Date of Award

January 2021

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Jennifer Culhane

Abstract

Opioid Use Disorder (OUD) during pregnancy is associated with high rates of maternal and neonatal morbidity. Guidelines recommend medications for OUD (MOUD); however, pregnant women have limited access to MOUD. First, we describe trends and factors associated with MOUD administration and retention in care (defined as treatment lasting 6 months or longer) among pregnant women with OUD. Second, we describe the prevalence and geographic distribution of Obstetrician-gynecologists trained to prescribe buprenorphine (henceforth referred to as X-waivered), the first-line treatment for OUD currently under-utilized. The first study is a retrospective nationwide, cross-sectional analysis of treatment episodes for primary OUD among pregnant women based on a national database of treatment episodes for substance use disorders at centers that receive federal funds. The second study is a cross-sectional, nationwide study linking physician-specific data to the county- and state-level data, including 31,211 obstetrician-gynecologists who treat Medicaid enrollees.There were 42,239 treatment episodes for primary OUD among pregnant women of age 15 to 49 reporting using heroin, a synthetic opioid, or non-prescribed methadone between 2013 and 2017 included in the analysis. Most episodes were among non-Hispanic White women (77.8%). Patients were mostly unemployed or not in the labor force (88.7%, 27,459). Heroin was the leading substance reported (65.0%, 27,459). MOUD was administered in 47.4% (20,013) of episodes. Retention occurred in 16.6% of episodes without MOUD and 37.8% of episodes with MOUD (p = 0.01). MOUD administration grew from 41% in 2013 to 52% in 2017, however, retention rates declined from 38% to 33%. Only 1.8% (560) of identified obstetrician-gynecologists were X-waivered. Those in counties with fewer than 5% uninsured residents had nearly twice the odds of being X-waivered compared to those in counties with greater than 15% uninsured residents. Compared to those located in metropolitan counties, Obstetrician-gynecologists in suburban counties were more likely to be X-waivered. Most treatment episodes for prenatal OUD did not include MOUD. Fewer than 2% of Obstetrician-gynecologists who treat Medicaid enrollees were X-waivered, and their geographic distribution skews in favor of suburbia. Our findings highlight significant gaps and growth areas in the U.S. addiction care system and may inform initiatives and policies aimed at improving maternal and child health.

Comments

This thesis is restricted to Yale network users only. This thesis is permanently embargoed from public release.

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