Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO.
Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO.
Am J Obstet Gynecol MFM. 2020 Nov;2(4):100225. doi: 10.1016/j.ajogmf.2020.100225. Epub 2020 Sep 15.
The incidence of opioid use disorder during pregnancy has risen dramatically in the last couple of decades. Despite the safety and efficacy of treatment for opioid use during pregnancy, pregnant women often cannot access treatment.
This study aimed to determine the availability of opioid agonist therapy to pregnant women in Missouri and Illinois and to compare different markers of treatment accessibility between opioid treatment programs and buprenorphine providers and between rural and urban practices.
Buprenorphine providers and opioid treatment programs in Missouri and Illinois were identified using the Substance Abuse and Mental Health Services Administration website. A phone audit was conducted to evaluate barriers to care, including whether clinics accepted new patients, pregnant patients, and insurance, and the time to the first appointment and appointment cost. Rural-urban commuting area codes and practice ZIP codes were used to determine whether practice location was rural or urban. Provider specialty was determined from state licensing databases.
There were 1363 buprenorphine providers and 98 opioid treatment programs listed. Clinics were clustered around metropolitan areas, and only 13% of buprenorphine providers (183 of 1363) and 5% of opioid treatment programs (5 of 98) were in rural areas. Despite 3 contact attempts for each clinic, we were unable to reach 42% of buprenorphine providers (401 of 965) and 14% of opioid treatment programs (14 of 98). Of those reached, 40% of buprenorphine providers (223 of 564) and 80% of opioid treatment programs (67 of 84) were accepting new pregnant patients (P=.01). Buprenorphine providers required more contact attempts (>2 attempts in 34% vs 15%; P<.0001) and had longer wait times for the first appointment (>7 days in 27% vs 4%; P=.002) than opioid treatment programs. Buprenorphine providers in urban areas required more attempts to reach (>2 attempts in 36% vs 24%; P=.03) and were less likely to accept Medicaid than those in rural areas (52% vs 74%; P=.008). More than 23% of buprenorphine provider listings (238 of 1038) contained incorrect information, whereas no opioid treatment program listing had incorrect information. Most buprenorphine providers were in primary care or psychiatry, whereas <5% of buprenorphine providers (43 of 1363) were obstetrician-gynecologists.
This is the first phone audit to evaluate access to opioid agonist therapy for pregnant women. Only a minority of buprenorphine providers offered care for this patient population, and a large proportion required multiple contact attempts and wait times of >7 days. Opioid treatment programs were more responsive and accepting of new pregnant patients but comprised a minority of clinics and were predominately located in urban areas. There is an urgent need for improved reliability of contact information for opioid agonist providers, timely intake and acceptance for treatment of pregnant patients, and overall improved access to clinics that are challenged by geographic and insurance status barriers.
在过去的几十年中，孕妇阿片类药物使用障碍的发病率急剧上升。尽管阿片类药物治疗在怀孕期间是安全有效的，但孕妇往往无法获得治疗。
本研究旨在确定密苏里州和伊利诺伊州孕妇获得阿片类激动剂治疗的情况，并比较阿片类药物治疗项目和丁丙诺啡提供者之间以及农村和城市实践之间不同的治疗可及性指标。
使用药物滥用和心理健康服务管理局网站确定密苏里州和伊利诺伊州的丁丙诺啡提供者和阿片类药物治疗项目。进行了电话审计，以评估护理障碍，包括诊所是否接受新患者、孕妇和保险，以及首次预约的时间和预约费用。农村-城市通勤区代码和实践邮政编码用于确定实践地点是否为农村或城市。从州许可数据库中确定提供者的专业。
列出了 1363 名丁丙诺啡提供者和 98 个阿片类药物治疗项目。诊所集中在大都市区，只有 13%的丁丙诺啡提供者（1363 名中的 183 名）和 5%的阿片类药物治疗项目（98 名中的 5 名）在农村地区。尽管每个诊所进行了 3 次联系尝试，但我们仍无法联系到 42%的丁丙诺啡提供者（965 名中的 401 名）和 14%的阿片类药物治疗项目（98 名中的 14 名）。在联系到的人中，40%的丁丙诺啡提供者（564 名中的 223 名）和 80%的阿片类药物治疗项目（84 名中的 67 名）接受新的孕妇（P=.01）。丁丙诺啡提供者需要更多的联系尝试（34%需要超过 2 次尝试，而 15%；P<.0001），并且首次预约的等待时间更长（27%超过 7 天，而 4%；P=.002）。城市地区的丁丙诺啡提供者需要更多的联系尝试（36%需要超过 2 次尝试，而 24%；P=.03），并且比农村地区的提供者更不愿意接受医疗补助（52%对 74%；P=.008）。超过 23%的丁丙诺啡提供者名单（1038 名中的 238 名）包含错误信息，而没有阿片类药物治疗项目的名单包含错误信息。大多数丁丙诺啡提供者是在初级保健或精神病学领域，而不到 5%的丁丙诺啡提供者（1363 名中的 43 名）是妇产科医生。
这是第一次电话审计评估孕妇阿片类激动剂治疗的可及性。只有少数丁丙诺啡提供者为这一患者群体提供护理，而且很大一部分需要多次联系尝试和超过 7 天的等待时间。阿片类药物治疗项目反应更灵敏，更愿意接受新的孕妇，但只占诊所的少数，主要分布在城市地区。迫切需要改善阿片类药物激动剂提供者的联系信息可靠性，及时接受和治疗孕妇，并整体改善面临地理和保险状况障碍的诊所的可及性。
