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Rahul Gupta, MD, MPH, MBA, FACPChief Medical and Health OfficerSenior Vice President

MATERNAL HEALTH & PERINATAL SAFETY SYMPOSIUM

NOVEMBER 1, 2019

Impact of the Opioid Epidemic on Women’s and Infants’ Health

OBJECTIVES• Discuss the clinical and

public health opportunities for better maternal and child health

• Using West Virginia case study, discuss the opioid crisis

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CONFLICTS OF INTEREST

None

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MARCH OF DIMES LEADS THE FIGHT FOR THE HEALTH OF ALL MOMS AND BABIES.

OUR MISSION

Slide 5

A BOLD VISION FOR MOMS AND BABIES

End Preventable Maternal Morbidity and

Mortality

End Preventable Prematurity and Infant

Mortality

End the Health Equity Gap

HEALTHY MOMS. STRONG BABIES.

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INCREASING PREMATURITY AND MATERNAL MORTALITY

Premature/preterm is less than 37 weeks of gestation. Preterm birth rate is defined as the percentage of live births born preterm. Maternal rate based on “bridged” race; race categories exclude Hispanics. Source: National Center for Health Statistics, 2014-2017 final natality dataPrepared by March of Dimes Perinatal Data Center, September 2019.

9.57

9.63

9.85

9.93

9.3

9.4

9.5

9.6

9.7

9.8

9.9

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2014 2015 2016 2017

Preterm birth rates, 2014-2017

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Slide 7

The opioid epidemicAs a Demand-Supply Issue

Slide 8

Opioid Epidemic - An Evolving Crisis for Moms and Babies

Supply-side drivers

Demand-side drivers

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Slide 9U.S. Prescribing Rate Maps  | Drug Overdose | CDC Injury Center, 2017

State Opioid Prescribing Rates, 2016

OPIOID PRESCRIBING

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Slide 1010

Prescriptions Filled in the U.S.Total Prescriptions filled per capita,  2016

All Products, Retail Channel

Source:  QuintilesIMS Xponent, 2017

Changes in Opioids Filled Rank State

% Change Rank State

% Change

1 Florida 0.3% 27 Washington -5.6%2 Georgia -0.3% 28 New York -6.2%3 Louisiana -2.2% 29 Iowa -6.5%4 Arkansas -2.2% 30 Kentucky -6.6%5 Wyoming -2.3% 31 California -6.6%6 Texas -2.9% 32 Virginia -6.6%7 Alaska -3.4% 33 New Jersey -6.6%8 Alabama -3.5% 34 Delaware -6.7%9 Utah -3.6% 35 Maryland -7.0%10 Nebraska -3.9% 36 Michigan -7.0%11 Mississippi -3.9% 37 New Mexico -7.8%12 Idaho -4.1% 38 Oregon -7.9%13 Kansas -4.2% 39 Colorado -8.1%14 Illinois -4.2% 40 District of Columbia -8.2%15 South Carolina -4.3% 41 Wisconsin -8.3%16 South Dakota -4.7% 42 Pennsylvania -8.6%17 Nevada -4.9% 43 Ohio -9.0%18 Montana -5.0% 44 Minnesota -9.7%19 Missouri -5.0% 45 Vermont -10.2%20 North Carolina -5.1% 46 Rhode Island -10.5%21 Hawaii -5.2% 47 Connecticut -10.8%22 North Dakota -5.2% 48 Maine -12.0%23 Oklahoma -5.2% 49 Massachusetts -12.7%24 Indiana -5.3% 50 New Hampshire -13.8%25 Arizona -5.5% 51 West Virginia -15.6%26 Tennessee -5.6% 52 Puerto Rico N/A

Percent Change in Filled Prescriptions, 2016 vs 2015Opioid Products

All states = -5.6% annual percentage of change

Source:  QuintilesIMS Xponent, 2017

U.S. total Opioidprescriptions 

2015 = 227,780,915

U.S. total Opioidprescriptions 

2016 = 215,051,279

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OUTCOMES FOR MOMS AND BABIES ARE IMPACTED BY

Healthcare system: Access to care, hospital & provider policies, insurance status

Personal health: Nutrition and access to healthy foods, overall health status including stress

Social environment: Educational status, social stress, job opportunities, work policies for families

Built environment: Housing, neighborhood safety, proximity to child care & employment

Behavioral health: alcohol, tobacco, and drug use

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OPIOID USE AMONG WOMENAbout 1 in 3

women of reproductive age filled an opioid prescription

between 2008 – 2012.

