To the Editor— A particularly challenging aspect of the opi­oid use disorder (OUD) epidemic is its impact on pregnant persons: 11.4% of the 11,782 pregnancy-associated deaths in the United States between 2010 and 2019 were related to substance use .1

In “Pregnant Mothers With Substance Use Problems and Their Treatment in North Carolina,” Mannelli and colleagues highlight the strategic efforts of North Carolina providers to address the serious public health challenge of OUD in preg­nant persons by amending the diagnosis-referral-treatment pathways.2 Interventions include embedding validated screening questions in electronic health records, increas­ing access to medications for OUD, and increasing access to behavioral counseling.2 These admirable interventions have potential for broader public health impact through part­nerships with sexual health clinics and those that care for pregnant people to address the congenital syphilis (CS) cri­sis. This syndemic approach would address syphilis, CS, and OUD by acknowledging the common drivers.

Nationally, we have observed alarming rates of CS.3 Substance use is linked to trends in female syphilis and sub­sequently CS. In North Carolina between 2012 and 2022, syphilis cases among women have increased by 547%, con­current with a rise in CS infections by 5600%.4 In 2022, over half (53%) of women who delivered a newborn with CS did not have documented prenatal care.4 Unpublished data from the North Carolina Department of Health and Human Services indicate that in 2021, pregnant people with syphilis reported exposures to alcohol, marijuana, cocaine, methamphetamine, narcotics/opioids, and heroin (in order of frequency), highlighting potential opportunities for inter­vention. Recent data from Arizona and Georgia reviewing CS pregnancy outcomes from 2018 to 2021 found that nearly half of persons with CS pregnancy outcomes had substance use exposure including tobacco, alcohol, cannabis, illicit opioids, or other nonprescription substances.5 In this study, per­sons with CS pregnancy outcomes were more likely to report illicit use of opioids and use of other “illicit, nonprescription substances” during pregnancy.5 The authors acknowledge the importance of social determinants of health (e.g., incar­ceration and housing insecurity) associated with a CS preg­nancy and concurrent OUD and the need to engage these vulnerable populations.5

As lack of prenatal care is one of the key factors of this public health concern, it is imperative to find new ways to increase health care access for all persons of reproductive age. Achieving health equity is a feat requiring multisector, multidisciplinary, community-based approaches to address­ing complex challenges, including increasing access to trans­portation, housing, employment, education, medication, and key staff (e.g., social workers and community care coordi­nators). Providers should be familiar with OUD resources in the community and consider more of a “no wrong door” approach to syphilis screening, prenatal care, and OUD treat­ment and referral.

Finally, exposure to the intersecting public health chal­lenges of OUD in pregnant persons, CS, and the associ­ated diagnosis-referral-treatment pathway should begin earlier, with education starting as early as medical school training.


This letter was initially published with several numerical errors and a missing citation that have been corrected. For more details, see Erratum to “Syndemic Approaches Are Needed to Address Maternal Substance Use and Syphilis in North Carolina.”