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Blandthorn J, Leung L, Loke Y, Lloyd-Jones DM, Thurman R, Bowman E, Bonomo Y. Prescription opioid use in pregnancy. Aust N Z J Obstet Gynaecol 2018; 58:494-498. [PMID: 29744859 DOI: 10.1111/ajo.12823] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 04/02/2018] [Indexed: 01/07/2023]
Abstract
Prescription medications, including opioid analgesics, are increasingly prescribed in Australia and internationally. More women are presenting in pregnancy with prescription opioid use which can potentially cause harm to the mother and fetus. This article outlines the different types of prescription opioids, defines how prescription opioid use disorder presents clinically and suggests a rational clinical approach to assess and manage patients in the context of pregnancy and their infants.
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Affiliation(s)
- Julie Blandthorn
- Women's Alcohol and Drug Service, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Laura Leung
- Pharmacy Department, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Yuan Loke
- Pharmacy Department, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - D Martyn Lloyd-Jones
- Department of Addiction Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Robin Thurman
- Women's Alcohol and Drug Service, Royal Women's Hospital, Melbourne, Victoria, Australia.,Maternal Fetal Medicine subspecialist affiliate, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Ellen Bowman
- Women's Alcohol and Drug Service, Royal Women's Hospital, Melbourne, Victoria, Australia.,Newborn Services, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Yvonne Bonomo
- Women's Alcohol and Drug Service, Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Addiction Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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Bisaga A, Mannelli P, Sullivan MA, Vosburg SK, Compton P, Woody GE, Kosten TR. Antagonists in the medical management of opioid use disorders: Historical and existing treatment strategies. Am J Addict 2018; 27:177-187. [PMID: 29596725 PMCID: PMC5900907 DOI: 10.1111/ajad.12711] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 03/02/2018] [Accepted: 03/03/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Opioid use disorder (OUD) is a chronic condition with potentially severe health and social consequences. Many who develop moderate to severe OUD will repeatedly seek treatment or interact with medical care via emergency department visits or hospitalizations. Thus, there is an urgent need to develop feasible and effective approaches to help persons with OUD achieve and maintain abstinence from opioids. Treatment that includes one of the three FDA-approved medications is an evidence-based strategy to manage OUD. The purpose of this review is to address practices for managing persons with moderate to severe OUD with a focus on opioid withdrawal and naltrexone-based relapse-prevention treatment. METHODS Literature available on PubMed was used to review the evolution of treatment strategies from the 1960s onward to manage opioid withdrawal and initiate treatment with naltrexone. RESULTS Emerging practices for extended-release naltrexone induction include the use of agonist tapers and adjuvant medications. Clinical challenges frequently encountered when initiating this therapy include managing withdrawal and ongoing opioid use during treatment. Clinical factors may inform decisions regarding patient selection and length of naltrexone treatment, such as recent opioid use and patient preferences. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Treatment strategies to manage opioid withdrawal have evolved, but many patients with OUD do not receive medication for the prevention of relapse. Clinical strategies for induction onto extended-release naltrexone are now available and can be safely and effectively implemented in specialty and select primary care settings. (© 2018 The Authors. The American Journal on Addictions Published by Wiley Periodicals, Inc. on behalf of The American Academy of Addiction Psychiatry (AAAP);27:177-187).
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Affiliation(s)
- Adam Bisaga
- Department of PsychiatryColumbia University College of Physicians and SurgeonsNew YorkNew York
| | - Paolo Mannelli
- Department of Psychiatry and Behavioral SciencesDuke University Medical CenterDurhamNorth Carolina
| | - Maria A. Sullivan
- Department of PsychiatryColumbia University College of Physicians and SurgeonsNew YorkNew York
- Alkermes Inc.WalthamMassachusetts
| | | | - Peggy Compton
- Department of Family and Community HealthSchool of NursingUniversity of PennsylvaniaPhiladelphiaPennsylvania
| | - George E. Woody
- Department of PsychiatryPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPennsylvania
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Lynch CD, Prasad MR. Causal Analysis in Evaluating Complex Health Interventions: Identifying the Optimal Treatment for Opioid Abuse in Pregnancy. Paediatr Perinat Epidemiol 2018; 32:223-224. [PMID: 29572908 DOI: 10.1111/ppe.12464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Courtney D Lynch
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH
| | - Mona R Prasad
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH
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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.
