51
|
Tith S, Bining G, Bollag L. Management of eight labor and delivery patients dependent on buprenorphine (Subutex™): A retrospective chart review. F1000Res 2018. [PMID: 29527296 PMCID: PMC5820592 DOI: 10.12688/f1000research.13350.2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Opioid use during pregnancy is a growing concern in the United States. Buprenorphine has been recommended by “The American College of Obstetrics and Gynecology” as an alternative to methadone to decrease risks associated with the use of illicit opioids during pregnancy. The partial μ-opioid agonists’ unique pharmacology, including its long half time and high affinity to the μ-opioid receptor, complicates patient management in a highly kinetic, and often urgent field like obstetric anesthesia. We reviewed our management and outcomes in this medically complex population. Methods: An Institutional Review Board (IRB) approved retrospective chart review was conducted of women admitted to the University of Washington Medical Center Labor and Delivery unit from July 2012 to November 2013 using buprenorphine. All deliveries, including intrauterine fetal demise, were included. Results: Eight women were admitted during this period to our L&D floor on buprenorphine. All required peri-partum anesthetic management either for labor and/or cesarean delivery management. Analgesic management included dilaudid or fentanyl PCA and/or continued epidural infusion, and in one instance ketamine infusion, while the pre-admission buprenorphine regimen was continued. Five babies were viable, two women experienced intrauterine fetal death at 22 and 36 weeks gestational age (GSA), respectively, and one neonate died shortly after delivery due to a congenital diaphragmatic hernia. Conclusions: This case series illuminates the medical complexity of parturients using buprenorphine. Different treatment modalities in the absence of evidence-based guidelines included additional opioid administration and continued epidural analgesia. The management of post-cesarean pain in patients on partial μ-opioid agonists remains complex and variable, and evidence-based guidelines could be useful for clinicians to direct care.
Collapse
Affiliation(s)
- Solina Tith
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Garinder Bining
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Laurent Bollag
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
52
|
Tith S, Bining G, Bollag L. Management of eight labor and delivery patients dependent on buprenorphine (Subutex™): A retrospective chart review. F1000Res 2018. [PMID: 29527296 DOI: 10.12688/f1000research.13350.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Opioid use during pregnancy is a growing concern in the United States. Buprenorphine has been recommended by "The American College of Obstetrics and Gynecology" as an alternative to methadone to decrease risks associated with the use of illicit opioids during pregnancy. The partial μ-opioid agonists' unique pharmacology, including its long half time and high affinity to the μ-opioid receptor, complicates patient management in a highly kinetic, and often urgent field like obstetric anesthesia. We reviewed our management and outcomes in this medically complex population. Methods: An Institutional Review Board (IRB) approved retrospective chart review was conducted of women admitted to the University of Washington Medical Center Labor and Delivery unit from July 2012 to November 2013 using buprenorphine. All deliveries, including intrauterine fetal demise, were included. Results: Eight women were admitted during this period to our L&D floor on buprenorphine. All required peri-partum anesthetic management either for labor and/or cesarean delivery management. Analgesic management included dilaudid or fentanyl PCA and/or continued epidural infusion, and in one instance ketamine infusion, while the pre-admission buprenorphine regimen was continued. Five babies were viable, two women experienced intrauterine fetal death at 22 and 36 weeks gestational age (GSA), respectively, and one neonate died shortly after delivery due to a congenital diaphragmatic hernia. Conclusions: This case series illuminates the medical complexity of parturients using buprenorphine. Different treatment modalities in the absence of evidence-based guidelines included additional opioid administration and continued epidural analgesia. The management of post-cesarean pain in patients on partial μ-opioid agonists remains complex and variable, and evidence-based guidelines could be useful for clinicians to direct care.
Collapse
Affiliation(s)
- Solina Tith
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Garinder Bining
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Laurent Bollag
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
53
|
Bachhuber MA, Mehta PK, Faherty LJ, Saloner B. Medicaid Coverage of Methadone Maintenance and the Use of Opioid Agonist Therapy Among Pregnant Women in Specialty Treatment. Med Care 2017; 55:985-990. [PMID: 29135769 DOI: 10.1097/mlr.0000000000000803] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Opioid agonist therapy (OAT) is the standard of care for pregnant women with opioid use disorder (OUD). Medicaid coverage policies may strongly influence OAT use in this group. OBJECTIVE To examine the association between Medicaid coverage of methadone maintenance and planned use of OAT in the publicly funded treatment system. RESEARCH DESIGN Retrospective cross-sectional analysis of treatment admissions in 30 states extracted from the Treatment Episode Data Set (2013 and 2014). SUBJECTS Medicaid-insured pregnant women with OUD (n=3354 treatment admissions). MEASURES The main outcome measure was planned use of OAT on admission. The main exposure was state Medicaid coverage of methadone maintenance. Using multivariable logistic regression models adjusting for sociodemographic, substance use, and treatment characteristics, we compared the probability of planned OAT use in states with Medicaid coverage of methadone maintenance versus states without coverage. RESULTS A total of 71% of pregnant women admitted to OUD treatment were 18-29 years old, 85% were white non-Hispanic, and 56% used heroin. Overall, 74% of admissions occurred in the 18 states with Medicaid coverage of methadone maintenance and 53% of admissions involved planned use of OAT. Compared with states without Medicaid coverage of methadone maintenance, admissions in states with coverage were significantly more likely to involve planned OAT use (adjusted difference: 32.9 percentage points, 95% confidence interval, 19.2-46.7). CONCLUSIONS Including methadone maintenance in the Medicaid benefit is essential to increasing OAT among pregnant women with OUD and should be considered a key policy strategy to enhance outcomes for mothers and newborns.
