Prenatal Drug Use and Newborn Health:
Federal Efforts Need Better Planning and Coordination
GAO-15-203: Published: Feb 10, 2015. Publicly Released: Feb 10, 2015.
What GAO Found
Federally funded research mostly focused on neonatal abstinence syndrome (NAS), and federal programs and other agency efforts made services available or conducted activities to address prenatal opioid use or NAS. From fiscal years 2008 through 2014, federal agencies obligated almost $21.6 million for 18 research projects related to prenatal opioid use or NAS, most of which focused on preventing, understanding, or treating NAS. Fourteen federal programs on substance abuse, health, and welfare—12 of which were administered by agencies within the Department of Health and Human Services (HHS)—made direct services available (such as screening and referral for treatment) or conducted other activities (such as training or technical assistance) to address prenatal opioid or NAS in fiscal years 2013 or 2014 as part of broader objectives. Outside of research and programs, 11 federal agencies made direct services available through their health systems or engaged in other efforts during fiscal years 2008 through 2014.
The gaps in efforts to address prenatal opioid use and NAS most commonly cited by federal agency officials and experts were related to the treatment of prenatal opioid use and NAS. With regard to research, the most commonly cited gaps were inadequate research on treatment of prenatal opioid use and the long-term effects of prenatal opioid exposure on children. Reasons cited for these research gaps included difficulties in conducting research, such as identifying and retaining pregnant women with substance use disorders for studies, and prenatal opioid use and NAS not being as high a priority as other research areas. With regards to programs, agency officials and experts most commonly cited the lack of available treatment programs for pregnant women and newborns with NAS, including the availability of comprehensive care and enabling services, such as transportation and child care. Reasons cited for these program gaps included the stigmatization and criminalization of pregnant women who use drugs. In addition to research and program gaps, other gaps cited by agency officials and experts included a lack of guidance on criminalization policies for states, screening and treatment practices, and opioid prescribing.
The Office of National Drug Control Policy (ONDCP)—the agency responsible for coordinating drug control efforts across federal agencies—plans and coordinates with other agencies by sharing information and developing national action items to address prenatal opioid use and NAS. However, ONDCP does not document its process for developing action items, including the information considered or discussions with agency officials. Within HHS—which has nine agencies that address prenatal opioid use or NAS—the department relies on its agencies to plan and coordinate individual efforts, and also has established a council that identifies activities that may influence, but are not targeted specifically at, prenatal opioid use and NAS. However, HHS lacks a focal point to lead planning and coordination of efforts related specifically to prenatal opioid use or NAS across the department. These limitations in planning and coordination by ONDCP and HHS may limit the effectiveness of federal efforts to reduce prenatal opioid use among pregnant women and rates of NAS. Additionally, there is a risk that federal efforts may be duplicated, overlapping, or fragmented.
Why GAO Did This Study
The prenatal use of opioids, including heroin and opioids prescribed for pain management, can produce a withdrawal condition in newborns known as NAS. A recent study found that cases of NAS have tripled over the last decade and that treatment costs for newborns with NAS—most of which are paid by Medicaid—are more than five times the cost of treating other newborns at birth.
GAO was asked to provide information on how federal agencies have addressed prenatal opioid use and NAS. In this report, GAO examines (1) federally funded research, federal programs, and other federal agency efforts related to prenatal opioid use or NAS; (2) gaps identified by federal agency officials and experts in efforts to address prenatal opioid use or NAS; and (3) how federal efforts to address prenatal opioid use or NAS are planned and coordinated. GAO analyzed information from federal agencies, including documents and data, on research, programs, and other agency efforts; interviewed federal agency officials and experts about gaps; and interviewed federal agency officials about planning and coordination of federal efforts.
What GAO Recommends
GAO recommends that ONDCP document the process for developing action items on prenatal opioid use and NAS and that HHS designate a focal point to lead departmental planning and coordination on these issues. ONDCP and HHS concurred with GAO's recommendations and provided technical comments that GAO incorporated as appropriate.
For more information, contact Vijay A. D'Souza at (202) 512-7114 or firstname.lastname@example.org.
Recommendations for Executive Action
Comments: In July 2018, ONDCP officials provided agendas for interagency meetings with other federal agencies which show that action items related to neonatal abstinence syndrome were discussed in 2014 and 2015. However, ONDCP officials did not provide us any formal documentation, such as meeting minutes, showing the process used or what gaps were considered in developing or implementing the action items. ONDCP officials told us the action items related to prenatal opioid use and NAS for the 2015 Strategy were completed in 2016 and 2017. No action items related to prenatal opioid use and NAS were included in the 2016 Strategy. ONDCP did not issue a 2017 Strategy and had not issued a 2018 Strategy as of August 2018. We will keep this recommendation open as ONDCP officials said that addressing prenatal opioid use and neonatal abstinence syndrome will continue to be an important policy consideration as the administration develops its next National Drug Control Strategy.
Recommendation: In order to ensure that efforts to address prenatal opioid use and NAS are systematically and effectively planned and coordinated across the federal government, the Director of ONDCP should document the process, including discussions held and information considered, of developing action items on prenatal opioid use and NAS. This may include documenting gaps that were considered in developing action items.
Agency Affected: Executive Office of the President: Office of National Drug Control Policy
Status: Closed - Implemented
Comments: In February 2015, we recommended that the Secretary of the Department of Health and Human Services (HHS) designate a focal point to lead department planning and coordination related to prenatal opioid use and neonatal abstinence syndrome (NAS). In April 2015, HHS informed us that HHS's Behavioral Health Coordinating Council tasked its Prescription Drug Abuse subcommittee, led by the Food and Drug Administration and the National Institute of Drug Abuse within the National Institutes of Health to be the focal point on these issues. The Prescription Drug Abuse subcommittee will also collaborate on these issues with other federal partners such as the Office of National Drug Control Policy, the Department of Justice, and the Department of Veterans Affairs, as appropriate. In May 2015, the Prescription Drug Abuse subcommittee also created a formal NAS workgroup co-led by the Substance Abuse and Mental Health Services Administration and the Indian Health Service.
Recommendation: In order to ensure that efforts to address prenatal opioid use and NAS are systematically and effectively planned and coordinated across HHS's agencies, the Secretary of HHS should designate a focal point, such as the Behavioral Health Coordinating Council or another entity, to lead departmental planning and coordination related to prenatal opioid use and NAS, including consideration of gaps in research, programs, and other efforts.
Agency Affected: Department of Health and Human Services