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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
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Mattocks KM, Clark R, Weinreb L. Initiation and Engagement with Methadone Treatment among Pregnant and Postpartum Women. Womens Health Issues 2017. [DOI: 10.1016/j.whi.2017.05.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Scott LF, Shieh C, Umoren RA, Conard T. Care Experiences of Women Who Used Opioids and Experienced Fetal or Infant Loss. J Obstet Gynecol Neonatal Nurs 2017; 46:846-856. [PMID: 28950109 DOI: 10.1016/j.jogn.2017.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To explore care experiences of women who used prescription or illicit opioids and experienced fetal or infant loss. DESIGN A qualitative, descriptive design with secondary data analysis. SETTING The Fetal and Infant Mortality Review program in an urban Midwestern county in the United States. PARTICIPANTS Eleven women with histories of prescription or illicit opioid use who experienced fetal or infant loss participated in the semistructured telephone or in-person interview portion of the mortality case review. METHODS We used thematic analysis to analyze interview data. RESULTS Five themes were identified related to the care experiences of participants throughout pregnancy and fetal/infant loss: Frustration and anger related to not being heard, feeling minimalized; Being overwhelmed with attempts to process and understand medical complications and outcomes; Profound sense of grief and coping with loss; Need to understand why and make difficult decisions; and Placing blame and guilt over death. CONCLUSION Our findings suggest that women who use opioids and experience fetal or infant loss have complex care, educational, and emotional needs. In the development of interventions for these women, it is important to address their unique and complex circumstances.
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Brown JD, Goodin AJ, Talbert JC. Rural and Appalachian Disparities in Neonatal Abstinence Syndrome Incidence and Access to Opioid Abuse Treatment. J Rural Health 2017; 34:6-13. [PMID: 28685864 DOI: 10.1111/jrh.12251] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/19/2017] [Accepted: 05/16/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Incidence of neonatal abstinence syndrome (NAS) is increasing due to the rise in opioid use. Rural states like Kentucky have been disproportionally impacted by opioid abuse, and this study determines NAS burden nationally and in Kentucky while quantifying differences in access to care between Appalachian and non-Appalachian counties. METHODS NAS rates were calculated using National (2013) and Kentucky (2008-2014) National Inpatient Sample discharge data. Births were identified using International Classification of Diseases v9 code 779.5 and live birth codes V30.x-V38.x. Counties were classified as rural, micropolitan, or metropolitan using census data. Proximity analysis was conducted via mapping from ZIP code centroid to nearest opioid treatment facility. Distance to treatment facilities was calculated and then compared using nonparametric testing for counties by rural and Appalachian status. RESULTS NAS cases tripled from 2008 to 2014 in Kentucky counties, with a 2013 NAS rate more than double the national NAS rate. Rural and Appalachian counties experienced an NAS increase per 1,000 births that was 2-2.5 times higher than urban/non-Appalachian counties, with a greater number of NAS births overall in Appalachian counties. All opioid treatment facility types were further from rural patients than micropolitan/metropolitan patients (P < .001), as well as further for Appalachians versus non-Appalachians (P < .001, all facility types). CONCLUSIONS NAS burden disparately affects rural and Appalachian Kentucky counties, while treatment options are disproportionately further away for these residents. Policy efforts to increase NAS prevention and encourage opioid abuse treatment uptake in pregnant women should address rural and Appalachian disparities.
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Affiliation(s)
- Joshua D Brown
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida
| | - Amie J Goodin
- Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida
| | - Jeffery C Talbert
- Department of Pharmacy Practice and Science, University of Kentucky, Lexington, Kentucky
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Heller NA, Logan BA, Morrison DG, Paul JA, Brown MS, Hayes MJ. Neonatal abstinence syndrome: Neurobehavior at 6 weeks of age in infants with or without pharmacological treatment for withdrawal. Dev Psychobiol 2017; 59:574-582. [PMID: 28561904 PMCID: PMC5562160 DOI: 10.1002/dev.21532] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 05/09/2017] [Indexed: 01/06/2023]
Abstract
Use and abuse of prescription opioids and concomitant increase in Neonatal Abstinence Syndrome (NAS), a condition that may lead to protracted pharmacological treatment in more than 60% of infants, has tripled since 2000. This study assessed neurobehavioral development using the NICU Network Neurobehavioral Scale in 6-week old infants with prenatal methadone exposure who did (NAS+; n = 23) or did not (NAS-; n = 16) require pharmacological treatment for NAS severity determined by Finnegan Scale. An unexposed, demographically similar group of infants matched for age served as comparison (COMP; n = 21). NAS+, but not NAS- group, had significantly lower scores on the regulation (p < .01) and quality of movement (p < .01) summary scales than the COMP group. The NAS+ and NAS- groups had higher scores on the stress-abstinence scale than the COMP group (p < .05). NAS diagnosis (NAS +) was associated with poorer regulation and quality of movement at 6 weeks of age compared to infants without prenatal methadone exposure from the same demographic.
