(36) National Estimates of Alcohol Use Disorder Diagnosis and Treatment in Pregnancy, 2006-2019

Background & Introduction: Alcohol use disorder (AUD) during pregnancy has received relatively little attention compared to other substance use disorders (i.e., opioids). There is presently no ACOG guidance on the role of pharmacologic AUD treatments in birthing people. Even though prenatal alcohol exposure is the leading cause of preventable disability in the United States, the prevalence of AUD diagnosis and treatment receipt has thoroughly not been examined in pregnant and postpartum people using national data. Recognizing that insurance disparities may impact access to medications for AUD (MAUD), we used an all-payer electronic health records (EHR)-based dataset spanning >100 health care organizations in the U.S. to estimate the prevalence of AUD diagnoses and MAUD receipt from 2006 to 2019.

Methods: We analyzed the TriNetX databases, a U.S.-based EHR-based dataset that is agnostic to payer type (including Epic Systems, Veterans Affairs, and military EHRs). As a "near real-time" database, TriNetX is continuously refreshed (as frequently as weekly) and is a component of the FDA's efforts to drug safety surveillance efforts in the U.S. (Sentinel Initiative). The lack of continuous insurance enrollment requirements is an important strength of the TriNetX data, permitting us to capture vulnerable subpopulations that are likely underrepresented in commercial insurance databases. We queried the TriNetX data to identify people with >1 delivery-related encounter from 2006-2019 and evaluated the number of individuals with AUD in the year before through after delivery who received >1 fill for acamprosate, disulfiram, and naltrexone during that timeframe. We secondarily calculated the prevalence of AUD over time.

Results: Across all years (2006-2019), 0.5% (n=3,599) of 649,013 birthing people in the TriNetX database had a diagnosis of AUD during pregnancy. Few people with AUD received MAUD in the year before through after delivery in the TriNetX data (1.4% naltrexone, 0.7% disulfiram, 0.6% acamprosate). Reflecting the high degree of comorbidity between AUD and other psychiatric disorders, approximately 40% of birthing people with AUD had diagnoses for mood (i.e., major depressive disorder) disorders postpartum. Interestingly, the annual prevalence of AUD diagnoses in birthing individuals saw significant increases in the TriNetX data, increasing from approximately 0.2% in 2006-2007 to 0.4% by 2018-2019. In our secondary analyses, we extended the observation period beyond 2019, finding that the prevalence of AUD diagnoses in birthing individuals increased to over 0.6% by 2024.

Conclusion & Discussion: Across all-payer EHR data, AUD diagnoses may be as prevalent as 0.5% during pregnancy, and rates of filled MAUD prescriptions are low, highlighting important unaddressed gaps in perinatal substance use disorders care in the U.S. While limitations exist in the clinical significance of AUD diagnoses in claims data (e.g., bias in reporting), the increase in prevalence of these diagnoses over time warrants further investigation. Multiple opportunities across the AUD cascade of care exist to address unmet needs of pregnant and postpartum people, with our data suggesting that receipt of AUD treatments is an area for targeted intervention.

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