In 2020, coinciding with the COVID-19 pandemic, increases in fentanyl-involved deaths nearly doubled amongst pregnant and postpartum women, according to a study published in the Journal of the American Medical Association. (1)
Opioids are commonly prescribed at delivery discharge for postsurgical pain management, but many post-partum women are naïve users, having no prior history of opioid use, making them high-risk for potential opioid abuse. (2, 3)
Using mortality data obtained from the restricted National Vital Statistics System, for the period between 2017-2020, study authors examined mortality records for pregnancy-associated deaths and categorized them into three groups: (i) pregnant at time of death, (ii) deceased within 42 days of giving birth (defined as early postpartum), and (iii) deceased within 43 to 365 days of giving birth (defined as late postpartum). (1)
Study authors examined annual overdose death rates and changes over the time period, by drug type and pregnancy category (i.e., pregnant, early and late postpartum), and compared these rates to those obtained for overdose-related mortality amongst persons who identified as female on their death certificate and were of reproductive age (15-44 years), but not pregnant or postpartum.
Study findings show that between 2017 and 2020, pregnancy-associated overdose mortality increased 81%, compared to a 38% increase among reproductive-age women overall. In addition, in 2020 opioid-related deaths nearly doubled for both groups with fentanyl and polysubstance use involvement. One explanation offered by the study author suggests that “Pregnant and postpartum people are known to face barriers to accessing drug treatment and harm reduction services, that when compounded by pandemic-associated stressors, health care shutdowns, and an increasingly volatile unregulated drug supply, may have increased fatal overdose risk,” said Bruzelius.
Why Was there an Increase in Opioid Prescriptions During COVID?
Apparently, women who gave birth after March 2020 filled significantly more prescriptions for opioid medications during their postpartum period, according to a recent study published on April 3, 2023, in JAMA Network Open. (3, 4)
These study authors compared existing trends of opioid prescription medications filled postpartum, during the period pre- and post-COVID 19 pandemic. Findings show that not only did postpartum women fill more opioid prescriptions, the strength of prescriptions was higher than those given to women who gave birth pre-pandemic.
Relationship between opioid exposure at childbirth and future high-risk use
Women with cesarean deliveries had higher opioid fill rates compared to women with vaginal deliveries, “and following the pandemic lockdowns (in March 2020) there was a sharp spike in opioid fill rates,” said study authors Steuart and Lawler. (3, 4) “It’s possible physicians were concerned that they wouldn’t see their patients as frequently during the lockdown and COVID surges and were attempting to compensate for that. But it’s also possible that the anxiety from the pandemic exacerbated women’s feelings of pain, prompting them to fill their prescriptions when they may not have prior to the COVID-19 outbreak.” (4)
Interventions for High-Risk Use in New Moms
New research has been recently funded to examine, longitudinally, predictors of high-risk use in the postpartum year in a cohort of birthing people. (5) If we look closely at the research on overdose mortality postpartum, there were higher cumulative overdose deaths occurring amongst women identified as late postpartum (45 – 365 days after giving birth). (1) Amongst researchers examining persistent opioid use following cesarean deliveries these patients were more likely to have psychiatric comorbidity and substance use/abuse. (6)
In 2022, the state of Massachusetts received $535 million from the opioid settlement funds. Under the terms of the Commonwealth’s approved State-Subdivision Agreement, forty percent (40%) of the funds will be directly allocated to the state’s municipalities to be spent on abatement strategies developed with input from the Opioid Recovery and Remediation Fund Advisory Council. (7) Hence, interventions aimed at pregnant women and postpartum care management, towards mitigating opioid related maternal deaths, will benefit from the incorporation of strategies supporting substance use prevention, treatment, and harm reduction efforts for both pregnant and postpartum women. (5)
References
- Bruzelius E, Martins SS. US Trends in Drug Overdose Mortality Among Pregnant and Postpartum Persons, 2017-2020. Jama. 2022;328(21):2159-61.
- Bateman BT, Franklin JM, Bykov K, Avorn J, Shrank WH, Brennan TA, et al. Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naïve women. Am J Obstet Gynecol. 2016;215(3):353.e1-.e18.
- Steuart SR, Lawler EC, Bagwell Adams G, Shone H, Abraham AJ. Comparison of Postpartum Opioid Prescriptions Before vs During the COVID-19 Pandemic. JAMA Netw Open. 2023;6(4):e236438.
- Beeson L. Postpartum women filled more opioid prescriptionsduring pandemic. In: UGAToday, editor. Health & Wellness • Science & Technology. Georgia. Accessed at URL: https://news.uga.edu/postpartum-women-filled-more-opioid-prescriptions-during-pandemic/2023.
- Matone M. A State-wide Study of Childbirth-Related Opioid Exposure and Conversion to Postpartum High-Risk Opioid Use. University of Pennsylvania and Children’s Hospital of Philadelphia: National Institute for Health Care Management; 2023.
- Bateman BT, Cole NM, Maeda A, Burns SM, Houle TT, Huybrechts KF, et al. Patterns of Opioid Prescription and Use After Cesarean Delivery. Obstet Gynecol. 2017;130(1):29-35.
- Testa M. Appropriation of Opioid Settlement Funds. Massachusetts Association of Health Boards, editor. Legal Guidance, Opioid Settlement Guidance. Wellesley, Massachusetts2022.
About the Author: Dr. Linda Marc is a consultant with expertise in the implementation of interventions for the prevention and treatment of opioid use disorders (OUD). She is the former National Implementation Director of a $21.3 million HRSA-funded initiative that implemented Buprenorphine Treatment, and Screening, Brief Intervention, and Referral to Treatment (SBIRT). Dr. Marc is currently CEO & Chief Science Officer of Behavioral Science International, LLC a public health consulting firm based in Massachusetts. She can be reached at <lindamarc@behavioralscienceintl.com> to consult on the implementation of prevention and treatment interventions for OUD.