Collapse
Affiliation(s)
- Marcus A Bachhuber
- *Department of Medicine, Division of General Internal Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY †Department of Obstetrics and Gynecology, Boston University School of Medicine ‡RAND Corporation, Boston, MA §Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | | | | |
Collapse
|
54
|
Washio Y, Wright EN, Flores D, Davis A, Chittams J, Anagnostopulos C, Kilby LM, Teitelman AM. Perspectives on HIV Testing Among WIC-Enrolled Postpartum Women: Implications for Intervention Development. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2017; 29:457-474. [PMID: 29068716 PMCID: PMC6266864 DOI: 10.1521/aeap.2017.29.5.457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Low-income minority women are disproportionately represented among those living with HIV in the U.S and also at-risk for substance abuse and intimate partner violence-collectively called the SAVA syndemic-which may impede HIV testing uptake. Views about HIV testing were assessed among women (ages 18-29) enrolled in a federally funded nutrition program for women, infants, and children (WIC) in a large Mid-Atlantic city. A survey (n = 80) and three focus groups were conducted in WIC offices located in neighborhoods with high HIV prevalence. Among this primarily minority sample, most would be interested in getting an HIV test if offered at WIC. Benefits included knowing one's HIV status, convenience, and accessible location, while transportation and peer/partner encouragement were enabling factors. Barriers included privacy concerns and intimate partner violence. Findings will be used to design an intervention to promote HIV testing among women who attend WIC and that proactively addresses reported barriers.
Collapse
Affiliation(s)
- Yukiko Washio
- University of Delaware College of Health Sciences, Newark, Delaware
| | | | | | - Annet Davis
- University of Pennsylvania School of Medicine, Philadelphia
| | - Jesse Chittams
- University of Pennsylvania School of Nursing, Philadelphia
| | | | - Linda M Kilby
- Philadelphia Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), North Inc
| | | |
Collapse
|
55
|
|
56
|
Wright TE. Screening, brief intervention, and referral to treatment for opioid and other substance use during infertility treatment. Fertil Steril 2017; 108:214-221. [PMID: 28697912 DOI: 10.1016/j.fertnstert.2017.06.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 06/06/2017] [Indexed: 01/04/2023]
Abstract
Opioid use and misuse have reached epidemic proportions in the United States, especially in women of childbearing age, some of whom seek infertility treatments. Substance use is much more common than many of the conditions routinely screened for during the preconception period, and it can have devastating consequences for the woman and her family. Substance use can worsen infertility, complicate pregnancy, increase medical problems, and lead to psychosocial difficulties for the woman and her family. The reproductive endocrinologist thus has an ethical and medical duty to screen for substance use, provide initial counseling, and refer to specialized treatment as needed. This article provides an overview of screening, brief intervention, and referral to treatment (SBIRT), a public health approach shown to be effective in ameliorating the harms of substance use.
Collapse
Affiliation(s)
- Tricia E Wright
- Department of Obstetrics, Gynecology and Women's Health, and Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii.
| |
Collapse
|
57
|
Tran TH, Griffin BL, Stone RH, Vest KM, Todd TJ. Methadone, Buprenorphine, and Naltrexone for the Treatment of Opioid Use Disorder in Pregnant Women. Pharmacotherapy 2017; 37:824-839. [PMID: 28543191 DOI: 10.1002/phar.1958] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pregnant women with opioid use disorder can be treated with methadone, buprenorphine, or naltrexone to reduce opioid use and improve retention to treatment. In this review, we compare the pregnancy outcomes of methadone, buprenorphine, and naltrexone in clinical trials and discuss the potential behavioral and developmental effects of these agents seen in offspring in animal studies. Important clinical considerations in the management of opioid use disorder in pregnant women and their infants are also discussed. Outside of pregnancy, buprenorphine is used in combination with naloxone to reduce opioid abuse and diversion. During pregnancy, however, the use of buprenorphine as a single agent is preferred to prevent prenatal naloxone exposure. Both methadone and buprenorphine are widely used to treat opioid use disorder; however, compared with methadone, buprenorphine is associated with shorter treatment duration, less medication needed to treat neonatal abstinence syndrome (NAS) symptoms, and shorter hospitalizations for neonates. Despite being the standard of care, medication-assisted treatment with methadone or buprenorphine is still underused, making it apparent that more options are necessary. Naltrexone is not a first-line treatment primarily because both detoxification and an opioid-free period are required. More research is needed to determine naltrexone safety and benefits in pregnant women. Animal studies suggest that changes in pain sensitivity, developmental processes, and behavioral responses may occur in children born to mothers receiving methadone, buprenorphine, or naltrexone and is an area that warrants future studies.
