Association of Pregnancy and Insurance Status With Treatment Access for Opioid Use Disorder

Factors Associated with Positive Toxicology at Delivery: Insights From the University of Maryland Medical System

OBJECTIVE

To explore factors associated with positive toxicology tests during birthing admissions within a hospital system employing universal toxicology testing.

METHODS

A retrospective cross-sectional study from 2019 to 2022, within a health system where toxicology tests are performed routinely during the birth admission. Substance use was defined as a positive toxicology test and race was self-reported. The association between substance use with race and insurance was analyzed. Assessments were made using descriptive statistics, chi-squared tests, and logistic regression models, controlling for maternal age, gestational age, birth year, insurance, and birth hospital. Separate analyses were conducted excluding cannabis from the toxicology evaluations.

RESULTS

Of 37,438 deliveries, 97% (36,323) underwent toxicology testing. Unadjusted odds for positive toxicology tests (including amphetamines, barbiturates, benzodiazepines, cannabis, cocaine, fentanyl, methadone, opioids (all), phencyclidine) were: Black (OR 1.91), Hispanic (OR 0.36), and Other (OR 0.56), compared with White. After adjusting for confounders, all groups showed decreased odds: Black (aOR 0.75), Hispanic (aOR 0.15), and Other (aOR 0.36). For insurance, the unadjusted odds were compared to private insurance: Public (OR 4.18) and Other (OR 1.81). When excluding cannabis, unadjusted odds for Black individuals increased (OR 1.21) while adjusted odds for Black, Hispanic, and 'Other' groups decreased relative to White individuals.

CONCLUSION

Substance use during pregnancy exhibits sociodemographic variations. Initial unadjusted findings indicated racial disparities in substance use. However, adjusted models shifted these initial observations. Findings highlight the intertwined nature of sociodemographic factors in toxicology test results. Study findings underscore the need for comprehensive research to inform interventions, focusing on racial and socioeconomic inequities.

Peripartum substance use and punitive laws: an update

This is a follow up on a 2016 article discussing the rise in punitive perinatal substance use laws. From 2016-2023, there has been a 39% increase in laws equating perinatal substance use with child abuse, and a 73% increase in mandated reporting laws, despite limited evidence that these laws are helpful. We write this update to raise awareness for providers, so they may better counsel patients on this topic and help advocate for treatment focused policies in their state.

Systemic barriers and stigma: Healthcare provider perspectives on perinatal and neonatal care in the fentanyl crisis

INTRODUCTION

The rise in fentanyl use during pregnancy has created new challenges in caring for women with opioid use disorders (OUD) and their infants with neonatal abstinence syndrome or neonatal opioid withdrawal syndrome (NAS/NOWS). Despite complexities in treating opioid-affected dyads, little research exists on healthcare workers' perspectives regarding fentanyl's impact on perinatal and neonatal care.

OBJECTIVES

Explore dynamic challenges fentanyl has brought to the care of perinatal women with OUD and their infants experiencing NAS/NOWS from healthcare providers' perspectives.

METHODS

Fifteen healthcare providers (neonatologists, OBGYNs, nurse practitioners, registered nurses, and pediatricians) from the Pacific Northwest completed an online qualitative survey with a mixture of Likert-type and open-ended questions. Reflexive thematic analysis was used to analyze open-ended responses.

RESULTS

Three themes emerged from provider data that reflect systemic failures in addressing the complex needs of perinatal women and their families and highlight challenges in implementation of evidence-based care: 1) Systemic Barriers to Perinatal and Infant Care, 2) Impact of Increasing Polysubstance Use on Neonates and Mothers, and 3) Stigma and Judgment from Healthcare Providers toward Perinatal Women with Substance Use Disorders.

CONCLUSIONS

Themes reflected how broad and interconnected systemic issues contribute to inadequate care and support for mothers and newborns in the context of rising fentanyl and polysubstance use. Themes echoed the root of the problems lies in systemic failures-issues within the healthcare system, societal attitudes, and policy frameworks that collectively fail to meet the complex and evolving needs of families affected by the ever-changing landscape of substance use.

State Policy Variation in Implementation of Federal Drug and Child Abuse Laws and Stigmatization of Pregnant and Postpartum Individuals with Opioid Use Disorder

Importance: Despite increased initiatives and funding to improve access to evidence-based treatments for opioid use disorder (OUD), including medications for OUD (mOUD), pregnant/postpartum individuals have significant obstacles to accessing these life-saving medications. Observations: Current legislation, specifically the Comprehensive Addiction and Recovery Act (CARA), mandates that the Governor of each state has systems in place to identify and address the needs of substance-exposed infants. However, this legislation removed the word "illegal" when defining substance use and left other important words in the law up to each individual state to define. These changes resulted in pregnant/postpartum individuals with OUD who were receiving legally prescribed mOUD, being subject to legal actions. In many states, such notifications result in investigation and punitive actions, which may include the removal of children from the care of postpartum individuals. These state policies have created additional barriers to accessing mOUD for pregnant and/or postpartum individuals. Research has demonstrated that pregnant individuals delay and/or avoid recommended prenatal care or decide to stop taking mOUD altogether, to prevent potential legal and child welfare-related consequences. This situation is problematic as it places individuals at risk of overdose and death and infants at risk of health complications. Importantly, such policies are subject to bias and disproportionately impact individuals of color and those from lower socioeconomic backgrounds. Conclusions and Relevance: The need to address and change the criminalization of pregnant/postpartum substance use laws to not penalize individuals adhering to the recommended standard of evidence-based care is urgent. Specific recommendations include: not relying on toxicology testing, reinstating "illegal/non-prescribed" language in legislation, implementing Plans of Safe Care, use of a two "track" reporting system, and federal support for states complying with Child Abuse Prevention and Treatment Act Reauthorization of 2010 (CAPTA) laws, increasing resources to improve outcomes for infants/postpartum individuals with OUD, and additional mandated training to educate key individuals, such as hospital/outpatient clinic providers and child-welfare workers.

Complex decision-making of people's use of opioid agonist therapy during pregnancy: Troubling the concept of 'non-compliance'

Clinical guidelines strongly recommend that pregnant people with opioid use disorder be offered Opioid Agonist Therapy (OAT); however, access to and retention in substance use services are influenced by a multitude of factors. We conducted 25 semi-structured qualitative interviews with pregnant and recently pregnant people who used opioids or OAT before their pregnancy. Participants were recruited from various health and social services, through social media and by word of mouth. For analysis, we used a voice-centred relational method; each transcript was read four times looking for different levels of influence in participants' stories (i.e., individual, interpersonal, societal). The participant's narratives highlighted how they navigated the expectations of 'good patient' and 'good mother.' We identified four trajectories of OAT use during pregnancy: two that represent 'compliance' and two that represent 'non-compliance.' While compliant patients used OAT out of concern for the health of their fetus and because it was medically recommended, the decision to not use OAT occurred in the context of weighing multiple, not only medical risks. Based on past experiences navigating health and social services, some participants made potentially medically risky decisions to avoid negative interactions with health and social care. Our results underscore that health and social service delivery is shaped by paternalistic measures aimed at controlling the behaviour of pregnant people who use drugs and reinforce the need for alternative approaches beyond control to foster more inclusive, supportive, and empathetic support for women who use drugs.

A cross-sectional study of differences in medication for opioid use disorder receipt among pregnant people enrolled in Medicaid in Oregon, United States

BACKGROUND AND AIMS

Medication is the gold standard to support a healthy pregnancy for pregnant people with opioid use disorder (OUD). This study measured inequities and differences in OUD medication treatment among pregnant people in Oregon, USA.

DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS

Our study population consisted of Medicaid enrollees across the US state of Oregon who had at least one live hospital birth between 2012 and 2020 and one diagnosis of OUD prenatally (n = 4363). We measured differences in demographic characteristics (age, race, ethnicity, location) among those with and without medication for OUD in the prenatal through 3-months postpartum period (any medication use, and by type), and compared exclusive methadone versus buprenorphine receipt. We report unadjusted and adjusted odds ratios.

FINDINGS

Adjusted odds ratios for medication for OUD were lower among American Indian/Alaska Native pregnant people compared with White pregnant people [adjusted odds ratio (aOR) 0.59 (95% confidence interval [CI] = 0.42, 0.83)], younger pregnant people compared with those aged 30-34 years [aOR, ages 15-19: 0.1 (95 CI = 0.06, 0.18); aOR, ages 20-24: 0.58 (95 CI = 0.49, 0.69)] and rural pregnant people compared with those in urban communities [aOR 0.58 (95 CI = 0.5-0.67)]. Rural pregnant people with OUD also had lower odds of methadone receipt [aOR 0.23 (95 CI = 0.17, 0.3)] and higher odds of buprenorphine receipt [aOR 3.99 (95 CI = 2.97, 5.35)] than other people in this study. Among those who received medication, Black pregnant people had increased odds of receiving methadone compared with buprenorphine [aOR 2.09 (95 CI = 1.1-3.97)].

CONCLUSIONS

In Oregon, USA, inequities in receipt of any medication for opioid use disorder were observed among pregnant people who identified as American Indian or Alaska Native, younger than 25, and living in rural communities. Black pregnant people in Oregon, USA, were more likely to receive methadone than buprenorphine.

Labor and Delivery Nurses' Perceptions of Their Colleagues' Attitudes and Behaviors Toward Pregnant Patients with Substance Use

OBJECTIVE

To understand labor and delivery nurses' attitudes and behaviors toward pregnant patients with substance use disorders or mental health concerns. Suicide and overdose are among the leading causes of preventable maternal deaths nationwide, underscoring the urgency of addressing issues related to supporting pregnant patients with behavioral health concerns.