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Affiliation(s)
- Nicole A Heller
- Department of Psychology, Siena College, Loudonville, New York
| | - Beth A Logan
- Hillman Center for Pediatric Transplantation, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | | | - Jonathan A Paul
- Graduate School of Biomedical Sciences and Engineering, University of Maine, Orono, Maine
| | - Mark S Brown
- Department of Pediatrics, Eastern Maine Medical Center, Bangor, Maine
| | - Marie J Hayes
- Department of Psychology and Graduate School of Biomedical Sciences & Engineering, University of Maine, Orono, Maine
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Jarlenski M, Barry CL, Gollust S, Graves AJ, Kennedy-Hendricks A, Kozhimannil K. Polysubstance Use Among US Women of Reproductive Age Who Use Opioids for Nonmedical Reasons. Am J Public Health 2017. [PMID: 28640680 DOI: 10.2105/ajph.2017.303825] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To determine the prevalence and patterns of polysubstance use among US reproductive-aged women who use opioids for nonmedical purposes. METHODS We used the National Survey of Drug Use and Health (2005-2014) data on female respondents aged 18 to 44 years reporting nonmedical opioid use in the past 30 days (unweighted n = 4498). We categorized patterns of polysubstance use in the past 30 days, including cigarettes, binge drinking, and other legal and illicit substances and reported prevalence adjusted for age, race/ethnicity, and educational attainment. RESULTS Of all women with nonmedical opioid use, 11% reported only opioid use. Polysubstance use was highest in non-Hispanic White women and women with lower educational attainment. The most frequently used other substances among women using opioids nonmedically were cigarettes (56.2% smoked > 5 cigarettes per day), binge drinking (49.7%), and marijuana (32.4%). Polysubstance use was similarly prevalent among pregnant women with nonmedical opioid use. CONCLUSIONS Polysubstance use is highly prevalent among US reproductive-aged women reporting nonmedical opioid use. Public Health Implications. Interventions are needed that address concurrent use of multiple substances.
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Affiliation(s)
- Marian Jarlenski
- Marian Jarlenski is with the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA. Colleen L. Barry and Alene Kennedy-Hendricks are with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Sarah Gollust, Amy J. Graves, and Katy Kozhimannil are with the Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Colleen L Barry
- Marian Jarlenski is with the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA. Colleen L. Barry and Alene Kennedy-Hendricks are with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Sarah Gollust, Amy J. Graves, and Katy Kozhimannil are with the Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Sarah Gollust
- Marian Jarlenski is with the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA. Colleen L. Barry and Alene Kennedy-Hendricks are with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Sarah Gollust, Amy J. Graves, and Katy Kozhimannil are with the Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Amy J Graves
- Marian Jarlenski is with the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA. Colleen L. Barry and Alene Kennedy-Hendricks are with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Sarah Gollust, Amy J. Graves, and Katy Kozhimannil are with the Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Alene Kennedy-Hendricks
- Marian Jarlenski is with the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA. Colleen L. Barry and Alene Kennedy-Hendricks are with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Sarah Gollust, Amy J. Graves, and Katy Kozhimannil are with the Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - Katy Kozhimannil
- Marian Jarlenski is with the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA. Colleen L. Barry and Alene Kennedy-Hendricks are with the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Sarah Gollust, Amy J. Graves, and Katy Kozhimannil are with the Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
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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.
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Acquavita SP, Kauffman SS, Talks A, Sherman K. Pregnant women with substance use disorders: The intersection of history, ethics, and advocacy. SOCIAL WORK IN HEALTH CARE 2016; 55:843-860. [PMID: 27676115 DOI: 10.1080/00981389.2016.1232670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Pregnant women with substance use disorders face many obstacles, including obtaining evidence-based treatment and care. This article (1) briefly reviews the history of pregnant women in clinical trials and substance use disorders treatment research; (2) identifies current ethical issues facing researchers studying pregnant women with substance use disorders; (3) presents and describes an ethical framework to utilize; and (4) identifies future directions needed to develop appropriate research and treatment policies and practices. Current research is not providing enough information to clinicians, policy-makers, and the public about maternal and child health and substance use disorders, and the data will not be sufficient to offer maximum benefit until protocols are changed.
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Affiliation(s)
- Shauna P Acquavita
- a School of Social Work , University of Cincinnati , Cincinnati , Ohio , USA
| | - Sandra S Kauffman
- b Department of Psychology , University of South Florida , Tampa , Florida , USA
| | - Alexandra Talks
- a School of Social Work , University of Cincinnati , Cincinnati , Ohio , USA
| | - Kate Sherman
- a School of Social Work , University of Cincinnati , Cincinnati , Ohio , USA
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Jumah NA, Edwards C, Balfour-Boehm J, Loewen K, Dooley J, Gerber Finn L, Kelly L. Observational study of the safety of buprenorphine+naloxone in pregnancy in a rural and remote population. BMJ Open 2016; 6:e011774. [PMID: 27799240 PMCID: PMC5093362 DOI: 10.1136/bmjopen-2016-011774] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES To describe the effect of in utero exposure to the buprenorphine+naloxone combination product in a rural and remote population. SETTING A district hospital that services rural and remote, fly-in communities in Northwestern Ontario, Canada. PARTICIPANTS A retrospective cohort study was conducted of 855 mother infant dyads between 1 July 2013 and 30 June 2015. Cases included all women who had exposure to buprenorphine+naloxone during pregnancy (n=62). 2 control groups were identified; the first included women with no opioid exposure in pregnancy (n=618) and the second included women with opioid exposure other than buprenorphine+naloxone (n=159). Women were excluded if they had multiple pregnancy or if they were part of a methadone programme (n=16). The majority of women came from Indigenous communities. OUTCOMES The primary outcomes were birth weight, preterm delivery, congenital anomalies and stillbirth. Secondary neonatal outcomes included gestational age at delivery, Apgar scores at 1 and 5 min, NAS Score >7 and treatment for neonatal abstinence syndrome (NAS). Secondary maternal outcomes included the number of caesarean sections, postpartum haemorrhages, out of hospital deliveries and transfer of care to tertiary centres. RESULTS No difference was found in the primary outcomes or in the Apgar score and caesarean section rate between in utero buprenorphine+naloxone exposure versus no opioid exposure in pregnancy. Compared to women taking other opioids, women taking buprenorphine+naloxone had higher birthweight babies (p=0.001) and less exposure to marijuana (p<0.001) during pregnancy. CONCLUSIONS Retrospective data suggest that there likely is no harm from taking buprenorphine+naloxone opioid agonist treatment in pregnancy. Larger, prospective studies are needed to further assess safety.
