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Abstract
The incidence of opioid use during pregnancy is increasing, and drug overdoses are a leading cause of postpartum mortality. Most women who are pregnant do not receive medications for treatment of opioid use disorder, despite the mortality benefit that these agents confer. Furthermore, buprenorphine is associated with milder symptoms of neonatal abstinence syndrome (NAS) compared with methadone. To describe the prevalence and geographic distribution across the US of obstetrician-gynecologists who can prescribe buprenorphine (henceforth described as X-waivered) in 2019. A cross-sectional, nationwide study linking physician-specific data to county- and state-level data was conducted from September 1, 2019, to March 31, 2020. Data were obtained on 31 211 obstetrician-gynecologists who accept Medicaid insurance through the Centers for Medicare & Medicaid Services Physician Compare data set and linked to the Drug Addiction Treatment Act buprenorphine-waived clinician list. State-level NAS incidence and county-level uninsured rates and rurality. Prevalence and geographic distribution of obstetrician-gynecologists who are trained to prescribe buprenorphine. Among the 31 211 identified obstetrician-gynecologists, 18 710 (59.9%) were women. Most had hospital privileges (23 236 [74.4%]) and worked in metropolitan counties (28 613 [91.7%]). Only 560 of the identified obstetrician-gynecologists (1.8%) were X-waivered. Obstetrician-gynecologists in counties with fewer than 5% uninsured residents had nearly twice the odds of being X-waivered (adjusted odds ratio [aOR], 1.59; 95% CI, 1.04-2.44; P = .04) compared with those in counties with greater than 15% uninsured residents. Compared with those located in metropolitan counties, obstetrician-gynecologists in suburban counties (eg, urban population of ≥20 000 and adjacent to a metropolitan area) were more likely to be X-waivered (aOR, 1.85; 95% CI, 1.26-2.71; P = .002). Compared with states with an NAS rate of 5 per 1000 births or less, obstetrician-gynecologists in states with an NAS rate of 15 per 1000 births or greater had nearly 5 times the odds of being X-waivered (aOR, 4.94; 95% CI, 3.60-6.77; P < .001). Obstetrician-gynecologists without hospital privileges were more likely to be X-waivered (aOR, 1.32; 95% CI, 1.08-1.61; P = .007). Fewer than 2% of obstetrician-gynecologists who accept Medicaid are able to prescribe buprenorphine, and their geographic distribution appears to be skewed in favor of suburban counties. This finding suggests that there is an opportunity for health systems and professional societies to incentivize X-waiver trainings among obstetrician-gynecologists to increase patients' access to buprenorphine, especially during pregnancy.
Highlights
The US opioid epidemic has impacted women who are pregnant at high rates
Obstetriciangynecologists in counties with fewer than 5% uninsured residents had nearly twice the odds of being X-waivered compared with those in counties with greater than 15% uninsured residents
Compared with those located in metropolitan counties, obstetrician-gynecologists in suburban counties were more likely to be X-waivered
Summary
The US opioid epidemic has impacted women who are pregnant at high rates. the overall proportion of admissions for drug treatment episodes among women who are pregnant has remained stable at 4%, the proportion reporting prescription opioids as the primary substance used increased substantially, from 1% to 19%, between 1992 and 2012.1 The rate of neonatal intensive care unit admissions owing to neonatal abstinence syndrome (NAS) has increased from 1.2 to 8 per 1000 births between 2000 and 2014 nationally, consistent with increased rates of opioid use during pregnancy.[2,3] In states disproportionately impacted by opioid use disorder (OUD) such as West Virginia and Maine, NAS rates are as high as 50.6 per 1000 births (West Virginia) and 80 per 1000 births (Maine).Standard of care for OUD in pregnancy includes pharmacotherapy.[4]. The US opioid epidemic has impacted women who are pregnant at high rates. The overall proportion of admissions for drug treatment episodes among women who are pregnant has remained stable at 4%, the proportion reporting prescription opioids as the primary substance used increased substantially, from 1% to 19%, between 1992 and 2012.1 The rate of neonatal intensive care unit admissions owing to neonatal abstinence syndrome (NAS) has increased from 1.2 to 8 per 1000 births between 2000 and 2014 nationally, consistent with increased rates of opioid use during pregnancy.[2,3] In states disproportionately impacted by opioid use disorder (OUD) such as West Virginia and Maine, NAS rates are as high as 50.6 per 1000 births (West Virginia) and 80 per 1000 births (Maine). Studies have reported that buprenorphine is not inferior to methadone on outcome measures assessing NAS and maternal and neonatal safety when treatment is initiated in the second trimester.[5,6,7] evidence suggests that buprenorphine confers additional benefits for neonates affected by NAS, including milder symptoms and shorter hospital lengths of stay, compared with neonates with in utero exposure to methadone.[5]
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