Medication-Assisted Treatment Use Among Pregnant Women With Opioid Use Disorder

The MATernaL and Infant NetworK to Understand Outcomes Associated with Treatment of Opioid Use Disorder During Pregnancy (MAT-LINK): Surveillance Opportunity

Pregnant women with opioid use disorder (OUD) are at risk of overdose, infectious diseases, and inadequate prenatal care. Additional risks include adverse pregnancy and infant outcomes, such as preterm birth and neonatal abstinence syndrome. Management and treatment of OUD during pregnancy are associated with improved maternal and infant outcomes. Professional organizations, including the American College of Obstetricians and Gynecologists, recommend offering opioid agonist pharmacotherapy (i.e., methadone or buprenorphine) combined with behavioral therapy as standard treatment for pregnant women with OUD. Other medications and herbal supplements have also been used by pregnant women for OUD. Determining which OUD treatments optimize maternal and infant outcomes is challenging given the host of potential factors that affect these outcomes. The Centers for Disease Control and Prevention initiated the MATernaL and Infant NetworK to Understand Outcomes Associated with Treatment of Opioid Use Disorder during Pregnancy (MAT-LINK) to monitor more than 2000 mothers and their infants, using data collected from geographically diverse clinical sites. Information learned from MAT-LINK will inform the future management and treatment of pregnant women with OUD.

Substance use disorders and risk of severe maternal morbidity in the United States

BACKGROUND

The contribution of substance use disorders to the burden of severe maternal morbidity in the United States is poorly understood. The objective was to estimate the independent association between substance use disorders during pregnancy and risk of severe maternal morbidity.

METHODS

Retrospective analysis of a weighted 53.4 million delivery hospitalizations from 2003 to 2016 among females aged>18 in the National Inpatient Sample. We constructed measures of substance use disorders using diagnostic codes for cannabis, opioids, and stimulants (amphetamines or cocaine) abuse or dependence during pregnancy. The outcome was the presence of any of the 21 CDC indicators of severe maternal morbidity. Using weighted multivariable logistic regression, we estimated the association between substance use disorders and adjusted risk of severe maternal morbidity. Because older age at delivery is predictive of severe maternal morbidity, we tested for effect modification between substance use and maternal age by age group (18-34 y vs >34 y).

RESULTS

Pregnant women with an opioid use disorder had an increased risk of severe maternal morbidity compared with women without an opioid use disorder (18-34 years: aOR: 1.51; 95 % CI: 1.41,1.61, >34 years: aOR: 1.17; 95 % CI: 1.00,1.38). Compared with their counterparts without stimulant use disorders, pregnant women with a simulant use disorder (amphetamines, cocaine) had an increased risk of severe maternal morbidity (18-34 years: aOR: 1.92; 95 % CI: 1.80,2.0, >34 years: aOR: 1.85; 95 % CI: 1.66,2.06). Cannabis use disorders were not associated with an increased risk of severe maternal morbidity.

CONCLUSION

Substance use disorders during pregnancy, particularly opioids, amphetamines, and cocaine use disorders, may contribute to severe maternal morbidity in the United States.

Barriers to accessing opioid agonist therapy in pregnancy

BACKGROUND

The incidence of opioid use disorder during pregnancy has risen dramatically in the last couple of decades. Despite the safety and efficacy of treatment for opioid use during pregnancy, pregnant women often cannot access treatment.

OBJECTIVE

This study aimed to determine the availability of opioid agonist therapy to pregnant women in Missouri and Illinois and to compare different markers of treatment accessibility between opioid treatment programs and buprenorphine providers and between rural and urban practices.

STUDY DESIGN

Buprenorphine providers and opioid treatment programs in Missouri and Illinois were identified using the Substance Abuse and Mental Health Services Administration website. A phone audit was conducted to evaluate barriers to care, including whether clinics accepted new patients, pregnant patients, and insurance, and the time to the first appointment and appointment cost. Rural-urban commuting area codes and practice ZIP codes were used to determine whether practice location was rural or urban. Provider specialty was determined from state licensing databases.

