Abstract
Objectives. To estimate use of medication for opioid use disorder (MOUD) and prescription opioids in pregnancy among mothers of infants with neonatal opioid withdrawal syndrome (NOWS).
Methods. We used linked 2016–2018 North Carolina birth certificate and newborn and maternal Medicaid claims data to identify infants with an NOWS diagnosis and maternal claims for MOUD and prescription opioids in pregnancy (n = 3395).
Results. Among mothers of infants with NOWS, 38.6% had a claim for MOUD only, 14.3% had a claim for prescription opioids only, 8.1% had a claim for both MOUD and prescription opioids, and 39.1% did not have a claim for MOUD or prescription opioids in pregnancy. Non-Hispanic Black women were less likely to have a claim for MOUD than non-Hispanic White women. The percentage of infants born full term and normal birth weight was highest among women with MOUD or both MOUD and prescription opioid claims.
Conclusions. In the 2016–2018 NC Medicaid population, 60% of mothers of infants with NOWS had MOUD or prescription opioid claims in pregnancy, underscoring the extent to which cases of NOWS may be a result of medically appropriate opioid use in pregnancy.
Over the past 2 decades in the United States, the prevalence of opioid use and opioid use disorder (OUD) in pregnancy has substantially increased.1 Medication for opioid use disorder (MOUD) is the recommended, evidence-based treatment of OUD in pregnancy.2 Prior research shows that MOUD, compared with detoxification or continued opioid use, is associated with improved outcomes, including reduced risk of return to drug use, improved engagement in treatment and prenatal care, and higher birth weights.3
Neonatal opioid withdrawal syndrome (NOWS) is an expected and treatable condition following prenatal exposure to opioids, including MOUD.4 NOWS is a drug withdrawal syndrome with symptoms including minor behavioral problems such as feeding difficulties and high-pitched crying and, less frequently, major problems such as failure to thrive and seizures.4 Nationally, the incidence of NOWS has increased alongside increases in opioid use and OUD in pregnancy.5
Understanding the extent to which NOWS cases are related to prenatal use of MOUD or prescription opioids as directed by a health care provider can inform appropriate pre- and postnatal intervention and reduce stigma associated with NOWS diagnoses. In 2 Florida counties from 2010 to 2012, among mothers of infants with NOWS, 41% used MOUD and 22% used prescription opioids in pregnancy.6 Across neonatal intensive care units in 33 states from 2012 to 2013, among infants with NOWS, 41% of mothers used MOUD and 24% used prescription opioids in pregnancy.7 In Tennessee from 2013 to 2016, 59% of mothers of infants with NOWS used MOUD in pregnancy.8
Although results from existing studies are informative, changes in opioid and other substance use patterns in pregnancy and enhanced efforts to engage pregnant populations in treatment signal a need for more recent estimates to inform current practice. Moreover, given that 80% of NOWS-related deliveries are funded by Medicaid,5 a focus on this population, which has not been explicitly examined in prior studies, is warranted. We used 2016–2018 North Carolina Medicaid and birth certificate data to conduct a descriptive study, estimating MOUD and prescription opioid use in pregnancy among mothers of infants diagnosed with NOWS.
METHODS
We used the 2016–2018 North Carolina Composite Linked Birth (Babylove) files, which include linked birth certificate and newborn and maternal Medicaid claims data. Data management and linkage are conducted by the North Carolina State Center for Health Statistics.
We used newborn Medicaid claims and birth certificate data to identify singleton infants born in 2016 to 2018. We defined NOWS as a diagnosis code of neonatal withdrawal symptoms (International Classification of Diseases, 10th Revision, Clinical Modification [ICD-10-CM] code P96.1)9 within 30 days of delivery.10
We estimated each woman’s pregnancy period using gestational age at delivery on the birth certificate and date of delivery in Medicaid claims. We defined MOUD use as at least 1 claim in pregnancy with a National Drug Code for buprenorphine or naltrexone or a Healthcare Common Procedure Coding System code for buprenorphine, methadone, or naltrexone. We defined prescription opioid use as at least 1 claim in pregnancy with an opioid National Drug Code, excluding MOUD.
