Knowledge of and concerns about long-acting reversible contraception among women in medication-assisted treatment for opioid use disorder

Pregnancy Rates Among Women Treated with Medication for Opioid Use Disorder

BACKGROUND

Treatment-seeking people with opioid use disorder (OUD) who are capable of pregnancy need accurate information about the potential impact of medication to treat OUD (MOUD) on fertility to make informed choices about treatment that are consistent with their reproductive wishes. There is a dearth of research on fertility associated with MOUD receipt in birthing people with OUD.

OBJECTIVE

To estimate the association between treatment with MOUD and odds of conception among birthing people using national administrative claims.

DESIGN

Retrospective case-crossover study using multi-state US administrative data (2006-2016). Dates of conception were estimated from delivery dates and served as "case" days for which MOUD exposures were compared to those on all other ("control") days of insurance enrollment.

PARTICIPANTS

Treatment-seeking people with OUD with a delivery during the observation period.

MAIN MEASURES

Odds ratios for conception from within-person fixed effects models were modeled as a function of exposure to MOUD (buprenorphine, methadone, extended-release depot naltrexone, or oral naltrexone) using conditional logistic regression.

KEY RESULTS

A total of 21,928 births among 19,133 people with OUD were identified. In the sample, 5873 people received buprenorphine, 1825 methadone, 486 extended-release naltrexone, and 714 oral naltrexone. Participants could receive more than one type of MOUD. Mean age was 28.2 years (SD = 2.2; range = 16-45), with 76.2% having Medicaid. vs. commercial insurance. Compared to no MOUD, periods of methadone (aOR = 0.55 [95% CI = 0.48-0.63]) or buprenorphine receipt (aOR = 0.84 [0.77-0.91]) were associated with fewer conceptions. Treatment periods with extended-release depot naltrexone compared to no medication were associated with higher odds of conception (aOR = 1.75 [1.22-2.50]) and there was no significant difference in conception with oral naltrexone (aOR = 1.02 [0.67-1.54]).

CONCLUSIONS

The association between MOUD and odds of conception among birthing people varied by type of MOUD, with extended-release naltrexone associated with higher odds of conceiving compared to no treatment. Clinical studies are urgently needed to investigate these findings further.

Sex and Female Empowerment (SAFE): Learning from health care providers, men and women to design a sexual health intervention for women with substance use disorders

BACKGROUND

Substance Use Disorder (SUD) treatment is a promising setting to provide sexual health education to women. This study examined barriers and possible solutions to effectively providing sexual health education and services during SUD treatment.

METHODS

To obtain a full picture of the barriers and solutions, 29 cisgender women and 17 cisgender men in treatment for a SUD and four health care providers in North Carolina were interviewed regarding the domains of pregnancy-planning, barriers to reproductive health services and contraception, selecting a method of contraception and desired aspects and elements of a sexual health intervention.

RESULTS

Eight themes and 12 sub-themes emerged that included how addiction impacts pregnancy planning and pregnancy motivations, the stigma and fear regarding accessing health services, the lack of accurate knowledge of the human reproductive cycle and contraceptive methods and worries about contraception side-effects. Recommendations for interventions to reduce unintended pregnancy in this treatment population included the need for simple and focused information given by trusted communicators in a short time frame in accessible locations, and offering incentives for participation such as food and transportation.

CONCLUSION

As SUD treatment providers and programs look to improve access to sexual health and contraceptive options for women with SUD, these eight themes provide helpful guidance in crafting future interventions.

Guideline No. 443a: Opioid Use Throughout Women's Lifespan: Fertility, Contraception, Chronic Pain, and Menopause

OBJECTIVE

To provide health care providers with the best evidence on opioid use and women's health. Areas of focus include general patterns of opioid use and safety of use; care of women who use opioids; stigma, screening, brief intervention, and referral to treatment; hormonal regulation; reproductive health, including contraception and fertility; sexual function; perimenopausal and menopausal symptoms; and chronic pelvic pain syndromes.

TARGET POPULATION

The target population includes all women currently using or contemplating using opioids.

OUTCOMES

Open, evidence-informed dialogue about opioid use will lead to improvements in patient care and overall health.

BENEFITS, HARMS, AND COSTS

Exploring opioid use through a trauma-informed approach offers the health care provider and patient with an opportunity to build a strong, collaborative, and therapeutic alliance. This alliance empowers women to make informed choices about their own care. It also allows for the diagnosis and possible treatment of opioid use disorders. Use should not be stigmatized, as stigma leads to poor "partnered care" (i.e., the partnership between the patient and care provider). Therefore, health care providers and patients must understand the potential role of opioids in women's health (both positive and negative) to ensure informed decision-making.