Collapse
Affiliation(s)
- Tran H Tran
- Pharmacy Practice, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois
| | - Brooke L Griffin
- Pharmacy Practice, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois
| | - Rebecca H Stone
- Pharmacy Practice, University of Georgia College of Pharmacy, Athens, Georgia
| | - Kathleen M Vest
- Pharmacy Practice, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois
| | - Timothy J Todd
- Pharmacy Practice, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois
| |
Collapse
|
58
|
Reddy UM, Davis JM, Ren Z, Greene MF. Opioid Use in Pregnancy, Neonatal Abstinence Syndrome, and Childhood Outcomes: Executive Summary of a Joint Workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, American College of Obstetricians and Gynecologists, American Academy of Pediatrics, Society for Maternal-Fetal Medicine, Centers for Disease Control and Prevention, and the March of Dimes Foundation. Obstet Gynecol 2017; 130:10-28. [PMID: 28594753 PMCID: PMC5486414 DOI: 10.1097/aog.0000000000002054] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In April 2016, the Eunice Kennedy Shriver National Institute of Child Health and Human Development invited experts to a workshop to address numerous knowledge gaps and to review the evidence for the screening and management of opioid use in pregnancy and neonatal abstinence syndrome. The rising prevalence of opioid use in pregnancy has led to a concomitant dramatic fivefold increase in neonatal abstinence syndrome over the past decade. Experts from diverse disciplines addressed research gaps in the following areas: 1) optimal screening for opioid use in pregnancy; 2) complications of pregnancy associated with opioid use; 3) appropriate treatments for pregnant women with opioid use disorders; 4) the best approaches for detecting, treating, and managing newborns with neonatal abstinence syndrome; and 5) the long-term effects of prenatal opioid exposure on children. Workshop participants identified key scientific opportunities to advance the understanding of opioid use disorders in pregnancy and to improve outcomes for affected women, their children, and their families. This article provides a summary of the workshop presentations and discussions.
Collapse
Affiliation(s)
- Uma M Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, the Tufts University School of Medicine, Boston, Massachusetts, and the Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | | |
Collapse
|
59
|
Abstract
Opioid abuse among pregnant women has reached epidemic proportions and has influenced maternal and child health policy at the federal, state, and local levels. As a result, we review the current state of opioid use in pregnancy and evaluate recent legislative and health policy initiatives designed to combat opioid addiction in pregnancy. We emphasize the importance of safe and responsible opioid-prescribing practices, expanding the availability and accessibility of medication-assisted treatment and standardizing care for neonates at risk of neonatal abstinence syndrome. Efforts to penalize pregnant women and negative consequences for disclosing substance use to health care providers are harmful and may prevent women from seeking prenatal care and other beneficial health care services during pregnancy. Instead, health care providers should advocate for health policy informed by scientific research and evidence-based practice to reduce the burden of prenatal opioid abuse and optimize outcomes for mothers and their neonates.
Collapse
|
60
|
Peripartum Anesthetic Management of the Opioid-tolerant or Buprenorphine/Suboxone-dependent Patient. Clin Obstet Gynecol 2017; 60:447-458. [DOI: 10.1097/grf.0000000000000288] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
61
|
Roper V, Cox KJ. Opioid Use Disorder in Pregnancy. J Midwifery Womens Health 2017; 62:329-340. [DOI: 10.1111/jmwh.12619] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 02/12/2017] [Accepted: 02/14/2017] [Indexed: 11/30/2022]
|
62
|
Foeller ME, Lyell DJ. Marijuana Use in Pregnancy: Concerns in an Evolving Era. J Midwifery Womens Health 2017; 62:363-367. [DOI: 10.1111/jmwh.12631] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 02/17/2017] [Accepted: 02/19/2017] [Indexed: 11/30/2022]
|
63
|
Abstract
This clinical case conference discusses the treatment of a pregnant woman with opioid use disorder in a comprehensive care program that includes buprenorphine pharmacotherapy. The presentation summarizes common experiences that pregnant women who receive buprenorphine pharmacotherapy face, and also what their prenatally opioid-exposed children confront in the immediate postpartum period. It describes the elements of a successful comprehensive care model and corollary neonatal abstinence syndrome treatment regimen. Expert commentary is included on issues that arise in the buprenorphine induction and maintenance throughout the prenatal and postpartum periods and in the treatment of co-occurring mental health problems during both the prenatal and postpartum periods, particularly the treatment of depression. There is also expert commentary on the care of opioid-exposed neonates, with attention to the treatment for neonatal abstinence syndrome.