We restricted the sample to mothers of infants diagnosed with NOWS who had continuous enrollment (≤ 30 total gap days) in Medicaid during pregnancy (n = 3395). We calculated the number and proportion who had a claim for MOUD, prescription opioids, both MOUD and prescription opioids, and neither in pregnancy. We compared available maternal and infant characteristics from the birth certificate across groups.
RESULTS
From 2016 to 2018, among mothers of infants diagnosed with NOWS, 38.6% had a claim for MOUD only, 14.3% had a claim for prescription opioids only, 8.1% had a claim for both MOUD and prescription opioids, and 39.1% did not have a claim for MOUD or prescription opioids in pregnancy (Table 1).
TABLE 1—
Maternal and Infant Characteristics Among Mothers of Infants With Diagnosed Neonatal Opioid Withdrawal Syndrome: North Carolina, 2016–2018
| All, No. (%) (n = 3395) | Only Medication for OUD Claims in Pregnancy, No. (%) (n = 1309) | Only Prescription Opioid Claims in Pregnancy, No. (%) (n = 484) | Medication for OUD and Prescription Opioid Claims in Pregnancy, No. (%) (n = 276) | Neither Type of Claim in Pregnancy, No. (%) (n = 1326) | |
| Maternal age, y | |||||
| < 25 | 972 (28.6) | 288 (22.0) | 127 (26.2) | 65 (23.6) | 492 (37.1) |
| 25–29 | 1287 (37.9) | 555 (42.4) | 181 (37.4) | 100 (36.2) | 451 (34.0) |
| 30–34 | 822 (24.2) | 359 (27.4) | 110 (22.7) | 84 (30.4) | 269 (20.3) |
| ≥ 35 | 314 (9.2) | 107 (8.2) | 66 (13.6) | 27 (9.8) | 114 (8.6) |
| Maternal race/ethnicity | |||||
| Non-Hispanic White | 2577 (75.9) | 1193 (91.1) | 328 (67.8) | 242 (87.7) | 814 (61.4) |
| Non-Hispanic Black | 542 (16.0) | 41 (3.1) | 99 (20.5) | 11 (4.0) | 391 (29.5) |
| Other non-Hispanic | 185 (5.4) | 49 (3.7) | 45 (9.3) | 16 (5.8) | 75 (5.7) |
| Hispanic | 91 (2.7) | 26 (2.0) | 12 (2.5) | 7 (2.5) | 46 (3.5) |
| Maternal education | |||||
| < high school | 1008 (29.8) | 370 (28.4) | 158 (32.6) | 73 (26.4) | 407 (30.8) |
| High school or GED | 1161 (34.3) | 442 (33.9) | 153 (31.6) | 95 (34.4) | 471 (35.6) |
| Some college | 1155 (34.1) | 471 (36.1) | 161 (33.3) | 105 (38.0) | 418 (31.6) |
| College, graduate, or professional school | 62 (1.8) | 21 (1.6) | 12 (2.5) | 3 (1.1) | 26 (2.0) |
| Maternal marital status | |||||
| Not married | 2587 (76.2) | 980 (74.9) | 352 (72.7) | 201 (73.1) | 1054 (79.5) |
| Married | 806 (23.8) | 328 (25.1) | 132 (27.3) | 74 (26.9) | 272 (20.5) |
| Tobacco use in pregnancy | |||||
| No | 1271 (37.5) | 373 (28.5) | 201 (41.8) | 87 (31.5) | 610 (46.1) |
| Yes | 2117 (62.5) | 936 (71.5) | 280 (58.2) | 189 (68.5) | 712 (53.9) |
| Infant gestational age | |||||
| < 37 completed weeks (preterm) | 593 (17.5) | 184 (14.1) | 103 (21.3) | 39 (14.1) | 267 (20.2) |
| ≥ 37 completed weeks (full term) | 2801 (82.5) | 1125 (85.9) | 381 (78.7) | 237 (85.9) | 1058 (79.8) |
| Infant birth weight | |||||
| Low (< 2500 g) | 680 (20.0) | 231 (17.6) | 107 (22.2) | 55 (19.9) | 287 (21.6) |
| Normal (≥ 2500 g) | 2714 (80.0) | 1078 (82.4) | 376 (77.8) | 221 (80.1) | 1039 (78.4) |
Note. OUD = opioid use disorder.