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Affiliation(s)
- Naana Afua Jumah
- Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | - Craig Edwards
- School of Public Health, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Kassandra Loewen
- Anishinaabe Bimaadiziwin Research Program, Sioux Lookout, Ontario, Canada
| | - Joseph Dooley
- Integrated Pregnancy Program, Sioux Lookout Meno Ya Win Health Centre, Sioux Lookout, Canada
| | - Lianne Gerber Finn
- Integrated Pregnancy Program, Sioux Lookout Meno Ya Win Health Centre, Sioux Lookout, Canada
| | - Len Kelly
- Anishinaabe Bimaadiziwin Research Program, Sioux Lookout, Ontario, Canada
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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]
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Laes JR, Wiegand T. Case Presentations from the Addiction Academy. J Med Toxicol 2016; 12:82-94. [PMID: 26586253 PMCID: PMC4781793 DOI: 10.1007/s13181-015-0520-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
In this article, a case-based format is used to address complex clinical issues in addiction medicine. The cases were developed from the authors' practice experience, and were presented at the American College of Medical Toxicology Addiction Academy in 2015. Section I: Drug and Alcohol Dependence and Pain explores cases of patients with co-occurring pain and substance use disorders. Section II: Legal and Policy Issues in Substance Use Disorders highlights difficult legal and policy questions in addiction medicine. Section III: Special Populations and Addictive Disorders delves into the complexity of addiction in special populations (pregnant, pediatric, and geriatric patients).
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Affiliation(s)
- JoAn R Laes
- Division of Addiction Medicine, Hennepin County Medical Center, 701 Park Avenue, Mail Code G5, Minneapolis, MN, 55415, USA.
| | - Timothy Wiegand
- University of Rochester Medical Center & Strong Memorial Hospital, Rochester, NY, USA
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Washio Y, Cassey H. Systematic Review of Interventions for Racial/Ethnic-Minority Pregnant Smokers. J Smok Cessat 2016; 11:12-27. [PMID: 26925170 PMCID: PMC4764131 DOI: 10.1017/jsc.2014.12] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Large disparities exist in smoking rates during pregnancy by racial/ethnic status. AIMS The current review examined controlled studies that predominantly included racial/ethnic-minority pregnant smokers for providing smoking cessation treatment. METHODS Two authors independently conducted the literature searches in the standard databases using a combination of the keywords with minority, pregnancy, smoking, and cessation identifiers. RESULTS The searches identified nine articles that met the inclusion criteria. Only two studies exclusively targeted specific minority groups. Most of them provided some form of brief smoking cessation counseling, with two combining with incentives and one combining with pharmacotherapy. Two studies provided intensive cognitive interventions. Pregnant smokers of American Indian or Alaska Native, Hispanic subgroups, and Asian or Pacific Islander are under-studied. CONCLUSIONS Future studies to treat minority pregnant smokers could target under-studied minority groups and may need to directly and intensely target smoking behavior, address cultural and psychosocial issues in an individualized and comprehensive manner, and analyze cost-benefit of an intervention.
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Affiliation(s)
- Yukiko Washio
- Treatment Research Institute, Philadelphia PA, 19106, U.S.A
| | - Heather Cassey
- Temple University, Department of Psychological, Organizational, and Leadership Studies, Philadelphia PA, 19122, U.S.A
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Goodman D. Improving Access to Maternity Care for Women with Opioid Use Disorders: Colocation of Midwifery Services at an Addiction Treatment Program. J Midwifery Womens Health 2015; 60:706-12. [DOI: 10.1111/jmwh.12340] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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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.
