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Early identification of high-risk groups can reduce harms associated with opioid use in pregnancy


New research from ICES and The Hospital for Sick Children (SickKids) uses a person-centered approach to identify which groups of pregnant people with opioid use are at a higher risk of postpartum drug overdose or death.

A new study published in JAMA Network Open included over 31,000 people with prenatal opioid use who had a live birth or stillbirth in Ontario between 2014 and 2019. This work builds on a previous study using ICES administrative health data that showed that five percent of births in Ontario during this same period had prenatal opioid exposure.

"This is the first study to use sophisticated statistical methods to group people by type of opioid use in pregnancy, in addition to important socio-demographic and clinical characteristics," says Dr. Astrid Guttmann, senior author of the study, chief science officer at ICES, staff paediatrician, and senior associate scientist in the Child Health Evaluative Sciences program at SickKids. 

There are different reasons why people use opioids in pregnancy, and sometimes it is for therapeutic purposes. However, most research on prenatal opioid use groups pregnant people based on broad categories of exposure, which does not consider diverse and individualized patterns of opioid use. 

A more holistic approach to analyze the data considers different circumstances for opioid use, including prescribed pain management, treatment of opioid use disorder, unregulated opioid use, social vulnerabilities and other concurrent mental or physical health conditions. All these factors can impact the health outcomes of pregnant people and their infants.

To explore these variables, the researchers developed five distinct groups of people with opioid use in pregnancy:

  • Short-term pain management with low comorbidity (44% of people with prenatal opioid use)
  • Pain management with comorbidity (23%)
  • Pain management in young people (15%, with highest representation of people aged 12 to 24 years)
  • Medication for opioid use disorder or unregulated opioid use (heroin, fentanyl, prescription opioids not as medically intended) (13%)
  • Mixed opioid use plus high social and medical needs (6%)

There was a high (1.5%) risk of postpartum drug toxicity and death for all groups, but compared to the first group (short-term opioid analgesic use and low comorbidity) the risk was highest in the fifth group (7%), which included people with mixed opioid use plus high social and medical needs. These groupings differentiated the risk of toxicity and death better than groups based on type of opioid use. 

“The highest risk group was not based solely on type of opioid use, but also included important risk factors such as pre-pregnancy medical and mental health issues, hospital care for non-opioid drug and alcohol use, as well as social vulnerabilities such as a history of homelessness, incarceration, and low-income,” says lead author Andi Camden, an ICES student and PhD candidate in the Child Health Evaluative Sciences program at SickKids and the University of Toronto's Dalla Lana School of Public Health. “The very high rate of toxicity or death that we documented in this group needs to be addressed with harm reduction interventions and strategies.”
The study also identified a group with the highest representation of young people (aged 12 to 24 years), characterized by short-term opioid use for pain management with complex needs. This group had higher rates of hospital care for pain and mental-health related issues.

This study is the first to account for multiple types of opioid exposure, highlighting the importance of providing targeted treatment to address the complex needs of some individuals. The results could be used to identify people at a greater risk of drug toxicity or death, and can help to inform harm reduction strategies, home visiting programs, and other interventions that support families affected by prenatal opioid use.

he study “Categorization of opioid use among pregnant people and association with overdose or death,” was published in the JAMA Network Open.

Author block: Camden A, To T, Ray JG, Gomes T, Bai L, Guttmann A.

ICES is an independent, non-profit research institute that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy. In October 2018, the institute formerly known as the Institute for Clinical Evaluative Sciences formally adopted the initialism ICES as its official name. For the latest ICES news, follow us on Twitter: @ICESOntario

The Hospital for Sick Children (SickKids) is recognized as one of the world’s foremost paediatric health-care institutions and is Canada’s leading centre dedicated to advancing children’s health through the integration of patient care, research and education. Founded in 1875 and affiliated with the University of Toronto, SickKids is one of Canada’s most research-intensive hospitals and has generated discoveries that have helped children globally. Its mission is to provide the best in complex and specialized family-centred care; pioneer scientific and clinical advancements; share expertise; foster an academic environment that nurtures health-care professionals; and champion an accessible, comprehensive and sustainable child health system. SickKids is a founding member of Kids Health Alliance, a network of partners working to create a high quality, consistent and coordinated approach to paediatric healthcare that is centred around children, youth and their families. SickKids is proud of its vision for “Healthier Children. A Better World.”


Niveen Saleh
Director of Communications, ICES
[email protected]

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