RESULTS

There were 1363 buprenorphine providers and 98 opioid treatment programs listed. Clinics were clustered around metropolitan areas, and only 13% of buprenorphine providers (183 of 1363) and 5% of opioid treatment programs (5 of 98) were in rural areas. Despite 3 contact attempts for each clinic, we were unable to reach 42% of buprenorphine providers (401 of 965) and 14% of opioid treatment programs (14 of 98). Of those reached, 40% of buprenorphine providers (223 of 564) and 80% of opioid treatment programs (67 of 84) were accepting new pregnant patients (P=.01). Buprenorphine providers required more contact attempts (>2 attempts in 34% vs 15%; P<.0001) and had longer wait times for the first appointment (>7 days in 27% vs 4%; P=.002) than opioid treatment programs. Buprenorphine providers in urban areas required more attempts to reach (>2 attempts in 36% vs 24%; P=.03) and were less likely to accept Medicaid than those in rural areas (52% vs 74%; P=.008). More than 23% of buprenorphine provider listings (238 of 1038) contained incorrect information, whereas no opioid treatment program listing had incorrect information. Most buprenorphine providers were in primary care or psychiatry, whereas <5% of buprenorphine providers (43 of 1363) were obstetrician-gynecologists.

CONCLUSION

This is the first phone audit to evaluate access to opioid agonist therapy for pregnant women. Only a minority of buprenorphine providers offered care for this patient population, and a large proportion required multiple contact attempts and wait times of >7 days. Opioid treatment programs were more responsive and accepting of new pregnant patients but comprised a minority of clinics and were predominately located in urban areas. There is an urgent need for improved reliability of contact information for opioid agonist providers, timely intake and acceptance for treatment of pregnant patients, and overall improved access to clinics that are challenged by geographic and insurance status barriers.

Buprenorphine dosing for the treatment of opioid use disorder through pregnancy and postpartum

PURPOSE OF REVIEW

Opioid-related deaths are a leading cause of mortality during pregnancy through 12 months postpartum. Buprenorphine use during pregnancy is increasing, yet expert opinion on its dosing through the perinatal period is limited. We provide a review of the current clinical literature on buprenorphine dosing during pregnancy through 12 months postpartum. and present data from a retrospective chart review of patients at our institution describing trends in buprenorphine dosing during pregnancy and postpartum. Utilizing this information, we synthesize findings to provide clinical recommendations for providers.

RECENT FINDINGS

Existing literature during pregnancy reflects how many women increase and split total daily buprenorphine doses as gestational age advances.

SUMMARY

We present data from a retrospective chart review of patients at our institution describing trends in buprenorphine dosing during pregnancy and postpartum. Utilizing this information, we synthesize findings to provide clinical recommendations for providers. Changes in the total daily dose of buprenorphine used across pregnancy and through 12 months postpartum at the individual level do not follow consistent patterns, highlighting substantial individual variability. Altogether, buprenorphine dosing should be individualized through pregnancy and postpartum with frequent evaluations by providers and solicited input from patients.

Polysubstance Use Among Pregnant Women With Opioid Use Disorder in the United States, 2007-2016

OBJECTIVE

To assess trends in polysubstance use among pregnant women with opioid use disorder in the United States.

METHODS

We conducted a time trend analysis of pooled, cross-sectional data from the National Inpatient Sample, an annual nationally representative sample of U.S. hospital discharge data. Among 38.0 million females aged 15-44 years with a hospitalization for delivery from 2007 to 2016, we identified 172,335 pregnant women with an International Classification of Diseases, Ninth Revision, Clinical Modification or International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis of opioid use disorder. Polysubstance use among pregnant women with opioid use disorder was defined as at least one co-occurring diagnosis of other substance use, including alcohol, amphetamine, cannabis, cocaine, sedative, or tobacco. We fit weighted multivariable logistic regression models to produce nationally representative estimates, including an interaction between year and rural compared with urban county of residence; controlled for age, race, and insurance type. Average predicted probabilities and 95% CIs were derived from regression results.