Collapse
|
64
|
Franchitto N, Jullian B, Salles J, Pelissier F, Rolland B. Management of precipitated opiate withdrawal syndrome induced by nalmefene mistakenly prescribed in opiate-dependent patients: a review for clinicians. Expert Opin Drug Metab Toxicol 2017; 13:669-677. [DOI: 10.1080/17425255.2017.1312340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Nicolas Franchitto
- Service d’Addictologie, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
- Centre Antipoison et de Toxicovigilance, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
- Institut National de la Santé et de la Recherche Médicale (INSERM) UMR 1027, Université Paul Sabatier, Toulouse, France
| | - Benedicte Jullian
- Service d’Addictologie, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
| | - Juliette Salles
- Service d’Addictologie, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
| | - Fanny Pelissier
- Centre Antipoison et de Toxicovigilance, Centre Hospitalo-Universitaire Toulouse-Purpan, Toulouse, France
| | - Benjamin Rolland
- Département de Psychiatrie et d'Addictologie, Centre Hospitalo-Universitaire Lille, Lille, France
| |
Collapse
|
65
|
Clinical Management of the Breast-Feeding Mother-Infant Dyad in Recovery From Opioid Dependence. J Addict Nurs 2017; 27:68-77. [PMID: 27272990 DOI: 10.1097/jan.0000000000000117] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Human milk is one of the most health-promoting and cost-effective nutritional substances known to humankind. Breastmilk provides substantial and remarkable physiological and psychological health benefits. Within the last decade, there has been a resurgence of breast-feeding in the United States and worldwide and an increased awareness of the immense health benefits for mothers, infants, and societies that support it. Each mother-baby dyad is a unique pair, with distinct relationships, biases, barriers, and obstacles. This article aims to address clinical management for the opioid-recovering breast-feeding dyad and to translate current evidenced-based practice findings, recommendations, and resources to best support this unique population. The recovering breast-feeding mother and newborn with opioid dependence deserve special consideration and expert care to foster their recovery and breast-feeding efforts. It is our moral and ethical responsibility as healthcare professionals to enable, foster, and promote breast-feeding among all families, especially those who stand to benefit the greatest. Substance recovery cannot be treated in isolation, nor can breast-feeding efforts; an interdisciplinary professional team effort promises the greatest chances for recovery success. With appropriate evidence-based practice support, training, and intervention by knowledgeable professionals, many women can overcome the biases and obstacles associated with opioid recovery to successfully breast-feed their babies.
Collapse
|
66
|
Sutter MB, Gopman S, Leeman L. Patient-centered Care to Address Barriers for Pregnant Women with Opioid Dependence. Obstet Gynecol Clin North Am 2017; 44:95-107. [DOI: 10.1016/j.ogc.2016.11.004] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
67
|
Pryor JR, Maalouf FI, Krans EE, Schumacher RE, Cooper WO, Patrick SW. The opioid epidemic and neonatal abstinence syndrome in the USA: a review of the continuum of care. Arch Dis Child Fetal Neonatal Ed 2017; 102:F183-F187. [PMID: 28073819 PMCID: PMC5730450 DOI: 10.1136/archdischild-2015-310045] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 12/05/2016] [Accepted: 12/07/2016] [Indexed: 11/03/2022]
Abstract
As the prescription opioid epidemic grew in the USA, its impact extended to pregnant women and their infants. This review summarises how increasing rates of neonatal abstinence syndrome resulted in a need to improve care to pregnant women and opioid-exposed infants. We discuss the variations in care delivery with particular emphasis on screening at-risk mothers, scoring systems for neonatal drug withdrawal, type and duration of pharmacotherapy, and discharge safety.
Collapse
Affiliation(s)
- Jason R Pryor
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA,Mildred Stahlman Division of Neonatology, Vanderbilt University, Nashville, Tennessee, USA
| | - Faouzi I Maalouf
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA,Mildred Stahlman Division of Neonatology, Vanderbilt University, Nashville, Tennessee, USA
| | - Elizabeth E Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Women’s Research Institute University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert E Schumacher
- Department of Pediatrics, University of Michigan Health Systems, Ann Arbor, Michigan, USA
| | - William O Cooper
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA,Vanderbilt Center for Health Services Research, Nashville, Tennessee, USA,Department of Health Policy, Vanderbilt University, Nashville, Tennessee, USA
| | - Stephen W Patrick
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA,Mildred Stahlman Division of Neonatology, Vanderbilt University, Nashville, Tennessee, USA,Vanderbilt Center for Health Services Research, Nashville, Tennessee, USA,Department of Health Policy, Vanderbilt University, Nashville, Tennessee, USA
| |
Collapse
|
68
|
Abstract
Opioid dependence is an epidemic in the United States, and the percentage of pregnant women who are opioid dependent has increased dramatically in the last decade. Pain management, already a concern for intrapartum and postpartum care, is complicated in the context of opioid dependence. This clinical review surveys the literature on pain management in opioid-dependent pregnant women to summarize current consensus and evidence to guide clinical practice. Points of consensus for pain management in opioid-dependent pregnant women include continual opioid maintenance therapy throughout the pregnancy and the postpartum period; adequate management of acute pain; the contraindication of opioid agonist-antagonists for pain management; and the need for interdisciplinary teams using a multimodal approach to provide optimal care to opioid-dependent pregnant women.