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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
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Welle-Strand GK, Skurtveit S, Tanum L, Waal H, Bakstad B, Bjarkø L, Ravndal E. Tapering from Methadone or Buprenorphine during Pregnancy: Maternal and Neonatal Outcomes in Norway 1996-2009. Eur Addict Res 2015; 21:253-61. [PMID: 25967268 DOI: 10.1159/000381670] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 03/16/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND The tapering of methadone or buprenorphine during pregnancy is an understudied and controversial issue. The aim of this study was to determine to what extent women tapered their opioid medication dose during pregnancy and what the neonatal outcomes were for those who tapered compared to the women who did not. METHODS The study was a mixed prospective/retrospective national cohort study of 123 Norwegian women in opioid maintenance treatment (OMT) during pregnancy and their neonates. A standardized questionnaire was administered to the women and medical information that could be used for verification was collected from hospitals and municipalities. RESULTS Two of the women came off the OMT-medication during pregnancy and another 15% tapered their OMT-medication dose more than 50%. The birth weights of methadone-exposed neonates of the women who tapered more than 50% were significantly higher than for the methadone-exposed neonates of the women tapering between 11 and 50%. No other significant differences were found. CONCLUSION Pregnant women in OMT who taper their OMT-medication dose should be monitored closely. We need studies that document the maternal well-being and fetal safety of maternal tapering of the OMT-medication during pregnancy.
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Jumah NA, Graves L, Kahan M. The management of opioid dependence during pregnancy in rural and remote settings. CMAJ 2014; 187:E41-E46. [PMID: 25288311 DOI: 10.1503/cmaj.131723] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Affiliation(s)
- Naana Afua Jumah
- Thunder Bay Regional Research Institute, Thunder Bay, Ont., and Department of Obstetrics and Gynaecology (Jumah), University of Toronto, Toronto, Ont.; Department of Family Medicine (Graves), Northern Ontario School of Medicine, Sudbury, Ont.; Department of Family and Community Medicine, University of Toronto, and Substance Use Service, Women's College Hospital (Kahan), Toronto, Ont.
| | - Lisa Graves
- Thunder Bay Regional Research Institute, Thunder Bay, Ont., and Department of Obstetrics and Gynaecology (Jumah), University of Toronto, Toronto, Ont.; Department of Family Medicine (Graves), Northern Ontario School of Medicine, Sudbury, Ont.; Department of Family and Community Medicine, University of Toronto, and Substance Use Service, Women's College Hospital (Kahan), Toronto, Ont
| | - Meldon Kahan
- Thunder Bay Regional Research Institute, Thunder Bay, Ont., and Department of Obstetrics and Gynaecology (Jumah), University of Toronto, Toronto, Ont.; Department of Family Medicine (Graves), Northern Ontario School of Medicine, Sudbury, Ont.; Department of Family and Community Medicine, University of Toronto, and Substance Use Service, Women's College Hospital (Kahan), Toronto, Ont
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72
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Pritham UA, McKay L. Safe management of chronic pain in pregnancy in an era of opioid misuse and abuse. J Obstet Gynecol Neonatal Nurs 2014; 43:554-567. [PMID: 25123962 DOI: 10.1111/1552-6909.12487] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2014] [Indexed: 01/17/2023] Open
Abstract
Safe and effective management of chronic pain in pregnancy is challenging. Use of over-the-counter analgesics, opioids, opioid substitution therapies, complementary and alternative therapies, antidepressants, and anxiolytics each have benefits and risks for the mother and neonate that must be considered. Because of their potency, opioids are often used despite associated risks for adverse effects, abuse, diversion, and addiction. Development of a pain management protocol for the counsel and care of pregnant women with pain is necessary.
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Abstract
The treatment of opioid dependence during pregnancy has historically consisted of either medication-assisted withdrawal or maintenance treatment with methadone. Buprenorphine maintenance treatment is emerging as a treatment during pregnancy with distinct benefits for the neonate and the pregnant woman. Buprenorphine is effective in decreasing the risk of relapse in pregnant women. In addition, prenatal use of buprenorphine appears to decrease the severity and duration of neonatal abstinence syndrome as compared with methadone maintenance. Management of buprenorphine includes initiation and maintenance treatment as well as careful planning for pain control during and after delivery and prevention of postpartum relapse risk. Only very small amounts of buprenorphine enter breast milk, making it a good option for those who elect to breast-feed. There is evidence that emerging collaborative care models are effective ways to deliver buprenorphine maintenance treatment, although more investigation is needed to generalize this to the obstetric setting.