EVIDENCE

A literature search was designed and carried out in PubMed and the Cochrane Library databases from August 2018 until March 2023 using following MeSH terms and keywords (and variants): opioids, illicit drugs, fertility, pregnancy, breastfeeding, and aging.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

All health care providers who care for women.

TWEETABLE ABSTRACT

Opioid use can affect female reproductive function; health care providers and patients must understand the potential role of opioids in women's health to ensure informed decision-making.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Association of Opioid Use Disorder and Provision of Highly Effective Inpatient Postpartum Contraception

We sought to examine the rates of the inpatient provision of postpartum long-acting and permanent methods (IPP LAPM) of contraception in patients with opioid use disorder (OUD). This is a retrospective cross-sectional regression analysis of the National Inpatient Sample between 2012 and 2016. Patients with a diagnosis of OUD that delivered and received postpartum permanent contraception or long acting reversible contraception placement during the same hospitalization were identified. Regression analyses were performed to identify the demographic and clinical factors associated with long acting and permanent contraception method utilization. Of the 22,294 patients with OUD who delivered during the study period, 2291 (10.3%) received IPP LAPM. The majority of patients (1989) (86.6%) with OUD who chose inpatient provision of long acting or permanent methods after delivery received permanent contraception. After adjusting for covariates, patients with OUD had an overall decreased probability of receiving IPP LAPM (aOR=0.89, 95% CI: 0.85-0.95), decreased probability of receiving permanent contraception (aOR: 0.82, 95% CI: 0.78-0.88), but an increased probability of receiving long-acting reversible contraception (aOR: 1.29, 95% CI: 1.04-1.60) compared to patients without OUD. This study highlights the continued need to ensure appropriate measures (such as antepartum contraceptive counseling, availability of access to inpatient LAPM, and removal of Medicaid policy barriers to permanent contraception) are in place so that the contraceptive needs of patients with OUD are fulfilled.

Barriers to and facilitators of hormonal and long-acting reversible contraception access and use in the US among reproductive-aged women who use opioids: A scoping review

Existing research has found that women who use opioids (WWUO) experience challenges to hormonal and long-acting reversible contraception (HC-LARC) access and use. Facilitators of such use are unclear. We conducted a scoping review to comprehensively map the literature on barriers to and facilitators of HC-LARC access and use in the United States among reproductive-aged WWUO. In accordance with the JBI Manual of Evidence Synthesis, we conducted literature searches for empirical articles published from 1990 to 2021. Independent reviewers screened references, first by titles and abstracts, then by full-text, and charted data of eligible articles. We coded and organized HC-LARC barriers and facilitators according to a four-level social-ecological model (SEM) and categorized findings within each SEM level into domains. We screened 4,617 records, of which 28 articles focusing on HC-LARC (n = 18), LARC only (n = 6), or testing an intervention to increase HC-LARC uptake (n = 4) met inclusion criteria. We identified 13 domains of barriers and 11 domains of facilitators across four SEM levels (individual, relationship, community, societal). The most frequently cited barriers and facilitators were methods characteristics, partner and provider relations, transportation, healthcare availability and accessibility, cost, insurance, and stigma. Future studies would benefit from recruiting participants and collecting data in community settings, targeting more diverse populations, and identifying neighborhood, social, and policy barriers and facilitators. Reducing barriers and improving equity in HC-LARC access and use among WWUO is a complex, multifaceted issue that will require targeting factors simultaneously at multiple levels of the social-ecological hierarchy to effect change.

Ethical Issues in Providing and Promoting Contraception to Women with Opioid Use Disorder

Women with opioid use disorder (OUD) face unique challenges meeting their reproductive goals. Because the rate of unintended pregnancy in this population is almost 80 percent, there has been a push to increase the use of contraceptives among reproductive-aged women with OUD.1 The patient-level ethical issues of such initiatives, however, are often overlooked. This review discusses the ethical issues in two realms: obtaining contraception when it is desired and avoiding contraceptive coercion when contraception is not desired. It is important that access to reproductive education and care be improved to ensure autonomous decision making by women with OUD. It is also necessary to be mindful of the history of oppressive and coercive contraception and sterilization policies in the United States. These policies have left a legacy of mistrust and continue to be manifested in the form of more subtly oppressive policies in contemporary medical practice. Such policies point to the ongoing stigmatization of, and implicit biases held against, women with OUD. Based on these ethical issues, solutions are suggested at the clinical, systemic, and societal levels.

