(78) Navigating Discrimination: Experiences of Pregnant Patients with Opioid Use Disorder

Background & Introduction: Pregnant individuals with opioid use disorder (OUD) confront both the physical and psychological challenges of addiction and societal stigma. Existing research underscores that stigma acts as a barrier to individuals accessing healthcare and appropriate addiction treatment [1]. There is evidence that administration of medications for opioid use disorder (MOUD), such as buprenorphine, result in improved neonatal and maternal outcomes [2]. Integrating pregnancy and OUD care results in improved pregnancy and neonatal outcomes including, less severe neonatal abstinence syndrome (NAS) [3]. To date, there are no studies assessing pregnant patients’ experiences with discrimination in healthcare settings and their impact on use of MOUD. The primary objective of this study is to assess levels of experienced discrimination by pregnant patients primarily seen in a clinic providing integrated pregnancy and OUD care, and if there is an association between discrimination and consistent use of MOUD. Secondarily, we assess if there are demographic disparities in levels of experienced discrimination and if higher levels correlate with negative maternal or neonatal outcomes.

Methods: This is an interim analysis of a mixed method study using surveys and semi-structured interviews. Participants were recruited from a clinic in Philadelphia staffed by Obstetrics and Gynecology-trained and Family Medicine-trained providers, offering integrated prenatal and OUD care alongside mental health and social work services. We administered the 7-item Discrimination in Medical Settings Scale (DMSS) to pregnant patients age ≥ 18 years with a diagnosis of OUD [4]. The scale was administered to pregnant patients with opioid use disorder in each trimester and once postpartum, allowing entry at any point during pregnancy and up to 1 year postpartum. Each item on the DMSS was scored from 1 (“never”) to 5 (“always”), with higher scores representing higher levels of experienced discrimination. Surveys included questions about prenatal and postpartum care experiences, with a free text field for additional details. Electronic medical records provided urine drug screen, pregnancy, and neonatal outcomes data. Student's t-tests were used to compare the DMSS scores between groups. Correlation and Cronbach’s alpha were calculated for the total DMSS score as well as each scale item. A subset of ten postpartum patients then participated in semi-structured interviews about their experiences with discrimination. Grounded theory analysis was used to generate themes.

Results: Thirty-three patients were enrolled in the survey study between May and December 2023. Mean age was 31.5 years. Fifteen (45%) identified as Black, 14 (42%) as white, and 4 (12%) as mixed or “other” race. Six patients were then surveyed. The mean DMSS score was 1.74 (SD 0.85), indicating low levels of experienced discrimination. Per-item mean scores ranged from 1.31 (SD 0.58) to 2.03 (SD 1.14). Many free text comments reflected positive experiences at the clinic: “[The clinic] has been open and nonjudgmental and I've felt a way I haven't felt anywhere else. When I try to be open and honest with providers and people who are a part of the healthcare team (at other facilities) about my past addictions I am immediately greeted with stigma and instantly am made to feel less than.” Results from the interviews found examples of both positive and negative experiences related to each DMSS item, though, similarly, there was a predominance of positive experiences.

Non-white patients (1.46, SD 0.79) exhibited lower overall DMSS scores than white patients (2.12, SD 0.80) (p=0.026). No score differences were observed between Hispanic and non-Hispanic patients. Seventeen (52%) patients tested positive for nonprescribed substances on at least one urine drug screen during pregnancy or postpartum, with opioids (33%), cocaine (15%), and amphetamines (15%) being the most common. Mean overall and per-item DMSS scores showed no significant differences between patients screening positive for substances and those who did not. Thirty-two (97%) patients used MOUD during pregnancy, and nine of them (28%) screened negative for buprenorphine at least once, indicating missed doses. No significant differences were found in mean overall and per-item DMSS scores between patients who screened negative for buprenorphine and those who consistently screened positive.

Twenty-two (67%) patients had delivered at the time of analysis. Among those who delivered, 12 (55%) experienced pregnancy complications, primarily preeclampsia (67%). Neonatal complications were observed in five (23%) cases, with all requiring neonatal intensive care unit (NICU) admission and three needing morphine for neonatal abstinence syndrome. No significant differences were found in mean overall and per-item DMSS scores between patients with or without pregnancy complications. However, a higher mean overall score was noted in patients with neonatal complications (2.34, SD 0.94) compared to those without (1.55, SD 0.69) (p=0.049). Cronbach’s alpha analysis for the full DMSS and each of the seven items yielded values exceeding 0.9, indicating excellent internal consistency. In interviews, patients still reported significant experiences of stigma from providers outside the specialized clinic, resulting in negative self-schemas related to motherhood, lower quality of care, and potentially negative health outcomes.

Conclusion & Discussion: In this study of patients seen at a clinic for pregnant individuals with OUD, low discrimination levels were reported overall during pregnancy. Non-white patients experienced less discrimination than white patients, possibly due to clinic staff diversity and a focus on minoritized populations. Despite high MOUD use, some patients missed doses. The study did not find a significant link between missed doses and perceived discrimination, possibly due to the overall low levels within the study population and small sample size.

Patients with neonatal complications had higher DMSS scores, suggesting negative experiences with hospital personnel postpartum, possibly in the NICU. Instances of feeling misunderstood or mistreated by providers were reported more frequently by those with neonatal complications. For example, one patient described an interaction postpartum: “I feel like she was treating me like an addict. Like she didn't want to touch me or deal with me.” This study shows that integrated pregnancy and OUD care may result in lower levels of discrimination, especially non-white patients, particularly compared to environments not specialized in addiction medicine. Future research could explore and compare experiences between pregnant patients seen in specialized OUD clinics and those attending regular obstetrics clinics for prenatal care.

References: [1] Cheetham, A., Picco, L., Barnett, A., Lubman, D. I., & Nielsen, S. (2022). The impact of stigma on people with opioid use disorder, opioid treatment, and policy. Substance abuse and rehabilitation, 1-12.

[2] Jones, H. E., Heil, S. H., Baewert, A., Arria, A. M., Kaltenbach, K., Martin, P. R., ... & Fischer, G. (2012). Buprenorphine treatment of opioid‐dependent pregnant women: a comprehensive review. Addiction, 107, 5-27.

[3] Goodman, D. J., Saunders, E. C., Frew, J. R., Arsan, C., Xie, H., Bonasia, K. L., ... & Brunette, M. F. (2022). Integrated vs nonintegrated treatment for perinatal opioid use disorder: retrospective cohort study. American Journal of Obstetrics & Gynecology MFM, 4(1), 100489.

[4] Peek, M. E., Nunez-Smith, M., Drum, M., & Lewis, T. T. (2011). Adapting the everyday discrimination scale to medical settings: reliability and validity testing in a sample of African American patients. Ethnicity & disease, 21(4), 502.