A Comprehensive Approach to the Opioid Epidemic

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The opioid epidemic is an exponentially expanding public health problem in the United States. In 2015, opioid overdoses claimed the lives of four Americans each hour, and currently more people die from overdoses than from auto accidents.1 How did we get here? As the former Surgeon General Vivek Murthy said in the lead-up to the release of the landmark report “Facing Addiction in America,”2 the path we find ourselves on was paved with good intentions. Fueled by fear of untreated pain, incorrect information on the opioid pain reliever's abuse potential, and unscrupulous marketing practices, the number of opioid pain relievers prescribed in the United States grew exponentially in recent decades.3 By 2012, 259 million prescriptions were written annually in the United States for opioid pain relievers—more than one for every American adult.4 Opioids, even when prescribed for legitimate pain, can lead to opioid use disorder.
Use of opioid pain relievers increased among all populations, including women of reproductive age and pregnant women. A recent Centers for Disease Control and Prevention report found that nearly a third of women of reproductive age were prescribed an opioid in the previous year,5 and analyses of state Medicaid programs find similarly high rates of opioid prescribing to pregnant women.6 Since 2000, rates of opioid use disorder among pregnant women and the number of newborns diagnosed with opioid withdrawal after birth, known as neonatal abstinence syndrome, have increased7,8; in 2012 alone, one child was born every 25 minutes with neonatal abstinence syndrome.8
While the opioid epidemic is evolving, there is an urgent need for a large expansion of treatment, especially for pregnant women. Currently, the vast majority of the population with substance use disorder are not receiving treatment.9 The high-risk population of pregnant and postpartum women and their newborns are in particular need of treatment resources. Many pregnant women receiving treatment for opioid use disorder are not receiving opioid-agonist therapies such as buprenorphine or methadone.10 Opioid-agonist therapies decrease the risk of relapse and overdose death for the pregnant woman and make it more likely that neonates will be born at term and have higher birth weights.11
In this issue of Obstetrics & Gynecology, four articles (see pages 10, 29, 36, and 42) highlight both the scope of the opioid epidemic and some potential paths forward.12–15 The executive summary of the recent National Institutes of Health–sponsored workgroup “Opioid Use in Pregnancy, Neonatal Abstinence Syndrome, and Childhood Outcomes” provides insight into best practices and knowledge gaps for pregnant women and newborns affected by opioid use, extending from pregnancy to long-term outcomes of opioid-exposed children. Importantly, it provides a specific roadmap for a research agenda to improve outcomes for this vulnerable population.12
Also in this issue, a series of articles spotlight a potential root cause of this problem—excess supply of prescribed opioids.13,14 Bateman and colleagues found that, among women undergoing cesarean delivery, the quantity of opioid pain relievers given at discharge was double what was consumed. Further, the authors found that the amount of opioid pain relievers prescribed did not correspond to a change in pain control or patient satisfaction. Almost all patients had not disposed of excess opioids, and most did not have a plan to dispose of them. The authors note that “…if our results generalize to the United States as a whole, there are approximately 20 million opioid tablets introduced into communities from leftover medication after the treatment of pain after cesarean delivery each year, which are potentially available for diversion or misuse.
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