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Receipt of Prescription Opioids in a National Sample of Pregnant Veterans Receiving Veterans Health Administration Care

  • Aimee R. Kroll-Desrosiers
    Correspondence
    Correspondence to: Aimee R. Kroll-Desrosiers, MS, Department of Quantitative Health Sciences, University of Massachusetts Medical School, 368 Plantation Street, Worcester, MA 01605. Phone: 1-508-856-3540; fax: 1-508-856-8993.
    Affiliations
    Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
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  • Melissa Skanderson
    Affiliations
    VA Connecticut Healthcare System, West Haven, Connecticut
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  • Lori A. Bastian
    Affiliations
    VA Connecticut Healthcare System, West Haven, Connecticut

    Division of General Internal Medicine, University of Connecticut, Farmington, Connecticut

    Pain Research, Informatics, Multimorbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut
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  • Cynthia A. Brandt
    Affiliations
    VA Connecticut Healthcare System, West Haven, Connecticut

    Pain Research, Informatics, Multimorbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut

    Yale Center for Medical Informatics, Yale School of Medicine, New Haven, Connecticut

    Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
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  • Sally Haskell
    Affiliations
    Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut

    VA Connecticut Healthcare System, West Haven, Connecticut
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  • Robert D. Kerns
    Affiliations
    Pain Research, Informatics, Multimorbidities, and Education Center, VA Connecticut Healthcare System, West Haven, Connecticut

    Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut

    Department of Neurology, Yale School of Medicine, New Haven, Connecticut

    Department of Psychology, Yale School of Medicine, New Haven, Connecticut
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  • Kristin M. Mattocks
    Affiliations
    Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts

    Research and Development, VA Central Western Massachusetts, Leeds, Massachusetts
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Published:November 05, 2015DOI:https://doi.org/10.1016/j.whi.2015.09.010

      Abstract

      Background

      A growing number of reproductive-age women veterans are returning from Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND). In 2010, 42% of women veterans receiving Veterans Health Administration (VHA) services were aged 18 to 45. Prescription opioid use has increased among all veterans over the past decade; however, exposure among pregnant veterans has not been examined.

      Methods

      We identified 2,331 women who delivered babies within the VHA system between 2001 and 2010. Delivery, opioid prescribing history, and demographic and health-related variables were obtained from a national database of veterans receiving VHA services. Receipt of an opioid prescription was defined as any filled VHA prescription for opioids in the 280-day pregnancy window before delivery. We developed a multivariable logistic regression model adjusted for sociodemographic, service-related, psychiatric diagnosis, and physical health variables to examine the odds of filling an opioid prescription during the pregnancy window.

      Findings

      Ten percent of pregnant veterans received VHA prescription opioids during their pregnancy window. Significant factors associated with opioid prescriptions included presence of any psychiatric diagnosis (adjusted odds ratio [aOR], 1.67; 95% CI, 1.24–2.26), diagnosis of back problems (aOR, 2.94; 95% CI, 1.92–4.49), or other nontraumatic joint disorders (aOR, 2.20; 95% CI, 1.36–3.58).

      Conclusions

      This study suggests that a substantial proportion of women veterans received VHA prescriptions for opioids during pregnancy. Providers should be aware of the potential risks of prescription opioid use during pregnancy, assess for potential undertreatment of psychiatric diagnoses, and consider alternate pain management strategies when possible.
      Over the past 10 years, an increasing number of women have returned from serving in Operations Enduring Freedom (OEF), Iraqi Freedom (OIF), and New Dawn (OND). Among OEF/OIF/OND women veterans utilizing Veterans Health Administration (VHA) health care in 2010, 42% were between the ages of 18 and 45 (

      Frayne, S. M., Phibbs, C. S., Friedman, S. A., Saechao, F., Berg, E., Balasubramanian, V., … Hayes, P. M. (2012). Sourcebook: Women veterans in the Veterans Health Administration. Volume 2. Sociodemographics and use of VHA and non-VA Care (Fee). (Vol. 2). Women's Health Evaluation Initiative, Women's Health Services, Veterans Health Administration, Department of Veterans Affairs: Washington DC. Available: www.womenshealth.va.gov/WOMENSHEALTH/docs/SourcebookVol2_508c_FINAL.pdf. Accessed June 17, 2014.

      ). The increasing number of young women veterans in VHA care has expanded the need for reproductive health care services, including services related to pregnancy and childbirth. From 2008 to 2012, the number of infant deliveries paid for by the VHA increased by 44% (
      • Mattocks K.M.
      • Frayne S.
      • Phibbs C.S.
      • Yano E.M.
      • Zephyrin L.
      • Shryock H.
      • Bastian L.A.
      Five-year trends in women Veterans' use of VA maternity benefits, 2008-2012.
      ).
      Prevalence in the use of prescription opioids has surged across the United States in recent years, and use in veterans is no exception (
      • Lew H.L.
      • Otis J.D.
      • Tun C.
      • Kerns R.D.
      • Michael E.
      • Cifu D.X.
      Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: Polytrauma clinical triad.
      ,
      • Wu P.C.
      • Lang C.
      • Hasson N.K.
      • Linder S.H.
      • Clark D.J.
      Opioid use in young veterans.
      ). Some evidence suggests that female veterans are more likely to receive prescription opioids compared with male veterans. Data from 2012 suggests a 42.9% rate of prevalent opioid receipt in women veterans compared with 32.9% in male veterans (
      • Mosher H.J.
      • Krebs E.E.
      • Carrel M.
      • Kaboli P.J.
      • Weg M.W.
      • Lund B.C.
      Trends in prevalent and incident opioid receipt: An observational study in Veterans Health Administration 2004-2012.
      ). This greater proportion of prescription opioid use in women may be associated with the higher likelihood of women veterans being diagnosed with chronic pain and back, musculoskeletal, or joint conditions compared with men (
      • Higgins D.M.
      • Kerns R.D.
      • Brandt C.A.
      • Haskell S.G.
      • Bathulapalli H.
      • Gilliam W.
      • Goulet J.L.
      Persistent pain and comorbidity among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans.
      ), a difference that holds after adjustment for demographic characteristics (
      • Haskell S.G.
      • Ning Y.
      • Krebs E.
      • Goulet J.
      • Mattocks K.
      • Kerns R.
      • Brandt C.
      Prevalence of painful musculoskeletal conditions in female and male veterans in 7 years after return from deployment in Operation Enduring Freedom/Operation Iraqi Freedom.
      ).
      Among pregnant women in the United States, estimates of prevalence of prescription opioid use range from 1% to 21% (
      • Bateman B.T.
      • Hernandez-Diaz S.
      • Rathmell J.P.
      • Seeger J.D.
      • Doherty M.
      • Fischer M.A.
      • Huybrechts K.F.
      Patterns of opioid utilization in pregnancy in a large cohort of commercial insurance beneficiaries in the United States.
      ,
      • Desai R.J.
      • Hernandez-Diaz S.
      • Bateman B.T.
      • Huybrechts K.F.
      Increase in prescription opioid use during pregnancy among Medicaid-enrolled women.
      ,
      • Epstein R.A.
      • Bobo W.
      • Martin P.R.
      • Morrow J.A.
      • Wang W.
      • Chandrasekhar R.
      • Cooper W.O.
      Increasing pregnancy-related use of prescribed opioid analgesics.
      ,
      • Keegan J.
      • Parva M.
      • Finnegan M.
      • Gerson A.
      • Belden M.
      Addiction in pregnancy.
      ,

