SARAH M. BAGLEY, MD ASSISTANT PROFESSOR OF MEDICINE AND PEDIATRICS BOSTON UNIVERSITY SCHOOL OF MEDICINE AMERSA ANNUAL CONFERENCE NOVEMBER 5, 2015 Overdose Risk Among Pregnant Women with Opioid Use Disorders

Background Pregnant women and women of reproductive age are prescribed opioids at high and increasing rates. (Desai et al 2014, Ailes EC, 2015) Overdose, most of which is opioid-related, has surpassed motor vehicle crashes as a leading cause of injury related death in women. (CDC, 2013) Increase of the rate of overdose death in women was higher than men between (CDC, 2013) Little is known about overdose frequency or factors associated with risk during pregnancy.

Objectives 1. To describe characteristics among late-term pregnant women with opioid use disorders who experienced past year non-fatal overdose and those who did not. 2. To determine the association of certain risk factors with past year non-fatal overdose.

Methods Baseline data was collected as part of RESPECT- Plus, an ongoing randomized controlled trial of a case management support intervention among patients with opioid use disorders at an obstetrics addiction clinic. The baseline questionnaire was completed during the third trimester prior to randomization and included questions about history of overdose. Past year overdose was determined by the questions, “Have you ever overdosed?”, followed by “In the past year, how many times have you overdosed?”

Methods Setting: Obstetrics clinic for pregnant women with substance use disorders at an urban, academic center Inclusion Criteria: patient of RESPECT clinic, treated with methadone or buprenorphine Exclusion Criteria: intent to relinquish custody after delivery

Analysis To explore the association of these factors with past year overdose (yes vs. no) we used generalized linear modeling for continuous candidate variables and chi- square or Fisher’s exact tests for categorical candidate variables.

Results Total % (n) (N=99) Past Year Overdose % (n) (n=14) Overdose, but not in past year % (n) (n=30) Never Overdosed %(n) (n=55) P-value Maternal Age mean in yrs (3.9)29.7(5.8)28.7 (4.5)0.02 Education (≥ High school) 83% (82)100% (14)77% (23)82% (45)0.15 Race/Ethnicity (White/Non- Hispanic) 73% (72)93% (13)74% (22)67% (37)0.16 Relationship Status (Married/in relationship) 82% (81)79% (11)87% (26)80% (44)0.70 Employment (unemployed) 74% (73)78.6 (11)73.3 (22)72.7 (40)0.64

Results Total % (n) (N=99) Past Year Overdose % (n) (n=14) Overdose, but not in past year % (n) (n=30) Never Overdosed %(n) (n=55) P-value Age of onset opioid use (years) 20.2 (4.7) 18.3 (1.9)19.9 (4.6)20.8 (5.2)0.19 Medication treatment (methadone) 55% (54) 64% (9)57% (17)51% (28)0.64 Housing Instability last 6 months (yes) 62% (60) 71% (10)63% (19)59% (31)0.66 Any mental health diagnosis (yes) 87% (86) 100% (14)97% (29)78% (43)0.02 Number of mental health diagnoses (mean, SD) 2.7 (1.6) 3.3 (1.6)3.0 (1.5)2.4 (1.7)0.11

Limitations Women not necessarily pregnant when overdose event occurred. All self-report data (could be a strength because reviewing medical records may undercount). Women in study were in treatment and stable- possible higher risk of overdose in actively using populations. Did not examine known risk factors for overdose (recent release from incarceration or detox, using alone).

Conclusions Pregnant women with opioid use disorders commonly experience nonfatal overdose during the year prior to delivery. Younger women and those with any mental health diagnosis may be at higher risk of overdose. Overdose prevention education is warranted among pregnant women who use opioids. Naloxone rescue kits should be offered to them and their social networks. Further research to understand how to reduce the risk of overdose in pregnant women is indicated.

Acknowledgments Howard Cabral PhD; Kelley Saia, MD; Christine Lloyd-Travaglini, MPH; Alexander Y Walley, MD, MSc; Ruth Rose-Jacobs, ScD RESPECT-Plus team Analysis: Boston University School of Public Health Data Coordinating Center Funding: United States Department of Health and Human Services, Agency for Children Youth and Families under the Abandoned Infants Act. Federal grant number: 90CB0186 and Research in Addiction Medicine Scholars Program, R25DA033211

References 1. Desai RJ et al. Increase in Prescription Opioid Use During Pregnancy Among Medicaid-Enrolled Women. Obstet Gynecol. 2014;123(5): 997– Ailes EC et al. Opioid prescription claims among women of reproductive age-United States, MMWR 2015; 64(2): Mack KA et al. Vital Signs: Overdoses of Prescription Opioid Pain Relievers and Other Drugs Among Women — United States, 1999–2010. MMWR 2013; 62(26): Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. (2014) Available from URL: