Suarez EA, Huybrechts KF, Straub L, Hernandez-Diaz S, Creanga AA, Connery HS, et al. Postpartum opioid-related mortality in publicly insured patients. Obstet Gynecol 2023;141.
The authors provided this information as a supplement to their article.
©2023 American College of Obstetricians and Gynecologists. Page 1 of 8
Appendix 1. Codes and Medications to Define Opioid Use Disorder
Category Codes
Opioid dependence or abuse ICD-9 diagnosis codes: 304.0x, 304.7x, 305.5x
Prescription opioid poisoning ICD-9 diagnosis codes: 965.00 965.02 965.09, E850.1 E850.2 Illicit opioid poisoning ICD-9 diagnosis codes: 965.01, E850.0
Buprenorphine ≥1 dispensing of buprenorphine, buprenorphine hcl, buprenorphine hcl/naloxone hcl, restricted to film or sublingual tablets
Methadone HCPCS codes: H0020, S0109
Suarez EA, Huybrechts KF, Straub L, Hernandez-Diaz S, Creanga AA, Connery HS, et al. Postpartum opioid-related mortality in publicly insured patients. Obstet Gynecol 2023;141.
The authors provided this information as a supplement to their article.
©2023 American College of Obstetricians and Gynecologists. Page 2 of 8
Appendix 2. International Classification of Diseases (ICD)-10 Codes to Define Causes of Death
Category Codes (primary cause of death only, unless otherwise specified) Opioid overdose Primary cause of death:• X40-X44: Accidental poisoning
• X60-X64: Intentional self-poisoning
• X85: Assault by drugs
• Y10-Y14: Poisoning of undetermined intent And, contributing cause of death:
• T40.0: Poisoning by opium
• T40.1: Poisoning by heroin
• T40.2: Poisoning by other opioids
• T40.3: Poisoning by methadone
• T40.4: Poisoning by other synthetic narcotics
• T40.6: Poisoning by other and unspecified narcotics Among deaths that were not classified as due to opioid overdose:
Pregnancy O00-O99: Pregnancy, childbirth, and the puerperium Circulatory system I00-I99: Diseases of the circulatory system
Cancer C00-C97: Malignant neoplasms
D37-D48: Neoplasms of uncertain or unknown behavior
Suicide X60-X84: Intentional self-harm
Y87.0: Sequelae or intentional self-harm
Homicide X85-Y09: Assault
Y87.1: Sequelae of assault Other drug and alcohol
related (not including suicide and homicide)
F10-F19: Mental and behavioral disorders due to psychoactive substance use
X40-X45: Accidental poisoning by and exposure to noxious substances
Y10-Y15: Poisoning by undetermined intent Other injuries V01-V99: Transport accidents
W00-X39: Other external causes of injury
X46-X49: Accidental poisoning by and exposure to noxious substances
Y16-Y34: Other external causes of undetermined intent Y85: Sequelae of transport accidents
Y86: sequelae of other accidents
Other diseases ICD-10 code not in any of the above categories Unknown cause No reported ICD-10 codes for cause of death Sensitivity analysis for opioid overdose death
Extended opioid overdose Meets opioid overdose definition (above)
OR, has one of the following codes as the primary or contributing cause:
T40.0: Poisoning by opium T40.1: Poisoning by heroin
Suarez EA, Huybrechts KF, Straub L, Hernandez-Diaz S, Creanga AA, Connery HS, et al. Postpartum opioid-related mortality in publicly insured patients. Obstet Gynecol 2023;141.
The authors provided this information as a supplement to their article.
