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.

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.

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.

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.

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.

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.

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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