(72) Racial Disparities in Substance Use Treatment and Perinatal Outcomes for Pregnant Women

Background & Introduction: Substance use during pregnancy poses a significant threat to both mothers and fetuses, constituting a major public health crisis in the United States. Overdose remains a leading cause of pregnancy-associated morbidity and mortality, with maternal opioid use rising dramatically over the past decade, indicating an urgent need for effective interventions [1]. Amidst the ongoing opioid epidemic, addressing racial disparities in care is paramount. Racial inequities are prevalent in both maternal-infant health and substance use disorder treatment outcomes, demanding focused attention [2]. Despite the critical importance, there is limited research on the specific racial disparities in treatment and outcomes affecting pregnant women with substance use disorder. Our study aimed to fill this gap by investigating the impact of maternal race on rates of initiation and maintenance of medication assisted treatment (MAT) and subsequent perinatal outcomes for pregnant women dealing with substance use disorder (SUD).

Methods: We conducted a retrospective cohort study of women receiving prenatal care through a specialized perinatal SUD program at a tertiary academic medical center from December 2019 to March 2023. Information pertaining to demographics, SUD patterns, MAT usage, and maternal and neonatal outcomes were abstracted from electronic records and compared across 2 groups - Non-Hispanic Black and Non-Hispanic White women. To look at SUD treatments, our primary study outcome was the rate of positive urine drug screens (UDS) for substances other than MAT at delivery admission. Our secondary outcomes were rates of initiation and maintenance of MAT during pregnancy. To look at perinatal outcomes, our study outcomes were – a maternal composite, including antepartum and postpartum – relapse, overdose and severe maternal morbidity (SMM), and a neonatal composite including pharmacologic treatment requiring Neonatal Abstinence Syndrome (NAS), NICU stay >7 days, SGA at birth and neonatal demise. Student’s t test and chi2 / Fisher’s exact tests were used to compare continuous and categorical data, respectively. Statistical significance was set at p ≤.05. Multivariable regression analyses were undertaken for predicting likelihood of composite outcomes while adjusting for age, parity, employment, insurance status, and co-occurring psychiatric diagnoses.

Results: Of the 485 patients in the study cohort, 125 (26%) self-identified as Black and 360 (74%) as White race. 81% (n=393) of the cohort overall had opioid use disorder (OUD). Rates of all SUDs were similar across groups except for cocaine (p <.01) and amphetamine use disorder (p <.01). Black women had higher parity (p <.01), were more likely to be single (p <.01), on governmental insurance (p <.01), and had fewer prenatal care visits (p <.01) with later gestational age at prenatal care initiation (p <.01). Notably, Black women were less likely to have been prescribed buprenorphine (Subutex) (p=.04) and buprenorphine/naloxone (Suboxone) (p <.01) in the past and were less likely to be on all types of MAT at conception (p <.01) and during pregnancy (p <.01). There was no significant difference in the rate of Methadone use prior to conception. Significantly, Black women were more likely to have a positive UDS at L&D admission (p=.02) even though gestational age at initiation of MAT and initiation rates during pregnancy were similar. Rates of the adverse maternal composite were significantly higher among Black patients (p=.04), while rates for the neonatal composite were similar. Black women had significantly higher odds for the adverse maternal composite [OR=1.73 (95% CI;1.1, 1.28), p=.03] in the multivariable regression analyses.

Conclusion & Discussion: Our study exposes alarming racial disparities in SUD treatment and perinatal outcomes. Specifically, Black women experienced restricted access to key MATs like Subutex and Suboxone, which offer substantial accessibility benefits especially during pregnancy [3]. Moreover, Black women also exhibited higher rates of positive urine drug screens at delivery and significantly elevated risks for adverse maternal outcomes. Notably, our study stands out as one of the few examining racial disparities in both SUD treatment and perinatal outcomes, making it a pioneering effort in the field of Addiction Medicine. These disparities stem from systemic biases within healthcare systems, compounded by socioeconomic factors and environmental stressors [4]. Addressing this issue demands comprehensive, community-based interventions that tackle social stigma, provide essential mental health support, and empower women economically. These holistic approaches are essential to creating a more equitable and inclusive healthcare system for all.

References: 1. Sanjanwala, A. R., Lim, G., & Krans, E. E. (2023). Opioids and Opioid Use Disorder in Pregnancy. Obstetrics and gynecology clinics of North America, 50(1), 229–240. https://doi.org/10.1016/j.ogc.2022.10.015
2. Schiff, D. M., Work, E. C., Foley, B., Applewhite, R., Diop, H., Goullaud, L., Gupta, M., Hoeppner, B. B., Peacock-Chambers, E., Vilsaint, C. L., Bernstein, J. A., & Bryant, A. S. (2022). Perinatal Opioid Use Disorder Research, Race, and Racism: A Scoping Review. Pediatrics, 149(3), e2021052368. https://doi.org/10.1542/peds.2021-052368
3. Rodriguez, C. E., & Klie, K. A. (2019). Pharmacological treatment of opioid use disorder in pregnancy. Seminars in perinatology, 43(3), 141–148. https://doi.org/10.1053/j.semperi.2019.01.003
4. Gao, Y. A., Drake, C., Krans, E. E., Chen, Q., & Jarlenski, M. P. (2022). Explaining Racial-ethnic Disparities in the Receipt of Medication for Opioid Use Disorder during Pregnancy. Journal of addiction medicine, 16(6), e356–e365. https://doi.org/10.1097/ADM.0000000000000979