DESIGN

We surveyed a subpopulation of nurses in Colorado to understand attitudes and behaviors toward patients with substance use disorders and mental health concerns.

RESULTS

Survey respondents were 154 nurses from 14 Colorado hospitals that represented 45% of the state's 2022 births: Half of the nurses reported their colleagues have negative attitudes and nearly one-third reported negative behaviors toward patients who disclose substance use. Qualitative data revealed instances of positive behaviors, with examples of supportive clinical care and resource provision for patients disclosing substance use. Negative examples described mistrust, negative attitudes, and lack of compassion toward patients, as well as instances of substandard clinical care.

CONCLUSIONS

In this study, negative attitudes and behaviors were noted by some labor and delivery nurses by their colleagues toward pregnant patients with substance use disorders. Positive behaviors were also reported. Comprehensive processes to decrease negative behaviors are necessary to improve care for pregnant patients and to decrease maternal mortality from suicide and accidental overdose.

Buprenorphine Treatment in Pregnancy and Maternal-Infant Outcomes

Importance

Opioid use disorder (OUD) in pregnancy has grown in the US. Buprenorphine, a medication to treat OUD, may improve pregnancy outcomes; however, most pregnant individuals do not receive it. Research evaluating buprenorphine use in pregnancy, its effects on the maternal-infant dyad, and in comparison to no treatment is limited.

Objective

To determine if treatment with buprenorphine for opioid use disorder in pregnancy is associated with improved maternal and infant outcomes compared to no treatment among mothers with OUD.

Design, Setting, and Participants

This retrospective cohort study included maternal-infant dyads continuously enrolled in the Tennessee Medicaid program from 20 weeks' estimated gestational age to 6 weeks post partum between 2010 and 2021. Medicaid administrative was linked to birth and death certificates. Data analysis was conducted from April to October 2024.

Exposure

Buprenorphine use during pregnancy.

Main Outcomes and Measures

Adverse pregnancy outcomes included preterm birth, neonatal intensive care unit (NICU) admission, infant death, severe maternal morbidity (SMM), intensive care unit admission, and maternal death. Logistic regression and propensity scores with overlap weighting were used to calculate adjusted predicted probabilities for adverse outcomes.

Results

Among 14 463 maternal-infant dyads, 7469 (51.6%) received buprenorphine treatment (median [IQR] maternal age, 27 [24-31] years). There was a statistically significant lower rate of adverse pregnancy outcomes among dyads treated with buprenorphine compared to untreated dyads (25.4% vs 30.8%; P < .001); the treatment group also had a lower rate of SMM events (5.4% vs 6.9%; P < .001), preterm births (14.1% vs 20.0%; P < .001), and NICU admissions (15.2% vs 17.2%; P = .001). In adjusted analyses, those with buprenorphine treatment had a 5.1 percentage point (pp; 95% CI, 3.5-6.7 pp) lower probability of any adverse outcomes, including a 1.2 pp (95% CI, 0.4-2.1 pp) lower probability of SMM, 1.7 pp (95% CI, 0.4-2.9 pp) lower probability of NICU admission, and 5.3 pp (95% CI, 4.0-6.6 pp) lower probability of preterm birth. The number needed to treat to avoid an adverse pregnancy outcome was 20.

Conclusions and Relevance

In this cohort study of pregnant individuals with OUD, buprenorphine treatment was associated with improved outcomes for the mother and infant, underscoring the need to improve access to treatment nationwide.

Changes in Specialty Crisis Services Offered Before and After the Launch of the 988 Suicide and Crisis Lifeline

Importance

The launch of the 988 Suicide and Crisis Lifeline (988) in July 2022 aimed to enhance access to crisis mental health services by replacing the National Suicide Prevention Lifeline with a more memorable number and expanding the Lifeline scope beyond suicide. However, 988's success relies on the availability of community crisis services.

Objective

To examine whether the launch of 988 was associated with the availability of crisis services.

Design, Setting, and Participants

This cohort study characterized trends in crisis services offered by US mental health treatment facilities (MHTFs) from November 1, 2021, through June 30, 2023. Longitudinal data were from the Mental Health and Addiction Treatment Tracking Repository, which contains daily instances from the Substance Abuse and Mental Health Services Administration's Behavioral Health Treatment Locator. The analysis includes licensed MHTFs that completed the National Substance Use and Mental Health Services Survey. Proportions of facilities offering 4 specific crisis services were calculated nationally and at the state level. Mixed-effects logistic regression was used to assess changes in availability of each crisis service after the launch of 988, controlling for MHTF characteristics.

Exposure

Launch of 988 in July 2022.

Main Outcomes and Measures

Outcomes were the availability of mobile crisis response services, psychiatric emergency walk-in services, suicide prevention services, or peer support services.

Results

Across 15 623 MHTFs (184 769 observations; 79 268 before and 105 501 after the 988 launch), the largest changes were observed for availability of peer support services, which increased from 39% (n = 31 170) before to 42% (n = 44 630) after the 988 launch (P < .001), and emergency psychiatric walk-in services, which decreased from 32% (n = 25 684) before to 29% (n = 30 300) after the 988 launch (P < .001). When controlling for MHTF characteristics, after the 988 launch, the odds of peer support availability increased 1.3% per month (odds ratio, 1.013; 95% CI, 1.009-1.018), and the odds of emergency psychiatric walk-in service availability decreased by 0.6% per month (odds ratio, 0.994; 95% CI, 0.989-0.999). Availability of other service types also decreased at the national level, with mobile crisis response decreasing from 22% (n = 17 071) before to 21% (n = 22 023) after the 988 launch and suicide prevention decreasing from 69% (n = 54 933) before to 68% (n = 71 905) after the 988 launch. Significant variation across states was observed in service availability trends before and after the 988 launch.

Conclusions and Relevance

This study found that the launch of 988 did not coincide with significant and equitable growth in the availability of most crisis services except for a small increase in peer support services. These findings suggest that strategies are needed to boost the financing and availability of crisis services to reduce disparities and increase 988's likelihood of success.

Rural-urban differences in substance use during pregnancy

PURPOSE

Drug overdoses are now a leading cause of pregnancy-related deaths in the United States. Despite evidence of rural-urban disparities in substance use, there has not yet been a nationally representative examination of rural-urban differences in perinatal substance use. This study provides a comprehensive examination of rural-urban disparities in perinatal substance use.

METHODS

This study uses cross-sectional data to examine 3499 pregnant women from the 2015-2019 National Survey on Drug Use and Health (NSDUH). Rural (nonmetro)-urban (metro) differences in past-month tobacco use, alcohol use, binge drinking, illicit drug use, and marijuana use were examined using Rao-Scott chi-square tests and multivariable logistic regression using complex survey weights.

FINDINGS

In 2015-2019, past-month tobacco use varied geographically, as rural pregnant participants were more likely to have used tobacco than those in small and large urban areas (24.7% vs. 15.2% and 8.2%, respectively, p < 0.0001). After controlling for sociodemographic and health care needs, rural pregnant women were more likely to report tobacco use (adjusted odds ratio [aOR]: 2.32, 95% confidence interval [CI]: 1.66, 3.25) but were less likely to report alcohol use (aOR: 0.58, 95% CI: 0.34, 0.98) than their large urban counterparts. There were no rural-urban differences in the odds of binge drinking, illicit drug use, or marijuana-only use in the past month.

CONCLUSIONS

Geographic variations in perinatal substance use highlight the need for tailored interventions targeting substance use prevention during pregnancy, prioritizing tobacco in rural areas and alcohol in urban areas.

Patterns of Medication for Opioid Use Disorder During Pregnancy, 7 Clinical Sites, MATernaL and Infant clinical NetworK (MAT-LINK), 2014-2021

OBJECTIVES

To describe patterns of medication for opioid use disorder (MOUD) during pregnancies in the opioid use disorder (OUD) cohort of MAT-LINK, a sentinel surveillance network of pregnancies at US clinical sites.

METHODS

Seven clinical sites providing care for pregnant people with OUD collected electronic health record data. Pregnancies were included in this analysis if (1) the pregnancy outcome occurred between January 2014 and August 2021, (2) the person had OUD, and (3) there was any electronic health record-documented MOUD during pregnancy. Analyses describing MOUD type, demographic characteristics, and timing during pregnancy were performed.

RESULTS

Among 3911 pregnancies with any documented MOUD, more than 90% of pregnancies with methadone were to publicly insured people, which was greater than percentages for pregnancies with other MOUD. Buprenorphine with naloxone and naltrexone were two MOUD types that were increasingly common among pregnant people in recent years. In most pregnancies, prenatal care and MOUD were first documented in the same trimester. During the first, second, and third trimesters, there were 37%, 61%, and 91% of pregnancies with MOUD, respectively. Approximately 87% (n = 3412) had only 1 documented MOUD type, versus 2 or 3 types. However, discontinuity in MOUD across trimesters was still observed.

CONCLUSIONS

In MAT-LINK's OUD cohort, the overall frequency of MOUD improved over the course of pregnancy. Contextual factors, such as insurance status and year of pregnancy outcome, might influence MOUD type. Prenatal care and MOUD might be facilitators for one another; however, there are still opportunities to improve early linkage and continuous access to both prenatal care and MOUD during pregnancy.

Overcoming barriers to traditional care delivery and pharmacy challenges: a qualitative study of buprenorphine, telehealth, and a digital therapeutic for opioid use disorder

BACKGROUND

The opioid epidemic contributes to increasing morbidity and mortality due to drug overdoses in the US, but barriers to traditional opioid use disorder (OUD) treatment prevent a vast majority of patients from accessing quality care and medications for opioid use disorder (MOUDs). Public Health Emergency (PHE) provisions during the COVID-19 pandemic relaxed in-person evaluation requirements for buprenorphine inductions, allowing for the expansion of telehealth care to OUD populations. This qualitative study explores patients' experiences with a novel digital therapeutic telehealth program with buprenorphine for OUD.