©2023 American College of Obstetricians and Gynecologists. Page 3 of 8
T40.2: Poisoning by other opioids T40.3: Poisoning by methadone T40.4: Poisoning by other narcotics
T40.6: Poisoning by other and unspecified narcotics
F11.X: Disorders related or resulting from abuse or mis-use of opioids
OR, has one of the following narcotics poisoning codes without a specified non-opioid code (T40.5, T40.7, T40.8, T40.9) as the primary or contributing cause:
X42: Accidental poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified X62: Intentional self-poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified Y12: Poisoning by and exposure to narcotics and psychodysleptics [hallucinogens], not elsewhere classified, undetermined intent
Suarez EA, Huybrechts KF, Straub L, Hernandez-Diaz S, Creanga AA, Connery HS, et al. Postpartum opioid-related mortality in publicly insured patients. Obstet Gynecol 2023;141.
The authors provided this information as a supplement to their article.
©2023 American College of Obstetricians and Gynecologists. Page 4 of 8
Appendix 3. Definitions of Risk Factors
Risk factor Definition
Age Maternal age at delivery
Race/ethnicity Maternal race/ethnicity based on enrollment files
Stillbirth/mixed birth Diagnosis codes for stillbirth or mixed birth (multiple gestation with live and still births) at delivery
Preterm birth Delivery at gestational age <37 weeks, as defined by presence of diagnosis codes for preterm delivery
Cesarean delivery Diagnosis and procedure codes for cesarean
Severe maternal morbidity Diagnosis codes for: acute heart failure, acute renal failure, acute liver disease, acute myocardial infarction, acute respiratory distress syndrome/respiratory failure, disseminated intravascular
coagulation/coagulopathy, coma, delirium, puerperal cerebrovascular disorders, pulmonary edema, pulmonary embolism, sepsis, shock, status asthmaticus, status epilepticus
Mental health disorders Diagnosis codes for: anxiety, depression, bipolar disorder, personality disorder, PTSD, schizophrenia, self-inflicted injuries, sleep disorders Opioid indications Diagnosis codes for: surgery, infections, arthritis, arthropathy, back
and neck pain, dental pain, urinary calculus, orthopedic injury, migraine/headache, abdominal pain, gout, cough, sciatica, peripheral neuropathy, postherpetic neuralgia, trigeminal neuralgia, other neuropathies. Fibromyalgia, sickle cell disease, CRPS, central pain, osteoarthritis, joint pain, rheumatoid arthritis, sarcoidosis, generalized pain, psychological pain, unspecified pain, cancer STDs/Hepatitis/HIV Genital herpes, syphilis and other venereal diseases, trichomoniasis,
human papillomavirus, Hepatitis B, Hepatitis C, HIV
Tobacco use Diagnosis and procedure codes for: tobacco use disorder, tobacco use history, tobacco use cessation
Psychotropic medication use Any dispensing of: antidepressants, antipsychotics, anxiolytics, barbiturates, benzodiazepines, triptans, anticonvulsants, hypnotics, psychostimulants
Other non-opioid substance
use disorders Diagnosis codes for: alcohol, cocaine, hallucinogen, marijuana, psychostimulant, and sedative use disorders
MOUD Buprenorphine: ≥1 dispensing of buprenorphine, buprenorphine hcl, buprenorphine hcl/naloxone hcl, restricted to film or sublingual tablets
Methadone: HCPCS codes H0020, S0109 Opioid dispensing Any dispensing of an opioid
Emergency department visit Any visit to the emergency department Hospitalization Any hospital visit or long-term stay Number of dispensed generic
medications Number of distinct generic drugs dispensed (does not count refills) Number of outpatient visits Count of distinct outpatient visits
Suarez EA, Huybrechts KF, Straub L, Hernandez-Diaz S, Creanga AA, Connery HS, et al. Postpartum opioid-related mortality in publicly insured patients. Obstet Gynecol 2023;141.
The authors provided this information as a supplement to their article.
©2023 American College of Obstetricians and Gynecologists. Page 5 of 8
Appendix 4. Distribution of timing of postpartum deaths by cause, among all pregnant individuals
and among pregnant individuals with OUD.
Suarez EA, Huybrechts KF, Straub L, Hernandez-Diaz S, Creanga AA, Connery HS, et al. Postpartum opioid-related mortality in publicly insured patients. Obstet Gynecol 2023;141.
The authors provided this information as a supplement to their article.