Provider Perspectives of Barriers to Contraceptive Access and Use among Women with Substance Use Disorders

OBJECTIVES

Previous studies conducted from the patient perspective indicate that women with substance use disorders (SUDs) experience extensive barriers to contraceptive access and use (CAU), but there is limited research investigating this topic from the provider perspective. We explored provider perspectives on the barriers to CAU for women with SUDs. As a secondary objective, we highlighted provider contraceptive counseling strategies to address patient CAU barriers.

METHODS

We conducted 24 qualitative interviews with a purposeful sample of women's health providers, including medical doctors, nurse practitioners, and certified nurse-midwives. We used thematic analysis to code the interviews with inductive codes and organized findings according to levels of influence within the Dahlgren and Whitehead rainbow model, a socioecological model of health.

RESULTS

Provider-reported barriers to CAU were identified at four levels of socioecological influence and included reproductive misconceptions; active substance use; trauma, interpersonal violence, and reproductive coercion; limited social support; lack of housing, employment, health insurance, and transportation; stigma; discrimination; and punitive prenatal substance use policies and child welfare reporting requirements. Strategies for addressing CAU barriers mainly focused on patient-centered communication, including open information exchange, shared decision-making, and relationship building. However, providers described disproportionately highlighting the benefits of long-acting reversible contraception (LARC) and directing conversations toward LARC when they perceived that such methods would help patients to overcome adherence and other challenges related to active substance use or logistical barriers. Notably, there was no mention of CAU facilitators during the interviews.

CONCLUSIONS

Providers perceived that women with SUDs experience a range of CAU barriers, which they addressed within the clinical setting through use of both patient-centered communication and highlighting the benefits of LARC when they perceived that such methods would help clients to overcome barriers. Improving CAU for women with SUDs will require multidisciplinary, multipronged strategies that prioritize reproductive autonomy and are implemented across clinical, community, and policy settings.

Integrating reproductive health care into substance use disorder services

People who use drugs face layered stigma and barriers to accessing reproductive health care services. At the same time, they have unique needs for compassionate, trauma-informed, low-barrier reproductive health care. We review the literature on collocated reproductive health care and substance use treatment services in this population and advocate for expansion of reproductive health care services at sites providing care for substance use disorder. Through this review article, we outline the evidence for and best practices in collocating reproductive health care within substance use disorder services.

A Review of Unintended Pregnancy in Opioid-Using Women: Implications for Nursing

BACKGROUND

Opioid use among reproductive-age women has greatly increased, resulting in high rates of opioid-exposed pregnancies, which are associated with negative outcomes, such as neonatal abstinence syndrome. Prevention of unintended pregnancy among opioid users is a critical pathway to reducing opioid-exposed pregnancies; however, little is known about pregnancy intention in this group. This article estimates the prevalence of unintended pregnancy among opioid-using women, thereby supporting efforts to develop interventions to reduce unintended pregnancy.

METHODS

A systematic literature search was conducted in PubMed, Web of Science, PsycINFO, and CINAHL, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses framework. Reference lists of articles were searched. Eligibility criteria included reported unintended pregnancy rates within a population of opioid-using women of reproductive age. The search was completed in July 2018 and updated in October 2019.

RESULTS

We identified 115 citations, screened 64 titles/abstracts, reviewed 31 full-text articles, and included 12 articles for this review. Rates of unintended pregnancy in opioid users were estimated in two ways, across the lifetime and for a current pregnancy, depending on study samples. Rates for both groups were high, with rates among currently pregnant opioid-using women (85%) compared with 45% among the general population.

CONCLUSIONS AND IMPLICATIONS

Unintended pregnancy rates in opioid-using women were strikingly high, indicating a critical need for intervention. Routine inclusion of pregnancy planning in opioid treatment care is indicated. Education regarding contraception and opioid treatment services is essential for nurses in these settings. Family planning and opioid treatment efforts can be optimized by care coordination, with focus on nurse training for screening and patient education.

