Abstract
Little is understood about pregnant individual with opioid use disorder (OUD)’s lifetime history of overdose. We performed a cross-sectional analysis of pregnant individuals with OUD enrolled in the Optimizing Pregnancy and Treatment Interventions for Moms 2.0 study (NCT03833245), a multi-site randomized controlled trial of patient navigation compared to usual care. We summarized participant demographics, overdose history and circumstances of most recent overdose. Of the 102 participants, 13% were ≥ 35 years old, 83% were White and 3.9% Hispanic or Latinx. Of the entire cohort, 65% had a lifetime history of overdose and 41% had at least one overdose within the past year. In the participants’ most recent overdose, 82% involved opioids and 30% sedatives. These findings suggest need for heightened awareness of overdose events.
Précis:
Nearly two thirds of pregnant individuals with opioid use disorder experience overdose in their lifetime and 41% had an overdose in the past year.
INTRODUCTION
Intentional and unintentional drug overdose is a leading cause of death for reproductive-aged, pregnant and postpartum individuals in the United States.1–4 Among individuals who died of a drug-related cause during pregnancy or up to one year postpartum, 25% had a previous nonfatal overdose event.5 However, less is understood about lifetime overdose history and circumstances of these events.3 We describe the demographics, circumstances, and substances involved in nonfatal overdoses among pregnant treatment-seeking individuals with opioid use disorder (OUD).
METHODS
This was a cross-sectional analysis of pregnant individuals enrolled in the Optimizing Pregnancy and Treatment Interventions for Moms (OPTI-Mom) 2.0 study (NCT03833245).6 This parent study was a two-group, single-blinded, multi-site, randomized interventional trial assessing patient navigation verses usual care for pregnant individuals with OUD. Recruitment took place from April 2019 to January 2022. We report demographics, including race and ethnicity, which are important social determinants of health in overdose rates.7 We summarize responses to the Overdose Experiences, Self and Witnessed – Drug Assessment Tool, a single item questionnaire about self-reported overdose events obtained at time of enrollment (7–32 weeks gestation).8 We also compared polysubstance use by overdose intentionality using Fisher’s exact test. All analyses were performed using Stata/MP 17.0 (StataCorp, College Station, Texas 77845, USA).
RESULTS
Of the 102 participants, 13% were ≥ 35 years old, 83% were White and 3.9% Hispanic or Latinx. The majority were multiparous (75%) and unmarried (76%). With respect to socioeconomic demographics, majority had public insurance (94%), a high school or equivalent education (65%), and were currently employed (53%). All met criteria for severe opioid use disorder and most had depression (83%) and anxiety (65%).
Of the entire cohort, 65% (n=66) reported a lifetime history of an overdose event, and nearly half (41%, n=42) had at least one overdose event in the past year (Table 1). Of the 66 who experienced an overdose, 27 participants (41%) reported polysubstance use (Figure 1). The most frequent substances involved in the participant’s most recent overdose were opioids (82%) followed by sedatives (30%) (Figure 1). There was no difference between number of substances used and intentionality of overdose (p=0.18) (Table 1).
Table 1.
Overdose experiences (N=102) among treatment-seeking pregnant individuals with opioid use disorder
| n | %* | ||
|---|---|---|---|
| How many times in your life have you overdosed? | |||
| 0 | 34 | 33.3 | |
| 1–2 | 31 | 30.4 | |
| ≥3 | 35 | 34.3 | |
| Missing | 2 | 2.0 | |
| When was the most recent time you took too many drugs or medications/pills? | |||
| Within the past year | 42 | 41.2 | |
| Within lifetime | 66 | 64.7 | |
| What occurred at time of last overdose?a | |||
| Ended up in a hospital | 21 | 31.8 | |
| 911 was called | 27 | 40.9 | |
| I helped myself | 18 | 27.3 | |
| Someone else helped me | 43 | 65.2 | |
| Other | 18 | 27.3 | |
| Did you take too much of these substances on purpose or accidentally during your last "overdose"?a (n=66) | |||
| Intentional | On purpose, I wanted to die | 5 | 7.6 |
| Didn’t want to die, but didn’t care about the risks | 18 | 27.3 | |
| Accidental | I did not know what the effect would be. | 14 | 21.2 |
| I lost track of how much I had taken or drank. | 17 | 25.8 | |
| Unsure/Other | 12 | 18.2 | |
| How many times in your life have you seen someone else overdose? | |||
| 0 | 14 | 13.9 | |
| 1–2 | 32 | 31.7 | |
| ≥3 | 55 | 54.5 | |
Percentages may not add up to 100 due to rounding or due to responses being non-exclusive
Includes only those responding to having 1+ overdose(s) (n=66)
Figure 1:
Substances used in most recent overdose event among pregnant individuals with opioid use disorder (n=66)
DISCUSSION
In this cohort of treatment-seeking pregnant individuals with OUD, nearly two-thirds of participants experienced an overdose event in their lifetime, and over one-third experienced an overdose event in the last year. This past-year overdose rate is higher compared to a population based cohort study in Massachusetts, which found a 5.5% rate of nonfatal overdose events in the year before or after delivery.3 These data suggest that current estimates of lifetime nonfatal overdose, a significant risk factor for subsequent fatal overdose,9 may be underestimated in this population.
The strengths of our study include prospective data collection about overdose experiences of pregnant treatment-seeking individuals with severe OUD. Because a significant proportion of overdose events in this cohort occurred outside of a healthcare facility, our data may provide a more accurate estimate of nonfatal overdoses than estimates based on claims data. Study recruitment occurred during the SARS-CoV-2 pandemic, therefore our results potentially reflect the increase in pandemic-related overdose events.10 Our results are primarily limited by the inclusion of only individuals engaged in prenatal and addiction care who agreed to enroll in a clinical trial, limiting generalizability of our findings.
We found a higher than previously reported rate of life-threatening overdose events among treatment-seeking pregnant individuals with severe OUD enrolled in a clinical trial. These results need to be confirmed in the broader population and harm reduction interventions should be incorporated into care including low barrier access to medications for OUD, naloxone co-prescription, fentanyl test strips, counseling against using alone among others.11
Footnotes
FINANCIAL DISCLOSURE:
Funds were paid to University of Utah for Dr. Smid from Alydia Inc for being site PI for a study of the JADA device. Dr. Smid and Jasmin E Charles PA-C serves as a medical consultant for Gilead Science Inc for hepatitis C treatment in pregnancy. Dr. Smid also reports money was paid to her institution from NIDA and CDC. The authors did not report any conflicts of interest.
Each author has confirmed compliance with the journal’s requirements for authorship.
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