Collapse
|
69
|
Neonatal Abstinence Syndrome and Ethical Approaches to the Identification of Pregnant Women Who Use Drugs. Obstet Gynecol 2017; 129:164-167. [DOI: 10.1097/aog.0000000000001781] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
70
|
Wright TE, Terplan M, Ondersma SJ, Boyce C, Yonkers K, Chang G, Creanga AA. The role of screening, brief intervention, and referral to treatment in the perinatal period. Am J Obstet Gynecol 2016; 215:539-547. [PMID: 27373599 PMCID: PMC11362984 DOI: 10.1016/j.ajog.2016.06.038] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/25/2016] [Accepted: 06/20/2016] [Indexed: 11/30/2022]
Abstract
Substance use during pregnancy is at least as common as many of the medical conditions screened for and managed during pregnancy. While harmful and costly, it is often ignored or managed poorly. Screening, brief intervention, and referral to treatment is an evidence-based approach to manage substance use. In September 2012, the US Centers for Disease Control and Prevention convened an Expert Meeting on Perinatal Illicit Drug Abuse to help address key issues around drug use in pregnancy in the United States. This article reflects the formal conclusions of the expert panel that discussed the use of screening, brief intervention, and referral to treatment during pregnancy. Screening for substance use during pregnancy should be universal. It allows stratification of women into zones of risk given their pattern of use. Low-risk women should receive brief advice, those classified as moderate risk should receive a brief intervention, whereas those who are high risk need referral to specialty care. A brief intervention is a patient-centered form of counseling using the principles of motivational interviewing. Screening, brief intervention, and referral to treatment has the potential to reduce the burden of substance use in pregnancy and should be integrated into prenatal care.
Collapse
Affiliation(s)
- Tricia E Wright
- Departments of Obstetrics, Gynecology, and Women's Health and of Psychiatry, University of Hawaii John A. Burns School of Medicine, Honolulu, HI.
| | | | - Steven J Ondersma
- Merrill-Palmer Skillman Institute, Departments of Psychiatry and Behavioral Neurosciences, and Obstetrics and Gynecology, Wayne State University, Detroit, MI
| | - Cheryl Boyce
- Division of Clinical Neuroscience and Behavioral Research, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD
| | - Kimberly Yonkers
- Departments of Psychiatry and of Obstetrics and Gynecology, and School of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT
| | - Grace Chang
- Department of Psychiatry, Harvard Medical School, Boston, MA; Department of Psychiatry, Department of Veterans Affairs Boston Healthcare System, Brockton, MA
| | - Andreea A Creanga
- Department of International Health and International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| |
Collapse
|
71
|
When treating pregnant women with opioid use disorder, the benefits of using opioid maintenance treatment outweigh the risks. DRUGS & THERAPY PERSPECTIVES 2016. [DOI: 10.1007/s40267-016-0281-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
72
|
Krans EE, Bogen D, Richardson G, Park SY, Dunn SL, Day N. Factors associated with buprenorphine versus methadone use in pregnancy. Subst Abus 2016; 37:550-557. [PMID: 26914546 DOI: 10.1080/08897077.2016.1146649] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Buprenorphine has recently emerged as a safe and effective treatment option for pregnant women with opioid use disorder (OUD) and is associated with superior neonatal outcomes. This study characterized and compared patient populations who used buprenorphine versus methadone during pregnancy in an academic medical center. METHODS Observational retrospective cohort evaluation of 791 pregnant women with OUD on opioid maintenance treatment from 2009 to 2012. Buprenorphine versus methadone use was defined as use after either (a) conversion from illicit opioid use during pregnancy or (b) ongoing prepregnancy use. Multivariable logistic regression was used to identify patient characteristics predictive of buprenorphine use. RESULTS Among 791 pregnant women, 608 (76.9%) used methadone and 183 (23.1%) used buprenorphine. From 2009 to 2012, buprenorphine use during pregnancy increased from 10.1% to 33.2%. Pregnant women using buprenorphine were significantly more likely to be older, married, employed, have more education, and have a history of prescription opioid use compared with women using methadone. In contrast, pregnant women using methadone were significantly more likely to have hepatitis C virus infection, use cocaine, benzodiazepines, or marijuana, and have a history of heroin and/or intravenous opioid use. In multivariable analysis, pregnant women who were older (odds ratio [OR] = 1.01; 95% confidence interval [CI]: 1.02, 1.11), were employed (1.87; 1.20, 2.90), and had a history of opioid maintenance treatment prior to pregnancy (2.68; 1.78, 4.02) were more likely to use buprenorphine during pregnancy. Pregnant women with a history of benzodiazepine use (0.48; 0.30, 0.77), who had children no longer in their legal custody (0.63; 0.40, 0.99), and who had a partner with a substance use history (0.37; 0.22, 0.63) were less likely to use buprenorphine during pregnancy. CONCLUSIONS Disparities exist among patients who use buprenorphine versus methadone during pregnancy and indicate the need to improve the availability and accessibility of buprenorphine for many pregnant women.