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74
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Prenatal and Postpartum Care of Women with Substance Use Disorders. Obstet Gynecol Clin North Am 2014; 41:213-28. [DOI: 10.1016/j.ogc.2014.02.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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75
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Pace CA, Kaminetzky LB, Winter M, Cheng DM, Saia K, Samet JH, Walley AY. Postpartum changes in methadone maintenance dose. J Subst Abuse Treat 2014; 47:229-32. [PMID: 24953167 DOI: 10.1016/j.jsat.2014.04.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 04/17/2014] [Accepted: 04/22/2014] [Indexed: 11/28/2022]
Abstract
The optimal approach to postpartum dosing among women treated with methadone maintenance is unclear. We examined doses among 101 methadone-maintained pregnant women 2, 6 and 12 weeks postpartum, and compared the incidence of having doses held for oversedation during pregnancy and postpartum. The average dose at delivery was 83.3mg, and the mean change from delivery to 12 weeks postpartum was -3.7 mg (95% CI -6.3, -1.1). The incidence of oversedation events per 10,000 days was 2.8 among pregnant women and 5.6 for postpartum women (incidence rate ratio [IRR] 2.04, 95% CI 0.66, 6.28). After adjusting for benzodiazepine prescriptions, the IRR of an oversedation event among postpartum women compared to pregnant women was 1.74 (95% CI 0.56, 5.30). In conclusion, postpartum dose changes were small in a methadone clinic using clinical assessments to determine dose. Although the incidence of oversedation events remained low postpartum, the clinically important but not statistically significant increase in events among postpartum women and those prescribed benzodiazepines requires further research. While there are not yet adequate data to support pre-specified postpartum dose reductions, the findings suggest that more frequent clinical assessments continuing as late as 12 weeks postpartum may be warranted.
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Affiliation(s)
- Christine A Pace
- Clinical Addictions Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118.
| | - Leah B Kaminetzky
- Boston University School of Medicine, 72 East Concord Street, Boston, MA 02118
| | - Michael Winter
- Data Coordinating Center, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118
| | - Debbie M Cheng
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118
| | - Kelley Saia
- Department of Obstetrics and Gynecology, Boston Medical Center, 850 Harrison Avenue, Boston, MA 02118
| | - Jeffrey H Samet
- Clinical Addictions Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118
| | - Alexander Y Walley
- Clinical Addictions Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118
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Gawronski KM, Prasad MR, Backes CR, Lehman KJ, Gardner DK, Cordero L. Neonatal outcomes following in utero exposure to buprenorphine/naloxone or methadone. SAGE Open Med 2014; 2:2050312114530282. [PMID: 26770721 PMCID: PMC4607220 DOI: 10.1177/2050312114530282] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 03/12/2014] [Indexed: 01/06/2023] Open
Abstract
Objectives: To study neonatal outcomes following buprenorphine/naloxone and methadone exposure during pregnancy. Methods: This study is a retrospective review of clinical and demographic information of 58 infants whose mothers were treated with buprenorphine/naloxone and 92 infants whose mothers were treated with methadone for opioid dependence during pregnancy. Results: Gestational age, birth weight, prematurity, admission to neonatal intensive care unit, and length of stay were similar between both groups of infants. Neonatal abstinence syndrome occurred less frequently among infants of mothers treated with buprenorphine/naloxone than those treated with methadone (64% and 80%, respectively, p = 0.03). All infants with neonatal abstinence syndrome were treated postnatally with methadone. There was a trend toward shorter duration of treatment and lower cumulative dosages of methadone among the buprenorphine/naloxone–exposed infants. Conclusions: No apparent significant adverse neonatal outcomes were detected following treatment with either maintenance medication; however, further prospective research is necessary to examine the safety and efficacy of buprenorphine/naloxone in pregnancy and its effects on the neonate.
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Affiliation(s)
| | - Mona R Prasad
- Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Carl R Backes
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - K Joy Lehman
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Debra K Gardner
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Leandro Cordero
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Clinical care for opioid-using pregnant and postpartum women: the role of obstetric providers. Am J Obstet Gynecol 2014; 210:302-310. [PMID: 24120973 DOI: 10.1016/j.ajog.2013.10.010] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 10/04/2013] [Accepted: 10/08/2013] [Indexed: 01/06/2023]
Abstract
We review clinical care issues that are related to illicit and therapeutic opioid use among pregnant women and women in the postpartum period and outline the major responsibilities of obstetrics providers who care for these patients during the antepartum, intrapartum, and postpartum periods. Selected patient treatment issues are highlighted, and case examples are provided. Securing a strong rapport and trust with these patients is crucial for success in delivering high-quality obstetric care and in coordinating services with other specialists as needed. Obstetrics providers have an ethical obligation to screen, assess, and provide brief interventions and referral to specialized treatment for patients with drug use disorders. Opioid-dependent pregnant women often can be treated effectively with methadone or buprenorphine. These medications are classified as pregnancy category C medications by the Food and Drug Administration, and their use in the treatment of opioid-dependent pregnant patients should not be considered "off-label." Except in rare special circumstances, medication-assisted withdrawal during pregnancy should be discouraged because of a high relapse rate. Acute pain management in this population deserves special consideration because patients who use opioids can be hypersensitive to pain and because the use of mixed opioid-agonist/antagonists can precipitate opioid withdrawal. In the absence of other indications, pregnant women who use opioids do not require more intense medical care than other pregnant patients to ensure adequate treatment and the best possible outcomes. Together with specialists in pain and addiction medicine, obstetricians can coordinate comprehensive care for pregnant women who use opioids and women who use opioids in the postpartum period.
