Opioid use disorder in pregnant women has been associated with a range of negative health outcomes for both mothers and their infants, including maternal death, preterm birth, stillbirth and neonatal abstinence syndrome (NAS).
Sadly, according to a CDC Morbidity and Mortality Weekly Report (MMWR)(www.cdc.gov) released Aug. 10, the number of pregnant women with opioid use disorder (OUD) who presented to hospital labor/delivery departments more than quadrupled between 1999 and 2014.
Researchers examined hospital discharge data from the Agency for Healthcare Research and Quality's 1999-2014 Healthcare Cost and Utilization Project(www.ahrq.gov) to conduct this first-ever multistate analysis of national and state-specific trends in OUD at delivery hospitalization.
Nationally, the prevalence of OUD among these women increased from 1.5 per 1,000 delivery hospitalizations in 1999 to 6.5 per 1,000 delivery hospitalizations in 2014, the CDC said. On average, the national prevalence rate grew by 0.4 per 1,000 each year.
- The number of pregnant women with opioid use disorder (OUD) who presented to hospital labor/delivery departments quadrupled between 1999 and 2014.
- According to hospital discharge data for those years, the prevalence of OUD nationally increased from 1.5 per 1,000 delivery hospitalizations in 1999 to 6.5 per 1,000 delivery hospitalizations in 2014.
- In addition, state-level trends increased in all 28 states with available data.
Rising state-level trends also were seen in the 28 states with available data. In 1999, the prevalence of OUD ranged from 0.1 per 1,000 delivery hospitalizations in Iowa to 8.2 per 1,000 delivery hospitalizations in Maryland; the prevalence in 2014 ranged from 0.7 per 1,000 delivery hospitalizations in the District of Columbia to 48.6 per 1,000 delivery hospitalizations in Vermont.
"These findings illustrate the devastating impact of the opioid epidemic on families across the U.S., including on the very youngest," said CDC Director Robert Redfield, M.D., in a news release.(www.cdc.gov) "Untreated opioid use disorder during pregnancy can lead to heartbreaking results. Each case represents a mother, a child and a family in need of continued treatment and support."
During the study period, the average annual rate increases were lowest in California and Hawaii (growth of less than 0.1 cases per 1,000 each year) and highest in Maine, New Mexico, Vermont, and West Virginia (all with growth of more than 2.5 cases per 1,000 each year).
Study Finds High Rates of Opioid Rx for Postpartum Women
Take the growing crisis of opioid misuse and addiction throughout the United States, combine it with the fact that delivery remains the most common reason for hospitalization nationwide, and you'd think that would provide a compelling reason to not routinely send postpartum women home with a prescription for the powerful drugs, right?
According to a study in the most recent issue of the American Journal of Obstetrics and Gynecology,(www.ajog.org) that very thing happens all too frequently. In fact, a yearlong cohort study that examined all deliveries at a single high-volume tertiary care center found that of the 12,326 women eligible for inclusion -- 9,038 of whom delivered vaginally and 3,288 who had a cesarean delivery -- 30.4 percent and 86.7 percent, respectively, received an opioid prescription at discharge.
Moreover, of women who received an opioid prescription for pain at discharge, the median morphine milligram equivalents (MMEs) prescribed was 200 (interquartile range 120-300) for those who delivered vaginally and 300 (interquartile range 200-300) among women who had a cesarean delivery.
Furthermore, almost half of the women who had a vaginal delivery (47.5 percent) and nearly a fifth of women who were postcesarean delivery (18.5 percent) used 0 MMEs during their final inpatient day. Similarly, 26.5 percent and 18.5 percent of women after vaginal and cesarean delivery, respectively, reported pain scores of 0 of 10 at discharge.
"Postpartum women are commonly prescribed opioids at the time of postpartum hospital discharge," wrote the study's authors. "There is a wide range of morphine milligram equivalents prescribed at hospital discharge following delivery, highlighting a lack of standardization.
"Furthermore, regardless of objective and subjective measures of pain prior to discharge, women received similar amounts of prescription morphine milligram equivalents following either vaginal or cesarean deliveries," they concluded.
"Even in states with the smallest annual increases, more and more women are presenting with opioid use disorder at labor and delivery," said Rear Adm. Wanda Barfield, M.D., M.P.H., of the U.S. Public Health Service and director of the CDC's Division of Reproductive Health, in the release. "These state-level data can provide a solid foundation for developing and tailoring prevention and treatment efforts."
The MMWR also noted that although variability by state could reflect differences in opioid prescribing rates or the comparative prevalence of illicit drug use, it also could reflect improved screening, diagnosis and treatment of OUD and NAS.
Addressing OUD With Pregnant Women
The CDC recommended a number of strategies physicians can use to address OUD among their pregnant patients, including:
- ensuring appropriate opioid prescribing that is in line with the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain;(www.cdc.gov)
- optimizing the use of prescription drug monitoring programs;(www.cdc.gov)
- implementing universal substance use screening at the first prenatal visit, as recommended in an opinion document(www.acog.org) developed by the American College of Obstetricians and Gynecologists in Collaboration with the American Society of Addiction Medicine;
- ensuring pregnant women with OUD have access to medication-assisted treatment(ncsacw.samhsa.gov) and related addiction services; and
- ensuring mothers with OUD receive adequate patient-centered postpartum care, including mental health and substance use treatment, relapse-prevention programs and family planning services.
More CDC Actions
The CDC also said it plans to help reduce the burden of OUD on pregnant women and their infants by supporting state-based perinatal quality collaboratives,(www.cdc.gov) which consist of state or multi-state networks of teams that work to improve quality of care for mothers and infants. This includes enhancing clinicians' ability to identify women with OUD during pregnancy and standardizing care for mothers and NAS-affected infants.
Additionally, the CDC has improved data collection related to OUD among postpartum women by expanding the Pregnancy Risk Assessment Monitoring System(www.cdc.gov) in some states to include questions that assess substance use before and during pregnancy.
Finally, the agency said it monitors and reports the incidence of NAS among infants, and so far, nine states have made NAS or the broader diagnosis of a substance-exposed infant reportable to state health departments.
"These data sources can provide a solid foundation for developing and tailoring OUD prevention and treatment efforts for pregnant women and women of reproductive age," the CDC's release concluded.
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