      Salihu, H., Mogos, M., Salemi, J. L., & Salinas, A. (2013). National trends in maternal use of opioid drugs during pregnancy. In 141st APHA Annual Meeting and Exposition. Boston, MA. Available: https://apha.confex.com/apha/141am/webprogram/Paper281434.html. Accessed June 4, 2014.

      ). A study of insurance beneficiaries found that 14.4% of women were dispensed a prescription opioid during their pregnancy (
      • Bateman B.T.
      • Hernandez-Diaz S.
      • Rathmell J.P.
      • Seeger J.D.
      • Doherty M.
      • Fischer M.A.
      • Huybrechts K.F.
      Patterns of opioid utilization in pregnancy in a large cohort of commercial insurance beneficiaries in the United States.
      ). Studies on the risks of opioid use during pregnancy for the mother and baby have been somewhat indecisive, given the difficulties in assessing opioid exposure over the course of a pregnancy (
      • Bateman B.T.
      • Hernandez-Diaz S.
      • Rathmell J.P.
      • Seeger J.D.
      • Doherty M.
      • Fischer M.A.
      • Huybrechts K.F.
      Patterns of opioid utilization in pregnancy in a large cohort of commercial insurance beneficiaries in the United States.
      ,
      • Chou R.
      • Fanciullo G.J.
      • Fine P.G.
      • Adler J.A.
      • Ballantyne J.C.
      • Davies P.
      • Miaskowski C.
      Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain.
      ). However, some studies have found maternal opioid exposure to be associated with an increased risk of fetal neural tube defects (
      • Meyer M.
      The perils of opioid prescribing during pregnancy.
      ,
      • Yazdy M.M.
      • Mitchell A.A.
      • Tinker S.C.
      • Parker S.E.
      • Werler M.M.
      Periconceptional use of opioids and the risk of neural tube defects.
      ), and among chronic users, development of opioid drug withdrawal symptoms, known as neonatal abstinence syndrome (
      • Broussard C.S.
      • Rasmussen S.A.
      • Reefhuis J.
      • Friedman J.M.
      • Jann M.W.
      • Riehle-Colarusso T.
      • Honein M.A.
      Maternal treatment with opioid analgesics and risk for birth defects.
      ,
      • Meyer M.
      The perils of opioid prescribing during pregnancy.
      ,
      • Patrick S.W.
      • Schumacher R.E.
      • Benneyworth B.D.
      • Krans E.E.
      • Mcallister J.M.
      • Davis M.M.
      Neonatal abstinence syndrome and association health care expenditures: United States, 2000-2009.
      ,
      • Patrick S.W.
      • Dudley J.
      • Martin P.R.
      • Harrell F.E.
      • Warren M.D.
      • Hartmann K.E.
      • Cooper W.O.
      Prescription opioid epidemic and infant outcomes.
      ). Neonatal abstinence syndrome manifests neurologically through symptoms such as tremors, irritability, and seizures, and through gastrointestinal symptoms including vomiting, dehydration, and diarrhea (
      • Hudak M.L.
      • Tan R.C.
      Neonatal drug withdrawal.
      ).
      Given the increasing rates of young women veterans receiving VHA services, the increase in prescription opioid use among veterans overall, and the prevalence of prescription opioid exposure during pregnancy in the general population, there is a need to quantify opioid prescribing patterns in pregnant veterans. Understanding the prevalence and risks of opioid prescriptions in pregnant veterans using VHA care is important to help improve preconception and pregnancy counseling around the risks and benefits of potentially teratogenic medications. Thus, our objectives were two-fold: 1) to describe the prevalence of opioid prescribing to pregnant veterans and 2) to examine predictors for receipt of opioids. We conducted an analysis of administrative data on women veterans enrolled in VHA health care from 2001 to 2010.

      Methods

      Study Design and Data Source

      This study was conducted using data from the Women Veteran's Cohort Study, described previously elsewhere (
      • Haskell S.G.
      • Mattocks K.
      • Goulet J.L.
      • Krebs E.E.
      • Skanderson M.
      • Leslie D.
      • Brandt C.
      The burden of illness in the first year home: Do male and female VA users differ in health conditions and healthcare utilization.
      ,
      • Scott J.C.
      • Pietrzak R.H.
      • Mattocks K.
      • Southwick S.M.
      • Brandt C.
      • Haskell S.
      Gender differences in the correlates of hazardous drinking among Iraq and Afghanistan veterans.
      ). The study population was obtained from the OEF/OIF/OND roster received from the Department of Defense Manpower Data Center. The roster was merged with Veterans Affairs (VA) administrative data, including the VA National Patient Care Database, the VA Corporate Data Warehouse (electronic health record data), and the VA Decision Support Systems database. The roster contains information on sex, race, date of birth, deployment dates, armed forces branch (Army, Navy, Air Force, Marines, or Coast Guard), and component (National Guard, Reserve, or active duty). Additionally, the VA National Patient Care Database and Decision Support Systems databases include information on health care use and cost, pharmacy and laboratory data, and diagnostic and procedure data for both inpatient and outpatient visits. VA fee basis files were used to examine veterans' receipt of pregnancy care from non-VA providers. This pooled database consists of 739,683 veterans who were enrolled in VHA health care at any point from 2001 to 2010.

      Study Sample and Definition of Determinants of Pregnancy

      We obtained information on 87,491 women, 67,037 who were of reproductive age (18–45 years old) and had used VHA medical or mental health services at least once during the study period. Our study included 2,331 women who had record of an infant delivery paid for by the VHA during this time period. Each woman contributed only one delivery to this analysis; for those who had multiple deliveries in the database (10.3%), only the first delivery was retained. Deliveries were identified through the identification of diagnostic-related groups (DRGs) related to vaginal or cesarean deliveries (DRGs 370–375, 765–768, 774, 775). These DRGs were found within codes of the Major Diagnostic Category 14 – Pregnancy, Childbirth and Puerperium (Appendix A). This methodology of using DRGs has been used previously with these data (
      • Mattocks K.M.
      • Frayne S.
      • Phibbs C.S.
      • Yano E.M.
      • Zephyrin L.
      • Shryock H.
      • Bastian L.A.
      Five-year trends in women Veterans' use of VA maternity benefits, 2008-2012.
      ).

      Definition of Outcome

      Opioid prescriptions were identified by an active prescription fill during the pregnancy window of any of the included drugs of interest (Appendix B). We defined receipt of prescription opioids during pregnancy in two different ways. The primary definition, “any prescription” was defined as at least one filled prescription for opioids in the VHA prescription data in the 280 days before delivery. Defining variables based on a 280-day window has been done previously with similar VA pregnancy data to capture all services and prescriptions that may have taken place during pregnancy, from very early stages ending with delivery (
      • Mattocks K.M.
      • Skanderson M.
      • Goulet J.L.
      • Brandt C.
      • Womack J.
      • Krebs E.
      • Haskell S.
      Pregnancy and mental health among women veterans returning from Iraq and Afghanistan.
      ). Additionally, we defined “long-term prescriptions” as receipt of prescription opioids for 90 consecutive days or longer, with 30 days or less of a gap, during the 280-day pregnancy window. This 90-day time reference for chronic use is commonly used in the literature (
      • Feinberg S.
      • Leong M.
      • Christian J.
      • Pasero C.
      • Fong A.
      • Feinberg R.
      • Pohl M.
      ACPA resource guide.
      ). Both prescription variables were coded dichotomously, yes versus no. Information on the indication for the prescription was not included in this analysis; therefore, the prescriptions defined here potentially include both analgesics and/or opioid agonist therapies for pregnant women with substance use disorders.

      Demographic and Health-Related Factors

      We chose potential factors associated with receipt of an opioid prescription based on previous literature on predictors of exposure during pregnancy and available information in our data (
      • Bateman B.T.
      • Hernandez-Diaz S.
      • Rathmell J.P.
      • Seeger J.D.
      • Doherty M.
      • Fischer M.A.
      • Huybrechts K.F.
      Patterns of opioid utilization in pregnancy in a large cohort of commercial insurance beneficiaries in the United States.
      ,
      • Desai R.J.
      • Hernandez-Diaz S.
      • Bateman B.T.
      • Huybrechts K.F.
      Increase in prescription opioid use during pregnancy among Medicaid-enrolled women.
      ,
      • Epstein R.A.
      • Bobo W.
      • Martin P.R.
      • Morrow J.A.
      • Wang W.
      • Chandrasekhar R.
      • Cooper W.O.
      Increasing pregnancy-related use of prescribed opioid analgesics.
      ,
      • Keegan J.
      • Parva M.
      • Finnegan M.
      • Gerson A.
      • Belden M.
      Addiction in pregnancy.
      ). These factors included demographic characteristics, such as age at the time of delivery, race, ethnicity, marital status, and education level, as well as military service characteristics including years since return from last deployment, service-connected disability rating, rank, component, and branch of service. Service-connected disability rating is measured as a percentage of 0% to 100%, a value determined by the Veterans Benefits Administration. A service-connected disability status of 0% is the lowest level of disability and is different from not having a disability (

      Frayne, S. M., Phibbs, C. S., Friedman, S. A., Saechao, F., Berg, E., Balasubramanian, V., … Hayes, P. M. (2012). Sourcebook: Women veterans in the Veterans Health Administration. Volume 2. Sociodemographics and use of VHA and non-VA Care (Fee). (Vol. 2). Women's Health Evaluation Initiative, Women's Health Services, Veterans Health Administration, Department of Veterans Affairs: Washington DC. Available: www.womenshealth.va.gov/WOMENSHEALTH/docs/SourcebookVol2_508c_FINAL.pdf. Accessed June 17, 2014.

      ). Here, we measured service-connected disability status dichotomously to compare those with either a non-service connected disability or a disability rating of 0% to those with a disability rating of greater than 0% (

      Frayne, S. M., Phibbs, C. S., Friedman, S. A., Saechao, F., Berg, E., Balasubramanian, V., … Hayes, P. M. (2012). Sourcebook: Women veterans in the Veterans Health Administration. Volume 2. Sociodemographics and use of VHA and non-VA Care (Fee). (Vol. 2). Women's Health Evaluation Initiative, Women's Health Services, Veterans Health Administration, Department of Veterans Affairs: Washington DC. Available: www.womenshealth.va.gov/WOMENSHEALTH/docs/SourcebookVol2_508c_FINAL.pdf. Accessed June 17, 2014.

      ). We also examined the potential impact of psychiatric diagnoses, including posttraumatic stress disorder, mild (dysthymia) and major forms of depression, bipolar disorder, and schizophrenia. All of these conditions were identified using International Conference for the Ninth Revision of the International Classification of Diseases (ICD-9) codes to flag a diagnosis at any time before delivery (Appendix A;

      Centers for Disease Control and Prevention, & National Center for Health Statistics. (2013). ICD - ICD-9-CM - International classification of diseases, 9th revision, clinical modification. Classification of diseases, functioning, and disability. Available: www.cdc.gov/nchs/icd/icd9cm.htm#ftp. Accessed August 1, 2014.

      ). Furthermore, we combined all psychiatric diagnosis categories, as listed, into a single variable that assessed presence of one or more psychiatric diagnosis, operationalized dichotomously as yes versus no. Additionally, we examined ICD-9 codes for drug and alcohol abuse/dependence before delivery (Appendix A). We also included a variable identifying positive screenings for military sexual trauma. The VHA uses a clinical reminder in the patient's electronic medical record to screen for military sexual trauma using a brief screening instrument, which has been described previously (
      • Kimerling R.
      • Gima K.
      • Smith M.W.
      • Street A.
      • Frayne S.
      The Veterans Health Administration and military sexual trauma.
      ). We considered health-related conditions that were diagnosed during the 280-day pregnancy window, because we hypothesized that the diagnosis of back problems, headaches, migraines, sprains and strains, or other nontraumatic joint disorders may be associated with opioid prescribing. All medical conditions were identified with at least one Clinical Classifications Software code (Appendix A;

      Agency for Healthcare Research and Quality. (2014). Clinical classifications software (CCS) 2014. Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project: Rockville, MD. Available: www.hcup-us.ahrq.gov/toolssoftware/ccs/CCSUsersGuide.pdf. Accessed January 15, 2015.

      ).

