Abstract
Objectives:
Pregnant and postpartum women and people (PPWP) who use opioids experience higher rates of morbidity, preterm labor, and stillbirth than those who do not. Although medication for opioid use disorder (MOUD) is the standard of treatment, utilization among PPWP has remained low due to MOUD stigma and misconceptions. The current report examined general and pregnancy-related MOUD attitudes, norms, and self-efficacy among PPWP seeking treatment.
Methods:
Participants (n = 33) receiving MOUD at a Midwestern clinic reported beliefs about MOUD in general using the Attitudes toward Methadone Questionnaire (modified to include all MOUD) and during pregnancy/post-partum using an investigator-generated scale based on previous research. Participants responded using a 5-point scale from “strongly agree” to “strongly disagree” with higher scores indicating more positive attitudes. Analyses examined the bivariate association of attitudes with MOUD subjective norms and self-efficacy, also measured via investigator-generated scales.
Results:
Respondents reported positive attitudes toward MOUD use during pregnancy, with most agreeing it was safe. However, up-to-half of participants reported uncertainty regarding the appropriate dosage of MOUD and its impact on the fetus and/or neonate. Both general and pregnancy/post-partum-related MOUD attitudes were positively associated with subjective norms toward MOUD.
Conclusions:
PPWP reported high uncertainty about MOUD use despite currently using it, emphasizing the need for strategies that assess and mitigate MOUD-related stigma. Findings suggest that familial support and stigma impact attitudes toward MOUD and highlight the importance of accurate psychoeducation and social supports for patients and their families to improve the acceptance and utilization of MOUD among PPWP.
Keywords: medication for opioid use disorder, pregnancy, stigma, women, opioids
Introduction
The national opioid crisis continues to pose a public health emergency across the lifespan, including for pregnant and postpartum women and people (PPWP) and their fetuses/neonates. PPWP who use opioids experience higher rates of severe morbidity, preterm labor, low-birth-weight neonates, and stillbirth than those who do not.1 The standard of care for opioid use disorder (OUD) among PWWP is medication for OUD (MOUD), which is associated with enhanced neonatal outcomes, breastfeeding, and lower substance use relative to non-pharmaceutical treatment.2 Despite its efficacy among PPWP, MOUD remains largely underutilized in this population (<60%).3,4
Stigma associated with MOUD use, or “intervention stigma,” during pregnancy has been identified as a barrier to utilization in qualitative research with PPWP and providers.5–8 Distinct from “condition stigma,” intervention stigma is associated with treatment rather than diagnosis (e.g., OUD), driven by micro- and macro- level factors (e.g., federal prescribing regulations, individual beliefs), and enacted by a range of actors (e.g., individual patients, providers, or society).9 Misconceptions (e.g., MOUD stereotype endorsement) and low subjective norms toward interventions (e.g., beliefs that others do not approve of MOUD) represent two forms of internally-enacted stigma10 associated with low self-efficacy over MOUD.11 These three factors (i.e., misconceptions, subjective norms, and self-efficacy regarding MOUD) have yet to be quantitatively examined among PPWP with OUD. This brief report seeks to describe misconceptions about MOUD specific to the pregnancy/postpartum period and examine the association of those misconceptions with the three aforementioned factors among a sample of PPWP receiving MOUD treatment. These objectives will provide a quantitative basis for assessing individual barriers to MOUD use among PPWP.
Methods
Participants (n = 33) were recruited from a Midwestern clinic designed to support PPWP with OUD from 2018–2020. Research assistants pre-screened patients via the clinic’s appointment portal for the following: >age 18, English fluency, opioid misuse history, and smartphone ownership. Eligible patients were approached after their appointment. Those choosing to enroll completed informed consent procedures and self-report survey measures via their smartphone before departing the clinic. All participants were receiving MOUD treatment at enrollment. Procedures were approved by the Washington University School of Medicine IRB.
Measures
MOUD misconceptions.
The 28-item Attitudes toward Methadone Questionnaire was modified to assess general attitudes toward MOUD, as it has been shown to reliably assess attitudes toward methadone and buprenorphine (throughout the survey, Medication Assisted Treatment [MAT] was used instead of MOUD).12 Participants were asked to “think of the specific medication you have been prescribed” when responding. Ten items created by the research team were added to the scale to assess attitudes toward MOUD use during pregnancy/post-partum (see Table 1). Responses were elicited on a five-point scale from “strongly disagree” to “strongly agree.” Scores range from 28–140 on the original scale and 5–50 on the pregnancy-related scale with higher scores indicating fewer misconceptions (i.e., positive attitudes).