Long-acting reversible contraceptives (LARCs) as harm reduction: a qualitative study exploring views of women with histories of opioid misuse

BACKGROUND

The sharp rise in opioid use disorder (OUD) among women coupled with disproportionally high rates of unintended pregnancy have led to a four-fold increase in the number of pregnant women with OUD in the United States over the past decade. Supporting intentional family planning can have multiple health benefits and reduce harms related to OUD but requires a comprehensive understanding of women's perspectives of preventing unintended pregnancies. The purpose of this study was to comprehensively evaluate the knowledge, attitudes and experiences as they relate to seeking contraception, particularly LARCs, among women with active or recovered opioid misuse.

METHODS

In-depth interviews and focus group discussions with 36 women with current or past opioid misuse were recorded and transcribed. Transcripts were coded by ≥ 2 investigators. Themes related to contraceptive care seeking were identified and contextualized within the Health Belief Model.

RESULTS

Our analysis revealed seven interwoven themes that describe individual level factors associated with contraceptive care seeking in women with current or past opioid misuse: relationship with drugs, reproductive experiences and self-perceptions, sexual partner dynamics, access, awareness of options, healthcare attitudes/experiences, and perceptions of contraception efficacy/ side effects. Overall, perceived susceptibility and severity to unintended pregnancy varied, but most women perceived high benefits of contraception, particularly LARC. However, perceived barriers were too high for most to obtain desired contraception to support family planning intentions.

CONCLUSIONS

The individual-level factors identified should inform the design of integrated services to promote patient-centered contraceptive counseling as a form of harm reduction. Interventions should reduce barriers to contraceptive access, particularly LARCs, and establish counseling strategies that use open, non-judgmental communication, acknowledge the continuum of reproductive needs, explore perceived susceptibility to pregnancy, and utilize peer educators.

Increasing access to family planning services among women receiving medications for opioid use disorder: A pilot randomized trial examining a peer-led navigation intervention

OBJECTIVE

High rates of unintended pregnancy occur among women with opioid use disorder (OUD). OUD treatment settings may provide an ideal opportunity to address the family planning needs of patients. However, few studies have rigorously evaluated interventions designed to address family planning needs in the OUD treatment setting. This study assessed the feasibility, acceptability, and preliminary efficacy of a peer-led navigation intervention designed to educate and link women receiving medications for OUD to family planning services.

METHODS

The study recruited women from four OUD treatment programs in Denver, Colorado, to participate in a pilot randomized controlled trial from March 2018 to February 2019. Eligible participants were English-speaking adult females who were neither pregnant nor desiring a pregnancy and who were not using a long-acting reversible contraceptive (LARC) method. Participants completed a baseline survey, and the study randomized them to receive a two-session, peer-led family planning navigation intervention or usual care. The study assessed feasibility by participant engagement in the intervention. The study used follow-up self-report surveys and electronic health record data to assess intervention acceptability and intervention efficacy for the primary outcomes of a family planning visit and use of a LARC method.

RESULTS

The study enrolled 119 women who were randomized to the Sexual Health Initiative for Navigation and Empowerment (SHINE) peer-led navigation intervention (n = 56) or usual care (n = 63). The average age was 32 (SD = 6.4); 76% were receiving methadone, 24% were receiving buprenorphine and 19% reported a treatment provider had ever discussed family planning with them. Most had a previous pregnancy (82%) and of these, 93% reported an unplanned pregnancy. Among intervention participants, 93% completed the first navigation session, 90% felt that intervention topics were important, 76% indicated that the information was new, and 82% found working with a peer helpful. At six months postbaseline, significantly more (p = 0.01) intervention participants (36%) received a family planning visit compared to control participants (14%). There was no between-group difference on use of LARC methods.

CONCLUSIONS

A peer-led family planning navigation intervention was feasible to implement, acceptable to participants, and showed evidence of preliminary efficacy. This model may be an effective and potentially sustainable approach to support the family planning needs of women in treatment for OUD.

Contraceptive Need, Intimate Partner Violence, and Reproductive Coercion Among Women Attending a Syringe Exchange Program

OBJECTIVE

Women who use drugs are at high risk of unintended pregnancy. This study describes contraceptive need, explores relationships between contraceptive use, intimate partner violence (IPV) and reproductive coercion, and unintended pregnancy, and assesses the acceptability of receiving contraceptive care at a syringe exchange program (SEP).

METHODS

Between August and October, 2017, written surveys were administered to 96 reproductive-aged women attending an SEP in Santa Ana, California. Data were analyzed using descriptive, bivariate, and multivariate statistics.