      Analytic Approach

      We first calculated the proportion of pregnant veterans in our sample who received an opioid prescription during their pregnancy window. Next, we conducted bivariate analyses to compare pregnant veterans on their opioid status: those who received an opioid prescription compared with those who did not receive an opioid prescription. We used χ2 tests for categorical variables and the Student t test for continuous variables. Sociodemographic, service-related, psychiatric diagnosis, and physical health variables that were significant at the .05 level were included in a logistic regression model which examined the odds of predictors associated with opioid status. Our final multivariable model consisted of the variables from the initial model that further met inclusion criteria in a backward selection process. We evaluated (and ruled out) multicollinearity by examining a correlation matrix of all proposed predictors and condition indices. We conducted a complete case analysis as missing data comprised less than 1.5% of our sociodemographic and service-related characteristics, and there were no differences in missingness between those who did and did not receive a prescription opioid (data not shown). Adjusted odds ratios (aOR) and 95% CIs for each predictor were reported.

      Results

      In our sample of 2,331 pregnant veterans, 231 (9.9%) filled a VHA prescription for an opioid during their pregnancy window, with 10 (0.4%) receiving prescriptions for more than 90 days with less than a 30-day gap between fill dates. Our population was mostly White (54.7%), non-Hispanic (82.2%), never married (65.9%), and high school graduates (85.5%). The majority of women had served in active duty (71.6%) and 96.9% were enlisted, the majority of in the Army (61.7%; Table 1). Sociodemographic characteristics, with the exception of marital status, were similar between opioid status groups. Those with an opioid prescription were more likely to be married compared with those without a prescription (p = .04). The number of years between delivery date and the date of last deployment was greater in women with a prescription opioid compared with women with no prescription during the pregnancy window (mean ± standard deviation, 3.5 ± 1.8 vs. 3.1 ± 1.8 years; p = .0002). Service-connected disability rating varied between opioid status groups, where 64.9% of women with a prescription had a service-connected disability rating of greater than 0% compared with 48.3% of women without a filled prescription (p < .001).
      Table 1Sociodemographic and Service-Connected Characteristics in Pregnant Veterans by Receipt of a Prescription Opioid
      CharacteristicTotal (n = 2,331)Any Filled prescription for Opioids in the Pregnancy Windowp Value
      Yes (n = 231)No (n = 2,100)
      Sociodemographic
       Age at delivery (y), mean ± SD (range)23.6 ± 3.6 (18–41)23.7 ± 3.6 (19–38)23.6 ± 3.6 (18–41).49
       Race, n (%).85
      White1274 (54.7)121 (52.4)1153 (54.9)
      Black461 (19.8)49 (21.2)412 (19.6)
      Other479 (20.6)46 (19.9)433 (20.6)
      Unknown115 (4.9)13 (5.6)102 (4.9)
       Ethnicity, n (%).49
      Hispanic298 (12.8)24 (10.4)274 (13.0)
      Non-Hispanic1916 (82.2)192 (83.1)1724 (82.1)
      Unknown115 (4.9)13 (5.6)102 (4.9)
       Marital status, n (%).04
      Married688 (29.5)83 (35.9)605 (28.8)
      Divorced/separated/widowed98 (4.2)6 (2.6)92 (4.4)
      Never married1537 (65.9)138 (59.7)1399 (66.6)
       Education level, n (%).60
      Less than high school36 (1.5)2 (0.9)34 (1.6)
      High school graduate1992 (85.5)199 (86.2)1793 (85.4)
      Greater than high school268 (11.5)24 (10.4)244 (11.6)
      Service connected
       Time at delivery since return from last deployment (y), mean ± SD (range)3.1 ± 1.8 (0.03–8.4)3.5 ± 1.8 (0.5–8.3)3.1 ± 1.8 (0.03–8.4)<.001
       Service-connected disability rating, n (%)<.001
      Non-service connected/0%1155 (49.6)79 (34.2)1076 (51.2)
      >0%1165 (50.0)150 (64.9)1015 (48.3)
       Rank, n (%).72
      Enlisted2259 (96.9)223 (96.5)2036 (97.0)
      Officer70 (3.0)6 (2.6)64 (3.0)
       Component, n (%).76
      Guard342 (14.7)30 (13.0)312 (14.9)
      Active1668 (71.6)168 (72.7)1500 (71.4)
      Reserves319 (13.7)31 (13.4)288 (13.7)
       Branch of service, n (%).31
      Army1439 (61.7)141 (62.0)1298 (61.8)
      Coast Guard1 (<1.0)0 (0.0)1 (<1.0)
      Air Force334 (14.3)38 (16.5)296 (14.1)
      Marine Corps148 (6.4)19 (8.2)129 (6.1)
      Navy407 (17.5)31 (13.4)376 (17.9)
      Table 2 indicates that a greater proportion of women with an opioid prescription during their pregnancy window had posttraumatic stress disorder, mild and major depression, bipolar disorder, and alcohol or drug abuse or dependence at any point before delivery compared with those who did not receive prescription opioids during the pregnancy window. Over half (52.4%) of those with a prescription had at least one psychiatric diagnosis compared with roughly 34% of those without a prescription (p < .001). A greater proportion of women with a filled opioid prescription had a positive military sexual trauma screen (17.8%) compared with women without a prescription (12.4%). Women with a filled prescription for an opioid in the 280-day pregnancy window were more likely to be diagnosed with back problems, headaches, migraines, sprains and strains, and other nontraumatic joint disorders during their pregnancies compared with women who did not receive an opioid prescription (all p < .05). Assessment of multiple comparisons by employing a Bonferroni adjustment did not affect the bivariate p values substantially. Additionally, the backward selection logistic regression model excluded any variables no longer found to be significant from our final multivariable findings.
      Table 2Psychiatric Diagnoses and Physical Health Conditions of Pregnant Veterans by Receipt of a Prescription Opioid
      DiagnosesTotal (n = 2,331), n (%)Any Filled Prescription for Opioids in the Pregnancy Window, n (%)p Value
      Yes (n = 231)No (n = 2,100)
      Psychiatric Diagnoses (ever diagnosed prior to delivery)
       Posttraumatic stress disorder483 (20.7)69 (29.9)414 (19.7)<.001
       Mild depression570 (24.5)85 (36.8)485 (23.1)<.001
       Major depression274 (11.8)45 (19.5)229 (10.9)<.001
       Bipolar disorder105 (4.5)20 (8.7)85 (4.1)<.01
       Schizophrenia3 (0.1)0 (0.0)3 (0.1).57
       Any psychiatric diagnosis837 (35.9)121 (52.4)716 (34.1)<.001
       Alcohol abuse/dependence114 (4.9)18 (7.8)96 (4.6).03
       Drug abuse/dependence51 (2.2)12 (5.2)39 (1.9)<.01
       Positive military sexual trauma screen302 (13.0)41 (17.8)261 (12.4).02
      Physical health conditions (diagnosis during pregnancy window)
       Back problems139 (6.0)40 (17.3)99 (4.7)<.001
       Headache39 (1.7)11 (4.8)28 (1.3)<.001
       Migraine48 (2.1)14 (6.1)34 (1.6)<.001
       Sprains and strains19 (0.8)5 (2.2)14 (0.7).02
       Other nontraumatic joint disorder111 (4.8)29 (12.6)82 (3.9)<.001
      Table 3 shows the results from the multivariable logistic model. Adjusted odds ratios were attenuated slightly from crude odds ratios. Our results suggest that service-connected disability ratings of greater than 0% increased the odds of a filled opioid prescription during the pregnancy window by 46% (95% CI, 1.07–1.99), after adjusting for other factors in the model. The presence of one or more psychiatric diagnosis increased the adjusted odds of a filled opioid prescription 1.7 times compared to those without a psychiatric diagnosis (95% CI, 1.24–2.26). Physical health conditions, specifically back problems (aOR, 2.94; 95% CI, 1.92–4.49) and other nontraumatic joint disorders (aOR, 2.20; 95% CI, 1.36–3.58), were associated with prescription opioid receipt during the pregnancy window. Although positive military sexual trauma screens or diagnosis of headache, migraine, or sprains and strains did not meet the significance level for inclusion in the final logistic model, all suggested a trend toward higher odds of filling an opioid prescription given presence of that specific condition.
      Table 3Factors Associated with Any Filled Opioid Prescription within the Pregnancy Window in Veterans (n = 2,331)
      VariableCrude OR95% CIAdjusted OR
      Adjusted odds ratios from a backward-selection logistic regression model with all factors found to be significant in bivariate analyses initially included (Hosmer and Lemeshow Goodness-of-Fit p = .7619).
      95% CI
      Marital status (married vs. never/not married)1.421.07–1.89
      Time at delivery since return from last deployment (years)1.151.07–1.24
      Service-connected disability rating (>0% vs. NSC/0%)2.011.51–2.681.461.07–1.99
      Psychiatric diagnoses (any diagnosis [prior to delivery] vs. no diagnosis)
       Any psychiatric diagnosis2.131.62–2.801.671.24–2.26
       Drug abuse/dependence2.901.50–5.622.141.08–4.26
       Alcohol abuse/dependence1.761.05–2.98
       Positive military sexual trauma screen1.521.06–2.18
      Physical health conditions (diagnosis within pregnancy window vs. no diagnosis within pregnancy window)
       Back problems4.232.85–6.292.941.92–4.49
       Headache3.701.82–7.54
       Migraine3.922.07–7.422.321.16–4.65
       Sprains and strains3.301.18–9.24
       Other nontraumatic joint disorder3.532.26–5.532.201.36–3.58
      Abbreviations: NSC, non-service connected disability; OR, odds ratio.
      Adjusted odds ratios from a backward-selection logistic regression model with all factors found to be significant in bivariate analyses initially included (Hosmer and Lemeshow Goodness-of-Fit p = .7619).

