IOM, 1990a). There is a dearth of studies on programs that deliver services tailored to women's needs.

Problems continue to be greatest for pregnant women. In the past, many treatment programs automatically excluded pregnant women because of liability concerns or concerns about lack of expertise with medical complications of pregnancy. Some areas of the country have enacted laws that classify drug abuse during pregnancy as a form of child abuse, which would lead to the placement of children in foster care. These laws do not seem to reduce drug abuse, but they may have the negative effect of discouraging pregnant drug users from seeking treatment (see Chapter 10). Exclusion of pregnant women from treatment programs is beginning to diminish, however. A recent survey of 294 drug treatment programs in five cities revealed that the majority of programs (70-83 percent) accepted pregnant women. Fewer programs, however, accepted women who were Medicaid recipients, and even fewer programs provided child care (Breitbart et al., 1994).

When pregnant women succeed in gaining access to treatment, they face yet another hurdle—the lack of pharmacotherapies specifically approved for use in pregnancy (IOM, 1995b). This problem is true for medications of all kinds, not just for those used in drug abuse treatment. Pharmaceutical firms rarely, if ever, seek Food and Drug Administration (FDA) approval for use of their products in pregnancy, mostly because of liability concerns. When pregnant heroin drug users, for example, need treatment to reduce drug use and the risk of HIV transmission to themselves and their unborn, their doctors are strongly discouraged by federal treatment regulations and by the manufacturer from prescribing LAAM. According to federal treatment regulations, pregnant women are offered methadone, which is not formally approved by the FDA for use in pregnancy. FDA has drafted guidelines recommending that future studies of antiaddiction medications include women, but the guidelines do not provide advice for a mechanism dealing with increased risk for product liability (Woody et al., 1996).

Treatment programs have recently become more prominent in some correctional settings, with therapeutic communities among the most common modalities. The therapeutic community provides a total treatment environment isolated from the rest of the prison population—separated from the drugs, the violence, and the norms and values that mitigate against treatment, habilitation, and rehabilitation. Treatment programs based in correctional settings sometimes include aftercare in the community after release from prison. Although therapeutic communities appear