister-Williams, et al. 2017.

For pregnant patients who use tobacco, clinicians should perform or refer for counseling or other psychosocial and behavioral treatment. A 2017 meta-analysis found a 17% reduction in low birth weight, a significantly higher mean birth weight and a 22% reduction in neonatal intensive care admissions among infants born to individuals who participated in psychosocial interventions for tobacco use Chamberlain, et al. 2017. Counseling, feedback, and incentive-based programs were reported to increase the proportion of individuals who stopped smoking in late pregnancy Chamberlain, et al. 2017.

It is important to discuss all available resources for supporting tobacco cessation with patients, including electronic resources. Providing continual support and addressing psychosocial stressors in the postpartum period are needed to ensure continued cessation success ACOG 2020.

Few data are available on the risks of active cannabis use while breastfeeding, and no clear guidance is available on the length of time to wait after cannabis use before breastfeeding; when counseling patients, it is important to discuss potential risks and benefits, reasons for cannabis use, and possible alternatives to use LactMed(d) 2022; Metz and Borgelt 2018; ACOG(b) 2017. Breastfeeding is not advised for individuals actively using cocaine or methamphetamine.

There are no U.S. Food and Drug Administration (FDA)-approved medications to treat stimulant use disorders (e.g., cocaine, amphetamine, and methamphetamine). A recent clinical trial found a potential benefit associated with bupropion and naltrexone in treating methamphetamine use disorder Trivedi, et al. 2021. No pregnant patients were included in the study.

Referral options include inpatient withdrawal management, an intensive outpatient substance use disorder (SUD) treatment program, treatment for a mental health condition and SUD (for patients with dual diagnosis), support groups (e.g., 12-step, SMART Recovery), apps (e.g., SMART Recovery, In the Rooms), public health nursing, community-based care management, peer support, recovery coaching, and any other psychosocial supports. Behavioral interventions, such as cognitive-behavioral therapy, motivational interviewing, and contingency management, may also play a role in assisting a pregnant patient to minimize substance use WHO 2014.

Date of current publication: August 8, 2023
Lead authors: Jessica Rodrigues, MS; Jessica M. Atrio, MD, MSc; and Johanna L. Gribble, MA
Writing group: Steven M. Fine, MD, PhD; Rona M. Vail, MD; Samuel T. Merrick, MD; Asa E. Radix, MD, MPH, PhD; Christopher J. Hoffmann, MD, MPH; Charles J. Gonzalez, MD
Committee: Medical Care Criteria Committee
Date of original publication: August 8, 2023

Throughout its guidelines, the New York State Department of Health (NYSDOH) AIDS Institute (AI) Clinical Guidelines Program recommends “shared decision-making,” an individualized process central to patient-centered care. With shared decision-making, clinicians and patients engage in meaningful dialogue to arrive at an informed, collaborative decision about a patient’s health, care, and treatment planning. The approach to shared decision-making described here applies to recommendations included in all program guidelines. The included elements are drawn from a comprehensive review of multiple sources and similar  attempts to define shared decision-making, including the Institute of Medicine’s original description [Institute of Medicine 2001]. For more information, a variety of informative resources and suggested readings are included at the end of the discussion.

The benefits to patients that have been associated with a shared decision-making approach include:

• Decreased anxiety [Niburski, et al. 2020; Stalnikowicz and Brezis 2020]
• Increased trust in clinicians [Acree, et al. 2020; Groot, et al. 2020; Stalnikowicz and Brezis 2020]
• Improved engagement in preventive care [McNulty, et al. 2022; Scalia, et al. 2022; Bertakis and Azari 2011]
• Improved treatment adherence, clinical outcomes, and satisfaction with care [Crawford, et al. 2021; Bertakis and Azari 2011; Robinson, et al. 2008]
• Increased knowledge, confidence, empowerment, and self-efficacy [Chen, et al. 2021; Coronado-Vázquez, et al. 2020; Niburski, et al. 2020]

Collaborative care: Shared decision-making is an approach to healthcare delivery that respects a patient’s autonomy in responding to a clinician’s recommendations and facilitates dynamic, personalized, and collaborative care. Through this process, a clinician engages a patient in an open and respectful dialogue to elicit the patient’s knowledge, experience, healthcare goals, daily routine, lifestyle, support system, cultural and personal identity, and attitudes toward behavior, treatment, and risk. With this information and the clinician’s clinical expertise, the patient and clinician can collaborate to identify, evaluate, and choose from among available healthcare options [Coulter and Collins 2011]. This process emphasizes the importance of a patient’s values, preferences, needs, social context, and lived experience in evaluating the known benefits, risks, and limitations of a clinician’s recommendations for screening, prevention, treatment, and follow-up. As a result, shared decision-making also respects a patient’s autonomy, agency, and capacity in defining and managing their healthcare goals. Building a clinician-patient relationship rooted in shared decision-making can help clinicians engage in productive discussions with patients whose decisions may not align with optimal health outcomes. Fostering open and honest dialogue to understand a patient’s motivations while suspending judgment to reduce harm and explore alternatives is particularly vital when a patient chooses to engage in practices that may exacerbate or complicate health conditions [Halperin, et al. 2007].