      Discussion

      We found that 10% of women veterans who used VHA care filled a prescription for an opioid at least once during their pregnancy window, which is comparable with a recent study conducted in the general U.S. population, where 14.4% of women had at least one filled prescription for an opioid during pregnancy (
      • Bateman B.T.
      • Hernandez-Diaz S.
      • Rathmell J.P.
      • Seeger J.D.
      • Doherty M.
      • Fischer M.A.
      • Huybrechts K.F.
      Patterns of opioid utilization in pregnancy in a large cohort of commercial insurance beneficiaries in the United States.
      ). Other studies have found that with the exception of cancer-related pain, headaches, chronic pain, genitourinary syndromes, and other orthopedic conditions were the most likely reasons for opioid use during pregnancy (
      • Campbell C.I.
      • Weisner C.
      • Leresche L.
      • Ray G.T.
      • Saunders K.
      • Sullivan M.D.
      • Von Korff M.
      Age and gender trends in long-term opioid analgesic use for noncancer pain.
      ,
      • Darnall B.D.
      • Stacey B.R.
      • Chou R.
      Medical and psychological risks and consequences of long-term opioid therapy in women.
      ,
      • Kellogg A.
      • Rose C.H.
      • Harms R.H.
      • Watson W.J.
      Current trends in narcotic use in pregnancy and neonatal outcomes.
      ,
      • Meyer M.
      The perils of opioid prescribing during pregnancy.
      ). In OEF/OIF/OND veterans, increases in the likelihood of receiving an opioid prescription in those with back pain, migraines, and posttraumatic stress disorder have been noted (
      • Macey T.A.
      • Morasco B.J.
      • Duckart J.P.
      • Dobscha S.K.
      Patterns and correlates of prescription opioid use in OEF/OIF veterans with chronic noncancer pain.
      ). This is consistent with the increased odds of exposure in pregnant veterans diagnosed with back pain, other nontraumatic joint disorders, and psychiatric diagnoses, including posttraumatic stress disorder, observed in our study.
      Women receiving pregnancy care in the VA are twice as likely to be diagnosed with posttraumatic stress disorder, depression, anxiety, schizophrenia, or bipolar disorder as compared with women without record of receiving pregnancy care in the VA (
      • Mattocks K.M.
      • Skanderson M.
      • Goulet J.L.
      • Brandt C.
      • Womack J.
      • Krebs E.
      • Haskell S.
      Pregnancy and mental health among women veterans returning from Iraq and Afghanistan.
      ). More than 35% of the women in our sample had at least one of these psychiatric diagnoses, the presence of which increased the odds of filling a prescription for an opioid. The number of veterans utilizing VA maternity benefits increased to 17.8 infant deliveries per 1,000 veterans from 2008 to 2012, with the majority of women having a service-connected disability rating (
      • Mattocks K.M.
      • Frayne S.
      • Phibbs C.S.
      • Yano E.M.
      • Zephyrin L.
      • Shryock H.
      • Bastian L.A.
      Five-year trends in women Veterans' use of VA maternity benefits, 2008-2012.
      ). If current trends continue, it is possible that greater numbers of women veterans will be seeking maternity care within the VA health care system, a substantial proportion of whom may have a comorbid physical health condition or psychiatric diagnosis. This necessitates the successful coordination of mental, physical, and maternal medical care for these women, especially in cases of chronic pain management where prescription opioids may be considered. Unfortunately, little is currently known about the coordination between VA care providers or outcomes for women who deliver in the VA (
      • Bean-Mayberry B.
      • Yano E.M.
      • Washington D.L.
      • Goldzweig C.
      • Batuman F.
      • Huang C.
      • Shekelle P.G.
      Systematic review of women veterans' health: Update on successes and gaps.
      ,
      • Mattocks K.M.
      • Skanderson M.
      • Goulet J.L.
      • Brandt C.
      • Womack J.
      • Krebs E.
      • Haskell S.
      Pregnancy and mental health among women veterans returning from Iraq and Afghanistan.
      ,
      • Mattocks K.M.
      • Frayne S.
      • Phibbs C.S.
      • Yano E.M.
      • Zephyrin L.
      • Shryock H.
      • Bastian L.A.
      Five-year trends in women Veterans' use of VA maternity benefits, 2008-2012.
      ,
      • West A.N.
      • Lee P.W.
      Associations between childbirth and women veterans' VA and non-VA Hospitalizations for major diagnostic categories.
      ).
      The Food and Drug Administration recently implemented labeling changes for extended-release and long-acting opioids to include detailed information on the risk of neonatal opioid withdrawal syndrome if these medications are taken during pregnancy (
      U.S. Food and Drug Administration
      New safety measures announced for extended-release and long-acting opioids.
      ). The Food and Drug Administration (
      • Schwarz E.B.
      • Longo L.S.
      • Zhao X.
      • Stone R.A.
      • Cunningham F.
      • Good C.B.
      Provision of potentially teratogenic medications to female veterans of childbearing age.
      ,
      U.S. Food and Drug Administration
      Content and format of labeling for human prescription drug and biological products; requirements for pregnancy and lactation labeling.
      ) and the VA (

