Full length articleNon-medical opioid use and sources of opioids among pregnant and non-pregnant reproductive-aged women
Introduction
The morbidity and mortality burden of the US opioid epidemic falls heavily on reproductive-age women. Between 1999 and 2010, drug overdose deaths related to opioid pain relievers increased fivefold among US women (Mack and Center For Disease Control, 2013). Although on average more men die from drug overdoses than women, including among those treated for opioid use disorders (Evans et al., 2015), the percentage increase in deaths since 1999 is greater among women, and the sex difference in overdose deaths is rapidly disappearing (Mack and Center For Disease Control, 2013). Reproductive-age women are more likely than younger or older women to require emergency care related to opioid misuse and abuse, in part owing to non-medical use of prescription opioid pain relievers (e.g., oxycodone, hydrocodone, fentanyl, morphine) (US Centers for Disesase Control and Prevention, 2016). Non-medical use (NMU) is defined as the “intentional use of a medication without a prescription, in a way other than as prescribed, or for the experience or feeling that it causes (Committee on Health Care for Underserved Women and The American College of Obstetricians and Gynecologists, 2012).”
Knowing the source of opioids for NMU is crucial to informing prevention efforts. The majority of persons with recent NMU report obtaining opioids from friends or family, who in turn report obtaining the opioids from medical professionals (Substance Abuse and Mental Health Services Administration, 2014). Indeed, prescribing practices – and policy efforts to address overprescribing – are a focus of broad strategies to combat the opioid epidemic (Dowell et al., 2016). Opioid prescribing has particular relevance as a potential source for NMU among reproductive-age women. A recent study showed that between 2008 and 2012, nearly 40% of reproductive-age female Medicaid beneficiaries and almost 30% of privately-insured reproductive-age women filled at least one opioid prescription annually (Ailes et al., 2012).
Gender-specific research on opioid NMU is needed, owing to the different use patterns and effects among men and women (Evans et al., 2015, Kerridge et al., 2015). One important aspect of understanding women’s opioid NMU during reproductive years is the potential for pregnancy, given that almost half (45%) of all US pregnancies are unintended (Finer and Zolna, 2016). Further, the percentage of pregnancies that are unintended is substantially higher among women with opioid use disorders (Heil et al., 2011). Over the last decade, NMU of prescription opioids during pregnancy nearly doubled, mirroring national trends in opioid NMU (Pan and Yi, 2013, Patrick et al., 2015a). This increase in prenatal opioid use poses a significant public health concern, with potential risk for both women and infants. Opioid use during pregnancy is associated with increased risk of newborn withdrawal, known as neonatal abstinence syndrome, and preterm birth, which is the largest contributor to infant mortality (Patrick et al., 2015b). Infants diagnosed with neonatal abstinence syndrome have longer, more complicated birth hospitalizations with clinical signs that range from feeding difficulty to seizures (De’souza, 2015, Creanga et al., 2012, Patrick et al., 2012, Tolia et al., 2015). Women themselves face significant medical and non-medical risks from opioid use during pregnancy, including increased risk of opioid use disorder, which is associated with increased odds of maternal cardiac arrest during delivery and with maternal death (Maeda et al., 2014). Substance use during pregnancy is also associated with broader risks, including intimate partner violence, and parental substance use is associated with involvement with foster care or child protective services (Young et al., 2007).
While pregnant women are an important policy-relevant group because of the risks described above, policy attention must encompass opioid NMU among the broader class of reproductive-age women. In spite of the growing impact of the opioid crisis among women, little of the emergent national attention has focused on addressing opioid use in this group generally, or prior to or during pregnancy specifically. More information on the patterns of and sources for opioid NMU among reproductive age women, including those who are pregnant, will inform public health and prevention efforts to mitigate the effects of the opioid epidemic on women, children and families. The goal of this study was to characterize non-medical prescription opioid use, including sources of opioids, among reproductive-age women in the US, distinguishing women based on pregnancy status.
Section snippets
Data and study population
We used pooled cross-sectional data from 2005 to 2014 from the National Survey of Drug Use and Health (NSDUH). The NSDUH provides population estimates of substance use and health-related behaviors in the U.S. general population. It utilizes multistage area probability sampling methods to select a representative sample of the U.S. civilian, non-institutionalized population aged 12 years or older for participation in the study. All respondents are ensured privacy when answering survey questions
Results
Table 1 presents weighted descriptive characteristics of reproductive-age U.S. women by pregnancy status and, for pregnant and non-pregnant women, comparing those with and without NMU of opioids. Four percent of women reported being pregnant at the time of the survey. Among pregnant women, 0.8% reported opioid NMU in the past 30 days. Compared with pregnant women with no opioid NMU, pregnant women with opioid NMU were younger, more likely to be unmarried, less educated, with lower household
Discussion
While the rates of NMU of opioids among reproductive-age women at first glance appear low (at 2.3% and 0.8% among non-pregnant and pregnant women respectively), the public health burden of NMU in this population is quite large. Annually, there are more than 6 million pregnancies each year in the US, occurring among 62 million reproductive-age women (Curtin et al., 2013). Our findings indicate that approximately 1.4 million reproductive-age women (2.3%) and 50,000 pregnant women (0.8%) have
Conclusions
Opioid NMU has health, social and cost consequences for reproductive-age women, and potential impacts are heightened during pregnancy, when a fetus may also be affected. Opioid NMU among reproductive-age women is a complex public health challenge affecting a vulnerable population. While friends and relatives were the most common source of opioids among reproductive-age women overall, pregnant women were more likely than non-pregnant women to list a doctor as the source of their opioids,
Conflict of interest
None.
Contributors
K. Kozhimannil conceived the study, acquired the data, supervised the analysis, and drafted portions of the manuscript. A. Graves conducted the analysis, contributed to data presentation, and drafted portions of the manuscript. M. Jarlenski, A. Kennedy-Hendricks, S. Gollust, and C. Barry contributed to the conception and design of the study, the analysis and interpretation of the results, data presentation, and public health and policy implications. All authors reviewed the results, revised the
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2019, Current Problems in Pediatric and Adolescent Health CareCitation Excerpt :This corresponds to an overall higher rate of health care utilization among women. In 2017, 2.3% of women of reproductive age reported nonmedical opioid use in the last 30 days,10 and the rate of OUD in this population more than quadrupled from 1999 to 2014.11 The high prevalence of opioid use among women of reproductive age translates to a large number of children at risk—both from prenatal drug exposure and from growing up in households with chronic challenges of addiction and recovery.