Relative to other groups, there was a higher percentage of younger women among those with neither MOUD nor prescription opioid claims (37.1% < 25 years). Nearly all women with MOUD (91.1%) and both MOUD and prescription opioid claims (87.7%) were non-Hispanic White. There was a higher percentage of non-Hispanic Black women among those with prescription opioid claims only (20.5%) and with neither MOUD nor prescription opioid claims (29.5%). The percentage of women who used tobacco in pregnancy was highest among those with MOUD claims only (71.5%) and with both MOUD and prescription opioid claims (68.5%). The percentage of infants born full term and normal birth weight was highest among women with MOUD claims (85.9% and 85.9%) or with both MOUD and prescription opioid claims (82.4% and 80.1%).
DISCUSSION
In the 2016–2018 North Carolina Medicaid population, 60% of mothers of infants with NOWS had MOUD or prescription opioid claims in pregnancy. Specifically, nearly half had a claim for MOUD and more than 1 in 5 had a claim for prescription opioids. This is consistent with previous research6,7 and documents the extent to which cases of NOWS may be due to medically appropriate opioid use in pregnancy.
Younger women and non-Hispanic Black women were underrepresented among mothers with MOUD or with both MOUD and prescription opioids in pregnancy. Previous studies have documented racial inequities in the treatment of OUD among pregnant populations.11 In addition, more than two thirds of women with MOUD or with both MOUD and prescription opioids used tobacco in pregnancy. This is notable, as tobacco use is associated with a greater severity of NOWS.12 Last, infants of mothers who had MOUD or both MOUD and prescription opioids in pregnancy were more likely to be full term and normal birth weight. This aligns with prior research3 and reinforces the potential benefits of MOUD in pregnancy for infant outcomes.
Interventions including prescription drug monitoring programs and prescribing guidelines have been implemented to reduce opioid use in pregnancy and resulting NOWS among infants. However, we found that 60% of mothers of infants with NOWS were either receiving the standard of care for treatment of OUD or a prescription opioid from a health care provider in pregnancy, suggesting alternative directions for intervention. First, efforts to ensure equitable access to MOUD should be prioritized. An understanding of the lived experiences and treatment barriers among non-White pregnant populations with OUD can inform efforts to address racial inequities in MOUD receipt. Second, because NOWS is an expected outcome of medically appropriate opioid use in pregnancy, efforts to promote the uptake of interventions that are effective in reducing the severity of NOWS (including tobacco cessation programs for pregnant persons receiving MOUD or prescription opioids12) or in treating NOWS (such as the “Eat, Sleep, Console” method13) should be prioritized.
These results should be interpreted in the context of some limitations. Prior research suggests that NOWS is underidentified in administrative data.10 Thus, some infants with NOWS may have been misclassified as not having NOWS, and our results may underestimate NOWS. In addition, some opioid treatment programs dispensing methadone do not accept Medicaid and only accept cash or check payment. If women paid for MOUD with cash or a check, this would not have been captured in the Medicaid claims data. Thus, our results may underestimate MOUD. Last, our results are specific to the North Carolina Medicaid population and may not generalize to other populations.
CONCLUSIONS
In the 2016–2018 North Carolina Medicaid population, 60% of mothers of infants diagnosed with NOWS had a claim for MOUD or a prescription opioid in pregnancy. By highlighting the use of treatment and opioids as prescribed by a health care provider among mothers of infants with NOWS, these results provide insights for intervention and can be used to reduce stigma associated with NOWS.
ACKNOWLEDGMENTS
This work was supported by an award from the National Center for Injury Prevention and Control in the Centers for Disease Control and Prevention (CDC) to the North Carolina Division of Public Health (Overdose Data to Action, cooperative agreement #5 NU17CE925024-02-00). Authors from the University of North Carolina at Chapel Hill were funded through a subcontract under this grant (contract #5118396).
Note. The CDC had no role in the study design, data collection, analysis, interpretation of results, nor decision to publish these findings.
CONFLICTS OF INTEREST
The authors have no conflicts of interest to disclose.
HUMAN PARTICIPANT PROTECTION
This study was reviewed and approved by the institutional review board at the University of North Carolina at Chapel Hill.
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