(12) Predictors of Buprenorphine Continuation Among Postpartum People With Opioid Use Disorder

Introduction: Opioid overdose is a significant cause of pregnancy-associated death in the United States, with rates highest in the immediate postpartum year. Treatment of opioid use disorder (OUD) with buprenorphine (BUP) is safe and effective in pregnancy and postpartum, and longer BUP duration is associated with lower likelihood of overdose. People with substance use disorder (SUD) are more likely to experience psychiatric comorbidities (e.g., anxiety, depression, post-traumatic stress disorder) than individuals without SUD, and psychiatric comorbidities are associated with less BUP adherence among individuals with OUD. To our knowledge, no study has examined the effect of psychiatric comorbidities and their treatment on BUP continuation among postpartum people. The current study examines the influence of (1) the presence of a psychiatric comorbidity and (2) behavioral health treatment on BUP discontinuation among postpartum people with OUD who were receiving BUP at the time of delivery.

Methods: This retrospective cohort study included pregnant patients who received BUP for OUD from January 2017 to March 2020 at an academic medical center that houses a comprehensive perinatal addiction program. The sample included patients who delivered while receiving BUP and were retained in treatment for at least one week postpartum. BUP continuation during the observation period (yes/no) was collected via a chart review and examination of the state prescription monitoring program done every four weeks. The week postpartum of BUP discontinuation was considered to be the last week they had BUP noted in their chart review or the patient was censored at 52 weeks, the maximum survival time, if they remained on BUP at week 52. This chart review identified the presence of psychiatric diagnoses and receipt of behavioral health therapy (both individual or group) as dichotomous (yes/no) variables. Patients were considered to have a psychiatric comorbidity if they had a diagnosis of a mental health condition other than SUD. Cox proportional hazard models estimated the time to BUP discontinuation comparing: (1) patients with a psychiatric comorbidity versus no comorbidity (2) among patients with a psychiatric comorbidity, who received behavioral health therapy during the observation period versus those who did not. The models controlled for age, race, incarceration status, and time on buprenorphine before delivery.

Results: Our sample included 138 patients with the majority being white (80.3%), enrolled in Medicaid (71.7%), and not incarcerated during pregnancy (78.3%). Psychiatric comorbidities were present in 102 (73.9%) of participants. Patients with a psychiatric comorbidity had significantly lower odds (HR .49; p-value = 0.002) of BUP discontinuation than those without a psychiatric comorbidity adjusted for all covariates. Additionally, among patients with a psychiatric comorbidity, patients receiving behavioral health therapy in the observation period had significantly lower odds (HR .55, p-value = 0.035) of discontinuing treatment adjusted for all covariates.

Conclusion: Within a sample of patients with OUD at a medical center that offers integrated SUD and mental health care during pregnancy and postpartum, both the presence of a psychiatric comorbidity and the receipt of behavioral health treatment were negatively associated with BUP treatment discontinuation through the vulnerable one-year period after delivery. Evidence-based approaches to improve health outcomes for postpartum individuals with OUD are urgently needed in the overdose crisis. Tailored interventions to increase access to mental health treatments for this population may be a promising area for further investigation.

References: Litz, M., & Leslie, D. (2017). The impact of mental health comorbidities on adherence to buprenorphine: A claims based analysis. The American journal on addictions, 26(8), 859-863.

Gabrielson SMB, Carwile JL, O’Connor AB, Ahrens KA. Maternal opioid use disorder at delivery hospitalization in a rural state: Maine, 2009-2018. Public Health. 2020;181:171–179

Arnaudo CL, Andraka-Christou B, Allgood K. Psychiatric Co-Morbidities in Pregnant Women with Opioid Use Disorders: Prevalence, Impact, and Implications for Treatment. Curr Addict Rep. 2017;4(1):1-13