      Department of Veterans Affairs, & Department of Defense. (2010). Management of opioid therapy for chronic pain. Washington, DC: Department of Veterans Affairs and Department of Defense. Available: www.healthquality.va.gov/guidelines/Pain/cot/COT_312_Full-er.pdf. Accessed July 22, 2014.

      ) both categorize opioids as class B or C medications, where there is some evidence of risk to the developing fetus, but not enough information is available to conclude that fetal risks outweigh the maternal benefits of use. Current VA opioid “safe prescribing” procedures involve a lengthy process of assessing current symptoms and medical history to determine the best therapeutic plan for chronic pain and other disorders, informing patients of potential risks and benefits, and screening for co-occurring substance use disorders (

      Department of Veterans Affairs, & Department of Defense. (2010). Management of opioid therapy for chronic pain. Washington, DC: Department of Veterans Affairs and Department of Defense. Available: www.healthquality.va.gov/guidelines/Pain/cot/COT_312_Full-er.pdf. Accessed July 22, 2014.

      ,

      Department of Veterans Affairs. (2013). Opioid therapy for chronic pain pocket guide. Available: www.healthquality.va.gov/guidelines/Pain/cot/OpioidPocketGuide23May2013v1.pdf. Accessed July 22, 2014.

      ,

      VA National Pain Management Program, & VA National Center for Ethics in Health Care. (n.d.). (2013). Taking opioids responsibly for your safety and the safety of others: Patient information guide on opioids for chronic pain. Available: www.ethics.va.gov/docs/policy/Taking_Opioids_Responsibly_2013528.pdf. Accessed August 23, 2014.

      ). The VA also has a computerized pharmacy order check that alerts providers when providing potentially teratogenic medications to women of childbearing age. In a recent review, VA guidelines for opioid prescriptions were found to be similar to those from other institutions, with comparable dosing thresholds, awareness of other drug interactions, drug testing standards, and risk assessment (
      • Nuckols T.K.
      • Anderson L.
      • Popescu I.
      • Diamant A.L.
      • Doyle B.
      • Di Capua P.
      • Chou R.
      Opioid prescribing: A systematic review and critical appraisal of guidelines for chronic pain.
      ). Although opioid use may be indicated during pregnancy for certain conditions, current guidelines do not provide specific information on risks and benefits. Understanding patients' specific needs is important to help reduce the potential risks to the fetus and mother.
      Our study has many strengths. We have a large, national sample of pregnant OEF/OIF/OND veterans, on whom opioid prescribing has not previously been studied. Our data include information on prescription opioid use, sociodemographics, physical conditions, psychiatric diagnoses, and delivery information. Our sample was similar to those of other studies of pregnant veterans in terms of demographic and service-related characteristics (
      • Mattocks K.M.
      • Skanderson M.
      • Goulet J.L.
      • Brandt C.
      • Womack J.
      • Krebs E.
      • Haskell S.
      Pregnancy and mental health among women veterans returning from Iraq and Afghanistan.
      ,
      • Mattocks K.M.
      • Frayne S.
      • Phibbs C.S.
      • Yano E.M.
      • Zephyrin L.
      • Shryock H.
      • Bastian L.A.
      Five-year trends in women Veterans' use of VA maternity benefits, 2008-2012.
      ). Additionally, we have information from administrative records, which confirm prescription fill. Nonetheless, our study also has limitations that may decrease the generalizability of our findings. We were unable to account for dose or indication in this work and cannot comment on the reasons for filled opioid prescriptions or determine causality from the associations examined herein. Our study sample likely underestimates the true number of veterans who received a prescription for an opioid during their pregnancy window, as we only have information on prescription use and deliveries that were covered by VHA health insurance. The use of our 280-day pregnancy window may have captured some opioid prescriptions outside of the actual duration of pregnancy; however, the VHA does not routinely collect information on other measures such as date of last menstrual period or gestational age at birth of the infant, which may have provided us with a more accurate calculation. Unlike other studies (
      • Bateman B.T.
      • Hernandez-Diaz S.
      • Rathmell J.P.
      • Seeger J.D.
      • Doherty M.
      • Fischer M.A.
      • Huybrechts K.F.
      Patterns of opioid utilization in pregnancy in a large cohort of commercial insurance beneficiaries in the United States.
      ), we were unable to examine physical health conditions outside of the pregnancy window, because we only had information on diagnoses during this time. We also could not examine infant measures as the VA does not routinely collect data on birth outcomes. Finally, we only included OEF/OIF/OND veterans who used VHA care during their pregnancy window. Our results may not be applicable to veterans of other military operations or those who did not use VHA care.

      Conclusions

      Ten percent of the pregnant veterans included in our study filled a prescription for an opioid at least once during or just prior to their pregnancy window. We found that service-connected disability ratings of greater than 0%, psychiatric diagnoses, and physical health conditions were associated with receipt of prescription opioids during the pregnancy window. Given the higher rates of physical conditions and psychiatric diagnoses of women veterans compared with the general population, future work should aim to capture a bigger representation of pregnant veterans and examine opioid exposure timing in relation to pregnancy.

      Implications for Practice and/or Policy

      This study suggests that a considerable proportion of women veterans fill a prescription for opioids at least once during their pregnancy window. Clinicians can play a crucial role in determining the needs of patients on a case-by-case basis and to identify alternative sources of pain management when possible. Given the high proportion of service-related disabilities and mental health conditions in veterans who received prescription opioids during their pregnancies, pregnant veterans should be assessed for potentially undertreated psychiatric and pain diagnoses before receipt of prescription opioids. Future guidelines should incorporate information on use of prescription opioids during pregnancy to help providers and patients make decisions regarding their use.