METHOD

Semi-structured qualitative interviews were conducted with a sub-sample (n = 15) of participants from a larger feasibility and acceptability pilot. Interviews explored participants' opioid use, OUD treatment history, previous MOUD experience, barriers to previous treatment attempts, medication adherence, counseling experience, treatment satisfaction, and comparisons between current and previous treatments.

RESULTS

Barriers to care in previous OUD treatment episodes included logistical and program related inconveniences (program attendance requirements, commute distances, transportation, appointment wait times, and clinic patient volumes), financial strain, unreliable access to prescribers, residential program experiences, and the availability of detox-only based treatments. Participants with previous treatment experiences contrasted these barriers with the virtual delivery study setting and reported that the characteristics of telehealth OUD care facilitated improved engagement and retention by overcoming many of these barriers through: no transportation requirements, open and flexible appointment scheduling, appointment times confined to care team meetings only, absence of provider availability concerns, and the ability to receive buprenorphine maintenance care from home. The primary barrier noted for virtual care delivery was the fulfillment of buprenorphine prescriptions from local pharmacies.

CONCLUSION

A novel digital therapeutic telehealth program was reported to overcome almost all of the barriers encountered by participants during previous traditional OUD treatment episodes, contributing to a growing body of evidence supporting the permanency of current PHE expansions for OUD telehealth care. Findings also emphasize the importance of coming to workable policy solutions for buprenorphine supply threshold constraints on local pharmacies that unintentionally constrict access for telehealth and other OUD patients.

Trends in and characteristics of drug overdose morbidity among pregnant and postpartum individuals in California, 2010-2018

Fatal drug overdoses among pregnant and postpartum individuals have risen dramatically over the past 10 years. Trends in and characteristics of nonfatal drug overdoses in this population, however, remain unknown, despite the importance of this outcome for maternal and infant health. We used statewide, longitudinally linked hospital and emergency department administrative claims data from California to characterize the incidence, trends, drug type involvement, and sociodemographic disparities in pregnancy-associated drug overdose between 2010 and 2019. Generalized linear models accounting for multiple deliveries per individual were used to test for trends; descriptive statistics were used for other study analyses. Of California individuals with a live delivery between 2010 and 2018, approximately 0.2% had a pregnancy-associated drug overdose. Nonfatal overdoses were nearly 60 times more common than fatal overdoses. Incidence of overdoses involving stimulants increased in frequency, while incidence of overdoses involving sedative/hypnotic drugs and psychotropic medications decreased in frequency. Risk of overdose was substantially higher among delivering individuals who were young, non-Hispanic Black, Medicaid patients, or who lived in nonmetropolitan areas. Ongoing public health surveillance of pregnancy-associated nonfatal drug overdose events and clinical interventions to reduce these events are critical for prevention efforts.

Opioid Use Disorder and Neonatal Opioid Withdrawal Syndrome in Rural Environments

Rural communities in the United States have seen a steep rise in opioid use disorder (OUD) during pregnancy, with a parallel increase in neonatal opioid withdrawal syndrome (NOWS). The birthing person-infant dyads affected by OUD and NOWS in rural areas face many barriers to accessing care. Innovative approaches have proven successful in improving health outcomes for affected birthing persons and newborns, but more work is needed to continue to improve access to prevention, treatment, and additional support services for this vulnerable population.

"Just Google It": A Qualitative Study of Reproductive-Age Women's Stigmatizing Experiences When Accessing Buprenorphine for Opioid Use Disorder

INTRODUCTION

The opioid crisis is increasingly impacting women, and access to buprenorphine to treat opioid use disorder (OUD) is limited by the number of providers authorized to dispense it. Stigma can represent an additional barrier to accessing medication for OUD. Qualitative data were analyzed from a randomized simulated patient field experiment of calls to outpatient buprenorphine-waivered providers.

OBJECTIVES

Our primary objective was to analyze descriptions of barriers women encountered when seeking buprenorphine to treat OUD to account for differential experiences based on pregnancy status, race/ethnicity, and insurance status. Our secondary objective was to identify potential intervention strategies to improve access to medications for OUD.

METHODS

The Health Stigma and Discrimination framework was applied to guide our study of barriers encountered by women seeking OUD treatment. Callers representing vocal features of white, Hispanic, and Black women and simulating ages 25-30 were randomized to represent combinations of public/private insurance and pregnant/not pregnant characteristics. Callers contacted 5,944 buprenorphine-waivered providers requesting to make an appointment to obtain medications to treat OUD. There were 15,358 free-text comments in response to the prompt "Please give an objective play-by-play of the description of what happened in this conversation." Data were coded and analyzed using an iterative inductive-deductive approach. We consulted six community experts, women who had sought treatment for OUD, to inform our study findings and identify patient-driven solutions to address barriers.

RESULTS

Findings revealed that experiences of interpersonal stigma were connected to systemic barriers such as stigmatizing behaviors within institutional cultures and normative practices. Key results indicate that race/ethnicity, pregnancy status, and insurance status influence experiences of stigma. For instance, Black and Hispanic callers reported experiencing race-based microaggressions, and pregnant women faced additional judgment and reduced access to treatment. Qualitative findings and community experts' insights underscored the necessity for the adoption of anti-stigma policies and practices that facilitate easier access to medications for OUD across socioecological levels.

CONCLUSIONS

The findings demonstrate a need for multilevel interventions to improve women's access to medications for OUD.

Association of Opioid Use Disorder-Related Service Trajectories during Pregnancy and Postpartum Health Service Use: A Group-Based Multitrajectory Modeling Study

OBJECTIVE

The aim of the study was to examine the relationship between opioid use disorder (OUD)-related service trajectories during pregnancy and postpartum emergency department (ED) and hospitalizations.

METHODS

We used the Merative MarketScan Commercial Claims and Encounters Database (2013-2021) to identify a cohort of pregnant individuals with OUD. We used group-based multitrajectory modeling to identify opioid-related treatment and service trajectories during pregnancy and examined their association with postpartum ED and hospital utilization.

RESULTS

Seven opioid-related treatment and service trajectories were identified in our cohort of 2,531 pregnant individuals with OUD. Compared to individuals initiating medications for OUD (MOUD) halfway through pregnancy but maintaining high adherence without ancillary services, those receiving only services throughout pregnancy had a higher risk of postpartum ED visits (HRED = 1.34). This latter group also faced significantly higher risks of postpartum hospitalizations, compared to adherent MOUD use (proportion of days covered ≥80%) alone, both throughout or in the latter half of pregnancy (HRHOS = 1.93; HRHOS = 1.60), and patients without MOUD or services (HRHOS = 1.43). Individuals initiating MOUD late in pregnancy with poor adherence and infrequent service use faced significantly higher risks of postdelivery hospitalization compared to consistent MOUD users throughout pregnancy (HRHOS = 2.33), or in the latter half, with or without services (HRHOS = 2.02; HRHOS = 1.93), and those not receiving MOUD or services (HRHOS = 1.73).

CONCLUSIONS

Adherent MOUD use either throughout pregnancy or the latter half of pregnancy, irrespective of other service use, was associated with better postpartum outcomes defined by fewer ED visits and hospitalizations.

Services for perinatal patients with opioid use disorder: a comprehensive Baltimore City-wide 2023 assessment

BACKGROUND

Overdose is a leading cause of maternal mortality; in response, maternal mortality review committees have recommended expanding substance use disorder (SUD) screening, improving collaboration between obstetric and SUD treatment providers, and reducing fragmentation in systems of care. We undertook an analysis of the perinatal SUD treatment landscape in Baltimore, Maryland in order to identify barriers to treatment engagement during pregnancy and the postpartum period and guide system improvement efforts.

METHODS

We conducted a survey of seven birthing hospitals, 31 prenatal care practices, and 108 SUD treatment providers in Baltimore from April-June 2023. Organizations were asked to quantify care for perinatal patients with opioid use disorder (OUD) as well as about screening, service availability, referral practices, and support needed to improve care.

RESULTS

61% of the 145 contacted organizations responded. Birthing hospitals reported caring for pregnant persons with OUD with greater frequency than prenatal care practices or SUD treatment programs. Most birthing hospitals and prenatal care practices reported screening for OUD at intake, but the minority reported using validated tools. Service availability varied by type of organization and type of service. In general, prenatal care practices offered the fewest number of SUD-related services. Most SUD treatment programs that offered buprenorphine or methadone to the general population also offered these medications to pregnant patients. Withdrawal management for comorbid alcohol/benzodiazepine use disorders during pregnancy was more limited. The majority of birthing hospitals and prenatal care practices reported offering neither direct naloxone distribution nor prescriptions. Few SUD treatment programs offered tailored services for perinatal patients or for parents of young children, and many programs do not permit children onsite. Respondents reported high levels of interest in education and consultative support on SUD treatment in pregnancy within obstetric settings and on pregnancy-related medical concerns within SUD programs.

CONCLUSIONS

This project provides a comprehensive picture of services available for treatment of perinatal OUD in a major US city. Results have served as a guide for ongoing citywide system improvement efforts by our project team and offer a model for other jurisdictions hoping to strengthen services for perinatal OUD and reduce maternal mortality.

Trends in maternal opioid use: Statewide differences by sociodemographic characteristics in Florida from 2000 to 2019

BACKGROUND

Maternal opioid use (MOU) remains a public health concern. Studies have demonstrated significant increases in MOU, but estimates using ICD-10-CM or stratified by sociodemographic variables are limited.

OBJECTIVES

Using a statewide, population-based dataset of Florida resident deliveries from 2000 to 2019, we examined the trend of MOU by age, race/ethnicity, education level, and insurance.

