A Systems Approach to Perinatal Opioid Exposure and Maternal Suicidality

Suicide is the leading cause of death for women during pregnancy and in the first year postpartum. Using data from a population of low-income Medicaid-enrolled women in the prenatal and 1-year postpartum periods, we propose to (1) identify patterns of perinatal opioid use and suicide attempt/death; (2) quantify the effect of opioid use on suicide attempt/death; and (3) examine whether a unique health care system in Oregon, known as Coordinated Care Organizations (CCOs), will prevent maternal opioid misuse and suicide attempt/death. In all aims we will examine disparities in the outcomes in terms of major social determinants of health (SDoH) such as race/ethnicity. Our hypothesis is that the risk of perinatal suicide attempt/death will increase with the level of perinatal exposure to opioids because opioid misuse has been linked to suicide ideation, attempt, and death. We hypothesize that the relation will be stronger for racial/ethnic minorities, rural residents, and those with a lower education level. We also hypothesize that the CCO model will lead to reductions in the risk of opioid use, suicide attempt, and death because it emphasizes primary and preventive care, physical-behavioral care integration, and care coordination. Because of CCOs' emphasis on SDoH and health disparities, we hypothesize that disparities in the outcomes will decline for racial/ethnic minorities, rural residents, and those with a lower education level, following the implementation of the CCO model.
We will analyze linked data from multiple administrative data sources in Oregon including birth and death certificates, Medicaid enrollment and claims files, and hospital discharge data. Our main study population will include all low-income women of reproductive age (15-44 years) who were enrolled in the Oregon Medicaid program during the perinatal period between 2008 and 2016, and were pregnant and gave birth (N = 77,652). Main outcome measures will include, among others, suicide attempt, suicide death, suicide attempt with opioid poisoning, opioid-related suicide, opioid abuse, opioid dependence, duration of opioid use, and morphine equivalent dose. We will use descriptive statistics to characterize opioid use and suicide attempt and death. Time-to-event analyses will be used to estimate the effect of opioid use on subsequent suicide attempt/death. We will conduct augmented quasi-experimental time-to-event analyses to evaluate the effect of the CCO model on perinatal opioid use and suicide attempt/death.
The proposed project will provide timely evidence on patterns and characteristics of perinatal suicide to inform suicide prevention strategies including effective novel care system practice approaches amenable to policy change. Results will translate to national and international efforts for suicide prevention and contribute to the reduction of maternal mortality and improvement in health and well-being of women and their families. Findings will also contribute to eliminating health disparities for populations that are disproportionately affected by suicide outcomes. At the successful completion of this study, next steps may include investigating other risk factors for suicide that are amenable to a health system/policy change (e.g., recreational marijuana). Future research may also investigate specific mechanisms through which CCO and other innovative health care models may be effective in preventing suicides.

Suicide is the leading cause of death for women during pregnancy and in the first year postpartum. Using data from a population of low-income Medicaid-enrolled women in the prenatal and 1-year postpartum periods, we propose to (1) identify patterns of perinatal opioid use and suicide attempt/death; (2) quantify the effect of opioid use on suicide attempt/death; and (3) examine whether a unique health care system in Oregon, known as Coordinated Care Organizations (CCOs), will prevent maternal opioid misuse and suicide attempt/death. In all aims we will examine disparities in the outcomes in terms of major social determinants of health (SDoH) such as race/ethnicity. Our hypothesis is that the risk of perinatal suicide attempt/death will increase with the level of perinatal exposure to opioids because opioid misuse has been linked to suicide ideation, attempt, and death. We hypothesize that the relation will be stronger for racial/ethnic minorities, rural residents, and those with a lower education level. We also hypothesize that the CCO model will lead to reductions in the risk of opioid use, suicide attempt, and death because it emphasizes primary and preventive care, physical-behavioral care integration, and care coordination. Because of CCOs' emphasis on SDoH and health disparities, we hypothesize that disparities in the outcomes will decline for racial/ethnic minorities, rural residents, and those with a lower education level, following the implementation of the CCO model.

We will analyze linked data from multiple administrative data sources in Oregon including birth and death certificates, Medicaid enrollment and claims files, and hospital discharge data. Our main study population will include all low-income women of reproductive age (15-44 years) who were enrolled in the Oregon Medicaid program during the perinatal period between 2008 and 2016, and were pregnant and gave birth (N = 77,652). Main outcome measures will include, among others, suicide attempt, suicide death, suicide attempt with opioid poisoning, opioid-related suicide, opioid abuse, opioid dependence, duration of opioid use, and morphine equivalent dose. We will use descriptive statistics to characterize opioid use and suicide attempt and death. Time-to-event analyses will be used to estimate the effect of opioid use on subsequent suicide attempt/death. We will conduct augmented quasi-experimental time-to-event analyses to evaluate the effect of the CCO model on perinatal opioid use and suicide attempt/death.

The proposed project will provide timely evidence on patterns and characteristics of perinatal suicide to inform suicide prevention strategies including effective novel care system practice approaches amenable to policy change. Results will translate to national and international efforts for suicide prevention and contribute to the reduction of maternal mortality and improvement in health and well-being of women and their families. Findings will also contribute to eliminating health disparities for populations that are disproportionately affected by suicide outcomes. At the successful completion of this study, next steps may include investigating other risk factors for suicide that are amenable to a health system/policy change (e.g., recreational marijuana). Future research may also investigate specific mechanisms through which CCO and other innovative health care models may be effective in preventing suicides.