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Buprenorphine uptake during pregnancy following the 2017 guidelines update on prenatal opioid use disorder

  • Max Jordan Nguemeni Tiako
    Affiliations
    Department of Internal Medicine, Brigham and Women’s Hospital, 75 Francis St., Boston, MA 02134
    Harvard Medical School, Boston, MA
    Urban Health Lab, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
    Center for Emergency Care and Policy Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
    Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV, Philadelphia, PA
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  • Angelica Meinhofer
    Affiliations
    Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV, Philadelphia, PA
    Weill Cornell School of Medicine, New York, NY
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  • Ari Friedman
    Affiliations
    Center for Emergency Care and Policy Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
    Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
    Leonard Davis Institute, Wharton School of Management, University of Pennsylvania, Philadelphia, PA
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  • Eugenia C. South
    Affiliations
    Urban Health Lab, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
    Center for Emergency Care and Policy Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
    Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
    Leonard Davis Institute, Wharton School of Management, University of Pennsylvania, Philadelphia, PA
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  • Rachel L. Epstein
    Affiliations
    Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA
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  • Zachary F. Meisel
    Affiliations
    Center for Emergency Care and Policy Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
    Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV, Philadelphia, PA
    Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
    Leonard Davis Institute, Wharton School of Management, University of Pennsylvania, Philadelphia, PA
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  • Jake R. Morgan
    Affiliations
    Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV, Philadelphia, PA
    Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA
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      Objective

      Prenatal opioid use disorder (OUD) has significantly risen, from 3.5 to 8.2 per 1000 deliveries between 2010 and 2017.
      • Hirai A.H.
      • Ko J.Y.
      • Owens P.L.
      • Stocks C.
      • Patrick S.W.
      Neonatal abstinence syndrome and maternal opioid-related diagnoses in the US, 2010-2017.
      In August 2017, options for the treatment of prenatal OUD expanded from methadone only: the American College of Obstetricians and Gynecologists (ACOG) and American Society of Addiction Medicine (ASAM) committee opinion on opioid use and OUD in pregnancy recommended buprenorphine as a noninferior alternative first-line treatment for prenatal OUD.
      Opioid use and opioid use disorder in pregnancy
      Committee Opinion No. 711. American College of Obstetricians and Gynecologists.
      However, evidence shows that pregnant patients receive medications for OUD at low rates
      • Nguemeni Tiako M.J.
      • Friedman A.
      • Culhane J.
      • South E.
      • Meisel Z.F.
      Predictors of initiation of medication for opioid use disorder and retention in treatment among U.S. pregnant women, 2013-2017.
      and face barriers when seeking treatment (especially concerning accessing buprenorphine)
      • Patrick S.W.
      • Richards M.R.
      • Dupont W.D.
      • et al.
      Association of pregnancy and insurance status with treatment access for opioid use disorder.
      and that few obstetrician-gynecologists are licensed to prescribe buprenorphine.
      • Nguemeni Tiako M.J.
      • Culhane J.
      • South E.
      • Srinivas S.K.
      • Meisel Z.F.
      Prevalence and geographic distribution of obstetrician-gynecologists who treat Medicaid enrollees and are trained to prescribe buprenorphine.
      Therefore, we sought to determine the influence of these guidelines on buprenorphine uptake among pregnant individuals with OUD.

      Study Design

      We analyzed 2014–2019 MarketScan Commercial Claims and Encounters Data. The longitudinal sample was composed of women aged 15 to 45 years with diagnosed OUD. Using causal inference methods, we estimated difference-in-differences models comparing changes in buprenorphine use before and after the ACOG-ASAM guideline between pregnant and nonpregnant (control group) women with OUD. Our policy variable of interest was the interaction between the postguideline and pregnancy indicators. Recognizing that there are likely individual characteristics correlated to both the exposure and outcome, we included individual-level fixed effects to capture all individual-specific time-invariant determinants of buprenorphine receipt. We regressed our buprenorphine outcomes on the policy interaction, pregnancy indicator, postguideline indicator, and individual fixed effects using ordinary least squares. We evaluated the difference-in-differences assumption of parallel trends in the exposure categories graphically. We chose this specific difference-in-differences approach, with nonpregnant women as a comparison group, to account for confounding factors affecting buprenorphine uptake and correlated with the guideline changes during this period. A P value threshold of.05 was used to determine statistical significance. Analyses were performed with Stata (version 16; StataCorp, College Station, TX). The Boston University Medical Campus Institutional Review Board ruled this study as Not Human Subjects Research.