METHODS

Florida administrative data was used to conduct a retrospective cohort study. MOU was identified using opioid-related hospital discharge diagnoses documented prenatally or at delivery. Maternal sociodemographic variables were obtained from Florida vital statistics. Joinpoint regression was used to identify statistically significant changes in the trends overall and stratified by sociodemographic variables. Results are presented as annual percentage changes (APC) and 95% confidence intervals.

RESULTS

Our sample included over 3.6 million Florida resident mothers; of which, MOU was identified in 1% (n = 22,828) of the sample. From 2000 to 2019, MOU increased over ten-fold from 8.7 to 94.7 per 10,000 live birth deliveries. MOU increased significantly from 2000 to 2011 (APC: 32.8; 95% CI: 29.4, 36.2), remained stable from 2011 to 2016, and decreased significantly from 2016 to 2019 (APC: 3.9; 95% CI: -6.6, -1.0). However, from 2016 to 2019, MOU increased among non-Hispanic Black mothers (APC: 9.2; 95% CI: 7.5, 11.0), and those ages 30-34 (APC: 2.9; 95% CI: 1.2, 4.6) and 35-39 (APC: 6.4; 95% CI: 4.3, 8.4).

CONCLUSIONS

Accurate prevalence estimates of MOU by sociodemographic factors are necessary to fully understand prevalence trends, describe the burden among sub-populations, and develop targeted interventions.

Association of Daily Doses of Buprenorphine With Urgent Health Care Utilization

Importance

Higher buprenorphine doses may benefit the increasing number of individuals using fentanyl and other synthetic opioids, but there is little empirical evidence on the efficacy of such higher doses.

Objective

To examine the association between higher buprenorphine doses (above 16 mg and 24 mg) and subsequent emergency department (ED) or inpatient service use among patients diagnosed with opioid use disorder.

Design, Setting, and Participants

This cross-sectional study was a retrospective analysis of health data from Optum's deidentified Clinformatics Data Mart Database from 2016 to 2021 for commercially insured individuals aged 18 years or older diagnosed with opioid use disorder (OUD). Eligible participants initiated buprenorphine after at least 90 days of enrollment and were dispensed at least a 14-day supply of buprenorphine. Data were analyzed from September 2023 through February 2024.

Exposures

Maximum buprenorphine dose received by a patient for 14 or more days: more than 24 mg, more than 16 mg to 24 mg, more than 8 mg to 16 mg, or 1 mg to 8 mg.

Main Outcomes and Measures

Days from initiation of the maximum buprenorphine dose to an ED or inpatient visit for a behavioral health diagnosis, controlling for patient demographics, comorbid conditions, time to reaching maximum dose, buprenorphine discontinuation, and pre-buprenorphine health care utilization.

Results

A total of 35 451 individuals with an OUD diagnosis who began buprenorphine treatment were identified (mean [SD] age, 46.2 [15.1] years; 20 983 male [59.2%]; 3326 Black [9.4%], 2411 Hispanic [6.8%], 26 712 White [75.3%]). The most common dose was more than 8 mg to 16 mg daily (14 802 patients [42.9%]), with 9669 patients (27.3%) in the 1 mg to 8 mg tier, 10 329 patients (29.1%) in the 8 mg to 16 mg tier, and 651 patients (1.8%) in the tier receiving more than 24 mg. Among all patients receiving buprenorphine, 12.5% experienced an ED or inpatient visit. Survival analysis shows patients receiving doses more than 24 mg and between 16 mg to 24 mg had longer times to ED or inpatient use than patients receiving from 8 mg to 16 mg (time ratio [TR], 1.11; 95% CI, 1.02 to 1.20) and more than 24 mg (TR, 1.37; 95% CI, 1.04 to 1.81). Findings for doses above 16 mg daily were consistent for observation windows as short as 365 days (more than 24 mg: TR, 1.48; 95% CI, 1.01-2.18; more than 16 mg to 24 mg: TR, 1.19; 95% CI, 1.06-1.32).

Conclusions and Relevance

These findings contribute to the sparse empirical research regarding potential benefits of higher-dose buprenorphine treatment of individuals with OUD. Clinicians should be aware of the potential effects of higher buprenorphine doses on health care utilization while policymakers work to ensure equitable access to individuals who could potentially benefit from higher doses.

Multiple marginalized identities: A qualitative exploration of intersectional perinatal experiences of birthing people of color with substance use disorder in Massachusetts

INTRODUCTION

Racial and ethnic inequities persist in receipt of prenatal care, mental health services, and addiction treatment for pregnant and postpartum individuals with substance use disorder (SUD). Further qualitative work is needed to understand the intersectionality of racial and ethnic discrimination, stigma related to substance use, and gender bias on perinatal SUD care from the perspectives of affected individuals.

METHODS

Peer interviewers conducted semi-structured qualitative interviews with recently pregnant people of color with SUD in Massachusetts to explore the impact of internalized, interpersonal, and structural racism on prenatal, birthing, and postpartum experiences. The study used a thematic analysis to generate the codebook and double coded transcripts, with an overall kappa coefficient of 0.89. Preliminary themes were triangulated with five participants to inform final theme development.

RESULTS

The study includes 23 participants of diverse racial/ethnic backgrounds: 39% mixed race/ethnicity (including 9% with Native American ancestry), 30% Hispanic or Latinx, 26% Black/African American, 4% Asian. While participants frequently names racial and ethnic discrimination, both interpersonal and structural, as barriers to care, some participants attributed poor experiences to other marginalized identities and experiences, such as having a SUD. Three unique themes emerged from the participants' experiences: 1) Participants of color faced increased scrutiny and mistrust from clinicians and treatment programs; 2) Greater self-advocacy was required from individuals of color to counteract stereotypes and stigma; 3) Experiences related to SUD history and pregnancy status intersected with racism and gender bias to create distinct forms of discrimination.

CONCLUSION

Pregnant and postpartum people of color affected by perinatal SUD faced pervasive mistrust and unequal standards of care from mostly white healthcare staff and treatment spaces, which negatively impacted their treatment access, addiction medication receipt, postpartum pain management, and ability to retain custody of their children. Key clinical interventions and policy changes identified by participants for antiracist action include personalizing anesthetic plans for adequate peripartum pain control, minimizing reproductive injustices in contraceptive counseling, and addressing misuse of toxicology testing to mitigate inequitable Child Protective Services (CPS) involvement and custody loss.

Addressing Perinatal Substance Use: A Triad Approach Led by the Colorado Perinatal Care Quality Collaborative

Unintentional overdose is a leading driver of maternal death in Colorado. The high volume of maternal deaths from preventable causes lends questions to failures in our clinical and community-based care for pregnant and postpartum people. The Colorado Maternal Mortality Review Committee identified 3 main contributors including stigma in the community and health care system, fragmentation of the health care system, and the need for more clinician training. The Colorado Perinatal Care Quality Collaborative led a 3-pronged intervention to address these challenges and improve perinatal care. The first intervention, the Colorado Alliance for Innovation on Maternal Health Substance Use Disorder quality improvement initiative, partnered with birthing hospitals statewide to institute universal screening and timely referral for individuals at risk of substance use disorder (SUD) and perinatal mood and anxiety disorders. The second intervention, the Improve Perinatal Access, Coordination, and Treatment for Behavioral Health initiative, established a perinatal support network within communities. This program assists individuals with SUD, perinatal mood and anxiety disorders, or social needs to navigate the perinatal period. The third intervention, the Colorado Maternal Overdose Matters Plus program, has enhanced in-hospital access to pharmacotherapy for pregnant and postpartum individuals with SUD through training and technical support. These collaborative initiatives aim to minimize barriers to care by integrating inpatient screening, treatment referrals, pharmacotherapy access, and community care support to mitigate maternal mortality in Colorado.

Geographic and Racial/Ethnic Differences in Access to Methamphetamine Detoxification Services, United States, 2021

INTRODUCTION

Methamphetamine detoxification before entering formal and longer term treatment may have a positive impact on treatment retention and success. Understanding geographic distribution of methamphetamine specialty detox services and differential access by race/ethnicity is critical for establishing policies that ensure equitable access across populations.

METHODS

We used the Mental health and Addiction Treatment Tracking Repository to identify treatment facilities that offered any substance use detoxification in 2021 (N=2346) as well as the census block group in which they were located. We sourced data from the US Census Bureau to identify the percentage of a census block group that was White, Black, and Hispanic. We used logistic regression to model the availability of methamphetamine-specific detox, predicted by the percentage of a block group that was Black and Hispanic. We adjusted for relevant covariates and defined state as a random effect. We calculated model-based predicted probabilities.

RESULTS

Over half (60%) of detox facilities offered additional detox services specifically for methamphetamine. Sixteen states had <10 methamphetamine-specific detox facilities. The predicted probability of methamphetamine-specific detox availability was 60% in census block groups with 0%-9% Black residents versus only 46% in census block groups with 90%-100% Black residents, and was 61% in census block groups with 0%-9% Hispanic residents versus 30% in census block groups with 90%-100% Hispanic residents.

CONCLUSIONS

During an unprecedented national methamphetamine crisis, access to a critical health care service was disproportionately lower in communities that were predominately Black and Hispanic. We orient our findings around a discussion of health disparities, residential segregation, and the upstream causes of the systematic exclusion of minoritized communities from health care.

Telehealth Availability for Mental Health Care During and After the COVID-19 Public Health Emergency

Importance

Telehealth services expanded rapidly during the COVID-19 public health emergency (PHE).

Objective

To evaluate changes in availability of telehealth services at outpatient mental health treatment facilities (MHTFs) throughout the US during and after the COVID-19 PHE.

