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Contents: Opioid Epidemic: Editorial

A Comprehensive Approach to the Opioid Epidemic

Patrick, Stephen W. MD, MPH

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doi: 10.1097/AOG.0000000000002118
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Stephen W. Patrick, MD, MPH
Stephen W. Patrick, MD, MPH:
Stephen W. Patrick, MD, MPH

The opioid epidemic is an exponentially expanding public health problem in the United States. In 2015, opioid overdoses claimed the lives of four Americans each hour, and currently more people die from overdoses than from auto accidents.1 How did we get here? As the former Surgeon General Vivek Murthy said in the lead-up to the release of the landmark report “Facing Addiction in America,”2 the path we find ourselves on was paved with good intentions. Fueled by fear of untreated pain, incorrect information on the opioid pain reliever's abuse potential, and unscrupulous marketing practices, the number of opioid pain relievers prescribed in the United States grew exponentially in recent decades.3 By 2012, 259 million prescriptions were written annually in the United States for opioid pain relievers—more than one for every American adult.4 Opioids, even when prescribed for legitimate pain, can lead to opioid use disorder.

Use of opioid pain relievers increased among all populations, including women of reproductive age and pregnant women. A recent Centers for Disease Control and Prevention report found that nearly a third of women of reproductive age were prescribed an opioid in the previous year,5 and analyses of state Medicaid programs find similarly high rates of opioid prescribing to pregnant women.6 Since 2000, rates of opioid use disorder among pregnant women and the number of newborns diagnosed with opioid withdrawal after birth, known as neonatal abstinence syndrome, have increased7,8; in 2012 alone, one child was born every 25 minutes with neonatal abstinence syndrome.8

While the opioid epidemic is evolving, there is an urgent need for a large expansion of treatment, especially for pregnant women. Currently, the vast majority of the population with substance use disorder are not receiving treatment.9 The high-risk population of pregnant and postpartum women and their newborns are in particular need of treatment resources. Many pregnant women receiving treatment for opioid use disorder are not receiving opioid-agonist therapies such as buprenorphine or methadone.10 Opioid-agonist therapies decrease the risk of relapse and overdose death for the pregnant woman and make it more likely that neonates will be born at term and have higher birth weights.11

In this issue of Obstetrics & Gynecology, four articles (see pages 10, 29, 36, and 42) highlight both the scope of the opioid epidemic and some potential paths forward.12–15 The executive summary of the recent National Institutes of Health–sponsored workgroup “Opioid Use in Pregnancy, Neonatal Abstinence Syndrome, and Childhood Outcomes” provides insight into best practices and knowledge gaps for pregnant women and newborns affected by opioid use, extending from pregnancy to long-term outcomes of opioid-exposed children. Importantly, it provides a specific roadmap for a research agenda to improve outcomes for this vulnerable population.12

Also in this issue, a series of articles spotlight a potential root cause of this problem—excess supply of prescribed opioids.13,14 Bateman and colleagues found that, among women undergoing cesarean delivery, the quantity of opioid pain relievers given at discharge was double what was consumed. Further, the authors found that the amount of opioid pain relievers prescribed did not correspond to a change in pain control or patient satisfaction. Almost all patients had not disposed of excess opioids, and most did not have a plan to dispose of them. The authors note that “…if our results generalize to the United States as a whole, there are approximately 20 million opioid tablets introduced into communities from leftover medication after the treatment of pain after cesarean delivery each year, which are potentially available for diversion or misuse.”13 Similarly, Osmundson and colleagues found that more than three quarters of women had, on average, an excess of 10 pills of oxycodone left over after cesarean delivery. In addition, only 6% of those women with extra pills had disposed of them.14 In a separate study, Prabhu and colleagues piloted a shared-decision model to engage women before discharge about their anticipated needs and desires for postdischarge pain medicine. Importantly, they found a 50% reduction in the initial quantity of opioid pain reliever prescribed compared with their institutional standard, without sacrificing patient satisfaction.15

The path needed to address this national crisis is complex and multifaceted. Although addressing supply is a vital prevention strategy, it is not enough to stem the tide of the opioid epidemic. Because the epidemic has been brewing for years, prevention strategies likely will take a while to produce population-wide results. There is a worry that decreasing the supply of opioid pain relievers, in isolation, may result in in unmet demand and subsequent substitution of less expensive heroin. Data suggest that four out of five people who use heroin began with misusing prescription opioids.16 Today, street values for heroin are less than for opioid pain relievers and are reduced further by drug dealers who cut heroin with more potent, illicitly manufactured fentanyl.17 Perhaps as a result, recently, the number of deaths attributed to opioid pain relievers has plateaued, coincident with a dramatic spike in heroin- and fentanyl-related deaths.1 Decreasing supply must be accompanied by a strategy to reduce the demand for opioids by improving access to treatment.