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Madgula RM, Groshkova T, Mayet S. Illicit drug use in pregnancy: effects and management. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/eog.10.54] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Minozzi S, Amato L, Bellisario C, Ferri M, Davoli M. Maintenance agonist treatments for opiate-dependent pregnant women. Cochrane Database Syst Rev 2013:CD006318. [PMID: 24366859 DOI: 10.1002/14651858.cd006318.pub3] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The prevalence of opiate use among pregnant women can range from 1% to 2% to as high as 21%. Heroin crosses the placenta and pregnant, opiate-dependent women experience a six-fold increase in maternal obstetric complications such as low birth weight, toxaemia, third trimester bleeding, malpresentation, puerperal morbidity, fetal distress and meconium aspiration. Neonatal complications include narcotic withdrawal, postnatal growth deficiency, microcephaly, neuro-behavioural problems, increased neonatal mortality and a 74-fold increase in sudden infant death syndrome. OBJECTIVES To assess the effectiveness of any maintenance treatment alone or in combination with psychosocial intervention compared to no intervention, other pharmacological intervention or psychosocial interventions for child health status, neonatal mortality, retaining pregnant women in treatment and reducing the use of substances. SEARCH METHODS We searched the Cochrane Drugs and Alcohol Group Trials Register (September 2013), PubMed (1966 to September 2013), CINAHL (1982 to September 2013), reference lists of relevant papers, sources of ongoing trials, conference proceedings and national focal points for drug research. We contacted authors of included studies and experts in the field. SELECTION CRITERIA Randomised controlled trials assessing the efficacy of any maintenance pharmacological treatment for opiate-dependent pregnant women. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS We found four trials with 271 pregnant women. Three compared methadone with buprenorphine and one methadone with oral slow-release morphine. Three out of four studies had adequate allocation concealment and were double-blind. The major flaw in the included studies was attrition bias: three out of four had a high drop-out rate (30% to 40%) and this was unbalanced between groups.Methadone versus buprenorphine: the drop-out rate from treatment was lower in the methadone group (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.41 to 1.01, three studies, 223 participants). There was no statistically significant difference in the use of primary substance between methadone and buprenorphine (RR 1.81, 95% CI 0.70 to 4.69, two studies, 151 participants). For both, we judged the quality of evidence as low. Birth weight was higher in the buprenorphine group in the two trials that could be pooled (mean difference (MD) -365.45 g (95% CI -673.84 to -57.07), two studies, 150 participants). The third study reported that there was no statistically significant difference. For APGAR score neither of the studies which compared methadone with buprenorphine found a significant difference. For both, we judged the quality of evidence as low. Many measures were used in the studies to assess neonatal abstinence syndrome. The number of newborns treated for neonatal abstinence syndrome, which is the most critical outcome, did not differ significantly between groups. We judged the quality of evidence as very low.Methadone versus slow-release morphine: there was no drop-out in either treatment group. Oral slow-release morphine seemed superior to methadone for abstinence from heroin use during pregnancy (RR 2.40, 95% CI 1.00 to 5.77, one study, 48 participants). We judged the quality of evidence as moderate.Only one study which compared methadone with buprenorphine reported side effects. For the mother there was no statistically significant difference; for the newborns in the buprenorphine group there were significantly fewer serious side effects.In the comparison between methadone and slow-release morphine no side effects were reported for the mother, whereas one child in the methadone group had central apnoea and one child in the morphine group had obstructive apnoea. AUTHORS' CONCLUSIONS We did not find sufficient significant differences between methadone and buprenorphine or slow-release morphineto allow us to conclude that one treatment is superior to another for all relevant outcomes. While methadone seems superior in terms of retaining patients in treatment, buprenorphine seems to lead to less severe neonatal abstinence syndrome. Additionally, even though a multi-centre, international trial with 175 pregnant women has recently been completed and its results published and included in this review, the body of evidence is still too small to draw firm conclusions about the equivalence of the treatments compared. There is still a need for randomised controlled trials of adequate sample size comparing different maintenance treatments.
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Affiliation(s)
- Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Via di Santa Costanza, 53, Rome, Italy, 00198
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Abstract
Many mothers are inappropriately advised to discontinue breastfeeding or avoid taking essential medications because of fears of adverse effects on their infants. This cautious approach may be unnecessary in many cases, because only a small proportion of medications are contraindicated in breastfeeding mothers or associated with adverse effects on their infants. Information to inform physicians about the extent of excretion for a particular drug into human milk is needed but may not be available. Previous statements on this topic from the American Academy of Pediatrics provided physicians with data concerning the known excretion of specific medications into breast milk. More current and comprehensive information is now available on the Internet, as well as an application for mobile devices, at LactMed (http://toxnet.nlm.nih.gov). Therefore, with the exception of radioactive compounds requiring temporary cessation of breastfeeding, the reader will be referred to LactMed to obtain the most current data on an individual medication. This report discusses several topics of interest surrounding lactation, such as the use of psychotropic therapies, drugs to treat substance abuse, narcotics, galactagogues, and herbal products, as well as immunization of breastfeeding women. A discussion regarding the global implications of maternal medications and lactation in the developing world is beyond the scope of this report. The World Health Organization offers several programs and resources that address the importance of breastfeeding (see http://www.who.int/topics/breastfeeding/en/).