Ailes EC, Dawson AL, Lind JN, et al. MMWR. 2015 Jan 23;64(2):37‐41.

0

1

2

3

4

5

6

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1999 2014

Per 1,000 deliveries

Haight SC, Ko JY, Tong VT, et al. MMWR. 2018 Aug 10; 67(31):845‐849.

Opioid use disorder rates at delivery increased by more than

4‐foldduring 1999 to 2014. 

Every 15 minutes, 

a baby was born with NAS

Nearly 100 babies

each day

y ( )

Babies born with NASexperience

serious medical problems

Winkelman, Villapiano, Kozhimannil, Davis & Patrick, 2018

In 2014, for NAS total 

hospital costs in the US were over

$563 million

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Statewide rates:

• Intrauterine Substance Exposure: 143 per 1,000

• NAS: 50.6 per 1,000

*Data are for WV residents

OPIOID USE IN WEST VIRGINIA

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CHALLENGES TO MOTHERS, INFANTS & CHILDREN (WV)

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Foster Care Placements Up 

Over 50%

5% of Infants Diagnosed with 

NAS

Early Intervention Costs 

Lack of SUD Treatment Options

SUD Increasingly Noted in Infant Death Reviews

Maternal Deaths Increased 72% from 2014‐2016

OUTCOMES ASSOCIATED WITH PRENATAL OPIOID EXPOSURE

?

Prescribing Remains a Major Issue

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Opioid Epidemic - An Evolving Crisis

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Supply-side drivers

Demand-side drivers

20Source:  Betz, Michael. The Link Between Economic Conditions and Overdose Deaths in OH, WV, KY, PA; The Ohio State University.

‐ Community economic disadvantage

‐ Mental health problems

‐ Relational problems

‐ Health conditions (chronic pain, sedentary life styles, etc.) 

DEMAND-SIDE FACTORS

Are Skills Transferable?

Ohio’s Industries

2000 2015

Manufacturing 15.4 10.4

Government and government enterprises

Retail trade 11.7 10.1

Health care and social assistance

9.9 12.8

Accommodation and food services

6.4 7.2

11.512.1

1992

< HS HS 2‐YEAR BACHELORS

2016

< HS HS 2‐YEAR BACHELORS

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Demand Side…

Forecasting the Opioid Epidemic

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Source: Jeanine M. Buchanich, Lauren C. Balmert, Donald S. BurkeExponential Growth Of The USA Overdose Epidemic

Considerations Half of prime age men NLF use daily pain medication (Krueger

2017)

LFP is lower in and fell in counties where prescription rates are higher (Kreuger 2017)

County employment growth in low-paying industries served as a protective factor against OD deaths, effect more for males (Betz and Jones)

Currently 47 million workers with HS degree or less

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HEALTHY MOMS.STRONG BABIES.

OPPORTUNITIES FOR PREVENTION

Policies, programs and research

•Create                a model

•Identify risk factors

•Identify opportunities for intervention

WEST VIRGINIA SOCIAL AUTOPSY CASE STUDY

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Preliminary Occurrence Deaths

Preliminary Resident Deaths

(Matched against death records, CSMP, 

Medicaid, EMS, BBHHF, and Corrections) 

2016 Overdose Fatality Analysis:Healthcare Systems Utilization, Risk Factors, and Opportunities for Intervention

FINDINGS

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WEST VIRGINIA OVERDOSE FATALITY ANALYSIS

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3 x more likely if the decedent had 3+ prescribers

70 x more likely if decedent filled prescriptions at 4+ pharmacies

7 out of 10 decedents were on Medicaid 3 out of 10 decedents received Naloxone

31%

Slide 29

WEST VIRGINIA CASE STUDY

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Slide 30

• Avoiding punitive models in favor of a more therapeutic and treatment-based approach

