Opioid Use in Females of Child-bearing Age

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Some obstetricians blame methadone clinics and buprenorphine providers for the high rate of opioid addiction they see in their pregnant population. OBs often seem angry that pregnant addicts are on methadone or buprenorphine.

This isn’t logical. Addiction medicine doctors are responding to the need for treatment in this population. We didn’t cause the opioid addiction problem; by the time pregnant opioid addicts see us, opioid addiction has been well-established. Addiction medicine doctors aren’t out combing the countryside, luring women of child-bearing years into our programs, trying to get them addicted to opioids. However, once opioid addiction is established, several decades of studies prove that medication-assisted treatment with methadone and buprenorphine produces the best results for both mother and child.

Now recent report from the Center for Disease Control (CDC) gives us a clue why so many pregnant women are addicted to opioids. The CDC’s January 23, 2015 issue of Morbidity and Mortality Weekly Report (better known as the MMWR) described a report on the frequency of opioid prescriptions in the U.S. for women of child-bearing years, aged 15 to 44:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6402a1.htm?s_cid=mm6402a1_w#tab

This data was collected each calendar year from 2008 through 2012 by a private firm with access to a massive database with information on over 5 million insured females aged 15 to 44.

The data revealed the percentage of women who filled at least one outpatient opioid prescription per year, and was further examined by region of the U.S., by type of insurance, by specific age groups, ethnicity, and by type of opioid prescribed. The data was collected not on pregnant women, but on women likely to become pregnant.

Averaging the four years of data, twenty-eight percent of the women with private insurance filled at least once opioid prescription per year, and thirty-nine percent of women with Medicaid filled at least one opioid prescription. On a slight positive note, the rates of opioid prescriptions hit a high mark in 2009, when twenty-nine percent of women with private insurance filled at least one opioid and a whopping forty-one percent of women covered by Medicaid filled at least one opioid prescription.

Granted, one prescription per year won’t cause an opioid addiction. But the study also looked at the average number of prescriptions per year in the women who did have at least one opioid prescription, and found women with private insurance averaged nearly three opioid prescriptions per year, and women with Medicaid averaged four and a half prescriptions per year. That’s not unexpected; Medicaid covered people tend to be sicker, with worse physical and mental health. Still, increased exposure to opioids correlates with increased rate of addiction to opioids.

In other words…U.S. doctors are prescribing a hell of a lot of opioids to women who can become pregnant.

Of the thirteen most commonly prescribed opioids to this age group, hydrocodone was the most commonly prescribed opioid for both privately insured and Medicaid insured women. Hydrocodone was prescribed to 17% of the privately insured women of child-bearing years, compared to 25% of Medicaid insured women. Next most common were codeine, oxycodone, tramadol, propoxyphene (taken off the market in 2010), hydromorphone (Dilaudid), meperidine (Demerol), morphine, and in ninth place was buprenorphine. Then came fentanyl, tapentadol, dihydrocodeine, and in last place was methadone, prescribed to one tenth of a percent of women of child-bearing years.

Keep in mind this last data point probably didn’t include methadone prescribed through opioid treatment programs, since Medicaid isn’t accepted as payment at many OTPs, and private insurance usually won’t pay for care at OTPs either. (In fact, this data likely underestimates the number of women prescribed opioids, since women with no insurance weren’t counted in the study.)

Prescribing rates were compared by the region of the U.S. The South has the highest rate of prescriptions for opioids in women of child-bearing years. Averaging all four years studied, the South prescribed opioids to 32% of women in this age group. The Northeast had the lowest rate, at 22%. The Northcentral and the West came in between, at 25% and 27% respectively.

This data mirrors what we’ve seen from other studies of regional prescribing rates for controlled substances (see my blog entry from August 25, 2014). I have my own opinions about why the rates are so different but for once I’m going to keep them to myself, lest I (again) anger my colleagues.

When separated by race, a much higher percentage of white women filled at least one opioid prescription per year, at 46%. This compares to 35% of black women and 34% of Hispanic women.

That’s dismaying, but is in line with previous studies that show black patients get prescribed opioid pain medications at a much lower rate than white patients with the same pain complaint when seen in emergency departments. One would assume this is due to racial bias, but there could be other reasons. For example, maybe whites demand opioid pain medication at a much higher rate than blacks. Obviously, we need more data to find out why we have such racial differences. In this case, being black could be a protective factor against developing iatrogenic (physician-caused) addiction, but is it at the cost of inadequate pain control? I don’t know.

When the data was examined by more narrowly defined age ranges, for women with private insurance, the highest percentage of prescribing was seen in the 30 to 34 age range, at 31%. For Medicaid-insured women, it was highest in the 40-44 age group, showing more than half of these women got at least one prescription for opioids per year.

This makes sense. The longer one is alive, the more medical issues one accumulates, perhaps needing pain control.

Here’s the bottom line: My interpretation of this study is that U.S. doctors, especially in the South, are prescribing too many pain pills to everyone, including to women who could become pregnant.

Around fifty percent of pregnancies in the U.S. are unplanned. With this many women getting pregnant without planning to do so, every doctor prescribing opioids needs to explain the risks of opioids during pregnancy. This includes opioid treatment program doctors like me.

Don’t blame the women. They don’t want to be addicted. In fact, no person with opioid addiction wanted or expected they would become addicted, even if they took their first opioid solely for the good feeling it produced. No one thinks they will become a hostage to opioids, especially if they are being prescribed these medications. How could patients know, when even doctors are poorly informed about the risk of developing opioid addiction?

Pregnant women with opioid addiction are not bad women, recklessly taking drugs and endangering their children. Most did not expect or plan to end up in this situation. These moms want to stop using, but the nature of opioid addiction shows that is a very difficult thing to do, and actually dangerous to try during pregnancy. Outcomes for both mom and baby have been proven to be best when the pregnant mom gets into treatment, on maintenance medications of methadone or buprenorphine.

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4 responses to this post.

  1. Posted by John Cunningham on February 9, 2015 at 2:48 am

    You are a gangster stigma shatterer jana… Deep respect I really hope people listen…I reckon they called it BANANNAS or ??? no one would even know or care… I am so sick of hearing friends pass away over the US why can’t they just have programmed DiaCetyl programs and injecting rooms so people can live life in safety and if they do happen to overdose their is someone there to bring them back.. I have been on this for to long and nothing has changed…It is the most clean in controlled doses when will they learn??? 37yrs I have been around but nothing has changed..It is just getting worse..WHY????? I am in Australia and I just can’t believe all the crap I have heard and seen…. From my point of view Drug Inc glamourising those murdering bastards where is the Police ??? Obamacare???? Obamacareless I think it is just so sad this kids dieing…Respect to you Jana xxxxx

    Reply

  2. Posted by William Taylor, MD on February 9, 2015 at 7:03 pm

    It’s not all physicians prescribing for pain.
    1. A lot of people with bad cough and colds get rx for opiate-containing antitussive.
    2. A lot of dentists prescribe a few days of pain pills for toothache or dental procedures.

    Both are legitimate ways to reduce patient suffering. The risk of inducing addiction is much less than three months of opiates for a fracture.

    Reply

  3. Posted by Daryl Scott on February 12, 2015 at 9:47 am

    @John if you can hear stories in the US, while you’re staying in Australia then you should focus on problems with your country, It’s not that there’s a perfect place to live with so try to help the people in your community and stop complaining. However, I agree there’s a really-really big problem in our country.

    Reply

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