Collapse
Affiliation(s)
- Elizabeth E Krans
- a Department of Obstetrics , Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine , Pittsburgh , Pennsylvania , USA.,b Department of Obstetrics , Gynecology and Reproductive Sciences, Magee-Womens Research Institute , Pittsburgh , Pennsylvania , USA
| | - Debra Bogen
- c Department of Pediatrics , University of Pittsburgh School of Medicine , Pittsburgh , Pennsylvania , USA
| | - Gale Richardson
- d Department of Psychiatry , University of Pittsburgh School of Medicine , Pittsburgh , Pennsylvania , USA
| | - Seo Young Park
- e Department of Medicine , University of Pittsburgh School of Medicine , Pittsburgh , Pennsylvania , USA
| | - Shannon L Dunn
- b Department of Obstetrics , Gynecology and Reproductive Sciences, Magee-Womens Research Institute , Pittsburgh , Pennsylvania , USA
| | - Nancy Day
- d Department of Psychiatry , University of Pittsburgh School of Medicine , Pittsburgh , Pennsylvania , USA
| |
Collapse
|
73
|
Newman A, Davies GA, Dow K, Holmes B, Macdonald J, McKnight S, Newton L. Rooming-in care for infants of opioid-dependent mothers: Implementation and evaluation at a tertiary care hospital. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2015; 61:e555-e561. [PMID: 27035006 PMCID: PMC4677958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
PROBLEM ADDRESSED Infants born to opioid-dependent women are admitted to intensive care units for management of neonatal abstinence syndrome (NAS), serious morbidity, and prevention of mortality; however, the disadvantages of this approach include infants experiencing more severe NAS and exhibiting a greater need for pharmacotherapy owing to the interference with mother-infant bonding. OBJECTIVE OF PROGRAM To implement a rooming-in program to support close uninterrupted contact between opioid-dependent women and their infants in order to decrease the severity of NAS scores, lessen the need for pharmacotherapy, and shorten hospital stays. PROGRAM DESCRIPTION Opioid-dependent pregnant women were assessed antenatally by a multidisciplinary team and provided with education and support. Psychosocial issues were addressed in collaboration with a community program developed to support addicted mothers. The mother-infant dyad was admitted postpartum to a private room and attended by nurses trained in Finnegan scoring. Infants remained with their mothers unless persistently elevated scores made transfer to neonatal intensive care units necessary for initiation of pharmacotherapy. CONCLUSION With the rooming-in program, the proportion of infants requiring pharmacotherapy decreased from 83.3% to 14.3% (P < .001) and the average length of stay decreased from 25 days to 8 days (P < .001). The rooming-in experience was rated favourably by participating mothers.
Collapse
|
74
|
Anand KJS, Campbell-Yeo M. Consequences of prenatal opioid use for newborns. Acta Paediatr 2015; 104:1066-9. [PMID: 26174725 DOI: 10.1111/apa.13121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 05/26/2015] [Accepted: 07/08/2015] [Indexed: 01/20/2023]
Abstract
UNLABELLED One-third of childbearing women take prescription opioids, previously occurring only in 6-7% of pregnant women. Prenatal opioid exposures may cause birth defects, altered brain development and neonatal abstinence syndrome (NAS). NAS incidence increased fourfold and length of stay increased from 13 to 19 days over 10 years (2004-2013), leading to sevenfold increases in NICU days due to NAS. Initial data suggest that recent NAS increases have resulted from increased use of prescription opioids rather than illicit drugs. CONCLUSION Paediatricians will have to manage the consequences of prenatal opioid exposures, as the offspring often have complex medical and social issues associated with these families.
Collapse
Affiliation(s)
- Kanwaljeet J. S. Anand
- Departments of Pediatrics, Anesthesiology, Anatomy & Neurobiology; University of Tennessee Health Science Center; Memphis TN USA
- Pain Neurobiology Lab; UT Neuroscience Institute; Memphis TN USA
| | - Marsha Campbell-Yeo
- School of Nursing and Departments of Pediatrics, Psychology and Neuroscience; Dalhousie University; Halifax NS Canada
- Centre for Pediatric Pain Research; IWK Health Centre; Halifax NS Canada
| |
Collapse
|
75
|
Polak K, Haug NA, Drachenberg HE, Svikis DS. Gender Considerations in Addiction: Implications for Treatment. CURRENT TREATMENT OPTIONS IN PSYCHIATRY 2015; 2:326-338. [PMID: 26413454 PMCID: PMC4578628 DOI: 10.1007/s40501-015-0054-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Kathryn Polak
- Virginia Commonwealth University 806 W. Franklin St., P.O. Box 842018, Richmond, VA 23284 804-477-5091,
| | - Nancy A. Haug
- PGSP-Stanford Psy.D. Consortium, Palo Alto University, The Gronowski Center, 5150 El Camino Real, C-24, Los Altos, CA 94022, 650-961-9300, ext. 3616,
| | | | - Dace S. Svikis
- Professor, Department of Psychology, Deputy Director, Institute for Women’s Health, Virginia Commonwealth University, 806 W. Franklin St., P.O. Box 842018, Richmond, VA 23284
| |
Collapse
|
76
|
Abstract
The rising prevalence of women with opioid addiction in pregnancy necessitates understanding of medical, ethical, and legal considerations on the part of obstetricians. In addition to briefly reviewing the medical care of opioid abuse in pregnancy, we offer a careful consideration of the stigmatization of addiction and resultant medicolegal sequelae. We advocate for improved access to opioid maintenance therapy and social services as a means of improving healthful pregnancy outcomes and decry recent trends in the criminalization of addiction nationwide.