Treatment needs are particularly pressing for the vulnerable population of pregnant women with opioid use disorder and their newborns, where treatment must be gender-specific, multidisciplinary, and comprehensive in nature and continued through the continuum of care, ideally from the prepregnancy period to the infant and developing child. A recent and hopeful development, the 21st Century Act, should provide $1 billion in grants to states for the provision of treatment for opioid use disorder, but this necessary first step cannot happen quickly enough. There is no silver bullet and no quick fix for the rising numbers of pregnant women and neonates affected by the opioid epidemic. The stakes are high, and collectively we must have a thoughtful public health response that is grounded in both research and compassion.

REFERENCES

1. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths—United States, 2010–2015. MMWR Morb Mortal Wkly Rep 2016;65:1445–52.
2. U. S. Department of Health and Human Services. Facing addition in America. Available at: https://addiction.surgeongeneral.gov/. Retrieved May 3, 2017.
3. Krans EE, Patrick SW. Opioid use disorder in pregnancy: health policy and practice in the midst of an epidemic. Obstet Gynecol 2016;128:4–10.
4. Paulozzi LJ, Mack KA, Hockenberry JM; Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC. Vital signs: variation among States in prescribing of opioid pain relievers and benzodiazepines—United States, 2012. MMWR Morb Mortal Wkly Rep 2014;63:563–8.
5. Ailes EC, Dawson AL, Lind JN, Gilboa SM, Frey MT, Broussard CS, et al. Opioid prescription claims among women of reproductive age—United States, 2008–2012. MMWR Morb Mortal Wkly Rep 2015;64:37–41.
6. Desai RJ, Hernandez-Diaz S, Bateman BT, Huybrechts KF. Increase in prescription opioid use during pregnancy among Medicaid-enrolled women. Obstet Gynecol 2014;123:997–1002.
7. Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal abstinence syndrome and associated health care expenditures: United States, 2000–2009. JAMA 2012;307:1934–40.
8. Patrick SW, Davis MM, Lehmann CU, Cooper WO. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012. J Perinatol 2015;35:650–5.
9. Substance Abuse and Mental Health Services Administration. Behavioral health trends in the United States: results from the 2014 National Survey on Drug Use and Health. Rockville (MD): Substance Abuse and Mental Health Services Administration; 2014.
10. Martin CE, Longinaker N, Terplan M. Recent trends in treatment admissions for prescription opioid abuse during pregnancy. J Subst Abuse Treat 2015;48:37–42.
11. Opioid abuse, dependence, and addiction in pregnancy. Committee Opinion No. 524. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;119:1070–6.
12. Reddy UM, Davis JM, Ren Z, Greene MF. Opioid use in pregnancy, neonatal abstinence syndrome, and childhood outcomes: executive summary of a joint workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, American College of Obstetricians and Gynecologists, American Academy of Pediatrics, Society for Maternal-Fetal Medicine, Centers for Disease Control and Prevention, and the March of Dimes Foundation. Obstet Gynecol 2017;130:10–28.
13. 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;130:29–35.
14. Osmundson SS, Schornack LA, Grasch JL, Zuckerwise MD, Young JL, Richardson MG. Postdischarge opioid use after cesarean delivery. Obstet Gynecol 2017;130:36–41.
15. Prabhu M, McQuaid-Hanson E, Hopp S, Burns SM, Leffert LR, Landau R, et al. A shared decision-making intervention to guide opioid prescribing after cesarean delivery. Obstet Gynecol 2017;130:42–46.
16. Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers—United States, 2002–2004 and 2008–2010. Drug Alcohol Depend 2013;132:95–100.
17. Frank RG, Pollack HA. Addressing the fentanyl threat to public health. N Engl J Med 2017;376:605–7.
© 2017 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.