©2023 American College of Obstetricians and Gynecologists. Page 6 of 8
Appendix 5. Characteristics of Pregnant Individuals With Nonopioid Overdose Death and Matched Controls
All pregnant individuals Pregnant individuals with OUD
Deaths, N (%) Controls, N (%) OR (95% CI)1 Deaths, N (%) Controls, N (%) OR (95% CI)1
Age in years
≤19 164 (13.0) 1,231 (19.6) 0.6 (0.5, 0.7) <11 <11 2.2 (0.5, 9.6)
20-24 358 (28.5) 2,352 (37.4) 0.7 (0.6, 0.8) 14 (21.9) 100 (31.3) 0.8 (0.4, 1.6)
25-29 (reference) 344 (27.3) 1,600 (25.4) 1 22 (34.4) 125 (39.1) 1
30-34 217 (17.2) 751 (11.9) 1.4 (1.1, 1.6) 19 (29.7) 67 (20.9) 1.6 (0.8, 3.3)
35-39 124 (9.9) 283 (4.5) 2.1 (1.6, 2.6) <11 15 (4.7) 1.6 (0.4, 5.4)
≥40 51 (4.1) 73 (1.2) 3.4 (2.3, 4.9) <11 <11 2.4 (0.4, 14.0)
Race/ethnicity
Asian/Pacific Islander 12 (1.0) 128 (2.0) 0.5 (0.3, 0.9) 0 (0.0) <11 -
Black 456 (36.2) 1,900 (30.2) 1.3 (1.1, 1.5) <11 25 (7.8) 1.3 (0.5, 3.7)
Hispanic or Latino 93 (7.4) 761 (12.1) 0.6 (0.5, 0.8) <11 <11 4.0 (1.0, 15.4)
Other/Unknown2 82 (6.5) 257 (4.1) 1.7 (1.3, 2.3) <11 15 (4.7) 1.1 (0.2, 6.0)
Non-white (combined category)3 643 (51.1) 3,046 (48.4) 1.1 (1.0, 1.3) 14 (21.9) 50 (15.6) 1.6 (0.8, 3.4)
White (reference) 615 (48.9) 3,244 (51.6) 1 50 (78.1) 268 (83.8) 1
Delivery characteristics
Stillbirth/mixed birth 52 (4.1) 37 (0.6) 7.4 (4.8, 11.4) <11 <11 5.5 (0.6, 54.6)
Preterm birth 273 (21.7) 637 (10.1) 2.5 (2.1, 2.9) 15 (23.4) 50 (15.6) 1.7 (0.9, 3.4)
Cesarean delivery 556 (44.2) 1,931 (30.7) 1.8 (1.6, 2.0) 33 (51.6) 107 (33.4) 2.3 (1.3, 4.0)
Severe maternal morbidity 400 (31.8) 84 (1.3) 36.0 (28.1, 46.1) 12 (18.8) 11 (3.4) 7.2 (2.9, 17.9)
Comorbidities
Mental health disorders 287 (22.8) 614 (9.8) 2.8 (2.4, 3.3) 39 (60.9) 170 (53.1) 1.4 (0.8, 2.6)
Opioid indications 688 (54.7) 2,376 (37.8) 2.0 (1.8, 2.3) 38 (59.4) 173 (54.1) 1.3 (0.7, 2.2)
STDs/Hepatitis/HIV 96 (7.6) 244 (3.9) 2.1 (1.6, 2.6) 13 (20.3) 48 (15.0) 1.5 (0.7, 3.0)
Suarez EA, Huybrechts KF, Straub L, Hernandez-Diaz S, Creanga AA, Connery HS, et al. Postpartum opioid-related mortality in publicly insured patients. Obstet Gynecol 2023;141.
The authors provided this information as a supplement to their article.