      Results

      Among 86,522 unique women included, 2137 (2.5%) were pregnant at least once during the study period. The mean (standard deviation) ages at baseline were 27.6 (6.0) years in the pregnant group and 30.9 (7.9) years in the control group (shown in the online Supplemental Table). Most patients resided in urban settings (70,704 [81.7%]). Our individual-level fixed effects model found a 2.1 percentage point (95% confidence interval [CI], 1.0–3.2) increase in the prevalence of buprenorphine use among pregnant women compared with nonpregnant women with OUD following the guideline change, corresponding to a 12% increase relative to the preguideline period (see Figure). In a sensitivity analysis, we excluded the year 2017, and the results remained similar (2.3%; 95% CI, 0.8–3.7; P<.001). Buprenorphine initiation rates increased after guideline release among those with no previous history of treatment from 12 initiations per 100 person-years (PY) to 13 per 100 PY in nonpregnant women and from 17 initiations per 100 PY to 21 per 100 PY in pregnant women (both P<.01).
      Figure thumbnail gr1
      FigureBuprenorphine administration by pregnancy status during the study period
      ACOG, American College of Obstetricians and Gynecologists; ASAM, American Society of Addiction Medicine.
      Nguemeni Tiako. Guidelines Change and Buprenorphine Uptake During Pregnancy. Am J Obstet Gynecol 2022.

      Conclusion

      Our findings suggested that the ACOG-ASAM 2017 OUD guidelines led to increased buprenorphine uptake among pregnant women with OUD compared with nonpregnant women. Professional society guidelines could be an effective tool to address the current US drug overdose epidemic.

      Appendix

      Supplemental TableDemographic characteristics of women with opioid use disorder by pregnancy history during the study period
      CharacteristicAll (N=86,522)Never pregnant (n=84,385)Ever pregnant (n=2137)Chi-squared P value
      Study sample
      Administration at any time (buprenorphine quarters)85,818 (15.1)82,188 (15.0)3630 (17.4)<.01
      Initiation, rates per 100 person-years15,818 (12.7)15,001 (12.5)817 (18.1)
      Preguideline initiation10,379 (12.4)9852 (12.2)527 (16.8)<.01
      Postguideline initiation5439 (13.4)5149 (13.1)290 (21.0)
      Age at first enrollment (y), mean (SD)30.8 (7.9)30.9 (7.9)27.6 (6.0)
       <3038,599 (44.6)37,290 (44.2)1309 (61.2)<.01
       ≥3047,923 (55.3)47,095 (55.8)828 (38.7)
      Regions
       Northeast17,462 (20.2)17,004 (20.2)458 (21.4)<.01
       Midwest15,426 (17.8)14,970 (17.7)456 (21.3)
       South39,494 (45.6)38,582 (45.7)912 (42.7)
       West13,371 (15.5)13,076 (15.5)295 (13.8)
       Unknown769 (0.9)753 (0.9)16 (0.7)
       Urban70,704 (81.7)68,970 (81.7)1734 (81.1).49
      Health plan types
       PPO51,007 (59.0)49,735 (58.9)1272 (59.5)<.01
       HMO7043 (8.1)6860 (8.1)183 (8.6)
       POS7184 (8.3)7074 (8.4)110 (5.1)
       Other21,288 (24.6)20,716 (24.5)572 (26.8)
      Comorbid substances at any time
       Alcohol18,117 (20.9)17,738 (21.0)379 (17.7)<.01
       Amphetamines8925 (10.3)8721 (10.3)204 (9.5).27
       Cannabis11,221 (13.0)10,929 (13.0)292 (13.7).33
       Cocaine8339 (9.6)8116 (9.6)223 (10.4).21
       Hallucinogens868 (1)858 (1.0)10 (0.5).01
       Sedative12,686 (14.7)12,406 (14.7)280 (13.1).04
      Relationship to employee
       Employee34,755 (40.2)34,090 (40.4)665 (31.1)<.01
       Spouse24,568 (28.4)23,965 (28.4)603 (28.2)
       Child or other dependent27,200 (31.4)26,330 (31.2)870 (40.7)
      Data are presented as number (percentage), unless otherwise specified.
      HMO, health maintenance organization; POS, point of service; PPO, preferred provider organization; SD, standard deviation.
      Nguemeni Tiako. Guidelines Change and Buprenorphine Uptake During Pregnancy. Am J Obstet Gynecol 2022.

      References

        • Hirai A.H.
        • Ko J.Y.
        • Owens P.L.
        • Stocks C.
        • Patrick S.W.
        Neonatal abstinence syndrome and maternal opioid-related diagnoses in the US, 2010-2017.
        JAMA. 2021; 325: 146-155
        • Opioid use and opioid use disorder in pregnancy
        Committee Opinion No. 711. American College of Obstetricians and Gynecologists.
        Obstet Gynecol. 2017; 130: e81-e94
        • Nguemeni Tiako M.J.
        • Friedman A.
        • Culhane J.
        • South E.
        • Meisel Z.F.
        Predictors of initiation of medication for opioid use disorder and retention in treatment among U.S. pregnant women, 2013-2017.
        Obstet Gynecol. 2021; 137: 687-694
        • Patrick S.W.
        • Richards M.R.
        • Dupont W.D.
        • et al.
        Association of pregnancy and insurance status with treatment access for opioid use disorder.
        JAMA Netw Open. 2020; 3e2013456
        • Nguemeni Tiako M.J.
        • Culhane J.
        • South E.
        • Srinivas S.K.
        • Meisel Z.F.
        Prevalence and geographic distribution of obstetrician-gynecologists who treat Medicaid enrollees and are trained to prescribe buprenorphine.
        JAMA Netw Open. 2020; 3e2029043