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Improving treatment of opioid use disorder in pregnancy: first define the workforce

      To the Editors:
      As Hollander et al
      • Hollander M.A.G.
      • Kelley D.
      • Krans E.E.
      • et al.
      Medical specialty of buprenorphine prescribers for pregnant women with opioid use disorder.
      report, the maternity care workforce in the United States has not adapted to care adequately for the growing number of pregnant women with opioid use disorder. We agree that obstetric providers could help fill a gap in opioid treatment during pregnancy, particularly in rural areas. However, we would like to draw attention to the problem of lumping a diverse group of medical specialties and provider types into a broad “primary care” category.
      First, this analysis does not differentiate important players in the maternity care workforce. Lumping family physicians with other primary care specialties in an analysis focused on the care of pregnant women with opioid use disorder discounts the contributions of family physicians who provide maternity care. Family medicine is the only 1 of these primary care specialties that is trained in both prenatal care and obstetrics.
      Second, lumping all primary care providers, but not all obstetric providers, confuses the issue. “Medical specialty” implies those trained in medicine (ie, physicians); “providers” indicates a broader group of clinicians who practice in a discipline. Certified nurse midwives (CNMs) should be included as obstetric providers, because they are growing in number and their eligibility to obtain a waiver could help to address the care gap. Buprenorphine waiver training is newly available for nurse practitioners (NPs), physician assistants (PAs), and CNMs, although longer and more intensive than for physicians; independent prescribing is limited in some states.
      • Andrilla C.H.
      • Moore T.E.
      • Patterson D.G.
      • Larson E.H.
      Geographic distribution of providers with a DEA waiver to prescribe buprenorphine for the treatment of opioid use disorder: a 5-year update.
      A more apt analysis would compare those clinicians (obstetrician/gynecologists, family physicians, and CNMs) who provide obstetrics care with those who do not.
      Finally, family physicians provide the majority of rural healthcare, including maternity care.
      • Fordyce M.A.
      • Chen F.M.
      • Doescher M.P.
      • Hart L.G.
      2005 physician supply and distribution in rural areas of the United States.
      Lumping family physicians with general practitioners, internal medicine, and pediatrics masks their rural impact. In 1 small study, family medicine was the most common specialty to prescribe buprenorphine in rural areas
      • Andrilla C.H.
      • Moore T.E.
      • Patterson D.G.
      Overcoming barriers to prescribing buprenorphine for the treatment of opioid use disorder: recommendations from rural physicians.
      ; pediatricians, internists, and obstetricians/gynecologists are less common in these locations.
      • Fordyce M.A.
      • Chen F.M.
      • Doescher M.P.
      • Hart L.G.
      2005 physician supply and distribution in rural areas of the United States.
      To expand care for pregnant people with opioid use disorder, we should begin by supporting family physicians, CNMs, NPs, and PAs who are already providing these services in rural and underserved communities. The maternity care workforce, which includes obstetricians/gynecologists, family physicians, midwives, NPs, and PAs, should work together to increase access to adequate high-quality care to pregnant and postpartum women with opioid use disorder in all geographic settings. Increasing the number of maternity care providers with buprenorphine waivers would begin to address access to treatment.

      References

        • Hollander M.A.G.
        • Kelley D.
        • Krans E.E.
        • et al.
        Medical specialty of buprenorphine prescribers for pregnant women with opioid use disorder.
        Am J Obstet Gynecol. 2019; 220: 502-503
        • Andrilla C.H.
        • Moore T.E.
        • Patterson D.G.
        • Larson E.H.
        Geographic distribution of providers with a DEA waiver to prescribe buprenorphine for the treatment of opioid use disorder: a 5-year update.
        J Rural Health. 2019; 35: 108-112
        • Fordyce M.A.
        • Chen F.M.
        • Doescher M.P.
        • Hart L.G.
        2005 physician supply and distribution in rural areas of the United States.
        (Final Report. Available at:)
        • Andrilla C.H.
        • Moore T.E.
        • Patterson D.G.
        Overcoming barriers to prescribing buprenorphine for the treatment of opioid use disorder: recommendations from rural physicians.
        J Rural Health. 2019; 35: 113-121

      Linked Article

      • Medical specialty of buprenorphine prescribers for pregnant women with opioid use disorder
        American Journal of Obstetrics & GynecologyVol. 220Issue 5
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          Opioid use disorder during pregnancy has quadrupled over the past decade, as have maternal and neonatal morbidity related to substance use.1 Although medication-assisted treatment (MAT) with methadone or buprenorphine during pregnancy significantly reduces the risk of adverse maternal and neonatal outcomes, many pregnant women do not receive MAT, and many opioid treatment providers do not provide MAT services for pregnant women, particularly in rural areas.2,3 Buprenorphine’s office-based availability and enhanced safety profile have resulted in federal, state, and local efforts to rapidly expand the number of buprenorphine-waivered physicians to meet increased demands for substance use treatment.
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        American Journal of Obstetrics & GynecologyVol. 221Issue 4
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          We thank Eden et al for their letter regarding an oversimplification of the medical specialties categorized as primary care in our analysis. We agree that family medicine physicians, certified nurse midwives, and advanced practice providers are important providers of maternity care services, especially in rural settings, and play a critical role closing both the maternity and substance use treatment gap for pregnant and postpartum women.
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