Options: Implicit in the shared decision-making process is the recognition that the “right” healthcare decisions are those made by informed patients and clinicians working toward patient-centered and defined healthcare goals. When multiple options are available, shared decision-making encourages thoughtful discussion of the potential benefits and potential harms of all options, which may include doing nothing or waiting. This approach also acknowledges that efficacy may not be the most important factor in a patient’s preferences and choices [Sewell, et al. 2021].

Clinician awareness: The collaborative process of shared decision-making is enhanced by a clinician’s ability to demonstrate empathic interest in the patient, avoid stigmatizing language, employ cultural humility, recognize systemic barriers to equitable outcomes, and practice strategies of self-awareness and mitigation against implicit personal biases [Parish, et al. 2019].

Caveats: It is important for clinicians to recognize and be sensitive to the inherent power and influence they maintain throughout their interactions with patients. A clinician’s identity and community affiliations may influence their ability to navigate the shared decision-making process and develop a therapeutic alliance with the patient and may affect the treatment plan [KFF 2023; Greenwood, et al. 2020]. Furthermore, institutional policy and regional legislation, such as requirements for parental consent for gender-affirming care for transgender people or insurance coverage for sexual health care, may infringe upon a patient’s ability to access preventive- or treatment-related care [Sewell, et al. 2021].

Health equity: Adapting a shared decision-making approach that supports diverse populations is necessary to achieve more equitable and inclusive health outcomes [Castaneda-Guarderas, et al. 2016]. For instance, clinicians may need to incorporate cultural- and community-specific considerations into discussions with women, gender-diverse individuals, and young people concerning their sexual behaviors, fertility intentions, and pregnancy or lactation status. Shared decision-making offers an opportunity to build trust among marginalized and disenfranchised communities by validating their symptoms, values, and lived experience. Furthermore, it can allow for improved consistency in patient screening and assessment of prevention options and treatment plans, which can reduce the influence of social constructs and implicit bias [Castaneda-Guarderas, et al. 2016].

Clinician bias has been associated with health disparities and can have profoundly negative effects [FitzGerald and Hurst 2017; Hall, et al. 2015]. It is often challenging for clinicians to recognize and set aside personal biases and to address biases with peers and colleagues. Consciously or unconsciously, negative or stigmatizing assumptions are often made about patient characteristics, such as race, ethnicity, gender, sexual orientation, mental health, and substance use [Avery, et al. 2019; van Boekel, et al. 2013; Livingston, et al. 2012]. With its emphasis on eliciting patient information, a shared decision-making approach encourages clinicians to inquire about patients’ lived experiences rather than making assumptions and to recognize the influence of that experience in healthcare decision-making.

Stigma: Stigma may prevent individuals from seeking or receiving treatment and harm reduction services [Tsai, et al. 2019]. Among people with HIV, stigma and medical mistrust remain significant barriers to healthcare utilization, HIV diagnosis, and medication adherence and can affect disease outcomes [Turan, et al. 2017; Chambers, et al. 2015], and stigma among clinicians against people who use substances has been well-documented [Stone, et al. 2021; Tsai, et al. 2019; van Boekel, et al. 2013]. Sexual and reproductive health, including strategies to prevent HIV transmission, acquisition, and progression, may be subject to stigma, bias, social influence, and violence.

In addition to the references cited below, the following resources and suggested reading may be useful to clinicians.

References

Acree ME, McNulty M, Blocker O, et al. Shared decision-making around anal cancer screening among black bisexual and gay men in the USA. Cult Health Sex 2020;22(2):201-16. [PMID: 30931831]

Avery JD, Taylor KE, Kast KA, et al. Attitudes toward individuals with mental illness and substance use disorders among resident physicians. Prim Care Companion CNS Disord 2019;21(1):18m02382. [PMID: 30620451]

Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J Am Board Fam Med 2011;24(3):229-39. [PMID: 21551394]

Castaneda-Guarderas A, Glassberg J, Grudzen CR, et al. Shared decision making with vulnerable populations in the emergency department. Acad Emerg Med 2016;23(12):1410-16. [PMID: 27860022]

Chambers LA, Rueda S, Baker DN, et al. Stigma, HIV and health: a qualitative synthesis. BMC Public Health 2015;15:848. [PMID: 26334626]