Design, Setting, and Participants

In this cohort study, callers posing as prospective clients contacted a random sample of 1404 MHTFs drawn from the Substance Abuse and Mental Health Services Administration's Behavioral Health Treatment Locator from December 2022 to March 2023 (wave 1 [W1]; during PHE). From September to November 2023 (wave 2 [W2]; after PHE), callers recontacted W1 participants. Analyses were conducted in January 2024.

Main Outcomes and Measures

Callers inquired whether MHTFs offered telehealth (yes vs no), and, if yes, whether they offered (1) audio-only telehealth (vs audio and video); (2) telehealth for therapy, medication management, and/or diagnostic services; and (3) telehealth for comorbid alcohol use disorder (AUD). Sustainers (offered telehealth in both waves), late adopters (did not offer telehealth in W1 but did in W2), nonadopters (did not offer telehealth in W1 or W2), and discontinuers (offered telehealth in W1 but not W2) were all compared.

Results

During W2, 1001 MHTFs (86.1%) were successfully recontacted. A total of 713 (71.2%) were located in a metropolitan county, 151 (15.1%) were publicly operated, and 935 (93.4%) accepted Medicaid as payment. The percentage offering telehealth declined from 799 (81.6%) to 765 (79.0%) (odds ratio [OR], 0.84; 95% CI, 0.72-1.00; P < .05). Among MHTFs offering telehealth, a smaller percentage in W2 offered audio-only telehealth (369 [49.3%] vs 244 [34.1%]; OR, 0.53; 95% CI, 0.44-0.64; P < .001) and telehealth for comorbid AUD (559 [76.3%] vs 457 [66.5%]; OR, 0.62; 95% CI, 0.50-0.76; P < .001) compared with W1. In W2, MHTFs were more likely to report telehealth was only available under certain conditions for therapy (141 facilities [18.0%] vs 276 [36.4%]; OR, 2.62; 95% CI, 1.10-3.26; P < .001) and medication management (216 facilities [28.0%] vs 304 [41.3%]; OR, 1.81; 95% CI, 1.48-2.21; P < .001). A total of 684 MHTFs (72.0%) constituted sustainers, 94 (9.9%) were discontinuers, 106 (11.2%) were nonadopters, and 66 (7.0%) were late adopters. Compared with sustainers, discontinuers were less likely to be private for-profit (adjusted OR [aOR], 0.28; 95% CI, 0.11-0.68) or private not-for-profit (aOR, 0.26; 95% CI, 0.14-0.48) after adjustment for facility and area characteristics.

Conclusions and Relevance

Based on this longitudinal cohort study of 1001 MHTFs, telehealth availability has declined since the PHE end with respect to scope and modality of services, suggesting targeted policies may be necessary to sustain telehealth access.

Buprenorphine prescribing and treatment accessibility in response to regulation changes due to the COVID-19 public health emergency

BACKGROUND

In 2021, over 80,000 fatal overdoses occurred in the United States. Since 2020, the federal government has enacted multiple regulatory changes around buprenorphine prescribing for opioid use disorder (OUD) to increase access to buprenorphine. This study aims to explore trends in buprenorphine treatment initiation pre- and post-public health emergency to evaluate changes in the context of X-waiver relaxations and telehealth allowances.

METHODS

In a cross-sectional study, all RI residents who filled a buprenorphine prescription at a pharmacy in Rhode Island (RI), Massachusetts, and Connecticut between January 2017 and December 2023 were obtained from the RI Prescription Drug Monitoring Program (PDMP). The study excluded buprenorphine products not approved for OUD treatment from the analysis. Identified individuals had initiated buprenorphine for OUD during the study period if they did not have a prior prescription or if they had >30 days without buprenorphine exposure between their prescriptions. Spearman's rank correlation tests were used to identify significant associations between outcomes and regulation changes.

RESULTS

The average number of patients dispensed buprenorphine did not significantly change over the study period, however the average number of initiates significantly decreased (ρ = -0.38255, p = .0003). The average number of providers prescribing CII-CV substances in RI has increased 3.4 % over the study period. The average percentage of prescribers in the PDMP prescribing buprenorphine for OUD doubled (ρ = 0.96075, p < .0001).

CONCLUSION

Though efforts have been made to increase buprenorphine initiation, buprenorphine initiates remain well below pre-PHE levels. Efforts must continue to eliminate existing barriers to treatment and improve access to individuals seeking treatment.

Substance use during pregnancy: the role of mindfulness in reducing stigma

Stigmatization is a significant healthcare barrier among individuals who utilize substances during pregnancy. Of the 3.6 million U.S. births each year, approximately 10% are affected by perinatal substance use, an estimate which is likely underestimated due to fear of stigma and prosecution. Of those experiencing perinatal substance use, less than 11% receive treatment, while maternal deaths due to overdose during the postpartum period have increased by 81% from 2017 to 2020. Societal perception of non-pregnant individuals experiencing substance use disorders recognizes the biological basis of addiction, whereas for pregnant individuals, societal perception slides into moral failing as the basis of addiction. Many recommendations and guidelines for decreasing substance use stigmatization among non-pregnant and pregnant individuals exist. We focus on the use of mindfulness in recognizing and addressing structural and social stigma within healthcare systems. Mindfulness has been extracted from its roots as an essential element of the Eightfold Path in Buddhism, which largely centers on living ethically to reduce suffering of self and others. By acknowledging the roots of mindfulness, providers can engage mindfully in practices that help identify one's overarching personal values and encourage one to lead healthcare encounters compassion and willingness to support help-seeking community members who are experiencing suffering. A deeper awareness of mindfulness practices within the context of ethical conduct can support healthcare shifts away from criminalization toward more patient- and family-centered approaches.

Availability of Medications for Opioid Use Disorder in Community Mental Health Facilities

Importance

Medications for opioid use disorder (MOUD) are an effective but underutilized treatment. Opioid use disorder prevalence is high among people receiving treatment in community outpatient mental health treatment facilities (MHTFs), but MHTFs are understudied as an MOUD access point.

Objective

To quantify availability of MOUD at community outpatient MHTFs in high-burden states as well as characteristics associated with offering MOUD.

Design, Setting, and Participants

This cross-sectional study performed a phone survey between April and July 2023 among a representative sample of community outpatient MHTFs within 20 states most affected by the opioid crisis, including all Certified Community Behavioral Health Centers (CCBHCs). Participants were staff at 450 surveyed community outpatient MHTFs in 20 states in the US.

Main Outcomes and Measures

MOUD availability. A multivariable logistic regression was fit to assess associations of facility, county, and state-level characteristics with offering MOUD.

Results

Surveys with staff from 450 community outpatient MHTFs (152 CCBHCs and 298 non-CCBHCs) in 20 states were analyzed. Weighted estimates found that 34% (95% CI, 29%-39%) of MHTFs offered MOUD in these states. Facility-level factors associated with increased odds of offering MOUD were: self-reporting being a CCBHC (odds ratio [OR], 2.11 [95% CI, 1.08-4.11]), providing integrated mental and substance use disorder treatment (OR, 5.21 [95% CI, 2.44-11.14), having a specialized treatment program for clients with co-occurring mental and substance use disorders (OR, 2.25 [95% CI, 1.14-4.43), offering housing services (OR, 2.54 [95% CI, 1.43-4.51]), and laboratory testing (OR, 2.15 [95% CI, 1.12-4.12]). Facilities that accepted state-financed health insurance plans other than Medicaid as a form of payment had increased odds of offering MOUD (OR, 1.95 [95% CI, 1.01-3.76]) and facilities that accepted state mental health agency funds had reduced odds (OR, 0.43 [95% CI, 0.19-0.99]).

Conclusions and Relevance

In this study of 450 community outpatient MHTFs in 20 high-burden states, approximately one-third offered MOUD. These results suggest that further study is needed to report MOUD uptake, either through increased prescribing at all clinics or through effective referral models.

Timing of treatment for opioid use disorder among birthing people

BACKGROUND

The number of pregnant women with opioid use disorder (OUD) has increased over time. Although effective treatment options exist, little is known about the extent to which women receive treatment during pregnancy and at what stage of pregnancy care is initiated.

METHODS

Using a national private health insurance claims database, we identified women aged 13-49 who gave birth in 2006-2019 and had an OUD or nonfatal opioid overdose (NFOO) diagnosis during the year prior to or at delivery. We then identified women who received their first OUD treatment prior to or during pregnancy. In this cross-sectional study, we investigated how rates and timing of the initial OUD treatment changed over time. Furthermore, we examined factors associated with early initiation of OUD treatment among birthing people.

RESULTS

Of the 7057 deliveries from 6747 women with OUD or NFOO, 63.3 % received any OUD treatment. Rates of OUD treatment increased from 42.9 % in 2006 to 69 % in 2019. Of those treated, in 2006, 54.5 % received their first treatment prior to conception and 24.2 % initiated care during the 1st trimester. In 2019, 68.9 % received their first treatment prior to conception, and 15.1 % initiated care during the 1st trimester. The percentage of women who were first treated in the 2nd trimester or later decreased from 21.2 % in 2006 to 16.1 % in 2019. Factors associated with early treatment initiation include being 25 years or older (age 25-34: aOR, 1.51, 95 % CI, 1.28-1.78; age 35-49: aOR, 1.82, 95 % CI, 1.39-2.37), living in urban areas (aOR, 1.28; 95 % CI, 1.05-1.56), having pre-existing behavioral health comorbidities such as anxiety disorders (aOR, 1.8; 95 % CI, 1.40-2.32), mood disorders (aOR, 1.63; 95 % CI, 1.02-2.61), and substance use disorder other than OUD (aOR, 2.56; 95 % CI, 2.03-3.32).