Collapse
|
77
|
Abstract
Opioid misuse during pregnancy is associated with negative outcomes for both mother and fetus due not only to the physiological effects of the drug but also to the associated social, medical and mental health problems that accompany illicit drug use. An interdisciplinary approach to the treatment of opioid use disorder during pregnancy is most effective. Ideally, obstetric and substance use treatment are co-located and ancillary support services are readily available. Medication-assisted treatment with methadone or buprenorphine is intrinsic to evidence-based care for the opioid-using pregnant woman. Women who are not stabilized on an opioid maintenance medication experience high rates of relapse and worse outcomes. Methadone has been the mainstay of maintenance treatment for nearly 50 years, but recent research has found that both methadone and buprenorphine maintenance treatments significantly improve maternal, fetal and neonatal outcomes. Although methadone remains the current standard of care, the field is beginning to move towards buprenorphine maintenance as a first-line treatment for pregnant women with opioid use disorder, because of its greater availability and evidence of better neonatal outcomes than methadone. However, there is some evidence that treatment dropout may be greater with buprenorphine relative to methadone.
Collapse
Affiliation(s)
- Christine M Wilder
- Addiction Sciences Division, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH, 45229, USA. .,Department of Veterans Affairs Medical Center, 3200 Vine Street, Cincinnati, OH, 45220, USA.
| | - Theresa Winhusen
- Addiction Sciences Division, Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH, 45229, USA
| |
Collapse
|
78
|
Krans EE, Cochran G, Bogen DL. Caring for Opioid-dependent Pregnant Women: Prenatal and Postpartum Care Considerations. Clin Obstet Gynecol 2015; 58:370-9. [PMID: 25775440 PMCID: PMC4607033 DOI: 10.1097/grf.0000000000000098] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pregnancy is an opportune time to identify opioid dependence, facilitate conversion to opioid maintenance treatment, and coordinate care with specialists in addiction medicine, behavioral health, and social services. Comprehensive prenatal care for opioid-dependent women involves the evaluation and the management of co-occurring psychiatric disorders, polysubstance use, infectious diseases, social stressors, and counseling regarding the importance of breastfeeding, contraception, and neonatal abstinence syndrome. Although the complex psychiatric, social, and environmental factors faced by this population pose significant challenges to obstetric care providers, the development of strong patient-provider relationships can facilitate the ability to deliver efficient and effective health care during pregnancy.
Collapse
Affiliation(s)
- Elizabeth E Krans
- Departments of *Obstetrics, Gynecology & Reproductive Sciences, Magee-Womens Research Institute ‡Pediatrics †School of Social Work, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | |
Collapse
|
79
|
Kreitinger C, Gutierrez H, Hamidovic A, Schmitt C, Sarangarm P, Rayburn WF, Leeman L, Bakhireva LN. The effect of prenatal alcohol co-exposure on neonatal abstinence syndrome in infants born to mothers in opioid maintenance treatment. J Matern Fetal Neonatal Med 2015; 29:783-8. [PMID: 25758627 DOI: 10.3109/14767058.2015.1018168] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This study examined the effects of prenatal alcohol exposure (PAE) on the incidence and severity of neonatal abstinence syndrome (NAS). STUDY DESIGN For this pilot study, 70 pregnant women on opioid maintenance therapy (OMT) were recruited from a perinatal substance abuse clinic. Subjects were categorized into three study groups based on the timing of alcohol use during pregnancy as assessed by repeated self-reported measures and a comprehensive panel of ethanol biomarkers. NAS outcomes included: duration of hospital stay, the need for pharmacological treatment of NAS, newborn age at the initiation of NAS treatment, duration of treatment and cumulative methadone dose administered. RESULTS The study included a large proportion of ethnic minorities (81.4% Hispanic, 5.7% American Indian), women with less than a high school education (52.2%) and unplanned pregnancy (82.9%). In multivariate analysis, PAE was not associated with NAS outcomes; however, one newborn diagnosed with fetal alcohol syndrome (FAS) demonstrated much more severe NAS compared to other PAE infants. Interestingly, 3rd trimester PAE was associated with a higher prevalence of microcephaly (62.5%) compared to the PAE abstaining group (36.8%; p = 0.08). CONCLUSION In this study, PAE was not associated with NAS severity; however, further examination in a larger study is needed.