      Acknowledgments

      This material is based on work supported by the Department of Veterans Affairs, Veterans Health Administration , Office of Research and Development ( CRE 12-008 ). All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. The views expressed in this article are those of the authors and do not reflect the position or policy of the Department of Veterans Affairs or the United States Government.

      Supplementary Data

      References

      1. Agency for Healthcare Research and Quality. (2014). Clinical classifications software (CCS) 2014. Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project: Rockville, MD. Available: www.hcup-us.ahrq.gov/toolssoftware/ccs/CCSUsersGuide.pdf. Accessed January 15, 2015.

        • Bateman B.T.
        • Hernandez-Diaz S.
        • Rathmell J.P.
        • Seeger J.D.
        • Doherty M.
        • Fischer M.A.
        • Huybrechts K.F.
        Patterns of opioid utilization in pregnancy in a large cohort of commercial insurance beneficiaries in the United States.
        Anesthesiology. 2014; 120: 1216-1224
        • Bean-Mayberry B.
        • Yano E.M.
        • Washington D.L.
        • Goldzweig C.
        • Batuman F.
        • Huang C.
        • Shekelle P.G.
        Systematic review of women veterans' health: Update on successes and gaps.
        Women's Health Issues. 2011; 21: S84-S97
        • Broussard C.S.
        • Rasmussen S.A.
        • Reefhuis J.
        • Friedman J.M.
        • Jann M.W.
        • Riehle-Colarusso T.
        • Honein M.A.
        Maternal treatment with opioid analgesics and risk for birth defects.
        American Journal of Obstetrics and Gynecology. 2011; 204: 314.e1-314.e11
        • Campbell C.I.
        • Weisner C.
        • Leresche L.
        • Ray G.T.
        • Saunders K.
        • Sullivan M.D.
        • Von Korff M.
        Age and gender trends in long-term opioid analgesic use for noncancer pain.
        American Journal of Public Health. 2010; 100: 2541-2547
      2. Centers for Disease Control and Prevention, & National Center for Health Statistics. (2013). ICD - ICD-9-CM - International classification of diseases, 9th revision, clinical modification. Classification of diseases, functioning, and disability. Available: www.cdc.gov/nchs/icd/icd9cm.htm#ftp. Accessed August 1, 2014.

        • Chou R.
        • Fanciullo G.J.
        • Fine P.G.
        • Adler J.A.
        • Ballantyne J.C.
        • Davies P.
        • Miaskowski C.
        Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain.
        Journal of Pain. 2009; 10: 113-130
        • Darnall B.D.
        • Stacey B.R.
        • Chou R.
        Medical and psychological risks and consequences of long-term opioid therapy in women.
        Pain Medicine. 2012; 13: 1181-1211
      3. Department of Veterans Affairs. (2013). Opioid therapy for chronic pain pocket guide. Available: www.healthquality.va.gov/guidelines/Pain/cot/OpioidPocketGuide23May2013v1.pdf. Accessed July 22, 2014.

      4. Department of Veterans Affairs, & Department of Defense. (2010). Management of opioid therapy for chronic pain. Washington, DC: Department of Veterans Affairs and Department of Defense. Available: www.healthquality.va.gov/guidelines/Pain/cot/COT_312_Full-er.pdf. Accessed July 22, 2014.

        • Desai R.J.
        • Hernandez-Diaz S.
        • Bateman B.T.
        • Huybrechts K.F.
        Increase in prescription opioid use during pregnancy among Medicaid-enrolled women.
        Obstetrics and Gynecology. 2014; 123: 997-1002
        • Epstein R.A.
        • Bobo W.
        • Martin P.R.
        • Morrow J.A.
        • Wang W.
        • Chandrasekhar R.
        • Cooper W.O.
        Increasing pregnancy-related use of prescribed opioid analgesics.
        Annals of Epidemiology. 2013; 23: 498-503
        • Feinberg S.
        • Leong M.
        • Christian J.
        • Pasero C.
        • Fong A.
        • Feinberg R.
        • Pohl M.
        ACPA resource guide.
        2014 edition. American Chronic Pain Association, Rocklin, California2014 (Available:) (Accessed June 4, 2014)
      5. Frayne, S. M., Phibbs, C. S., Friedman, S. A., Saechao, F., Berg, E., Balasubramanian, V., … Hayes, P. M. (2012). Sourcebook: Women veterans in the Veterans Health Administration. Volume 2. Sociodemographics and use of VHA and non-VA Care (Fee). (Vol. 2). Women's Health Evaluation Initiative, Women's Health Services, Veterans Health Administration, Department of Veterans Affairs: Washington DC. Available: www.womenshealth.va.gov/WOMENSHEALTH/docs/SourcebookVol2_508c_FINAL.pdf. Accessed June 17, 2014.

