Date of Award

Summer 2021

Document Type

Open Access Dissertation

Department

Epidemiology and Biostatistics

First Advisor

Suzanne McDermott

Abstract

Nationally, individuals with disability, like those with chronic health conditions, have higher rates of opioid use and misuse and are prescribed higher dosages than those without disability. Because opioid agonists and antagonists can cross the placenta rapidly, there is biological plausibility that they may have an impact on birth outcomes. Therefore, monitoring prescription opioid use, particularly among pregnant women, is of great public health importance. While evidence for the impact of opioid use on preterm birth and low birthweight are conflicting; findings are consistent that opioid use during pregnancy is associated with a higher risk of small for gestational age, neonatal abstinence syndrome, admission to the neonatal intensive care unit (NICU), as well as longer length of stay in the hospital.

To date, only one study has compared prescription opioid use during pregnancy between women with and without disability, which was done among Tennessee Medicaid beneficiaries between 1995 and 2009. My dissertation links hospital discharge, pharmacy, and birth certificate data from South Carolina Medicaid beneficiaries, who had a live birth between 2008 and 2017. Disability was defined through diagnostic codes to group the women into categories of discrete pathology, i.e., intellectual and developmental disabilities (IDD), inflammatory conditions, longstanding physical disability, and psychiatric conditions, which is a unique feature of my research. The aims of my dissertation are to answer: (1) are pregnant women with disability prescribed opioids more and at higher dosages than those without disability?; (2) is prescription opioid use during pregnancy a mediator of the relationship between the interaction of chronic pain and disability status and low birthweight, preterm birth, and small for gestational age?; (3) is the cumulative dosage of prenatal opioid prescriptions or the interaction of chronic pain and disability status associated with neonatal abstinence syndrome, admission to the neonatal intensive care unit, and length of stay in the hospital?

Are Pregnant Women with Disability Prescribed Opioids More and At Higher Dosages Than Those Without Disability?Yes. Bivariate analyses and adjusted negative binomial regression were utilized to obtain adjusted rate ratios for total opioid prescriptions and total morphine milligram equivalents (MME) during pregnancy per live birth, comparing those with disability to those without. Overall, those with disability had a significantly higher adjusted rate ratio of total opioid prescriptions (aRR: 2.36; 95% CI: 2.21-2.52) and total MME (aRR: 2.29; 95% CI: 2.07-2.52) during pregnancy per live birth than those without disability.

Is Prescription Opioid Use During Pregnancy a Mediator of the Relationship Between the Interaction of Chronic Pain and Disability Status and Low Birthweight, Preterm Birth, and Small For Gestational Age?No. Adjusted causal mediation and logistic regression analyses were utilized to disentangle the relationship between maternal disability and chronic pain status and adverse birth outcomes, whether the relationship is mediated by prescription opioid use during pregnancy. Those with disability and chronic conditions with pain symptoms had 52% higher odds (95% confidence interval (CI): 1.43-1.62) of preterm birth, 33% higher odds (95% CI: 1.24-1.42) of low birthweight, and 8% higher odds (95% CI: 1.02-1.15), than those with neither disability nor conditions with chronic pain symptoms. Prescription opioid use did not mediate the association between disability and adverse birth outcomes.

Is The Cumulative Dosage of Prenatal Opioid Prescriptions or the Interaction of Chronic Pain and Disability Status Associated with Neonatal Abstinence Syndrome, Admission to the Neonatal Intensive Care Unit, and Length Of Stay In The Hospital?Yes and no. Using logistic and Poisson regression models, a 10-unit increase in cumulative, prenatal morphine milligram equivalents (MME) was associated with 2.2% higher odds of NAS (95% confidence interval (CI): 1.7%-2.6%), after adjustment. All levels of conditions of disability overall and pain symptoms were significantly associated with increased odds of NAS. A 10-unit increase in cumulative, prenatal MME was associated with 0.02% higher rate of LOS per live birth, after adjustment. An increase in cumulative, prenatal MME was not associated with increased odds of NICU admission, after adjustment.

Rights

© 2021, Chelsea Lynes Richard

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