Postpartum Opioid-Related Mortality in Patients With Public Insurance

Co-occurring conditions during pregnancy and hospitalizations in the first year postpartum among persons with opioid use disorder

INTRODUCTION

Pregnant persons with opioid use disorder (OUD) face a multitude of comorbid conditions that may increase the risk of adverse drug and health outcomes. This study characterizes typologies of comorbidities among pregnant persons with OUD and assesses the associations of these typologies with hospitalizations in the first year postpartum.

METHODS

A cohort of pregnant persons with OUD at delivery in 2018 were identified in a Pennsylvania statewide hospital dataset (n = 2055). Latent class analysis assessed 12 comorbid conditions including substance use disorders (SUDs), mental health conditions, and infections. Multivariable logistic regressions examined the association between comorbidity classes and hospitalizations (all-cause, OUD-specific, SUD-related, mental health-related) during early (0-42 days) and late (43-365 days) postpartum.

RESULTS

A three-class model best fit the data. Classes included low comorbidities (56.9% of sample; low prevalence of co-occurring conditions), moderate polysubstance/depression (18.4%; some SUDs, all with depression), and high polysubstance/bipolar disorder (24.7%; highest probabilities of SUDs and bipolar disorder). Overall, 14% had at least one postpartum hospitalization. From 0 to 42 days postpartum, the moderate polysubstance/depression and high polysubstance/bipolar disorder classes had higher odds of all-cause and mental health-related hospitalization, compared to the low comorbidities class. From 43 to 365 days postpartum, the high polysubstance/bipolar disorder class had higher odds of all-cause hospitalizations, while both the high polysubstance/depression and moderate polysubstance/bipolar disorder classes had higher odds of SUD-related and mental health-related hospitalizations compared to the low comorbidities class.

CONCLUSIONS

Findings highlight the need for long-term, multidisciplinary healthcare delivery interventions to address comorbidities and prevent adverse postpartum outcomes.

Provider-patient relationships and trauma among pregnant patients with opioid-use disorder

BACKGROUND AND OBJECTIVES

The provider-patient relationship is integral to medical practice and health outcomes, particularly among vulnerable patient populations. This study compared the provider-patient relationship among pregnant patients with opioid-use disorder (OUD), who did or did not have a history of moderate to severe trauma.

METHODS

This was an exploratory data analysis of 119 patients enrolled in the Support Models for Addiction Related Treatment trial. Probable posttraumatic stress disorder (PTSD) was determined by a score ≥ 31 on the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. The provider-patient relationship was assessed at 26 ± 4 weeks of pregnancy using the Kim Alliance Scale (KAS). Multivariable regression was used to examine the association of KAS with probable PTSD among pregnant people with OUD.

RESULTS

The mean KAS score for pregnant participants without probable PTSD (N = 88) was 61.4 (SD ± 2.8) and for pregnant participants with probable PTSD (N = 31) was 59.6 (SD ± 3.7). Results demonstrated significant differences in KAS scores between those with and without probable PTSD after adjusting for demographic variables. Adjusted mean total KAS scores and scores on Empowerment and Communication subscales were significantly lower among those with probable PTSD compared to those without (p = .04 and 0.02, respectively) but did not differ significantly on Collaboration and Integration subscales.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Analyses show an association between probable PTSD and provider-patient relationship among pregnant patients with OUD, with those with probable PTSD having a worse alliance with obstetric providers. This novel finding helps characterize the provider-patient relationship among a uniquely vulnerable population and can inform efforts to integrate trauma-informed practices into prenatal care.

Psychological distress among postpartum women who took opioids during pregnancy: the role of perceived stigma in healthcare settings

This study examined the relationship between perceived stigma in healthcare settings during pregnancy and psychological distress and well-being in the postpartum period among individuals who took opioids while pregnant. Analyses included 134 birth mothers of opioid-exposed infants. At 0-1 months postpartum, perceived stigma and psychological distress were measured using the Prenatal Opioid use Perceived Stigma scale and measures from the Patient-Reported Outcome Measurement Information System (PROMIS). Food insecurity, housing instability, and Adverse Childhood Experiences (ACEs) were also assessed. Linear and generalized linear mixed-effect models were conducted to compare PROMIS scale scores and unmet needs by stigma, adjusting for site/location, age, race/ethnicity, marital status, education, public insurance, and parity. More than half of participants (54%) perceived stigma in healthcare settings. Individuals reporting stigma had higher depression, anxiety, and anger scores (p < 0.001) indicating greater psychological distress in the postpartum period compared to those reporting no stigma, after controlling for demographic characteristics. In addition, they scored significantly lower on the PROMIS meaning and purpose scale, an indicator of well-being (p = 0.002). Those reporting stigma were more likely to have food insecurity (p = 0.003), three or more ACEs (p = 0.040), verbal or physical abuse during pregnancy (p < 0.001), and less emotional support (p = 0.006) than those who did not. An association was observed between perceived stigma in the prenatal period and psychological distress in the postpartum period, providing support for stigma reduction interventions and education for healthcare providers on trauma-informed care.

Buprenorphine Extended-Release Treatment for Opioid Use Disorder in the Postpartum Period

Buprenorphine extended-release (XR) is an extended-release monthly injection to treat opioid use disorder (OUD). This retrospective case series includes 15 postpartum patients who were treated with buprenorphine-XR at a single center and reports on their outcomes. The average total daily sublingual buprenorphine dose before initiation of buprenorphine-XR was 16.25 mg (SD±7.76, range 2-32 mg). Overall, 137 total doses of buprenorphine-XR were administered between May 17, 2021, and April 11, 2023. Urine toxicology test results were negative for opioids other than buprenorphine in the majority (80.0%) of patients once appropriate maintenance doses were achieved. Euphoria and intoxication were not reported. A minority of patients (20.0%) discontinued buprenorphine-XR. Although more extensive research is needed before widespread use, buprenorphine-XR may be a favorable treatment for OUD in this high-risk population.

State Laws on Substance Use Treatment for Incarcerated Pregnant and Postpartum People

Background

Incarcerated perinatal populations report high rates of substance use in the United States (US). Despite this, substance use disorder (SUD) treatment is not routinely available in carceral settings and state policies related to the provision of substance use screening and treatment are unknown.

Methods

We conducted a systematic search in WestLaw through the end of the 2020 legislative session combining the terms "pregnant" and "postpartum" with terms for incarceration and related terms. The search returned 453 statutes from 43 states. A deductive codebook of various maternal health topics was developed. Legislative texts related to SUD screening and treatment were extracted for textual analysis.

Results

Of the 43 states identified as having at least 1 state statute pertaining to pregnant or postpartum incarcerated people, 7 states had statutes relevant to SUD screening and treatment. Statutes related to substance use screening, education, treatment and diversion programs, program eligibility, aftercare and release planning, and funding appropriations.

Conclusions

The majority of states across the U.S. lack legislation that address SUD screening and treatment among incarcerated perinatal populations. Given the known limited access to SUD treatment for perinatal populations in custody, increasing legislative statutes could increase access to essential care.