Association between buprenorphine dose and outcomes among pregnant persons with opioid use disorder

Abstract

Background: Opioid use disorder contributes to maternal morbidity and mortality in the United States. Little is known about how the patterns of buprenorphine dose and duration throughout pregnancy may affect neonatal and postpartum outcomes.

Objective: To determine the associations between trajectories of buprenorphine utilization and dose during pregnancy on maternal and neonatal health outcomes.

Study design: Retrospective cohort study among 2925 pregnant persons with opioid use disorder, followed from the estimated start date of pregnancy through 90 days after delivery. We used administrative healthcare data from Medicaid-enrolled individuals to assess buprenorphine dose and use and maternal (postpartum buprenorphine continuation and overdose) and neonatal (low birthweight, neonatal abstinence syndrome (NAS)) outcomes. Group-based trajectory modelling was used to identify trajectories of buprenorphine dose and use during pregnancy. Weighted multivariable logistic regression assessed the association between buprenorphine trajectories and outcomes.

Results: We identified 8 trajectories of buprenorphine utilization and dose during pregnancy. Regression analyses found that high doses of buprenorphine and a longer duration of buprenorphine use during pregnancy was associated with higher odds of postpartum buprenorphine continuation and reduced rates of overdose. Higher doses and longer duration of buprenorphine treatment were not associated with an increase in NAS or term low birth weight, relative to moderate or low doses or shorter treatment duration.

Conclusion: A longer duration and higher dose of buprenorphine treatment during pregnancy were associated with improved odds of postpartum buprenorphine continuation and were not associated with adverse neonatal outcomes.

Keywords: buprenorphine; low birthweight; neonatal abstinence syndrome; opioid use disorders; overdose; pharmacoepidemiology; postpartum care; substance use disorders.

FIGURE. Group-based trajectories of buprenorphine dose and duration during pregnancy

A–C, Group-based trajectories of buprenorphine dose and duration of use during pregnancy among Medicaid-enrolled patients with opioid use disorder. Data from 2925 persons enrolled in Pennsylvania Medicaid from 2009 to 2019. Group-based trajectories were modeled with a flexible functional form and the best fit was chosen based on model fit statistics as well as clinical relevance. As shown in Figure, among patients with prepregnancy buprenorphine use and who consistently used buprenorphine throughout pregnancy (Group A, Panel A), 3 trajectories were identified: high dose (mean daily dose (MDD) 22.35 mg), moderate dose (MDD 14.76 mg), low dose (MDD 6.97 mg). Among patients who initiated buprenorphine during pregnancy (group B, panel B), 3 trajectories were identified: first trimester, moderate dose initiation (MDD 10.58 mg), second trimester, moderate dose initiation (MDD 5.98 mg), and third trimester, low dose initiation (MDD 1.46 mg). Among patients with prepregnancy buprenorphine use, but who discontinued buprenorphine use during pregnancy, 2 trajectories were identified: first trimester, low dose discontinuation (MDD 2.24 mg), second trimester, moderate dose discontinuation (MDD 6.80 mg).