With the opioid crisis in the United States, we have seen increasing rates of opioid use across multiple sectors of our population, including women of reproductive-age.  Patterns of use differ according to gender, with some studies showing alarmingly high rates of opioid use in young women. For example, the Center for Disease Control’s Youth Risk Behavior Surveillance Study observed that prescription opioid misuse in high school girls was more common than in their male counterparts (8.3% vs. 6.1% for current use), and could be as high as 16.1% for lifetime use in girls.

The risks of opioid use are significant, especially during pregnancy, when opioid use is associated with higher risk of pregnancy loss, adverse pregnancy outcomes, and neonatal abstinence syndrome. However, our data regarding the characteristics of opioid use during pregnancy are limited. Existing studies of opioid use during pregnancy have been limited to Medicaid participants, a specific state or community, and often rely solely on self-reports of opioid use.

To better understand opioid use in a more diverse and nationally representative sample, researchers analyzed cross-sectional data from 21,905 pregnancies of individuals enrolled in the Environmental Influences on Child Health Outcomes (ECHO) Program between 1990 and 2021. The ECHO Program is a National Institutes of Health (NIH)- funded consortium of pediatric cohort studies across the US designed to investigate the effects of early life exposures in children from diverse racial, sociodemographic, and geographic contexts across the United States.

Opioid use (prescribed or unprescribed) was identified using medical records, maternal toxicology screens, and self-report.

Opioid use was present in 2.8% (n = 591) of pregnancies. The majority of people who used opioids in pregnancy were non-Hispanic White (67%) and had at least some college education (69%). The researchers observed that the vast majority (86%) of opioid users in this sample were users of prescription opioids; only 5% reported using heroin during pregnancy.  Those who used opioids reported high rates of alcohol use (32%), tobacco use (39%), marijuana use (16%), and use of illegal drugs (10%) during pregnancy.

Opioid use during pregnancy was associated with non-Hispanic White race, pregnancy during the years 2010-2012, higher parity, tobacco use, and use of illegal drugs during pregnancy.  

In addition, the researchers observed that among participants who used an opioid during pregnancy, 45% had a history of depression and 37% had a history of anxiety.  Maternal depression was associated with increased odds of opioid use during pregnancy by more than two-fold (adjusted odds ratio 2.42, 95% confidence interval: 1.95-3.01). 

How Can We Decrease Opioid Use During Pregnancy? 

In this large study including pregnancies from individuals living across the United States, the researchers observed that 2.8% of women used opioids during pregnancy. In contrast to other studies which have surveyed more restricted populations, this study gives us a look at a more representative sample of women and a better understanding of what opioid use looks like in the general population.  

One of the most concerning findings in this study is that opioid use during pregnancy co-occurs with other variables that are associated with worse pregnancy outcomes and worse neurodevelopmental outcomes in offspring, specifically use of alcohol, tobacco, marijuana and other drugs. In addition, maternal depression — which has also been associated with worse pregnancy outcomes — increases risk for prenatal opioid use.  Thus, these women with depression who use opioids during pregnancy may experience the additive effects of harmful exposures.

This study does not provide information on the frequency or severity of opioid use, nor does it examine the prevalence of opioid use disorder. It is likely that women with substance use disorders would be less likely to participate in this type of longitudinal study examining child outcomes related to concerns about the involvement of child protective services.  While the current study may not provide information on this population, it does give us a better sense of opioid use in the general population.  

Our ability to reduce prenatal exposure to opioids and to create effective programs, policies, and practices requires empirical data representing the diverse communities throughout the United States. Further elucidation of the reasons for use of prescription opioids during pregnancy should be prioritized, as should the development of reliable screening tools for opioid use.  In addition, further studies are needed to examine whether screening for depression and polysubstance use may be useful for preventing opioid use.  

Ruta Nonacs, MD PhD

Nguyen RHN, Knapp EA, Li X, Camargo CA, et al. Characteristics of Individuals in the United States Who Used Opioids During Pregnancy.  J Womens Health (Larchmt). 2022 Nov 9.

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