©2023 American College of Obstetricians and Gynecologists. Page 7 of 8
Tobacco use 239 (19.0) 883 (14.0) 1.5 (1.2, 1.7) 28 (43.8) 148 (46.3) 0.9 (0.5, 1.6)
Psychotropic medication use 312 (24.8) 626 (10.0) 3.1 (2.6, 3.6) 24 (37.5) 114 (35.6) 1.1 (0.6, 1.9)
Substance abuse
OUD diagnosis in pregnancy 64 (5.1) 53 (0.8) 6.7 (4.6, 9.7) 64 (100) 320 (100) -
Other non-opioid substance use
disorders 75 (6.0) 164 (2.6) 2.4 (1.8, 3.2) 18 (28.1) 69 (21.6) 1.5 (0.8, 2.8)
MOUD in pregnancy 22 (1.7) 29 (0.5) 4.0 (2.3, 7.1) 22 (34.4) 164 (51.3) 0.5 (0.3, 0.8)
MOUD after delivery 16 (1.3) 25 (0.4) 4.2 (2.5, 7.1) 14 (21.9) 133 (41.6) 0.5 (0.2, 0.9)
Legend: 1Odds ratios were adjusted for state to account for matching of opioid overdose death cases to non-death controls. 2“Other”
race/ethnicity includes American Indian, Alaskan Native, and more than one race. 3Race/ethnicity groups collapsed to White and non-White due to small counts in non-White groups in OUD population. Event counts are obscured when <11 in MAX due to the Centers for Medicare and Medicaid Services cell size suppression policy.
CI: confidence interval; MOUD: medications for opioid use disorder; OR: odds ratio; OUD: opioid use disorder
Suarez EA, Huybrechts KF, Straub L, Hernandez-Diaz S, Creanga AA, Connery HS, et al. Postpartum opioid-related mortality in publicly insured patients. Obstet Gynecol 2023;141.
The authors provided this information as a supplement to their article.
©2023 American College of Obstetricians and Gynecologists. Page 8 of 8
Appendix 6. Health Care Utilization of Pregnant Individuals With Nonopioid Overdose Death and Matched Controls
All pregnant individuals Pregnant individuals with OUD Non-opioid
overdose deaths
(N=1258) Matched controls (N=6290)
Non-opioid overdose deaths
(N=64) Matched controls (N=320) Healthcare utilization during pregnancy
Opioid dispensing, N (%) 296 (23.5) 698 (11.1) 20 (31.3) 74 (23.1)
Emergency department visit, N (%) 448 (35.6) 1363 (21.7) 24 (37.5) 122 (38.1)
Hospitalization, N (%) 183 (14.5) 296 (4.7) 19 (29.7) 97 (30.3)
Number of dispensed generic medications, median (IQR) 2 (1, 5) 1 (0, 3) 3 (1, 5) 3 (1, 5)
Number of outpatient visits, median (IQR) 16 (8, 29) 12 (7, 21) 22.5 (11.5, 37) 24 (12, 41) Healthcare utilization after delivery
Opioid dispensing, N (%) 760 (60.4) 3285 (52.2) 38 (59.4) 169 (52.8)
Emergency department visit, N (%) 695 (55.2) 1536 (24.4) 44 (68.8) 133 (41.6)
Hospitalization, N (%) 280 (22.3) 216 (3.4) 16 (25.0) 18 (5.6)
Number of dispensed generic medications, median (IQR) 4 (1, 9) 3 (1, 5) 5.5 (1, 10.5) 4 (2, 7)
Number of outpatient visits, median (IQR) 4 (2, 8) 3 (1, 5) 5 (2, 12.5) 4 (2, 10)
Legend: Healthcare utilization during pregnancy was measured from 90 days prior to delivery until the day prior to the delivery admission date or 3 days prior to the delivery date for deliveries occurring in outpatient settings. Healthcare utilization after delivery was measured from the day after delivery until the day prior to death or the matched day after delivery in controls. For hospitalizations, both the admission and discharge date had to fall within the utilization window. This avoided capturing the delivery hospitalization or a hospitalization that ended in death.
Event counts are obscured when <11 in MAX due to the CMS cell size suppression policy.