CONCLUSION

Overall, rates of OUD treatment increased over time, and more women initiated OUD treatment prior to conception. Despite these improvements, over one-third of pregnant women with OUD/NFOO either received no treatment or did not initiate care until the 3rd trimester in 2019. Future research should examine barriers to OUD treatment initiation among pregnant women.

Clinically defining the opioid-exposed birthing person and infant as a dyad to support bedside care, surveillance, and research

Introduction

An increased incidence of maternal opioid use disorder (OUD) and neonatal abstinence syndrome (NAS) has prompted recommendations supporting a dyadic approach to care for birthing persons and their infants. However, there are no consensus guidelines outlining how the dyad is clinically defined.

Methods

To examine how the opioid-exposed birthing person-infant dyad has been defined for purposes of data collection and research, a literature review applying the RAND/UCLA Appropriateness Method was conducted.

Results

The search yielded 320 abstracts, with 110 articles identified as having a dyadic focus. While no articles included a specific definition for the dyad, 33 (30%) contained a descriptive reference to the birthing person-infant dyad. Thematic analysis revealed eight recurring elements characteristic of the dyad: (1) engagement, (2) communication, (3) bonding, (4) attachment, (5) mutual responsiveness, (6) reciprocity, (7) synchrony, and (8) attunement. Integrating these elements revealed the interactional relationship between the opioid-exposed birthing person and infant as the foundational principle that defines the dyad.

Discussion

This definition shifts the focus of the opioid-exposed dyad from two individual patient populations to an interactional relationship that has broad applicability for clinical use, public health data collection, and research considerations.

Risk of Death at 1 Year Following Postpartum Opioid Exposure

OBJECTIVE

Opioids are commonly prescribed to women for acute pain following childbirth. Postpartum prescription opioid exposure is associated with adverse opioid-related morbidities but the association with all-cause mortality is not well studied. This study aimed to examine the association between postpartum opioid prescription fills and the 1-year risk of all-cause mortality among women with live births.

METHODS

In a retrospective cohort study of live births among women enrolled in Tennessee Medicaid (TennCare) between 2007 and 2015, we compared women who filled two or more postpartum outpatient opioid prescriptions (up to 41 days of postdelivery discharge) to women who filled one or fewer opioid prescription. Women were followed from day 42 postdelivery discharge through 365 days of follow-up or date of death. Deaths were identified using linked death certificates (2007-2016). We used Cox's proportional hazard regression and inverse probability of treatment weights to compare time to death between exposure groups while adjusting for relevant confounders. We also examined effect modification by delivery route, race, opioid use disorder, use of benzodiazepines, and mental health condition diagnosis.

RESULTS

Among 264,135 eligible births, 216,762 (82.1%) had one or fewer maternal postpartum opioid fills and 47,373 (17.9%) had two or more fills. There were 182 deaths during follow-up. The mortality rate was higher in women with two or more fills (120.5 per 100,000 person-years) than in those with one or fewer (57.7 per 100,000 person-years). The risk of maternal death remained higher in participants exposed to two or more opioid fills after accounting for relevant covariates using inverse probability of treatment weighting (adjusted hazard ratio: 1.46 [95% confidence interval: 1.01, 2.09]). Findings from stratified analyses were consistent with main findings.

CONCLUSION

Filling two or more opioid prescriptions during the postpartum period was associated with a significant increase in 1-year risk of death among new mothers.

KEY POINTS

· Opioid prescribing in the postpartum period is common.. · Prior studies show that >1 postnatal opioid fill is associated with adverse opioid-related events.. · > 1 opioid fill within 42 days of delivery was associated with an increase in 1-year risk of death..

Trends and Disparities in Perinatal Opioid Use Disorder Treatment in Medicaid, 2007-2012

We described Medicaid-insured women by receipt of perinatal opioid use disorder (OUD) treatment; and trends and disparities in treatment. Using 2007 to 2012 Medicaid Analytic eXtract data from 45 states and D.C., we identified deliveries among women with OUD. Regressions modeled the association between patient characteristics and receipt of any OUD treatment, medication for OUD (MOUD), and counseling alone during the perinatal period. Rates of any OUD treatment and MOUD for women with perinatal OUD increased over the study period, but trends differed by subgroup. Compared with non-Hispanic White women, Black and American Indian/Alaskan Native (AI/AN) women were less likely to receive any OUD treatment, and Black women were less likely to receive MOUD. Over time, the disparity in receipt of MOUD between Black and White women increased. Overall gains in OUD treatment were driven by improvements in perinatal OUD care for White women and obscured disparities for Black and AI/AN women.

Integrated Care for Pregnant and Parenting People With Substance Use

Caring for pregnant people with substance use requires knowledge about specific substances used, treatment options, and an integrated, trauma-informed care team. This chapter will discuss crucial information for clinicians regarding evidence-based practice for screening, intervention, and ongoing support for pregnant people and their families impacted by substance use.

Substance use and treatment characteristics among pregnant and non-pregnant females, 2015-2019

INTRODUCTION

In the United States (US), pregnant females who use substances face increased morbidity and mortality risks compared to non-pregnant females. This study provides a national snapshot of substance use and treatment characteristics among US reproductive-aged females, including those who are pregnant.

METHODS

Our sample included females aged 15-44 years (n=97,830) from the 2015-2019 National Survey on Drug Use and Health (NSDUH) data. We calculated weighted percentages of past-month alcohol or drug use and past-year substance use disorder (SUD), stratified by pregnancy status. We also calculated weighted percentages of past-year treatment setting and payer. Pearson chi-square tests were conducted to determine if percentages were statistically significantly different.

RESULTS

Compared to non-pregnant females, pregnant females had lower prevalence of past-month illicit drug use excluding cannabis (1.6% vs. 4.3%, p<0.01), cannabis use (5.3% vs. 12.5%, p<0.01), binge drinking (4.5% vs. 29.3%, p<0.01) and past-year SUD (7.1 vs. 8.8%, p<0.01). Less than 13% of females with SUD received treatment regardless of pregnancy status, but treatment use was higher among pregnant females compared to non-pregnant females (12.8% vs. 10.5%). However, there were no statistically significant differences in past-year treatment use, setting, or treatment payer.

DISCUSSION

The prevalence of substance use and SUD was lower among pregnant females compared to non-pregnant females in 2015-2019. Low uptake of substance use treatment suggests that barriers exist to treatment-seeking among reproductive-aged women. Further exploration of stigma, payment, and access to treatment, and how they differ by pregnancy status, is needed.

Co-Locating Obstetrics and Addiction Medicine Clinics to Improve Attendance in Services for Pregnant People with Opioid Use Disorder

Objective

Pregnant people receiving treatment for opioid use disorders (OUD) are at significant risk of return to use during the postpartum period. Recently, practice groups and other national organizations have called for the co-location of addiction medicine and obstetric care to reduce the burden on pregnant and postpartum people with OUD associated with engaging in treatment. This paper examines the effectiveness of co-locating services in retaining pregnant people with OUD in care following childbirth.

Methods

A records review of pregnant people receiving medication for OUD between 2012 and 2017 in stand-alone addiction medicine clinic (n = 23) and from 2017 to 2021 following the creation of an integrated addiction medicine-obstetric care clinic (n = 67) was conducted to compared rates of attendance in both obstetric and addiction medicine services.

Results

Findings from this study suggest that individuals receiving services in a co-located clinic had significantly fewer missed appointments during the postpartum period relative to individuals who sought care at separate addiction medicine and obstetric care clinics.

Conclusions

Results from this study support the potential for co-locating clinics to reduce barriers to accessing obstetric and addiction medicine services, as well as support continued attendance in care across a vulnerable period.

Buprenorphine use and setting type among reproductive-aged women self-reporting nonmedical prescription opioid use

INTRODUCTION

Screening for opioid misuse and treatment for opioid use disorder are critical for reducing morbidity and mortality. We sought to understand the extent of self-reported past 30-day buprenorphine use in various settings among women of reproductive age with self-reported nonmedical prescription opioid use being assessed for substance use problems.

METHODS

The study collected data from individuals being assessed for substance use problems using the Addiction Severity Index-Multimedia Version in 2018-2020. We stratified the sample of 10,196 women ages 12-55 self-reporting past 30-day nonmedical prescription opioid use by buprenorphine use and setting type. We categorized setting types as: buprenorphine in specialty addiction treatment, buprenorphine in office-based opioid treatment, and diverted buprenorphine. We included each woman's first intake assessment during the study period. The study assessed number of buprenorphine products, reasons for using buprenorphine, and sources of buprenorphine procurement. The study calculated frequency of reasons for using buprenorphine to treat opioid use disorder outside of a doctor-managed treatment, overall and by race/ethnicity.

RESULTS

Overall, 25.5 % of the sample used buprenorphine in specialty addiction treatment, 6.1 % used buprenorphine prescribed in office-based treatment, 21.7 % used diverted buprenorphine, and 46.7 % reported no buprenorphine use during the past 30 days. Among women who reported using buprenorphine to treat opioid use disorder, but not as part of a doctor-managed treatment, 72.3 % could not find a provider or get into a treatment program, 21.8 % did not want to be part of a program or see a provider, and 6.0 % reported both; a higher proportion of American Indian/Alaska Native women (92.1 %) reported that they could not find a provider or get into a treatment program versus non-Hispanic White (78.0 %), non-Hispanic Black (76.0 %), and Hispanic (75.0 %) women.

CONCLUSIONS

Appropriate screening for nonmedical prescription opioid use to assess need for treatment with medication for opioid use disorder is important for all women of reproductive age. Our data highlight opportunities to improve treatment program accessibility and availability and support the need to increase equitable access for all women.

County-level Factors and Treatment Access Among Insured Women With Opioid Use Disorder

BACKGROUND

An over 40% increase in overdose deaths within the past 2 years and low levels of engagement in treatment call for a better understanding of factors that influence access to medication for opioid use disorder (OUD).