RESULTS

Polysubstance use among women with opioid use disorder increased from 60.5% (95% CI 58.3-62.8%) to 64.1% (95% CI 62.8%-65.3%). Differential time trends in polysubstance use among women with opioid use disorder were found in rural compared with urban counties. Large increases in amphetamine use occurred among those in both rural and urban counties (255.4%; 95% CI 90.5-562.9% and 150.7%; 95% CI 78.2-52.7%, respectively), similarly to tobacco use (30.4%; 95% CI 16.9-45.4% and 23.2%; 95% CI 15.3-31.6%, respectively). Cocaine use diagnoses declined among women with opioid use disorder at delivery in rural (-70.5%; 95% CI -80.4% to -55.5%) and urban (-61.9%; 95% CI -67.6% to -55.1%) counties. Alcohol use diagnoses among those with opioid use disorder declined -57% (95% CI -70.8% to -37.7%) in urban counties but did not change among those in rural counties.

CONCLUSION

Over the past decade, polysubstance use among pregnant women with opioid use disorder has increased more rapidly in rural compared with urban counties in the United States, with amphetamines and tobacco use increasing most rapidly.

Infective Endocarditis as a Complication of Intravenous Drug Use in Pregnancy: A Retrospective Case Series and Literature Review

Objective  An increase in opioid use disorder and subsequent intravenous drug use has led to an increase in sequalae that may complicate pregnancy, such as infective endocarditis. Infective endocarditis has the potential for significant maternal and neonatal morbidity and mortality. We sought to examine the management considerations and clinical implications of intravenous drug use-related infective endocarditis in pregnancy from our center's experience. Study Design  Retrospective study of management of pregnancies complicated by infective endocarditis as a result of active intravenous drug use at an academic tertiary care hospital from January 2012 through December 2019. Results  Twelve women with active intravenous drug use histories were identified as having clinical and echocardiographic features consistent with infective endocarditis. Six women were discharged against medical advice and did not complete the full course of recommended antibiotic regimen. Eight women were started or continued on opioid agonist therapy during their hospitalization. Four neonates required neonatal intensive care unit admission for pharmacologic treatment for neonatal abstinence syndrome. Conclusion  Management of intravenous drug use-associated infective endocarditis in pregnancy involves more than treating the acute condition. In pregnant women with opioid use disorder and infective endocarditis, addiction and chronic psychosocial conditions need to be addressed to optimize care.

Assessment of Racial and Ethnic Disparities in the Use of Medication to Treat Opioid Use Disorder Among Pregnant Women in Massachusetts

Importance

Racial and ethnic disparities persist across key health and substance use treatment outcomes for mothers and infants. The use of medications, such as methadone or buprenorphine, for the treatment of opioid use disorder (OUD) has been associated with improvements in the outcomes of mothers and infants; however, only half of all pregnant women with OUD receive these medications. The extent to which maternal race or ethnicity is associated with the use of medication to treat OUD, the duration of the use of medication to treat OUD, and the type of medication used to treat OUD during pregnancy are unknown.

Objective

To examine the extent to which maternal race and ethnicity is associated with the use of medications for the treatment of OUD in the year before delivery among pregnant women with OUD.

Design, Setting, and Participants

This retrospective cohort study used a linked population-level statewide data set of pregnant women with OUD who delivered a live infant in Massachusetts between October 1, 2011, and December 31, 2015. Of 274 234 total deliveries identified, 5247 deliveries among women with indicators of having OUD were included in the analysis. Maternal race and ethnicity were defined as white non-Hispanic, black non-Hispanic, or Hispanic based on self-reported data on birth certificates.

Main Outcomes and Measures

Main outcomes were the receipt of any medication for OUD, the consistency of the use of medication (at least 6 continuous months of use before delivery, inconsistent use, or no use) for the treatment of OUD, and the type of medication (methadone or buprenorphine) used to treat OUD. Multivariable models were adjusted for maternal sociodemographic characteristics, comorbidities, and any significant interactions between the covariates and race and ethnicity.

