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CME / ABIM MOC / CE

Does Opioid Use Affect Postpartum Death Rates?

  • Authors: News Author: Marcia Frellick; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 4/14/2023
  • Valid for credit through: 4/14/2024, 11:59 PM EST
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0.25 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
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Target Audience and Goal Statement

This activity is intended for obstetricians/gynecologists/women’s health physicians, psychiatrists, family medicine/primary care physicians, internists, public health and prevention officials, nurses, pharmacists, physician assistants, and other members of the healthcare team for women taking opioids in the postpartum period.

The goal of this activity is for learners to be better able to describe incidence and risk factors for postpartum opioid overdose death and other causes of postpartum death in women with opioid use disorder (OUD).

Upon completion of this activity, participants will:

  • Describe incidence and risk factors for postpartum opioid overdose death and other causes of postpartum death in women with OUD, according to a cohort study using Medicaid healthcare utilization data
  • Identify clinical and public health implications of incidence and risk factors for postpartum opioid overdose death and other causes of postpartum death in women with OUD, according to a cohort study using Medicaid healthcare utilization data
  • Outline implications for the healthcare team


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News Author

  • Marcia Frellick

    Freelance writer, Medscape

    Disclosures

    Marcia Frellick has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has no relevant financial relationships.

Editor/Nurse Planner

  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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CME / ABIM MOC / CE

Does Opioid Use Affect Postpartum Death Rates?

Authors: News Author: Marcia Frellick; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 4/14/2023

Valid for credit through: 4/14/2024, 11:59 PM EST

processing....

Clinical Context

Women with opioid use disorder (OUD) may be at increased but poorly characterized risk for causes of maternal mortality other than fatal overdose. Most pregnant women with OUD have comorbid depression and anxiety, both strong risk factors for suicide.

They may also have greater risk for homicide, drug-related accidents, or medical complications from OUD, including endocarditis, sepsis, and liver failure. Increased susceptibility to certain obstetric complications may also raise risk for postpartum mortality.

Study Synopsis and Perspective

Opioid overdose and other preventable causes are important contributors to postpartum death rates, Medicaid claims data show, particularly in women who have a recent history of OUD, according to research published in Obstetrics and Gynecology.[1]

Opioid overdose deaths account for up to 10% of pregnancy-associated deaths in the United States, and 75% of the deliveries of women with OUD are covered by Medicaid, according to lead author Elizabeth Suarez, PhD, MPH, with the division of pharmacoepidemiology and pharmacoeconomics at Brigham and Women's Hospital and Harvard Medical School in Boston, Massachusetts, and colleagues.

Nearly 5 Million Deliveries Studied

Researchers studied claims data from Medicaid and the National Death Index database in the United States from 2006 to 2013 for 4,972,061 deliveries. They also identified a subgroup of women with a documented history of OUD in the 3 months before delivery.

They found the incidence of postpartum opioid overdose deaths was 5.4 per 100,000 deliveries (95% CI: 4.5, 6.4) among all in the study and 118 per 100,000 (95% CI: 84, 163) among individuals with OUD.

Incidence of all-cause postpartum death was 6 times higher in women with OUD than in all the women studied. Common causes of death of women with OUD were other drug- and alcohol-related deaths (47/100,000); suicide (26/100,000); and other injuries, including accidents and falls (33/100,000).

Risk factors strongly linked with postpartum opioid overdose death included mental health and other substance use disorders.

Medication Significantly Lowers Death Risk

The authors also documented the benefit of buprenorphine or methadone for OUD.

For women with OUD who used medication to treat opioid use disorder (MOUD) postpartum, odds for opioid overdose death were 60% lower (odds ratio [OR] 0.4 [95% CI: 0.1, 0.9]).

As important as use of MOUD, Marcela Smid, MD, MS, wrote in an accompanying editorial,[2] is noting that 80% of the women in this study who died of opioid overdoses had contact with a healthcare provider before death.

"Both of these results indicate that we have the means and opportunity to prevent these deaths," wrote Smid, with the division of maternal fetal medicine, University of Utah Health in Salt Lake City, Utah.

Dismal Numbers on Obstetricians/Gynecologists Trained to Prescribe Medications

She pointed out some barriers, however. Most clinicians, she noted, lack time and training to prescribe buprenorphine, and in 2019, fewer than 2% of obstetricians/gynecologists (Ob/Gyns) who accept Medicaid were able to prescribe it.

Her charge to Ob/Gyns: "We need to help identify individuals who are at high risk of OUD or opioid overdose by screening."

A validated screening tool should be used at prenatal and postpartum appointments.

On a bigger scale, she urged Medicaid to be expanded for a full year postpartum through the American Rescue Act's State Plan Amendment, something only 28 states and Washington, DC, have done so far.

Smid pointed out some good news, however: The Biden Administration signed the Consolidated Appropriations Act 2023, which eliminated the "X" waiver.

Now all clinicians who have a Drug Enforcement Administration (DEA) registration that includes Schedule III authority can prescribe buprenorphine for OUD if applicable state law allows it.

That calls for medical schools and residency programs to prioritize addiction medicine as a core competency, Smid advised.

Getting Naloxone to Patients, Families

One of the potential interventions the study authors suggested is providing naloxone prescriptions and training to pregnant and postpartum women who have a substance use history and to their partners and significant others.

Mishka Terplan, MD, MPH, explained, "It's one thing to write a prescription; it's another thing for the person to actually get the medication."