OBJECTIVE

To examine whether county-level characteristics influence a caller's ability to secure an appointment with an OUD treatment practitioner, either a buprenorphine-waivered prescriber or an opioid treatment program (OTP).

RESEARCH DESIGN AND SUBJECTS

We leveraged data from a randomized field experiment comprised of simulated pregnant and nonpregnant women of reproductive age seeking treatment for OUD among 10 states in the US. We employed a mixed-effects logistic regression model with random intercepts for counties to examine the relationship between appointments received and salient county-level factors related to OUD.

MEASURES

Our primary outcome was the caller's ability to secure an appointment with an OUD treatment practitioner. County-level predictor variables included socioeconomic disadvantage rankings, rurality, and OUD treatment/practitioner density.

RESULTS

Our sample comprised 3956 reproductive-aged callers; 86% reached a buprenorphine-waivered prescriber and 14% an OTP. We found that 1 additional OTP per 100,000 population was associated with an increase (OR=1.36, 95% CI: 1.08 to 1.71) in the likelihood that a nonpregnant caller receives an OUD treatment appointment from any practitioner.

CONCLUSIONS

When OTPs are highly concentrated within a county, women of reproductive age with OUD have an easier time securing an appointment with any practitioner. This finding may suggest greater practitioners' comfort in prescribing when there are robust OUD specialty safety nets in the county.

Differences in medicaid expansion effects on buprenorphine treatment utilization by county rurality and income: A pharmacy data claims analysis from 2009-2018

Background

Although use of buprenorphine for treating opioid use disorder increased over the past decade, buprenorphine utilization remains limited in lower-income and rural areas. We examine how the Affordable Care Act Medicaid expansion influenced buprenorphine initiation rates by county income and evaluate how associations differ by county rural-urban status.

Methods

This study used nationwide 2009-2018 IQVIA retail pharmacy data and a comparative interrupted time series framework-a hybrid framework combining regression discontinuity and difference-in-difference approaches. We used piecewise linear estimation to quantify changes in buprenorphine initiation rates before and after Medicaid expansion.

Results

The sample included observations from 376,704 county-months. We identified 5,227,340 new buprenorphine treatment episodes, with an average of 9.2 new buprenorphine episodes per month per 100,000 county residents. Among urban counties, those with the lowest median incomes experienced significantly larger increases in buprenorphine initiation rates associated with Medicaid expansion than counties with higher median incomes (5-year rates difference est=3525.3, se=1695.3, p = 0.04). However, among rural counties, there was no significant association between buprenorphine initiation rates and county median income after Medicaid expansion (5-year rates difference est=979.0, se=915.8, p = 0.29).

Conclusions

Medicaid expansion was associated with a reduction in income-related buprenorphine disparities in urban counties, but not in rural counties. To achieve more equitable buprenorphine access, future policies should target low-income rural areas.

Access to Prenatal Care Among Patients With Opioid Use Disorder in Florida: Findings From a Secret Shopper Study

OBJECTIVE

To evaluate access to prenatal care for pregnant patients receiving medication for opioid use disorder (MOUD) under Medicaid coverage in Florida.

METHODS

A cross-sectional, secret shopper study was conducted in which calls were made to randomly selected obstetric clinicians' offices in Florida. Callers posed as a 14-week-pregnant patient with Medicaid insurance who was receiving MOUD from another physician and requested to schedule a first-time prenatal care appointment. Descriptive statistics were used to report our primary outcome, the callers' success in obtaining appointments from Medicaid-enrolled physicians' offices. Wait time for appointments and reasons the physician offices refused appointments to callers were collected.

RESULTS

Overall, 2,816 obstetric clinicians are enrolled in Florida Medicaid. Callers made 1,747 attempts to contact 1,023 randomly selected physicians' offices from June to September 2021. Only 48.9% of medical offices (n=500) were successfully reached by phone, of which 39.4% (n=197) offered a prenatal care appointment to the caller. The median wait time until the first appointment was 15 days (quartile 1: 7; quartile 3: 26), with a range of 0-55 days. However, despite offering an appointment, 8.6% of the medical offices stated that they do not accept Medicaid insurance payment or would accept only self-pay. Among the 60.6% of callers unable to secure an appointment, the most common reasons were that the clinician was not accepting patients taking methadone (34.7%) or was not accepting any new patients with Medicaid insurance (23.8%) and that the pregnancy would be too advanced by the time of the first available appointment (7.3%).

CONCLUSION

This secret shopper study found that the majority of obstetric clinicians' offices enrolled in Florida Medicaid do not accept pregnant patients with Medicaid insurance who are taking MOUD. Policy changes are needed to ensure access to adequate prenatal care for patients with opioid use disorder.

Partnering for the future clinic: A multidisciplinary perinatal substance use program

OBJECTIVE

The current model of obstetric care does not integrate multiple subspecialty services for high-risk pregnancies with substance use disorder (SUD), resulting in fragmented care. We describe the framework of our multidisciplinary and integrated perinatal substance use clinic and provide recent clinical outcomes.

METHODS

We detail the Partnering for the Future (PFF) clinic, which integrates numerous subspecialty and support services for patients with SUDs and complex mental health needs. Additionally, a retrospective chart review of patients receiving care in the PFF clinic from 2017 to 2021 was completed.

RESULTS

Seven integrated services are detailed with a focus on reducing stigma, providing trauma-informed care and mitigating harm. During the study period, 182 patients received care in PFF clinic, with opioid use disorder the most common indication for care. Co-occurring mental illness was common (81%). NICU admissions and severe NOWS diagnosis declined after the implementation of Eat-Sleep-Console. Social services identified care coordination, transportation assistance and adjustment counseling as the most common needs. A novel virtual behavioral health consultation service was successfully launched.

CONCLUSIONS

Our integrated care model supports the holistic care of pregnant people with SUD and mental health disease. Patient-centered care and co-located services have improved perinatal outcomes, particularly for opioid-exposed pregnancies.

Trends in Geographic Proximity to Substance Use Disorder Treatment

INTRODUCTION

This study aims to assess the trends in the number and characteristics of substance use disorder (SUD) treatment facilities within the county of residence of adults aged 50+ years over time.

METHODS

Using retrospective longitudinal data from the 1992-2018 Health and Retirement Study merged with the county-level data on all licensed treatment facilities in the country, linear mixed models were estimated to calculate geographic accessibility to SUD treatment, adjusted for person-level demographics, state-level controls, and calendar year-fixed effects. Analysis was conducted in 2022.

RESULTS

Overall, older adults experienced a decline in the average number of SUD treatment facilities within their counties of residence from 4.80 per 100,000 residents (95% CI=4.69, 4.92) in 1992 to 4.50 (95% CI=4.35, 4.64) in 2018. However, the number accepting Medicare increased from 0.26 (95% CI=0.21, 0.30) in 1992 to 1.88 (95% CI=1.80, 1.96) facilities per 100,000 (42% of facilities); Medicaid increased from 0.20 (95% CI=0.13, 0.26) in 1992 to 3.50 (95% CI=3.39, 3.62) facilities per 100,000 (78% of facilities) in 2018. Older adults living in more rural areas experienced the most growth in SUD treatment facilities per capita in their counties but with less significant growth in facilities offering medication for opioid use disorder than those living in more urban areas.

CONCLUSIONS

Despite increases in the number of SUD treatment facilities in rural areas, there has been less growth in nearby facilities offering evidence-based medication treatment for opioid use disorder.

Leveraging Population Health Datasets to Advance Maternal Health Research

BACKGROUND

Maternal mortality is a public health crisis in the U.S., with no improvement in decades and worsening disparities during COVID-19. Social determinants of health (SDoH) shape risk for morbidity and mortality but maternal structural and SDoH are under-researched using population health data. To expand knowledge of those at risk for or who have experienced maternal morbidity and inform clinical, policy, and legislative action, creative use of and leveraging existing population health datasets is logical and needed.

METHODS

We review a sample of population health datasets and highlight recommended changes to the datasets or data collection to better inform existing gaps in maternal health research.

RESULTS

Across each of the datasets we found insufficient representation of pregnant and postpartum individuals and provide recommendations to enhance these datasets to inform maternal health research.

CONCLUSIONS

Pregnant and postpartum individuals should be oversampled in population health data to facilitate rapid policy and program evaluation. Postpartum individuals should no longer be hidden within population health datasets. Individuals with pregnancies resulting in outcomes other than livebirth (e.g., abortion, stillbirth, miscarriage) should be included, or asked about these experiences.

Perinatal outcomes in women referred to the West Virginia University Assist Connect and Encourage (ACE) - A program of the Drug Free Moms and Babies Project (DFMB) for women with substance use during pregnancy

The main objective of this study was to analyze perinatal outcomes of women with substance use disorder in pregnancy who participated in the West Virginia University Medicine Drug Free Moms and Babies Assist Connect and Encourage program (DFMB/ACE) compared to women who were not enrolled in the program. This was a retrospective cohort study conducted in an l Academic Tertiary Care Center. Women who enrolled in DFMB/ACE services from 2018 to 2019 were termed as the intervention group. Their outcomes were compared to 734 women who delivered at the hospital between July 2015 and December 2019 with a positive urine drug screen on admission but were not enrolled in the DFMB/ACE program. Perinatal outcomes evaluated include low birth weight, preterm labor, neonatal intensive care unit (NICU) admission, preterm birth, neonatal abstinence syndrome (NAS), cesarean delivery, cord toxicology result, hepatitis c prevalence, and breastfeeding at the time of discharge. Participants of the DFMB/ACE group had a lower risk of having a preterm birth (OR = 0.56 95% CI 0.36-0.86) compared to the control group. The DFMB/ACE group had higher birth weight compared to the non-DFMB group (2865.7 g. vs. 2657.9 g, p = 0.004). NICU admission, NAS, mode of delivery, cord toxicology, and breastfeeding rates were not statistically different between the two groups. Hepatitis C rates were significantly higher in the intervention vs. non-intervention group (OR = 2.74 95 %CI 1.80 - 4.16). We concluded that the DFMB/ACE program interventions for women with substance use in pregnancy improves some perinatal outcomes for mothers and their newborns.