Table 1.
Responses to study-created items
| MOUD Misconceptions in Pregnancy/post-partum | % Disagree | Agree | Not sure |
|
| |||
| It is safe to use MAT the entire time you are pregnant | 8 | 76 | 15 |
| MAT is the safest treatment option for pregnant women with addictions | 12 | 73 | 15 |
| Your MAT dosage will stay the same over the course of pregnancy* | 52 | 20 | 28 |
| The more MAT you take, the higher chance your baby will experience Neonatal Abstinence Syndrome (NAS)* | 24 | 28 | 48 |
| You need to take less MAT closer to the birth date* | 36 | 16 | 48 |
| If you start MAT while pregnant, your baby will experience withdrawal side effects | 15 | 31 | 54 |
| Your prenatal care provider needs to know your MAT dose | 8 | 88 | 4 |
| You do not need to meet with your MAT prescriber after birth* | 73 | 12 | 15 |
| Your doctor and MAT prescriber do not need to be in contact after birth* | 77 | 8 | 15 |
| You should keep the same dosage of MAT after birth* | 15 | 38 | 46 |
|
| |||
| Subjective Norms | Mean | SD | |
|
| |||
| People who are important to me think I [should not – should] use MAT | 5.42 | 2.0 | |
| People who are important to me would [disapprove – approve] of my using MAT | 5.55 | 2.0 | |
| People who are important to me want me to use MAT: [Unlikely – Llikely] | 5.79 | 1.8 | |
|
| |||
| Self-Efficacy | Mean | SD | |
|
| |||
| How confident are you that you will continue to use MAT? [Not at all confident –Very confident] | 5.96 | 1.66 | |
| How sure are you that you could continue to use MAT if you wanted to? [Not at all sure –Very sure] | 6.00 | 1.66 | |
| For me, continuing MAT is: [very easy –very difficult] | 5.58 | 1.79 | |
| How sure are you that you will be able to take MAT as prescribed? [Not at all sure –Very sure] | 6.30 | 1.53 | |
| How much control do you have over whether you do or do not take MAT? [Very little control –Complete control] | 5.94 | 1.71 | |
Note:
Indicates items reverse-coded in scale construction. For subjective norms and self-efficacy, participants were displayed a numerical scale with with bracketed prompts on each end.
Subjective norms.
We created three questions to assess subjective norms on a seven-point scale (see Table 1). Scores were summed and ranged from 3–21 with higher scores indicating more supportive subjective norms toward MOUD.
Self-efficacy.
We created five items to assess perceived capability to use MOUD on a seven-point scale from “not at all” to “very” (see Table 1). Summary scores ranged from 5–35 with higher scores indicating more self-efficacy.
Data Analysis
Analyses were conducted using SAS 9.4. Means, standard deviations, and reliability estimates (Cronbach’s alpha) were calculated for each scale and frequencies examined for each question of the study-generated scales. Zero-order Pearson’s correlations were computed to examine the association between variables.
Results
Participant demographics are summarized in Table 2. Participants reported using buprenorphine (n=22; 66%) and methadone (n=10%) (one did not report). Measures of general attitudes based on the Attitudes toward Methadone Questionnaire (M=105.09, SD=15.34), subjective norms (M=16.75, SD=5.35), and self-efficacy (M=29.82, SD=7.26) had high internal consistency (α≥.79), but the study-created scale assessing MOUD attitudes during pregnancy/post-partum (M=34.50, SD=4.88) had low internal consistency (α=.47). Respondents reported uncertain attitudes about MOUD during pregnancy/postpartum, with over one-third responding “not sure” on four questions (see Table 1). Respondents were particularly uncertain about proper dosage of MOUD during pregnancy/post-partum (28–48%) and its fetal/neonatal impact (48–54%). Conversely, participants had positive attitudes about MOUD use during pregnancy (73–76% agreed it was safe).
Table 2.