Results

The sample included 5247 pregnant women with OUD who delivered a live infant in Massachusetts during the study period. The mean (SD) maternal age at delivery was 28.7 (5.0) years; 4551 women (86.7%) were white non-Hispanic, 462 women (8.8%) were Hispanic, and 234 women (4.5%) were black non-Hispanic. A total of 3181 white non-Hispanic women (69.9%) received any type of medication for the treatment of OUD in the year before delivery compared with 228 Hispanic women (49.4%) and 108 black non-Hispanic women (46.2%). Compared with white non-Hispanic women, black non-Hispanic and Hispanic women had a substantially lower likelihood (adjusted odds ratio [aOR], 0.37; 95% CI, 0.28-0.49 and aOR, 0.42; 95% CI, 0.35-0.52, respectively) of receiving any medication for the treatment of OUD. Stratification by maternal age identified greater disparities among younger women. Black non-Hispanic and Hispanic women also had a lower likelihood (aOR, 0.24; 95% CI, 0.17-0.35 and aOR, 0.34; 95% CI, 0.27-0.44, respectively) of consistent use of medication for the treatment of OUD compared with white non-Hispanic women. With respect to the type of medication used to treat OUD, black non-Hispanic and Hispanic women had a lower likelihood (aOR, 0.60; 95% CI, 0.40-0.90 and aOR, 0.77; 95% CI, 0.58-1.01, respectively) than white non-Hispanic women of receiving buprenorphine treatment compared with methadone treatment.

Conclusions and Relevance

This study found racial and ethnic disparities in the use of medications to treat OUD during pregnancy, with black non-Hispanic and Hispanic women significantly less likely to use medications consistently or at all compared with white non-Hispanic women. Further investigation of patient, clinician, treatment program, and system-level factors associated with these findings is warranted.

Intrauterine Substance Exposure and the Risk for Subsequent Physical Abuse Hospitalizations

OBJECTIVE

To describe the relative risk for a physical abuse hospitalization among substance exposed infants (SEI) with and without neonatal abstinence syndrome (NAS).

METHODS

We created a nationally representative US birth cohort using the 2013 and 2014 Nationwide Readmissions Databases. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify newborns, predictor variables, and subsequent hospitalizations for physical abuse within 6 months of discharge from newborns' birth hospitalization. Predictor variables included newborn demographics, prematurity or low birth weight, and intrauterine substance exposure: non-SEI, SEI without NAS, and SEI with NAS. Multiple logistic regression calculated adjusted relative risks and 95% confidence intervals. A subanalysis of newborns with narcotic exposure was performed.

RESULTS

There were 3,740,582 newborns in the cohort; of which 13,024 (0.4%) were SEI without NAS and 20,196 (0.5%) SEI with NAS. Overall, 1247 (0.03%) newborns were subsequently hospitalized for physical abuse within 6 months. Compared to non-SEI, SEI with NAS (adjusted relative risks: 3.84 [95% confidence intervals: 2.79-5.28]) were at increased risk for having a subsequent hospitalization for physical abuse, but SEI without NAS were not. A similar pattern was observed among narcotic-exposed infants; infants with NAS due to narcotics were at increased risk, but narcotic-exposed infants without NAS were not.

CONCLUSIONS

Our results suggest that newborns diagnosed with NAS are at increased risk of physical abuse during early infancy, above that of substance-exposed infants without NAS. These results should improve the identification of higher-risk infants who may benefit from more rigorous safety planning and follow-up care.

Advancing preventive interventions for pregnant women who are opioid using via the integration of addiction and mental health research

Purpose of Review

This review examines how research focused on treatment for opioid use in perinatal populations and preventive interventions for postpartum psychopathology have remained separate, despite significant overlap.

Recent Findings

Guidelines for best practice in caring for pregnant women with opioid use disorder suggest the use of medication-assisted treatment with additional comprehensive care, including behavioral and mental health interventions. However, intervention research often mutually excludes these two populations, with studies of behavioral interventions for opioid use excluding women with psychopathology and research on preventive interventions for postpartum psychopathology excluding women who are substance using.

Summary

There is a limited evidence-base to inform the selection of appropriate preventive interventions for pregnant women with opioid use disorder that can address opioid use and/or treatment adherence and concurrent mental health risks. We argue it is critical to integrate research on pregnant women who are opioid using and preventive perinatal mental health interventions to catalyze pivotal change in how we address the opioid epidemic within this growing population.