        • Haskell S.G.
        • Mattocks K.
        • Goulet J.L.
        • Krebs E.E.
        • Skanderson M.
        • Leslie D.
        • Brandt C.
        The burden of illness in the first year home: Do male and female VA users differ in health conditions and healthcare utilization.
        Women's Health Issues. 2011; 21: 92-97
        • Haskell S.G.
        • Ning Y.
        • Krebs E.
        • Goulet J.
        • Mattocks K.
        • Kerns R.
        • Brandt C.
        Prevalence of painful musculoskeletal conditions in female and male veterans in 7 years after return from deployment in Operation Enduring Freedom/Operation Iraqi Freedom.
        Clinical Journal of Pain. 2012; 28: 163-167
        • Higgins D.M.
        • Kerns R.D.
        • Brandt C.A.
        • Haskell S.G.
        • Bathulapalli H.
        • Gilliam W.
        • Goulet J.L.
        Persistent pain and comorbidity among Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn veterans.
        Pain Medicine. 2014; 15: 782-790
        • Hudak M.L.
        • Tan R.C.
        Neonatal drug withdrawal.
        Pediatrics. 2012; 129: e540-e560
        • Keegan J.
        • Parva M.
        • Finnegan M.
        • Gerson A.
        • Belden M.
        Addiction in pregnancy.
        Journal of Addictive Diseases. 2010; 29: 175-191
        • Kellogg A.
        • Rose C.H.
        • Harms R.H.
        • Watson W.J.
        Current trends in narcotic use in pregnancy and neonatal outcomes.
        American Journal of Obstetrics and Gynecology. 2011; 204: 259.e1-259.e4
        • Kimerling R.
        • Gima K.
        • Smith M.W.
        • Street A.
        • Frayne S.
        The Veterans Health Administration and military sexual trauma.
        American Journal of Public Health. 2007; 97: 2160-2166
        • Lew H.L.
        • Otis J.D.
        • Tun C.
        • Kerns R.D.
        • Michael E.
        • Cifu D.X.
        Prevalence of chronic pain, posttraumatic stress disorder, and persistent postconcussive symptoms in OIF/OEF veterans: Polytrauma clinical triad.
        Journal of Rehabilitation Research & Development. 2009; 46: 697-702
        • Macey T.A.
        • Morasco B.J.
        • Duckart J.P.
        • Dobscha S.K.
        Patterns and correlates of prescription opioid use in OEF/OIF veterans with chronic noncancer pain.
        Pain Medicine. 2011; 12: 1502-1509
        • Mattocks K.M.
        • Frayne S.
        • Phibbs C.S.
        • Yano E.M.
        • Zephyrin L.
        • Shryock H.
        • Bastian L.A.
        Five-year trends in women Veterans' use of VA maternity benefits, 2008-2012.
        Women's Health Issues. 2014; 24: e37-e42
        • Mattocks K.M.
        • Skanderson M.
        • Goulet J.L.
        • Brandt C.
        • Womack J.
        • Krebs E.
        • Haskell S.
        Pregnancy and mental health among women veterans returning from Iraq and Afghanistan.
        Journal of Women's Health. 2010; 19: 2159-2166
        • Meyer M.
        The perils of opioid prescribing during pregnancy.
        Obstetrics and Gynecology Clinics of North America. 2014; 41: 297-306
        • Mosher H.J.
        • Krebs E.E.
        • Carrel M.
        • Kaboli P.J.
        • Weg M.W.
        • Lund B.C.
        Trends in prevalent and incident opioid receipt: An observational study in Veterans Health Administration 2004-2012.
        Journal of General Internal Medicine. 2015; 30: 597-604
        • Nuckols T.K.
        • Anderson L.
        • Popescu I.
        • Diamant A.L.
        • Doyle B.
        • Di Capua P.
        • Chou R.
        Opioid prescribing: A systematic review and critical appraisal of guidelines for chronic pain.
        Annals of Internal Medicine. 2014; 160: 38-47
        • Patrick S.W.
        • Dudley J.
        • Martin P.R.
        • Harrell F.E.
        • Warren M.D.
        • Hartmann K.E.
        • Cooper W.O.
        Prescription opioid epidemic and infant outcomes.
        Pediatrics. 2015; 135: 842-850
        • Patrick S.W.
        • Schumacher R.E.
        • Benneyworth B.D.
        • Krans E.E.
        • Mcallister J.M.
        • Davis M.M.
        Neonatal abstinence syndrome and association health care expenditures: United States, 2000-2009.
        Journal of the American Medical Association. 2012; 307: 1934-1940
      6. Salihu, H., Mogos, M., Salemi, J. L., & Salinas, A. (2013). National trends in maternal use of opioid drugs during pregnancy. In 141st APHA Annual Meeting and Exposition. Boston, MA. Available: https://apha.confex.com/apha/141am/webprogram/Paper281434.html. Accessed June 4, 2014.

        • Schwarz E.B.
        • Longo L.S.
        • Zhao X.
        • Stone R.A.
        • Cunningham F.
        • Good C.B.
        Provision of potentially teratogenic medications to female veterans of childbearing age.
        Medical Care. 2010; 48: 834-842
        • Scott J.C.
        • Pietrzak R.H.
        • Mattocks K.
        • Southwick S.M.
        • Brandt C.
        • Haskell S.
        Gender differences in the correlates of hazardous drinking among Iraq and Afghanistan veterans.
        Drug and Alcohol Dependence. 2013; 127: 15-22
        • U.S. Food and Drug Administration
        Content and format of labeling for human prescription drug and biological products; requirements for pregnancy and lactation labeling.
        Federal Register. 2008; 73 (Available:)
        • U.S. Food and Drug Administration
        New safety measures announced for extended-release and long-acting opioids.
        Center for Drug Evaluation and Research, Silver Spring, Maryland2014 (Available:) (Accessed July 22, 2014)
      7. VA National Pain Management Program, & VA National Center for Ethics in Health Care. (n.d.). (2013). Taking opioids responsibly for your safety and the safety of others: Patient information guide on opioids for chronic pain. Available: www.ethics.va.gov/docs/policy/Taking_Opioids_Responsibly_2013528.pdf. Accessed August 23, 2014.

        • West A.N.
        • Lee P.W.
        Associations between childbirth and women veterans' VA and non-VA Hospitalizations for major diagnostic categories.
        Military Medicine. 2013; 178: 1250-1255
        • Wu P.C.
        • Lang C.
        • Hasson N.K.
        • Linder S.H.
        • Clark D.J.
        Opioid use in young veterans.
        Journal of Opioid Management. 2010; 6: 133-139
        • Yazdy M.M.
        • Mitchell A.A.
        • Tinker S.C.
        • Parker S.E.
        • Werler M.M.
        Periconceptional use of opioids and the risk of neural tube defects.
        Obstetrics and Gynecology. 2013; 122: 838-844

      Biography

      Aimee R. Kroll-Desrosiers, MS, is a doctoral candidate in the Clinical and Population Health Research program and a biostatistician in the Department of Quantitative Health Sciences at the University of Massachusetts Medical School.
      Melissa Skanderson, MS, is a Programmer at the VA Connecticut Healthcare System.
      Lori A. Bastian, MD, MPH, is Senior Research Associate of the Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center at the VA Connecticut Healthcare System. She is a Professor, Division Chief of General Internal Medicine, and Associate Dean for Career Development at the University of Connecticut Health Center.
      Cynthia A. Brandt, MD, MPH, is a Professor of Emergency Medicine at Yale School of Medicine and investigator at VA Connecticut Healthcare System. She focuses on informatics and health services research.
      Sally Haskell, MD, is the Deputy Chief Consultant for Women's Health Service and Director of Comprehensive Women's Health for the Veterans Health Administration. She is a General Internist, Women's Health Services Researcher, and Associate Professor of Medicine Yale School of Medicine.
      Robert D. Kerns, PhD, is Special Advisor for Pain Research for the Veterans Health Administration, Director of the Pain Research, Informatics, Multimorbidities, and Education (PRIME) Center at the VA Connecticut Healthcare System, and Professor of Psychiatry, Neurology, and Psychology at Yale University.
      Kristin M. Mattocks, PhD, MPH, is Associate Chief of Staff for Research and Education at VA Central Western Massachusetts Healthcare System and Associate Professor of Quantitative Health Sciences and Psychiatry at the University of Massachusetts Medical School.