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PROBLEM:: In the United States, maternal mortality review committees (MMRC) are providing compelling data that drug-related deaths are emerging as a leading cause of pregnancy-associated death (death during pregnancy or up to a year postpartum). Recommendations from the MMRC consistently highlight screening all pregnant and postpartum women for drug use and improving access to evidence-based substance use disorder and mental health treatment. Unfortunately, many providers lack the confidence, skills and necessary resources to screen for substance use, provide basic behavioral health services or facilitate referral to high-quality services in their clinical settings. Our profession’s collective lack of response to a leading cause of maternal death represents a missed opportunity for potentially life-saving interventions. A SOLUTION:: We call on our fellow obstetrician gynecologists to incorporate the lessons learned from MMRC and integrate addiction assessment and treatment into prenatal and postpartum care. Provider level integration of behavioral health services is, however, insufficient to fully address the magnitude of drug-related maternal deaths in the US. We, therefore, ask colleagues to address the structural/systemic barriers to care identified in MMRC. By doing so, we can prevent drug-related maternal deaths.

OBJECTIVE: To test whether an individualized opioidprescription protocol (IOPP) with a shared decisionmaking component can be used without compromising postcesarean pain management. METHODS: In this multicenter randomized controlled noninferiority trial, we compared IOPP with shared decision making with a fixed quantity of opioid tablets at hospital discharge. We recruited at 31 centers participating in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Study participants had uncomplicated cesarean births. Follow-up occurred through 12 weeks postdischarge. Individuals with complicated cesarean births or history of opioid use in the pregnancy were excluded. Participants were randomized 1:1 to IOPP with shared decision making or fixed quantity (20 tablets of 5 mg oxycodone). In the IOPP group, we calculated recommended tablet quantity based on opioid use in the 24 hours before discharge. After an educational module and shared decision making, participants selected a quantity of discharge tablets (up to 20). The primary outcome was moderate to severe pain (score 4 or higher [possible range 0-10]) on the BPI (Brief Pain Inventory) at 1 week after discharge. A total sample size of 5,500 participants was planned to assess whether IOPP with shared decision making was not inferior to the fixed quantity of 20 tablets. RESULTS: From September 2020 to March 2022, 18,990 individuals were screened and 5,521 were enrolled (n52,748 IOPP group, n52,773 fixed-quantity group). For the primary outcome, IOPP with shared decision making was not inferior to fixed quantity (59.5% vs 60.1%, risk difference 0.67%; 95% CI, 22.03% to 3.37%, noninferiority margin 25.0) and resulted in significantly fewer tablets received (median 14 [interquartile range 4-20] vs 20, P,.001) through 90 days postpartum. CONCLUSION: Compared with fixed quantity, IOPP with shared decision making was noninferior for outpatient postcesarean analgesia at 1 week postdischarge and resulted in fewer prescribed opioid tablets at discharge. [ABSTRACT FROM AUTHOR]

Background and aims: Patient navigation (PN) may benefit pregnant individuals with opioid use disorder (OUD) by improving treatment adherence. We examined participant enrollment, session delivery and assessment feasibility for a PN intervention among pregnant participants and compared PN preliminary effectiveness for OUD treatment engagement with participants in usual care (UC). Design: This study was a pilot single‐blinded multi‐site randomized trial. Setting: Two academic medical centers in Pennsylvania (n = 57) and Utah (n = 45), United States participated. Participants: One hundred and two pregnant adult participants unestablished (fewer than 6 weeks) on medication for OUD (MOUD) were randomized to PN (n = 53) or UC (n = 49). Intervention: PN was composed of 10 prenatal sessions (delivered after baseline but before the prenatal assessments) and four postnatal sessions (delivered before the 2‐ and 6‐month postpartum assessments) focused upon OUD treatment and physical/mental health needs. UC involved brief case management. Measurements Feasibility assessments included consent, session delivery and assessment rates. Mixed‐effect models for intent‐to‐treat (ITT) and per protocol (PP, received six or more sessions) populations were estimated to compare outcomes of MOUD use, secondary outcomes of substance use disorder (SUD) treatment attendance and non‐prescribed opioid use, and exploratory outcome of overdose at baseline, predelivery and 2 and 6 months postpartum. Findings We consented 87% (106 of 122) of the proposed target, delivered ~60% of sessions delivered and completed ≥ 75% assessments. PN ITT and PP had better MOUD adherence, SUD treatment attendance, non‐prescribed opioid use and overdose outcomes than UC. Notable changes included good evidence for greater percentage change in days for PN PP MOUD use from baseline to 2 months postpartum [PN = 28.0 versus UC = −10.9, 95% confidence interval (CI) = 9.7, 62.1] and some evidence for baseline to 6 months postpartum (PN = 45.4 versus UC = 23.4, 95% CI = −0.7, 48.2). PN PP percentage change in days for SUD treatment attendance also showed good evidence for improvements from baseline to prenatal assessment (PN = 7.4 versus UC = −21.3, 95% CI = 3.3, 53.5). PN compared to UC participants reported fewer overdoses at 2 months (PN = 11.9%/UC = 16.1%) and at 6 months postpartum (PN = 3.8%/UC = 6.2%). Conclusions: Patient navigation appears to be associated with improvements in opioid use disorder treatment engagement and overdoses during pregnancy. This pilot trial shows the feasibility of the intervention and a future large‐scale trial. [ABSTRACT FROM AUTHOR]