"What can we do? We can think about how to get naloxone into people's hands at discharge from the hospital after they give birth, instead of prescribing. That would mean that health systems need to prioritize this," he said. "We give people discharge medications all the time."

Still, naloxone cannot be seen as the answer, he said.

He compared it to defibrillators in public places, which are for rescues, not reversing a population problem.

The best help, he says, will be continuation of treatment.

"Addiction is a chronic condition," he says, "but often we only provide episodic care. We see that particularly in pregnancy. Once the pregnancy is finished, there's not categorical continuation of insurance."

Even if you do have insurance, it is hard to find a clinic that is family friendly, he noted.

Problem Probably Understated

He also said that although the study was well done given the data available, he is frustrated that researchers still have to depend on billing data and cannot capture factors such as child care availability, living wages, and continuation of health insurance. In addition, not everyone is coded correctly for OUD.

"It's all Medicaid, so it's only people who continued with care," he pointed out. That means these numbers may actually underrepresent the problem.

Still, he said, it is important to realize the magnitude of deaths this study does highlight in this population. In people with OUD in the postpartum period, the deaths are more than 1 in 1000.

"That should be alarming," Terplan said. "That's a very big number from a public health perspective."

Coauthor Kathryn J. Gray received payment from Aetion Inc.; BillionToOne; and Roche. Funds were paid to the University of Utah for Smid from Alydia Inc. for being the site principal investigator for a study of the JADA device, and from Gilead Sciences, Inc. for Smid's study of hepatitis C in pregnancy; she was also a consultant for Organon and Rhia Ventures. Terplan reports no relevant financial relationships.

Study Highlights

  • This cohort study used Medicaid Analytic eXtract health care utilization data linked to the US National Death Index from 2006 to 2013.
  • Inclusion criteria were pregnant individuals with live or stillbirths and continuous enrollment for 3 months preceding delivery (4,972,061 deliveries).
  • Researchers estimated cumulative incidence of death between delivery and 1-year postpartum.
  • Among deaths, opioid overdose was the cause in 9.7%, with incidence of 5.4/100,000 (95% CI: 4.5, 6.4) among all women and 118/100,000 (95% CI: 84, 163) among women with documented history of OUD of in the 3 months before delivery.
  • Incidence of all-cause postpartum death was 6-fold higher among women with OUD than among all women.
  • Incidence of death among pregnant individuals with OUD was more than double the incidence in the full population for every cause of death except cancer.
  • Common causes of death in individuals with OUD were other drug- and alcohol-related deaths (47/100,000); suicide (26/100,000); and other injuries, including accidents and falls (33/100,000).
  • Risk factors strongly associated with postpartum opioid overdose death included severe maternal morbidity, mental health, and other substance use disorders.
  • Among patients with OUD, postpartum use of MOUD (buprenorphine or methadone) was associated with 60% lower odds for opioid overdose death (OR 0.4 [95% CI: 0.1, 0.9]).
  • Women who died of opioid overdoses did not have less healthcare utilization during pregnancy or postpartum than matched control participants who did not die postpartum; 80% had contact with a healthcare provider before death.
  • The investigators concluded that compared with the general population, postpartum individuals with OUD have 20-fold higher incidence of postpartum opioid overdose death, which accounts for ~ 10% of all postpartum deaths.
  • They also have a high incidence of postpartum death from other preventable causes of premature mortality, including other drug- and alcohol-related deaths, nonopioid substance-related injuries, accidents, and suicide.
  • Patients with OUD and severe maternal morbidity were at particularly high risk.
  • Use of MOUD is strongly associated with lower opioid-related mortality.
  • The findings suggest potential avenues for intervention through interaction during postpartum outpatient and emergency department visits and through increased MOUD access and maintenance during the first-year postpartum, which strongly protected against overdose.
  • Other evidence-based prevention interventions could include naloxone prescribing and training to pregnant and postpartum women with substance use history and their partners and significant others, screening and brief interventions to lower substance use and suicide risk, and emphasizing personal safety (safe driving, preventing falls, averting domestic violence).
  • Such interventions targeting this high-risk group of patients during the postpartum period are needed to help prevent overdose and other causes of maternal death.
  • Study limitations include inability to capture deaths occurring during pregnancy, lack of generalizability to patients who lose Medicaid eligibility and potentially lose access to treatment, and likely underestimated incidence of opioid overdose death.
  • An accompanying editorial noted that the high proportion of women with fatal opioid-overdoses who saw a healthcare provider before death and the protective effect of postpartum MOUD suggest means and opportunity to prevent these deaths.
  • Still, most clinicians lack time and training to prescribe buprenorphine, and < 2% of Ob/Gyns accepting Medicaid in 2019 were able to prescribe it.
  • The editorial also recommended Medicaid expansion for a full year postpartum through the American Rescue Act's State Plan Amendment.
  • As all clinicians with DEA Schedule III authority can prescribe buprenorphine for OUD if allowed by applicable state law, medical schools and residency programs should prioritize addiction medicine as a core competency.

Clinical Implications

  • Opioid overdose and other preventable causes are important contributors to postpartum deaths, particularly in women with recent OUD.
  • Interventions targeting this high-risk group of patients after delivery are needed to help prevent overdose and other causes of maternal death.
  • Implications for the Healthcare Team: Clinicians should use a validated screening tool at prenatal and postpartum visits to help identify individuals at high risk for OUD or opioid overdose and collaborate to ensure the patient is provided with the appropriate resources.

 

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