Collapse
Affiliation(s)
- Christine Kreitinger
- a Department of Pharmacy Practice and Administrative Sciences , College of Pharmacy and
| | - Hilda Gutierrez
- a Department of Pharmacy Practice and Administrative Sciences , College of Pharmacy and
| | - Ajna Hamidovic
- a Department of Pharmacy Practice and Administrative Sciences , College of Pharmacy and
| | - Cheryl Schmitt
- a Department of Pharmacy Practice and Administrative Sciences , College of Pharmacy and.,b Department of Family and Community Medicine , School of Medicine, University of New Mexico , Albuquerque , NM , USA
| | - Preeyaporn Sarangarm
- c Department of Pharmacy , University of New Mexico Hospital , Albuquerque , NM , USA , and
| | - William F Rayburn
- d Department of Obstetrics and Gynecology , School of Medicine, University of New Mexico , Albuquerque , NM , USA
| | - Lawrence Leeman
- b Department of Family and Community Medicine , School of Medicine, University of New Mexico , Albuquerque , NM , USA .,d Department of Obstetrics and Gynecology , School of Medicine, University of New Mexico , Albuquerque , NM , USA
| | - Ludmila N Bakhireva
- a Department of Pharmacy Practice and Administrative Sciences , College of Pharmacy and.,b Department of Family and Community Medicine , School of Medicine, University of New Mexico , Albuquerque , NM , USA
| |
Collapse
|
80
|
Kouyoumdjian F, Wiwcharuk J, Green S. Optimizing continuity of care throughout incarceration: case and opportunities. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2015; 61:107-e72. [PMID: 25676638 PMCID: PMC4325853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Fiona Kouyoumdjian
- Postdoctoral fellow at the Centre for Research on Inner City Health at St Michael's Hospital in Toronto, Ont, and a family physician at the Hamilton-Wentworth Detention Centre.
| | - Jill Wiwcharuk
- Family physician with the Shelter Health Network in Hamilton, the Maternity Centre of Hamilton, and the Brantford General Emergency Department in Ontario
| | - Samantha Green
- Family physician at St Michael's Hospital and Primary Care Lead at Inner City Health Associates in Toronto
| |
Collapse
|
81
|
Goodman DJ, Milliken CU, Theiler RN, Nordstrom BR, Akerman SC. A Multidisciplinary Approach to the Treatment of Co-occurring Opioid Use Disorder and Posttraumatic Stress Disorder in Pregnancy: A Case Report. J Dual Diagn 2015; 11:248-57. [PMID: 26457976 PMCID: PMC4762276 DOI: 10.1080/15504263.2015.1104484] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Perinatal opioid use disorders negatively impact maternal and neonatal outcomes and are a public health problem of increasing severity. More than half of women with a substance use disorder have a history of posttraumatic stress disorder that, if not adequately addressed, can impede substance use disorder treatment. This case report describes complexities in the treatment of a pregnant woman with opioid use disorder and posttraumatic stress disorder and reviews the psychotherapeutic and pharmacologic approaches available to treat these co-occurring disorders in pregnancy. This case demonstrates the importance of early screening and intervention for co-occurring posttraumatic stress disorder in pregnant women who use substances in a closely coordinated, multidisciplinary approach to improve outcomes for women and their infants.
Collapse
Affiliation(s)
- Daisy J Goodman
- a Department of Obstetrics and Gynecology , Dartmouth-Hitchcock Medical Center and Geisel School of Medicine , Lebanon , New Hampshire , USA
| | - Catherine U Milliken
- b Department of Psychiatry , Geisel School of Medicine at Dartmouth , Lebanon , New Hampshire , USA
| | - Regan N Theiler
- a Department of Obstetrics and Gynecology , Dartmouth-Hitchcock Medical Center and Geisel School of Medicine , Lebanon , New Hampshire , USA
| | - Benjamin R Nordstrom
- b Department of Psychiatry , Geisel School of Medicine at Dartmouth , Lebanon , New Hampshire , USA
| | - Sarah C Akerman
- b Department of Psychiatry , Geisel School of Medicine at Dartmouth , Lebanon , New Hampshire , USA
| |
Collapse
|
82
|
Abstract
Psychosocial and behavioral interventions are used to address substance use and dependence during pregnancy, having particular value when providers and pregnant women are seeking to minimize drug exposures to the fetus. Numerous factors, including difficulty recruiting participants and the ethical challenges to conducting randomized controlled trials with women during pregnancy, have limited research in this area. The existing literature, however, does contain early investigations into the practicality and efficacy of contingency management, motivational support, and cognitive behavioral therapies adapted for pregnant women. This article describes these approaches to treatment, summarizes programmatic examples, and highlights the role nurses may play with this special population.
Collapse
|
83
|
Mozurkewich EL, Rayburn WF. Buprenorphine and methadone for opioid addiction during pregnancy. Obstet Gynecol Clin North Am 2014; 41:241-53. [PMID: 24845488 DOI: 10.1016/j.ogc.2014.02.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Buprenorphine and methadone are opioid-receptor agonists used as opioid substitution therapy during pregnancy to limit exposure of the fetus to cycles of opioid withdrawal and reduce the risk of infectious comorbidities of illicit opioid use. As part of a comprehensive care plan, such therapy may result in improved access to prenatal care, reduced illicit drug use, reduced exposure to infections associated with intravenous drug use, and improved maternal nutrition and infant birth weight. This article describes differences in patient selection between the two drugs, their relative safety during pregnancy, and changes in daily doses as a guide for prescribing clinicians.
Collapse
Affiliation(s)
- Ellen L Mozurkewich
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, MSC 10 5580, 1 University of New Mexico, Albuquerque, NM 87131, USA.
| | - William F Rayburn
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, MSC 10 5580, 1 University of New Mexico, Albuquerque, NM 87131, USA
| |
Collapse
|