BACKGROUND: Prescription opioid use is increasing nationwide, with Tennessee having the second highest per capita prescription rate for opioids in 2011. From 2007 to 2012, the use of opioids among women aged 20 years and over was 7.2%, which is a particular concern as opioid use during pregnancy has been directly linked to neonatal abstinence syndrome (NAS). In Tennessee during 2013-2014, there were 2,232 reported cases of NAS. The American College of Obstetricians and Gynecologists (ACOG) guidelines recommend maintenance treatment for pregnant women on opioids, although supporting evidence is mixed. We examined the association of prescription opioid exposure during pregnancy with the development of NAS, among women in Tennessee who gave birth during 2013-2014.
METHODS: Data from the Tennessee Controlled Substances Monitoring Database (CSMD) was linked to Tennessee birth certificate data during 2013-2014, to identify all births to women receiving opioid prescriptions. Those data were then linked to the Tennessee Department of Health reportable diseases database to identify any of those births resulting in NAS. Stepwise logistic regression was utilized to assess multiple risk factors for NAS.
RESULTS: Of 1,213,863 women aged 12-55 in the CSMD database, 25,118 were actively taking prescription opioids during a pregnancy resulting in a live birth, of which 650 presented with NAS. Cumulative milligram morphine equivalents (MME) received during pregnancy (p<0.0370) and cumulative days’ supply of opioids (p<0.0001) were significantly associated with developing NAS, though there was significant interaction between these risk factors (p<0.0021). After adjusting for confounders, lack of prenatal care (OR = 2.7; 95%CI=1.8 – 4.0), education ≤ high school (OR=1.6; 95% CI=1.3 – 1.9), low birth weight (OR=1.4; 95% CI=1.1 – 1.8), non-Black race (OR=4.0; 95% CI=2.6 – 6.2) were all significantly associated with NAS, as was receipt of any buprenorphine/hydrochloride, buprenorphine/naloxone, oxycodone hydrochloride, or methadone hydrochloride.
CONCLUSIONS: We identified multiple risk factors for NAS among women using prescription opioids during pregnancy, including cumulative MMEs and drug type, which should be carefully considered when treating pregnant women. Further studies assessing change in MME during pregnancy would add insight into the validity of the ACOG recommendations.