美国大型州医疗补助计划中孕妇丁丙诺啡治疗的依从轨迹。
Adherence trajectories of buprenorphine therapy among pregnant women in a large state Medicaid program in the United States.
机构信息
Department of Pharmaceutical Outcomes & Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA.
Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
出版信息
Pharmacoepidemiol Drug Saf. 2019 Jan;28(1):80-89. doi: 10.1002/pds.4647. Epub 2018 Sep 7.
PURPOSE
Little is known about the longitudinal patterns of buprenorphine adherence among pregnant women with opioid use disorder, especially when late initiation, nonadherence, or early discontinuation of buprenorphine during pregnancy may increase the risk of adverse outcomes. We aimed to identify distinct trajectories of buprenorphine use during pregnancy, and factors associated with these trajectories in Medicaid-enrolled pregnant women.
METHODS
A retrospective cohort study included 2361 Pennsylvania Medicaid enrollees aged 15 to 46 having buprenorphine therapy during pregnancy and a live birth between 2008 and 2015. We used group-based trajectory models to identify buprenorphine use patterns in the 40 weeks prior to delivery and 12 weeks postdelivery. Multivariable multinomial logistic regression models were used to identify factors associated with specific trajectories.
RESULTS
Six distinct trajectories were identified. Four groups initiated buprenorphine during the first trimester of the pregnancy (early initiators): 31.6% with persistently high adherence, 15.1% with moderate-to-high adherence, 10.5% with declining adherence, and 16.7% with early discontinuation. Two groups did not initiate buprenorphine until midsecond or third trimester (late initiators): 13.5% had moderate-to-high adherence and 12.6% had low-to-moderate adherence. Factors significantly associated with late initiation and discontinuation were younger age, non-white race, residents of rural counties, fewer outpatient visits, more frequent emergency department visits and hospitalizations, and lower buprenorphine daily dose.
CONCLUSIONS
Six buprenorphine treatment trajectories during pregnancy were identified in this population-based Medicaid cohort, with 25% of women initiating buprenorphine late during pregnancy. Understanding trajectories of buprenorphine use and factors associated with discontinuation/nonadherence may guide integration of behavioral treatment with obstetrical/gynecological care to improve buprenorphine treatment during pregnancy.
目的
对于患有阿片类药物使用障碍的孕妇，人们对其在怀孕期间的丁丙诺啡用药依从性的纵向模式知之甚少，特别是当孕妇在怀孕期间晚期开始、不依从或提前停止丁丙诺啡治疗时，可能会增加不良结局的风险。我们旨在确定孕妇在怀孕期间丁丙诺啡使用的不同轨迹，以及在宾夕法尼亚州医疗补助计划（Medicaid）参保的孕妇中与这些轨迹相关的因素。
方法
本回顾性队列研究纳入了 2361 名在 2008 年至 2015 年期间怀孕并分娩且在怀孕期间接受丁丙诺啡治疗的年龄在 15 至 46 岁的宾夕法尼亚州医疗补助计划参保者。我们使用基于群组的轨迹模型来确定分娩前 40 周和分娩后 12 周的丁丙诺啡使用模式。采用多变量多项逻辑回归模型来确定与特定轨迹相关的因素。
结果
确定了六种不同的轨迹。四组在妊娠的前三个月（早期开始者）开始使用丁丙诺啡：31.6%为持续高依从性，15.1%为中至高依从性，10.5%为依从性下降，16.7%为早期停药。两组直到中第二个或第三个三个月才开始使用丁丙诺啡（晚期开始者）：13.5%为中高依从性，12.6%为中低至中度依从性。与晚期开始和停药显著相关的因素是年龄较小、非白种人、农村县居民、门诊就诊次数较少、急诊就诊和住院次数较多以及丁丙诺啡日剂量较低。
结论
在这项基于人群的医疗补助队列中，确定了六种怀孕期间丁丙诺啡治疗轨迹，其中 25%的女性在怀孕期间晚期开始使用丁丙诺啡。了解丁丙诺啡使用的轨迹和与停药/不依从相关的因素，可能有助于将行为治疗与产科/妇科护理相结合，以改善怀孕期间的丁丙诺啡治疗。
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