Chen CH, Kang YN, Chiu PY, et al. Effectiveness of shared decision-making intervention in patients with lumbar degenerative diseases: a randomized controlled trial. Patient Educ Couns 2021;104(10):2498-2504. [PMID: 33741234]

Coronado-Vázquez V, Canet-Fajas C, Delgado-Marroquín MT, et al. Interventions to facilitate shared decision-making using decision aids with patients in primary health care: a systematic review. Medicine (Baltimore) 2020;99(32):e21389. [PMID: 32769870]

Coulter A, Collins A. Making shared decision-making a reality: no decision about me, without me. 2011. https://www.kingsfund.org.uk/sites/default/files/Making-shared-decision-making-a-reality-paper-Angela-Coulter-Alf-Collins-July-2011_0.pdf

Crawford J, Petrie K, Harvey SB. Shared decision-making and the implementation of treatment recommendations for depression. Patient Educ Couns 2021;104(8):2119-21. [PMID: 33563500]

FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics 2017;18(1):19. [PMID: 28249596]

Greenwood BN, Hardeman RR, Huang L, et al. Physician-patient racial concordance and disparities in birthing mortality for newborns. Proc Natl Acad Sci U S A 2020;117(35):21194-21200. [PMID: 32817561]

Groot G, Waldron T, Barreno L, et al. Trust and world view in shared decision making with indigenous patients: a realist synthesis. J Eval Clin Pract 2020;26(2):503-14. [PMID: 31750600]

Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health 2015;105(12):e60-76. [PMID: 26469668]

Halperin B, Melnychuk R, Downie J, et al. When is it permissible to dismiss a family who refuses vaccines? Legal, ethical and public health perspectives. Paediatr Child Health 2007;12(10):843-45. [PMID: 19043497]

Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. 2001. https://www.ncbi.nlm.nih.gov/books/NBK222274/

KFF. Key data on health and health care by race and ethnicity. 2023 Mar 15. https://www.kff.org/racial-equity-and-health-policy/report/key-data-on-health-and-health-care-by-race-and-ethnicity/ [accessed 2023 May 19]

Livingston JD, Milne T, Fang ML, et al. The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review. Addiction 2012;107(1):39-50. [PMID: 21815959]

McNulty MC, Acree ME, Kerman J, et al. Shared decision making for HIV pre-exposure prophylaxis (PrEP) with black transgender women. Cult Health Sex 2022;24(8):1033-46. [PMID: 33983866]

Niburski K, Guadagno E, Abbasgholizadeh-Rahimi S, et al. Shared decision making in surgery: a meta-analysis of existing literature. Patient 2020;13(6):667-81. [PMID: 32880820]

Parish SJ, Hahn SR, Goldstein SW, et al. The International Society for the Study of Women’s Sexual Health process of care for the identification of sexual concerns and problems in women. Mayo Clin Proc 2019;94(5):842-56. [PMID: 30954288]

Robinson JH, Callister LC, Berry JA, et al. Patient-centered care and adherence: definitions and applications to improve outcomes. J Am Acad Nurse Pract 2008;20(12):600-607. [PMID: 19120591]

Scalia P, Durand MA, Elwyn G. Shared decision-making interventions: an overview and a meta-analysis of their impact on vaccine uptake. J Intern Med 2022;291(4):408-25. [PMID: 34700363]

Sewell WC, Solleveld P, Seidman D, et al. Patient-led decision-making for HIV preexposure prophylaxis. Curr HIV/AIDS Rep 2021;18(1):48-56. [PMID: 33417201]

Stalnikowicz R, Brezis M. Meaningful shared decision-making: complex process demanding cognitive and emotional skills. J Eval Clin Pract 2020;26(2):431-38. [PMID: 31989727]

Stone EM, Kennedy-Hendricks A, Barry CL, et al. The role of stigma in U.S. primary care physicians’ treatment of opioid use disorder. Drug Alcohol Depend 2021;221:108627. [PMID: 33621805]

Tsai AC, Kiang MV, Barnett ML, et al. Stigma as a fundamental hindrance to the United States opioid overdose crisis response. PLoS Med 2019;16(11):e1002969. [PMID: 31770387]

Turan B, Budhwani H, Fazeli PL, et al. How does stigma affect people living with HIV? The mediating roles of internalized and anticipated HIV stigma in the effects of perceived community stigma on health and psychosocial outcomes. AIDS Behav 2017;21(1):283-91. [PMID: 27272742]

van Boekel LC, Brouwers EP, van Weeghel J, et al. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug Alcohol Depend 2013;131(1-2):23-35. [PMID: 23490450]