Sample characteristics and descriptive statistics (N = 33)
| N (%) | |
|---|---|
|
| |
| Age range | |
| 18 – 30 y | 23 (70) |
| > 30 y | 10 (30) |
| Race & Ethnicity | |
| White | 21 (64) |
| African American | 11 (33) |
| “Other” | 1 (3) |
| Education | |
| GED, High school degree, or below | 18 (55) |
| College and above | 15 (45) |
| Employment | |
| Unemployed | 25 (76) |
| Employed | 8 (24) |
| Living arrangement | |
| Unhoused | 3 (9) |
| Housed | 30 (91) |
| Insurance coverage | |
| Medicaid | 29 (88) |
| Military or VA-provided | 1 (3) |
| Private insurance | 3 (9) |
| Perinatal State | |
| Pregnant | 28 (85) |
| Postpartum | 5 (15) |
Note: Sample size may vary due to missing items
Attitudes toward MOUD during pregnancy/post-partum were positively associated with general MOUD attitudes (r=.46, p=.018). General attitudes were also positively associated with subjective norms (r=.42, p=.014) but not significantly associated with self-efficacy (r=.24, p=.178). Attitudes toward MOUD during pregnancy followed a similar pattern: they were positively associated with subjective norms (r=.48, p=.011) but not self-efficacy (r=.22, p=.283).
Discussion
PPWP in our study endorsed high uncertainty about MOUD use during pregnancy/postpartum despite currently using MOUD. Although most agreed MOUD was safe during pregnancy/postpartum, PPWP were uncertain about its dosage and fetal/neonatal impact. Previous qualitative evidence found that the risk of neonatal opioid withdrawal syndrome (NOWS) while using MOUD contributes to significant internalized stigma among PPWP.6,7 External stigma from previous providers and the broader community, including the criminalization of NOWS, exacerbate this stigma and lead to dissonance about MOUD use even among PPWP who recognize it as the safest treatment option.8 To combat this stigma at the individual level, PPWP require detailed, nonjudgmental psychoeducation about MOUD use and NOWS. A recent pilot study of a single Education and Motivational Counseling session for women with OUD found approximately half of participants enrolled in MOUD treatment, an uptake rate well above those reported in complementary pilot studies.13 Other psychoeducational approaches used to support MOUD uptake among other populations, including group and cognitive behavioral therapy, may also support PPWP.14 At the structural level, non-punitive policies and provider trainings for obstetricians, pediatricians, and social workers/case managers that emphasize NOWS as a side-effect of a life-saving medication may reduce external stigma and improve MOUD utilization.
Both general and pregnancy/post-partum-specific attitudes toward MOUD were associated with positive subjective norms, supporting previously described theories of intervention stigma.9 Taken with previous evidence that partnered women demonstrate higher internalized OUD stigma (i.e., condition stigma) than non-partnered women,15 findings suggest that PPWP’s families also require supportive, accurate psychoeducation to reduce stigma and promote treatment uptake. Among PPWP with limited familial support, psychosocial supports such as peer groups are important mechanisms for mitigating stigma.6
The primary limitation of this study is inclusion of only those prescribed MOUD, who may have more positive attitudes due to provider information and experience with efficacy. Examination of MOUD stigma is needed among those not seeking treatment to best understand how it influences MOUD uptake among PPWP. Other limitations include the small sample size, which precluded us from examining sociodemographic differences in variables. This is an important area for future research given inequities in MOUD utilization by PPWP’s sociodemographic characteristics.3 Finally, the scale created to assess attitudes toward MOUD during pregnancy/postpartum had low reliability, perhaps due to high proportions of uncertain responses.
Despite limitations, the current study is one of the first to quantify MOUD attitudes among PPWP. Findings emphasize the importance of psychoeducation about MOUD’s impact on the developing fetus and parental wellbeing. Assessment and prevention of MOUD stigma among PPWP and families is critical for improving acceptance and use among this population. Future research should examine the impact of external stigma from interdisciplinary providers and others on the development of internalized MOUD stigma among PPWP.
Funding:
Research reported in this publication was supported by the National Institute on Drug Abuse [Grant#: K02 DA043657 (PI: Patricia Cavazos-Rehg)], the Substance Abuse and Mental Health Services Administration [Grant#: 1H79TI081697 (Grantee: Missouri Department of Mental Health)], and the National Center for Advancing Translational Sciences [Grant#: KL2 TR002346 (PI: Reeds)].
Footnotes
Conflicts of interest: none
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