RESULTS

Most women used methamphetamines (79%) and/or heroin (74%). The majority (62%) did not use contraception during last sex with a man. Half (50%) reported a history of unintended pregnancy. Many (62%) experienced IPV or reproductive coercion in the previous 3 months. Experiencing IPV or reproductive coercion was not associated with contraceptive use or unintended pregnancy. The majority (56%) were interested in receiving contraceptive care from the SEP; history of unintended pregnancy (adjusted odds ratio [aOR] 3.5, 95% confidence interval [CI] 1.3-10.0) and depression (aOR 4.55, 95% CI 1.24-16.69) were associated with interest in contraceptive services.

CONCLUSIONS

Our findings suggest that referrals for contraceptive care and direct provision of contraceptive methods at SEPs may be an acceptable approach to addressing the unmet family planning needs of women who use substances. Innovative approaches like these have the potential to impact the high prevalence of unintended pregnancy among this population; however, high prevalence of IPV and reproductive coercion must also be acknowledged by providers when providing counseling for contraceptive services.

Contraceptive decision making among pregnancy-capable individuals with opioid use disorder at a tertiary care center in Massachusetts

OBJECTIVE

To explore contraceptive decision making among recently pregnant patients with a history of opioid use disorder.

STUDY DESIGN

We conducted semi-structured qualitative interviews, based on principles of the Ottawa Decision Support Framework, with 20 recently pregnant individuals diagnosed with opioid use disorder at a tertiary care medical center in Massachusetts. We audio-recorded the interviews and they were transcribed verbatim. We analyzed our interview data using inductive and deductive coding.

RESULTS

Participants value the availability of barrier methods as a means of preventing both sexually transmitted infections and pregnancy. For some participants, housing instability makes storing contraceptive methods and managing personal hygiene related to bleeding patterns difficult. For others, housing instability impacts their overall fertility goals. Side effects including weight gain, interactions with mood stabilizing medications, concern regarding post-operative opioids, or intrinsic aspects of a method that serve as reminders of opioid use may be unacceptable given the risk of relapse. The relapsing and remitting arc of recovery make remembering important aspects of both short- and long-acting contraceptive method use difficult, yet participants offer strategies to aid in doing so.

CONCLUSION

When choosing a contraceptive method participants in our study exhibit similarities to individuals with other chronic medical conditions as well as motivations specific to opioid use disorder. Their contraceptive decisions are grounded in integrating a method into a chaotic life, preventing relapse, and protecting future fertility.

IMPLICATIONS

Our data highlight how lived experiences at the intersection of active opioid use disorder and recovery fundamentally shape the lens through which pregnancy-capable individuals with opioid use disorder view their contraceptive decisions.

Sex and female empowerment (SAFE): A randomized trial comparing sexual health interventions for women in treatment for opioid use disorder

BACKGROUND

Unintended pregnancies are prevalent among women with opioid use disorder (OUD). The Sex and Female Empowerment (SAFE) project developed a social-cognitive, theory-driven intervention to increase acceptance of and adherence to contraceptive practices among women receiving medication for OUD (MOUD). This study evaluated the feasibility and acceptability of two SAFE interventions (Face-to-face and Computer-adapted) compared to usual care as well as their efficacy to improve contraception utilization.

METHODS

This pilot randomized trial enrolled 90 heterosexual, non-pregnant, reproductive-age women receiving MOUD. Participants were randomized into either a: SAFE Face-to-face intervention, SAFE Computer-adapted intervention, or usual care (UC) condition (n = 30 each) and followed for 6 months. Outcome measures included intervention completion, intervention satisfaction, attendance at a contraception consultation appointment, and long-acting reversible contraceptive (LARC) method receipt. A generalized linear model was used for inferential testing and to estimate least squares means (predicted probabilities for binary outcomes) and their standard errors.

RESULTS

Compared to the UC condition, both the SAFE Face-to-face and the SAFE Computer-adapted intervention had higher intervention completion [Means (Standard Errors) = 0.97 (.03) and 0.97 (.03), respectively, vs. 0.53 (.09); ps<.001], higher intervention satisfaction [Ms (SEs) = 3.7 (.11) and 3.8 (.11), respectively, vs. 3.1 (.11); ps<0.001), higher contraception consultation visit attendance [Ms(SEs) = 0.80 (.07) and 0.73 (.08) vs. 0.33 (.09); p < .001], and greater LARC receipt [Ms(SEs) = 0.77 (.08) and 0.73 (.08) vs. 0.23 (.08); p < .001).