Office-Based Management of Perinatal Substance Use and Substance Use Disorder for the General Obstetrician-Gynecologist

This is a review of substance use and substance use disorder in pregnancy, intended for the generalist obstetrician-gynecologist. Herein, the authors discuss legal considerations, outline definitions, review screening tools, introduce special considerations and harm reduction, caution the use of urinary toxicology testing, and touch on the screening, brief intervention, and referral to treatment model. Furthermore, the authors provide a brief overview of the prevalence, maternal and neonatal risks, and treatment approaches for commonly used substances.

Patient and Community Factors Affecting Treatment Access for Opioid Use Disorder

OBJECTIVE

To examine whether access to treatment for women with opioid use disorder (OUD) varied by race and ethnicity, community characteristics, and pregnancy status.

METHODS

We conducted a secondary data analysis of a simulated patient caller study of buprenorphine-waivered prescribers and opioid-treatment programs in 10 U.S. states. We conducted multivariable analyses, accounting for potential confounders, to evaluate factors associated with likelihood of successfully securing an appointment. Descriptive statistics and significance testing examined 1) caller characteristics and call outcome by assigned race and ethnicity and clinic type (combined, opioid-treatment programs, and buprenorphine-waivered prescribers) and 2) clinic and community characteristics and call outcome by community race and ethnicity distribution (majority White vs majority Black, Hispanic, Asian, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander) and clinic type. A multiple logistic regression model was fitted to assess the likelihood of obtaining an appointment by callers' race and ethnicity and pregnancy status with the exposure of interest being majority Black, Hispanic, Asian, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander community distribution.

RESULTS

In total, 3,547 calls reached clinics to schedule appointments. Buprenorphine-waivered prescribers were more likely to be in communities that were more than 50% White (88.9% vs 77.3%, P<.001), and opioid-treatment programs were more likely to be in communities that were less than 50% White (11.1% vs 22.7%, P<.001). Callers were more likely to be granted appointments in majority Black, Hispanic, Asian, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander communities (adjusted odds ratio [aOR] 1.06, 95% CI 1.02-1.10 per 10% Black, Hispanic, Asian, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander community population) and at opioid-treatment programs (aOR 4.94, 95% CI 3.52-6.92) and if they were not pregnant (aOR 1.79, 95% CI 1.53-2.09).

CONCLUSION

Clinic distribution and likelihood of acceptance for treatment varied by community race and ethnicity distribution. Access to treatment for OUD remains challenging for pregnant people and in many historically marginalized U.S. communities.

Interventions to Support Engagement in Addiction Care Postpartum: Principles and Pitfalls

There is a fundamental disconnect between the optimal management of addiction in general and care delivery in pregnancy and postpartum. Addiction is a chronic condition requiring some degree of management across the life course. Yet, in the US, reproductive care is episodic and centers more on pregnancy than at other stages of the reproductive life course. Pregnancy is prioritized in access to insurance as almost all pregnant people are Medicaid eligible but access ends at varying points postpartum. This results in a structural mismatch: the episodic management of the chronic condition of addiction only within gestational periods. Though people with substance use disorder (SUD) may access care in pregnancy, treatment attrition is common postpartum. Postpartum is a time of increased vulnerabilities where insurance churn and newborn caretaking responsibilities collide in a context of care withdrawal from the health system and health providers. In part in consequence, return to use, SUD recurrence, overdose, and overdose death are more common postpartum than in pregnancy, and drug deaths have become a leading cause of maternal deaths in the US. This review addresses interventions to support engagement in addiction care postpartum. We begin with a scoping review of model programs and evidence-informed interventions that have been shown to increase continuation of care postpartum. We then explore the realities of contemporary care through a review of clinical and ethical principles, with particular attention to harm reduction. We conclude with suggestions of strategies (clinical, research, and policy) to improve care postpartum and highlight potential pitfalls in the uptake of evidence-based and person-centered services.

Maternal Opioid Use Disorder and the Risk of Postneonatal Infant Mortality

Importance

The risk of serious long-term outcomes for infants born to individuals with opioid use disorder (OUD) is not fully characterized, nor is it well understood whether risks are modified by infant diagnosis of neonatal opioid withdrawal syndrome (NOWS).

Objective

To characterize the risk of postneonatal infant mortality among infants with a NOWS diagnosis or born to individuals with OUD.

Design, Setting, and Participants

The study team conducted a retrospective cohort study of 390 075 infants born from 2007 through 2018 to mothers who were enrolled in Tennessee Medicaid from 183 days prior to delivery through 28 days post partum (baseline). Maternal and infant baseline characteristics were measured using administrative claims and birth certificates, and infants were followed up from day 29 post partum through day 365 or death. Deaths were identified using linked death certificates through 2019. These data were analyzed from February 10, 2022, through March 3, 2023.

Exposure

Infant exposures included birth to an individual with OUD or postnatal diagnosis of NOWS. The study team defined a pregnant individual's OUD status (maternal OUD) as having OUD diagnosis or a maintenance medication prescription fill during baseline; this study defined NOWS as having NOWS diagnosis up to day 28. Groups were categorized by exposures as maternal OUD with NOWS (OUD positive/NOWS positive), maternal OUD without NOWS (OUD positive/NOWS negative), no documented maternal OUD with NOWS (OUD negative/NOWS positive), and no documented maternal OUD or NOWS (OUD negative/NOWS negative, unexposed).

Main Outcome and Measures

The outcome was postneonatal infant death, confirmed by death certificates. Cox proportional hazards models were used, adjusting for baseline maternal and infant characteristics, to estimate adjusted hazard ratios (aHRs) and 95% CIs for the association between maternal OUD or NOWS diagnosis with postneonatal death.

Results

Pregnant individuals in the cohort had a mean (SD) age of 24.5 (5.2) years; 51% of infants were male. The study team observed 1317 postneonatal infant deaths and incidence rates of 3.47 (OUD negative/NOWS negative, 375 718), 8.41 (OUD positive/NOWS positive, 4922); 8.95 (OUD positive/NOWS negative, 7196), and 9.25 (OUD negative/NOWS positive, 2239) per 1000 person-years. After adjustment, the risk of postneonatal death was elevated for all groups, relative to the unexposed: OUD positive/NOWS positive (aHR, 1.54; 95% CI, 1.07-2.21), OUD positive/NOWS negative (aHR, 1.62; 95% CI, 1.21-2.17), and OUD negative/NOWS positive (aHR, 1.64; 95% CI, 1.02-2.65).

Conclusions and Relevance

Infants born to individuals with OUD or with a NOWS diagnosis had an increased risk of postneonatal infant mortality. Future work is necessary to create and evaluate supportive interventions for individuals with OUD during and after pregnancy to reduce adverse outcomes.

Time to pay attention: an underrecognized casualty of the opioid epidemic

Maternal mortality and overdose deaths have both been on the rise in the USA, but the relationship between the two is unclear. Recent reports have pointed toward accidental overdoses and suicides as leading causes of maternal mortality. This short communication collected data on psychiatric-related deaths, suicide and drug overdose, from each state's Maternal Mortality Review Committee to better conceptualize the rate at which these deaths are occurring. Data was collected from each state's most recent online MMRC legislative report and met inclusion criteria if the reports included the number of deaths due to suicide and accidental overdoses during each review period, as well if the report encompassed data from 2017. Fourteen reports met inclusion criteria, cumulatively reviewing 1929 maternal deaths. Of these deaths, 603 (31.3%) were due to accidental overdose, while 111 (5.7%) were due to suicide. These findings highlight the need for increased psychiatric care in the pregnant and postpartum period, specifically for substance use disorders. Increasing screening for depression and substance use, decriminalizing substance use during pregnancy, and extending Medicaid coverage to 12 months postpartum on a national level are all interventions that could significantly reduce maternal deaths.

Prevalence of Buprenorphine Providers Requiring Cash Payment From Insured Women Seeking Opioid Use Disorder Treatment

CONTEXT

Medications for opioid use disorder (OUD) are known to be effective, especially in reducing the risk of overdose death. Yet, many individuals suffering from OUD are not receiving treatment. One potential barrier can be the patient's ability to access providers through their insurance plans.

DATA AND METHODS

We used an audit (simulated patient) study methodology to examine appointment-granting behavior by buprenorphine prescribers in 10 different US states. Trained callers posed as women with OUD and were randomly assigned Medicaid or private insurance status. Callers request an OUD treatment appointment and then asked whether they would be able to use their insurance to cover the cost of care, or alternatively, whether they would be required to pay fully out-of-pocket.

FINDINGS

We found that Medicaid and privately insured women were often asked to pay cash for OUD treatment--40% of the time over the full study sample. Such buprenorphine provider requests happened more than 60% of the time in some states. Areas with more providers or with more generous provider payments were not obviously more willing to accept the patient's insurance benefits for OUD treatment. Rural providers were less likely to require payment in cash in order for the woman to receive care.

CONCLUSIONS

State-to-state variation was the most striking pattern in our field experiment data. The wide variation suggests that women of reproductive age with OUD in certain states face even greater challenges to treatment access than perhaps previously thought; however, it also reveals that some states have found ways to curtail this problem. Our findings encourage greater attention to this public health challenge and possibly opportunities for shared learning across states.