Maternal and infant characteristics associated with maternal opioid overdose in the year following delivery

Abstract

Background and AimsOpioid-related overdose is increasingly linked to pregnancy-associated deaths, but factors associated with postpartum overdose are unknown. We aimed to estimate the strength of the association between maternal and infant characteristics and postpartum opioid-related overdose. Design Retrospective cohort study using a linked, population-level data set. Setting Massachusetts, United States. Conclusion Among women who delivered live infants in Massachusetts, USA between 2012 and 2014, maternal diagnosis of OUD, prior non-fatal overdose, infant diagnosis of NAS and high unscheduled health-care utilization appeared to be positively associated with postpartum opioid overdose. However, more than half of postpartum overdoses in that period were to women without a diagnosis of OUD. Engagement in methadone or buprenorphine treatment in the month prior to delivery was not sufficient to reduce the odds of postpartum overdose. Participants Women who delivered one or more live births from 2012 to 2014 (n = 174 517). Measurements The primary outcome was opioid-related overdose in the postpartum year. We used multivariable logistic regression to explore the independent associations of maternal (demographics, substance use, pregnancy) and infant [gestational age, birthweight, neonatal abstinence syndrome (NAS)] characteristics with postpartum opioid overdose. Findings were stratified by maternal opioid use disorder (OUD) diagnosis. Findings There were 189 deliveries to women who experienced ≥ 1 opioid overdose in the first year postpartum (11 of 10 000 deliveries). Among women with postpartum opioid overdose, 46.6% had an OUD diagnosis within 12 months before delivery. In our adjusted model, maternal diagnosis of OUD [adjusted odds ratio (aOR) = 3.61, 95% confidence interval (CI) = 1.73-7.51] and prior non-fatal overdose (aOR = 2.40, 95% CI = 1.11-5.17) were most strongly associated with postpartum overdose. After stratifying by OUD status, infant diagnosis of NAS (OUD + aOR = 2.03, 95% CI = 1.26-3.27; OUD -aOR = 2.79, 95% CI = 1.12-6.93) and high unscheduled health-care utilization (OUD + aOR = 2.27, 95% CI = 1.38-3.73; OUD -aOR = 2.11, 95% CI = 1.24-3.58) were positively associated with postpartum overdose in both groups. 90% of substance use-related pregnancy-associated deaths occurred after 6 weeks postpartum, compared with 60% of all other pregnancy-associated deaths [1][2][3][4][5]. In Massachusetts, the 7-12 months following delivery were

Rooming‐in and loss of child custody: key factors in maternal overdose risk

“…Addiction recently published a research report on maternal and infant characteristics associated with maternal opioid overdose in the year following delivery. 1 We commend and support Nielsen et al for drawing attention to the increased risk of maternal overdose during the first year post-partum and associated risk factors. We believe that two major potential risk factors for overdose were overlooked in the aforementioned study: lack of rooming-in and loss of child custody.…”

“…We thank Mackay and colleagues for highlighting the importance of post-delivery factors that can impact maternal relapse and overdose [1]. We agree that a compassionate, dyadic care environment for opioid-exposed mothers and infants during the delivery hospitalization can help support and maintain recovery in the early postpartum period.…”

“…9 Given that a growing body of literature suggests that rooming-in can reduce NAS scores, and that higher NAS scores are associated with an increased risk of maternal overdose, we believe that rooming-in should be considered a critical factor in future analyses looking at risk for maternal overdose. 1 Although more research is needed, studies examining loss of child custody show an increase in the rates of substance use, mental illness, trauma, criminal activity and mortality, which further reduces the chance of parenting in the future, fuelling the cycle of addiction and trauma. [10][11][12][13][14] When a mother loses custody of her baby she is at high risk of relapse, given the trauma of that experience and loss of the chance to be a parent.…”

Early lessons from maternal mortality review committees on drug-related deaths—time for obstetrical providers to take the lead in addressing addiction

“…61,62 Punitive policies that define substance use as child abuse or neglect increase the likelihood of adverse outcomes including neonatal abstinence syndrome and preterm birth, 63 which in turn increases the risk of maternal overdose. 64 Women are frequently labeled as "noncompliant" when they miss appointments or are not completely abstinent during pregnancy. 65e67 These descriptions are often devoid of the context in which women's "noncompliance" occurs.…”

Improving Measures of Dyadic Outcomes in Perinatal Substance Use Research

“…We found an association with an International Classification of Diseases code for NAS in claims data, not severity of withdrawal, and maternal overdose. We hypothesized that this is more likely a proxy for maternal diagnosis of opioid use disorder (OUD), because 70% of the infant cases of NAS were to women with evidence of OUD [8]. To better examine this association, we need to improve our ability to characterize the type of in utero opioid exposures (prescribed versus non-prescribed opioids) and the severity of withdrawal signs that result in an infant diagnosis of NAS.…”