• NAS surveillance based on birth defects surveillance

• Reducing excess prescribing

• Understanding the long-term outcomes of NAS: Tennessee Pilot

NEONATAL ABSTINENCE SYNDROME / OPIOID CRISIS

Lind JN,  et al. Leveraging Existing Birth Defects Surveillance Infrastructure to Build Neonatal Abstinence Syndrome Surveillance Systems — Illinois, New Mexico, and Vermont, 2015–2016. MMWR Morb Mortal Wkly Rep 2019;68:177–180. DOI: http://dx.doi.org/10.15585/mmwr.mm6807a3

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DRUG-FREE MOMS AND BABIES

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DRUG FREE MOMS AND BABIES PROGRAM

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Integrate behavioral health and maternity care

Incorporate SBIRT (Screening, Brief Intervention and Referral to Treatment) model into existing service delivery

Long-term follow-up with participants from pregnancy through their infant’s 2nd birthday

Increase outreach to moms and reduce stigma by training providers

ACTIONS TO TAKE

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Slide 34

ENSURING ACCESS TO CARE

• Protecting access to quality health insurance, including coverage for people with pre-existing conditions and the requirement that all plans cover maternity and newborn care

• Expanding access to Medicaid, including extending coverage for mothers after childbirth

• Improving access to group prenatal care through enhanced payment and other efforts

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SUPPORTIVE PREGNANCY CARE

Group prenatal care:• Reduces preterm birth among Black women

by 41%; 33% reduction among women of all races/ethnicities

• Improves psychological outcomes, including readiness for labor and delivery

• Empowers women and increases satisfaction with care

March of Dimes has developed a new model of group prenatal care: Supportive Pregnancy Care• Less costly to implement and easier to

sustain

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SUPPORTING HEALTHY WOMEN & HEALTHY BABIES

• Preventing maternal mortality through maternal mortality review committees, improved data collection, and related efforts, with a focus on health equity

• Preventing preterm birth and reducing disparities through efforts such as tobacco prevention and cessation, birth spacing, and access to 17P

• Advancing policies to support mothers and reduce health disparities in the workplace, such as pregnancy nondiscrimination and breastfeeding promotion

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BIRTH EQUITYMarch of Dimes has created a guide to terms and concepts and a consensus statement around birth equity

IMPLICIT BIAS TRAININGFOR MATERNITY CARE PROVIDERSAddress unconscious attitudes and stereotypes Improve patient-provider communications and treatment decisionsIn-person training and virtual resources being developed by March of Dimes and Quality Interactions

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ADVANCING RESEARCH & SURVEILLANCE

• Advancing the future of newborn screening by testing each newborn for every condition on the Recommended Uniform Screening Panel (RUSP) and maintaining a robust birth defects surveillance system

• Promoting research to help pregnant and breastfeeding women and their health care providers know what medications are safe for them and their infants

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SEARCHING FOR ANSWERS – 2019-2020CENTER FOR SOCIAL SCIENCE RESEARCH

Could a women’s race/ethnicity or zip code keep her from having a

healthy baby?

GEOGRAPHICDISPARITIES

This study will uncover how disparities relate to

geography, social and/or economic factors.

WORKFORCE PARTICIPATION

This study will investigate the link between birth outcomes and working

conditions for hourly, part-time, and ‘gig economy’

jobs

Could the type of jobs available to women in places they live impact

birth outcome?

What is known about the causes of racial and

ethnic disparities in birth outcomes?

SOCIAL FACTORS IN PRETERM

The goal of this Consensus Statement is to establish

shared thought leadership on the current status of science regarding the

etiology of the Black-White disparity in preterm birth.

Could a policy mandating paid family

leave increase the number of working

moms?

PAID LEAVE

This study will estimate the impact of access to paid parental leave on

labor force participation.

What would happen if the Affordable Care Act was

reversed?

AFFORDABLE CARE ACT

This study will model the potential impact of the

loss of the ACA on health outcomes, health care

utilization, and disparities.

COST OF PREMATURITY

What does prematurity cost our society?

This study will estimate the cost of medical care,

special education services, and lost productivity due to

premature birth.

THANK YOURahul Gupta, MD, MPH, MBA, FACPSVP, Chief Medical and Health Officer

Twitter:@drguptamd@marchofdimesWebsite:Marchofdimes.org

Join the Collaborative:Marchofdimes.org/collaborative

Facebook:Facebook.com/marchofdimes