A pilot multisite study of patient navigation for pregnant women with opioid use disorder

The opioid crisis continues to affect pregnant and postpartum women the United States, with the number of pregnant women diagnosed with opioid use disorder (OUD) quadrupling over the last decade. The associated increase in morbidity and mortality among mother and baby warrants prompt, targeted intervention efforts that improve engagement, linkage of care, and treatment retention. Patient navigation (PN) is a chronic care intervention that can directly address this need by helping women identify medical, behavioral, and psychosocial care goals. Moreover, PN can assist women in preparing for, engaging in, and maintaining patient participation in necessary services. Specifically, PN includes strengths-based case management, 1-1 clinical support, motivational interviewing, and addiction-relapse prevention programming. The objective of this article is to present the study protocol of a pilot multisite randomized clinical trial, entitled: Optimizing Pregnancy and Treatment Interventions for Moms 2.0 (OPTI-Mom 2.0; NCT03833245). In this study, we build upon a proof-of-concept study, employing evidence-informed frameworks for protocol and intervention expansion in order to construct a PN intervention tailored for pregnant women with OUD in central Utah and southwestern Pennsylvania. Our protocol provides an initial framework of a potentially impactful intervention and may guide development of future programs. Importantly, this study further establishes the evidence-base-with potential to ameliorate serious adverse opioid-related outcomes and improve health for women and their children.

Management of the Cardiovascular Complications of Substance Use Disorders During Pregnancy

PURPOSE OF REVIEW

Substance use disorder in pregnancy and subsequent cardiovascular complications are on the rise in the USA. The care of pregnant women with substance use disorder is complex, and requires a thorough understanding of mechanisms of action, pathophysiology, and cardiovascular response during pregnancy. The goal of this review is to provide information about the most common drugs of abuse in pregnancy and to recommend management guidelines.

RECENT FINDINGS

Pregnant women with substance use disorder are at increased risk of significant cardiovascular complications, both as a direct effect of acute intoxication as well as the secondary risk from infection and cardiotoxicity associated with chronic use. This risk must be considered in the antepartum management, delivery, and postpartum periods. Understanding the increased cardiovascular risk of pregnant women with substance use disorder, as well as specific drug interactions, anesthesia considerations, best practices, and management considerations, is important for all clinicians caring for this population.

Association of Punitive and Reporting State Policies Related to Substance Use in Pregnancy With Rates of Neonatal Abstinence Syndrome

IMPORTANCE

Despite the rapidly changing policy environment regarding substance use during pregnancy, information is lacking on the association of state policies with neonatal abstinence syndrome (NAS).

OBJECTIVE

To determine if punitive or reporting state policies related to substance use during pregnancy are associated with NAS rates.

DESIGN, SETTING, AND PARTICIPANTS

This repeated cross-sectional study used retrospective, difference-in-difference analysis of live births in the State Inpatient Databases from 8 US states in varying years between January 1, 2003, and December 31, 2014. States without punitive or reporting policies were compared with states with policies before and after policy enactment using logistic regression models adjusted for individual and county-level factors and state and year fixed effects. Analyses were conducted from April 10, 2019, to July 30, 2019.

EXPOSURES

Time since enactment of state policies related to substance use in pregnancy, county-level rurality and unemployment, and presence of specialized treatment programs for pregnant and postpartum women in a county.

MAIN OUTCOME AND MEASURES

Rates of NAS.

RESULTS

Among 4 567 963 live births, 23 377 neonates (0.5%) received a diagnosis of NAS. Among neonates with NAS, 3394 (14.5%) lived in counties without any treatment programs specifically for pregnant and postpartum women, 20 323 (86.9%) lived in metropolitan counties, and 8135 (34.8%) lived in counties in the highest unemployment quartile. In adjusted analyses among neonates in states with punitive policies, odds of NAS were significantly greater during the first full calendar year after enactment (adjusted odds ratio, 1.25; 95% CI, 1.06-1.46; P = .007) and more than 1 full year after enactment (adjusted odds ratio, 1.33; 95% CI, 1.17-1.51; P < .001). After regression adjustment, the annual NAS rate was 46 (95% CI, 43-48) neonates with NAS per 10 000 live births in states without punitive policies; 57 (95% CI, 48-65) neonates with NAS per 10 000 live births in states with punitive policies during the first full year after enactment; and 60 (95% CI, 56-65) neonates with NAS per 10 000 live births in states with punitive policies in effect for more than 1 full year. There was no association between reporting policies and odds of NAS.

CONCLUSIONS AND RELEVANCE

In this repeated cross-sectional analysis of 8 states, states with punitive policies were associated with greater odds of NAS immediately and in the longer term, but there was no association between NAS and states with reporting policies.