CONCLUSIONS

SAFE appears feasible and efficacious for supporting women in contraception decision-making. Integrating SAFE into women's comprehensive OUD treatment services holds promise to increase contraceptive decision-making and initiation of a chosen method.

"Health Is on the Back Burner:" Multilevel Barriers and Facilitators to Primary Care Among People Who Inject Drugs

BACKGROUND

The estimated 2.2 million people who inject drugs (PWID) in the USA experience significant gaps in preventive healthcare and a high burden of infectious, psychiatric, and other chronic diseases. Many PWID rely on emergency medical services, which are costly and not designed to deliver preventive services, manage chronic conditions, or address social needs.

OBJECTIVE

The objective of this study was to explore barriers and facilitators to primary care utilization from the perspectives of PWID in New England, a region highly affected by the overdose crisis.

DESIGN

Participants completed semi-structured qualitative interviews exploring substance use and healthcare utilization patterns.

PARTICIPANTS

We recruited 78 PWID through community-based organizations (e.g., syringe service programs) in 16 urban and non-urban communities throughout Massachusetts and Rhode Island.

APPROACH

Thematic analysis identified barriers and facilitators to primary care utilization at the individual, interpersonal, and systemic levels.

KEY RESULTS

Among 78 PWID, 48 described recent primary care experiences; 33 had positive experiences and 15 described negative experiences involving discrimination or mistrust. Individual-level barriers to primary care utilization included perceived lack of need and competing priorities (e.g., avoiding opioid withdrawal, securing shelter beds). Interpersonal-level barriers included stigma and perceived low quality of care for PWID. Systemic-level barriers included difficulty navigating healthcare systems, inadequate transportation, long wait times, and frequent provider turnover. Participants with positive primary care experiences explained how appointment reminders, flexible hours, addiction medicine-trained providers, case management services, and transportation support facilitated primary care utilization and satisfaction.

CONCLUSIONS

Findings regarding the multilevel barriers and facilitators to accessing primary care among PWID identify potential targets for programmatic interventions to improve primary care utilization in this population. Based on these findings, we make recommendations for improving the engagement of PWID in primary care as a means to advance individual and public health outcomes.

Factors Affecting Contraception Access and Use in Patients With Opioid Use Disorder

Maternal opioid use disorder increased > 4-fold from 1999 to 2014 and is associated with poor maternal and fetal outcomes. Women with opioid use disorder are at 2 to 3 times greater risk for unintended pregnancy than the general population and may face additional barriers to accessing and effectively using contraception compared to women without opioid use disorder, particularly highly effective long-acting reversible contraception. Additionally, women with opioid use disorder tend to use less effective forms of contraception such as condoms alone. Barriers to contraceptive access include patient misconceptions or knowledge gaps regarding reproductive health and family planning, cost, intimate partner violence, fear of criminalization, difficulty accessing care, comorbid health conditions, and health care provider misconceptions or practice limitations. Strategies that may assist women with opioid use disorder in achieving their family planning goals include colocation of family planning services within opioid treatment facilities, optimization of patient care services to minimize the need for costly and/or time consuming follow-up, increasing provider education and awareness of best practices in family planning and opioid use disorder treatment, and providing patient-centered family planning education and counseling. Additional research is needed to identify and develop strategies that empower women who use opioids to effectively access and use their preferred contraceptive method.

Contraceptive Knowledge among Females and Males Receiving Medication Treatment for Opioid Use Disorder Compared to Those Seeking Primary Care

BACKGROUND

Rates of unintended pregnancy among women receiving medication treatment for opioid use disorder (mOUD) are high, likely due in part to low rates of contraceptive use. Lack of knowledge about contraception may be contributing to inadequate contraceptive use. Objectives: To compare contraceptive knowledge among women and men receiving mOUD relative to a comparison group seeking primary care. Methods: We surveyed 332 reproductive-age women and men receiving mOUD or primary care with the recently validated 25-item Contraceptive Knowledge Assessment. We examined overall differences between patient groups and between females and males using two-way analyses of variance; individual item differences were tested using logistic regression. Results: The mean percent of total correct responses was lower among individuals receiving mOUD (n = 167) relative to the comparison group (n = 165), 47.7% vs. 53.8%, respectively (p < .001), and higher among females (n = 169) relative to males (n = 163), 56.1% vs. 45.2%, respectively (p < .001). Individual item analyses revealed patient group and sex differences primarily in the areas of contraceptive efficacy, attributes of contraceptive methods, and fertility awareness. Conclusion: While there were modest differences between patient groups and sexes, the results suggest a deficit in contraceptive knowledge across all groups. Substance use disorder treatment clinics could be an opportunistic setting in which to provide accurate information about contraception to patients with OUD and other substance use disorders.

