Introduction: The number of pregnant women with opioid use disorder (OUD) has risen recently. The American Academy of Obstetrics and Gynecology recommends opioid agonist therapy (OAT) with methadone or buprenorphine for the treatment of pregnant patients with OUD (ACOG 2017). However, a recent study showed less than half of these patients receive maintenance OAT during pregnancy (Jordan et al., 2021). Multiple studies have compared outcomes of methadone maintenance therapy versus buprenorphine maintenance on neonates and found both to be efficacious and safe (Meyer et al., 2015, Zedler et al., 2016). Addressing barriers to evidence-based treatment for this population is complex. Understanding the initial treatment of pregnant patients with opioid use disorders in the inpatient setting may give insight into barriers to expansion of OAT.
Methods: Data for this study was obtained from the EHR. Subjects with the following criteria were identified: pregnant patients, age >18, with Opioid Use Disorder admitted to the Behavioral Health Unit between 2013-2020. For those meeting criteria, length of stay (LOS), Against Medical Advice Discharges (AMA), readmissions within the following twelve months were obtained from the EHR. Subjects were divided into groups based on treatment received for OUD: methadone maintenance, methadone detoxification, buprenorphine maintenance, and buprenorphine detoxification. The primary outcome was the effect of treatment type on length of stay. We also compared treatment type with likelihood of readmission. ANOVA was used to investigate the association between medical treatment plans and length of stay. Fisher’s exact test was used to investigate the association between medical treatment plans and likelihood of readmission. Only subjects meeting the following requirements were selected for Fisher’s and ANOVA analyses: (1) under one of these medical treatment plans: methadone detoxification, methadone maintenance, buprenorphine detoxification or buprenorphine maintenance; (2) not Against Medical Advice discharges and (3) in first admission category.
Results: There was a statistically significant difference in length of stay between medical treatment plans (p=0.005). Those under buprenorphine maintenance had statistically shorter length of stay (mean= 3.09 ±1.53 days) compared to those under methadone maintenance (mean= 4.67 ± 2.27 days) (p=0.021). The readmission rates after one year were 41% (Methadone Detoxification ), 29% (Methadone Maintenance), 22% (Buprenorphine Detoxification ), and 15% (Buprenorpine Maintenance). The rates for leaving against medical advice were 30% (Methadone Detoxification), 29% (Methadone Maintenance), 39% (Buprenorphine Detoxification), and 8% (Buprenorpine Maintenance). These differences did not attain statistical significance.
Conclusion: Among pregnant patients with OUD admitted to the behavioral health unit, those started on buprenorphine maintenance had a shorter hospital stay than those placed on methadone maintenance. Patients treated with buprenorphine maintenance also had fewer readmissions than those treated with methadone detoxification, methadone maintenance or buprenorphine detoxification. Methadone has been the gold standard treatment for pregnant patients with OUD, but induction and titration to therapeutic dose typically take longer than buprenorphine due to full agonist and pharmacokinetic properties. Shorter hospital admissions and decrease in readmissions may decrease cost to both the patient and healthcare system. Future studies need to enroll a more ethnically diverse population.
References: Nguemeni Tiako MJ, Friedman A, Culhane J, South E, Meisel ZF. Predictors of Initiation of Medication for Opioid Use Disorder and Retention in Treatment Among U.S. Pregnant Women, 2013-2017. Obstet Gynecol. 2021 Apr 1;137(4):687-694. doi: 10.1097/AOG.0000000000004307. PMID: 33706349.
Opioid use and opioid use disorder in pregnancy. Committee Opinion No. 711. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e81–94
Meyer MC, Johnston AM, Crocker AM, Heil SH. Methadone and buprenorphine for opioid dependence during pregnancy: a retrospective cohort study. J Addict Med. 2015;9(2):81-86. doi:10.1097/ADM.0000000000000092 Zedler BK, Mann AL, Kim MM, et al. Buprenorphine compared with methadone to treat pregnant women with opioid use disorder: a systematic review and meta-analysis of safety in the mother, fetus and child. Addiction. 2016;111(12):2115-2128. doi:10.1111/add.13462