Contraceptive Method Choices in Women With and Without Opioid Use Who Have Infants in the Neonatal Intensive Care Unit and Nursery

Objective: The aim of this study was to examine whether a history of opioid use predicts tier 1 contraceptive use or plan to use in women with infants in the neonatal intensive care unit (NICU) and nursery.

Materials and Methods: We conducted a self-administered, anonymous survey in women with infants in three local NICUs and two postpartum units from November 2018 to May 2019. Women were recruited while visiting their infants in the NICU or in their postpartum rooms. Our survey included adapted questions from the Centers for Disease Control and Prevention (CDC) Pregnancy Risk Assessment Monitoring System (PRAMS) questionnaire, the National Institute of Drug Abuse (NIDA) Modified ASSIST Screening Tool, and ones written by our team. The questions asked about contraceptive use and opioid use. We compared the responses of women with and without a history of opioid use. We conducted a multivariable regression analysis and applied the backward elimination method to identify whether opioid use was a predictor of tier 1 contraceptive use or plan to use.

Results: A total of 122 women completed the survey. Fifty-three women (43.4%) reported opioid use in the month before pregnancy and/or during pregnancy, while 69 (56.6%) women reported no opioid use and comprised the control group. Multivariable regression analysis showed that opioid use was not associated with the use or planned use of tier 1 contraceptives (adjusted odds ratio [aOR] 1.47; confidence interval [95% CI] 0.54–4.01). Older maternal age predicted tier 1 choice (aOR 1.12; 95% CI 1.04–1.21), while African American women were less likely to use or plan to use tier 1 contraceptives compared with white women (aOR 0.21; 95% CI 0.08–0.56).

Conclusion: A history of opioid use was not independently associated with women using or planning to use tier 1 methods, while age and race were predictors.

Perceptions of long-acting reversible contraception among women receiving medication for opioid use disorder in Vermont

OBJECTIVES

To evaluate perceptions of long-acting reversible contraceptives (LARC) among women receiving medication for opioid use disorder.

STUDY DESIGN

Cross-sectional survey of 200 women receiving medication for opioid use disorder in Vermont.

RESULTS

A considerable proportion of women receiving medication for opioid use disorder in Vermont reported previous use of an IUD (40%) and/or a subdermal contraceptive implant (16%); the majority of prior LARC users were satisfied with their IUD (68%) or their implant (74%). Of the 38% of participants who had never considered IUD use, 85% percent (64/75) said that they knew nothing or only a little about IUDs. Of the 61% of participants who had never considered an implant, 81% percent (98/121) said that they knew nothing or only a little about the contraceptive method. The most commonly reported reasons for a lack of interest in the IUD and/or implant were concerns about side effects and preference for a woman-controlled method.

CONCLUSIONS

Gaps in LARC knowledge are common among those who have not used LARCs and concerns about side effects and preferences for a woman-controlled method limit some women's interest in these contraceptives. Additionally, reasons for dissatisfaction among past users are generally similar for IUD and implant and include irregular bleeding and having a bad experience with the method.

IMPLICATIONS

Efforts to increase awareness of LARC methods among women receiving medication for opioid use disorder should address concerns about side effects and reproductive autonomy and encourage satisfied LARC users to share their experiences with their social networks.

Factors associated with long-acting reversible contraception use among women Veterans in the ECUUN study

OBJECTIVES

The objective of this study is to understand patient-, provider- and system-level factors associated with long-acting reversible contraception (LARC) use among women Veterans and with receipt of LARC methods within the Veterans Affairs (VA) system.

STUDY DESIGN

We analyzed data from a national telephone-based survey of 2302 women ages 18-44 receiving primary care in VA. Multivariable regression was used to examine adjusted associations of participant-reported patient-, provider- and facility-level factors with LARC use and within-VA receipt of LARC among women Veterans.

RESULTS

Among 987 women Veterans at risk of unintended pregnancy, 294 (30%) reported using LARC, 65% of whom had received their method within VA. Higher LARC use was observed among women who were multiparous vs. nulliparous [adjusted odds ratio (aOR)=1.52; 95% confidence interval (CI)=1.04-2.22] and did not desire future pregnancies (aOR=1.88; 95% CI=1.31-2.68). Although overall LARC uptake was not associated with any provider- or facility-level factors, receipt of these methods within VA was associated with receiving both general and gender-specific health care by a single provider (aOR=2.81; 95% CI=1.20-6.61) and with receiving care within a women's health clinic (aOR=2.54; 95% CI=1.17-5.50).

CONCLUSIONS

While patient-level factors were more strongly correlated with use of LARC, provider- and system-level factors influence whether women received these methods within VA.

IMPLICATIONS

This study of patient-, provider- and system-level correlates of LARC use in VA, the country's largest integrated healthcare system, highlights that women Veterans share similar patient-level factors associated with LARC use as the general population and that continuity with providers and comprehensive women's health services can facilitate LARC access.

Neonatal abstinence syndrome

Neonatal abstinence syndrome refers to the signs and symptoms attributed to the cessation of prenatal exposure (via placental transfer) to various substances. This Primer focuses on neonatal abstinence syndrome caused by opioid use during pregnancy - neonatal opioid withdrawal syndrome (NOWS). As the global prevalence of opioid use has alarmingly increased, so has the incidence of NOWS. NOWS can manifest with varying severity or not at all, for unknown reasons, but is likely to be associated with multiple factors, both maternal (for example, smoking and additional substance exposures) and neonatal (gestational age, sex and genetics). Care for the infant with NOWS begins with addressing the issues experienced by pregnant women with opioid use disorder. Co-occurring mental illness, economic hardship, intimate partner violence, infectious diseases and limited access to care are common in these women and can result in poor maternal and neonatal outcomes. Although there is no consensus regarding optimal NOWS management, non-pharmacological interventions (such as breastfeeding and rooming-in of the mother and the baby) have become a priority, as they can ameliorate symptoms without the need for further opioid exposure. Untreated NOWS can be associated with morbidity in early infancy, and the long-term consequences of fetal opioid exposure are only beginning to be understood.

Prenatal intent and postpartum receipt of long-acting reversible contraception among women receiving medication-assisted treatment for opioid use disorder

BACKGROUND

Many women with opioid use disorder (OUD) do not use highly effective postpartum contraception such as long-acting reversible contraception (LARC). We evaluated factors associated with prenatal intent and postpartum receipt of LARC among women receiving medication-assisted treatment (MAT) for OUD.

STUDY DESIGN

This was a retrospective cohort study of 791 pregnant women with OUD on MAT who delivered at an academic institution without immediate postpartum LARC services between 2009 and 2012. LARC intent was defined as a documented plan for postpartum LARC during pregnancy and LARC receipt was defined as documentation of LARC placement by 8 weeks postpartum. We organized contraceptive methods into five categories: LARC, female sterilization, short-acting methods, barrier methods and no documented method. Multivariable logistic regression identified characteristics predictive of prenatal LARC intent and postpartum LARC receipt.

RESULTS

Among 791 pregnant women with OUD on MAT, 275 (34.8%) intended to use postpartum LARC and only 237 (29.9%) attended the postpartum visit. Among 275 women with prenatal LARC intent, 124 (45.1%) attended their postpartum visit and 50 (18.2%) received a postpartum LARC. Prenatal contraceptive counseling (OR 6.67; 95% CI 3.21, 13.89) was positively associated with LARC intent. Conversely, older age (OR 0.95; 95% CI 0.91, 0.98) and private practice provider (OR 0.48; 95% CI 0.32, 0.72) were negatively associated with LARC intent. Although parity was not predictive of LARC intent, primiparous patients (CI 0.49; 95% CI 0.26, 0.97) were less likely to receive postpartum LARC.

CONCLUSIONS

Discrepancies exist between prenatal intent and postpartum receipt of LARC among pregnant women with OUD on MAT. Immediate postpartum LARC services may reduce LARC access barriers.

IMPLICATIONS

Despite prenatal interest in using LARC, most pregnant women with OUD on MAT did not receive postpartum LARC. The provision of immediate postpartum LARC services may reduce barriers to postpartum LARC receipt such as poor attendance at the postpartum visit.

Opioid Use Disorders and Pregnancy

Opioid use disorder presents an increased risk of complications in pregnancy, particularly when untreated. To optimize outcomes, medication-assisted treatment using methadone or buprenorphine as a part of a comprehensive care model is recommended. Neonatal abstinence syndrome and poor fetal growth remain significant complications of this disorder despite maternal treatment.