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Abstract
Pregnancy in opioid users poses a number of problems to treating physicians. Most guidelines recommend maintenance treatment to manage opioid addiction in pregnancy, with methadone being the gold standard. More recently, buprenorphine has been discussed as an alternate medication. The use and efficacy of buprenorphine in pregnancy is still controversial. This article reviews the current database on the basis of a detailed and critical literature search performed in MEDLINE (206 counts). Most of the relevant studies (randomised clinical trials and one national cohort sample) were published in the last 2 years and mainly compared buprenorphine with methadone. Some studies are related to maternal outcomes, others to foetal, neonatal or older child outcomes. With respect to maternal outcomes, most studies suggest that buprenorphine has similar effects to methadone. Very few data from small studies discuss an effect of buprenorphine on neurodevelopment of the foetus. Neonatal abstinence syndrome is common in infants of both buprenorphine- and methadone-maintained mothers. As regards neonatal outcomes, buprenorphine has the same clinical outcome as methadone, although some newer studies suggest that it causes fewer withdrawal symptoms. Since hardly any studies have investigated the combination of buprenorphine with naloxone (which has been suggested to possibly have teratogenic effects) in pregnant women, a switch to buprenorphine monotherapy is recommended in women who become pregnant while receiving the combination product. These novel findings indicate that buprenorphine is emerging as a first-line treatment for pregnant opioid users.
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Epstein RA, Bobo WV, Martin PR, Morrow JA, Wang W, Chandrasekhar R, Cooper WO. Increasing pregnancy-related use of prescribed opioid analgesics. Ann Epidemiol 2013; 23:498-503. [PMID: 23889859 PMCID: PMC3888316 DOI: 10.1016/j.annepidem.2013.05.017] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 05/29/2013] [Accepted: 05/29/2013] [Indexed: 01/06/2023]
Abstract
PURPOSE To quantify the prevalence of prescribed opioid analgesics among pregnant women enrolled in Tennessee Medicaid from 1995 to 2009. METHODS Retrospective cohort study of 277,555 pregnancies identified from birth and fetal death certificates, and linked to previously validated, computerized pharmacy records. Poisson regression was used to estimate trends over time, rate ratios, and 95% confidence intervals (CI). RESULTS During the study period, 29% of pregnant women filled a prescription for an opioid analgesic. From 1995 to 2009, any pregnancy-related use increased 1.90-fold (95% CI, 1.83-1.98), first trimester use increased 2.27-fold (95% CI, 2.14-2.41), and second or third trimester use increased 2.02-fold (95% CI, 1.93-2.12), after adjusting for maternal characteristics. Any pregnancy-related, first trimester, and second or third trimester use were each more likely among mothers who were at least 21 years old, white, non-Hispanic, prima gravid, resided in nonurban areas, enrolled in Medicaid owing to disability, and who had less than a high school education. CONCLUSIONS Opioid analgesic use by Tennessee Medicaid-insured pregnant women increased nearly 2-fold from 1995 to 2009. Additional study is warranted to understand the implications of this increased use.
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Affiliation(s)
- Richard A Epstein
- Department of Psychiatry, Vanderbilt University, Nashville, TN 37212, USA.
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83
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Psychosocial characteristics and poly-drug use of pregnant women enrolled in methadone maintenance treatment. Neurotoxicol Teratol 2013; 38:46-52. [DOI: 10.1016/j.ntt.2013.04.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 04/17/2013] [Accepted: 04/17/2013] [Indexed: 01/06/2023]
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Kraus ML, Alford DP, Kotz MM, Levounis P, Mandell TW, Meyer M, Salsitz EA, Wetterau N, Wyatt SA. Statement of the American Society Of Addiction Medicine Consensus Panel on the use of buprenorphine in office-based treatment of opioid addiction. J Addict Med 2013; 5:254-63. [PMID: 22042215 DOI: 10.1097/adm.0b013e3182312983] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Opioid addiction affects over 2 million patients in the United States. The advent of buprenorphine and the passage of the Drug Addiction Treatment Act in 2000 have revolutionized the opioid treatment delivery system by granting physicians the ability to administer office-based opioid treatment (OBOT), thereby giving patients greater access to treatment. The purpose of this consensus panel was to synthesize the most current evidence on the use of buprenorphine in the office-based setting and to make recommendations that will enable and allow additional physicians to begin to treat opioid-addicted individuals. METHODS Literature published from 2000 to 2009 was searched using the PubMed search engine and yielded over 375 articles published in peer-reviewed journals, including some that were published guidelines. These articles were submitted to a consensus panel composed of researchers, educators, and clinicians who are leaders in the field of addiction medicine with specific expertise in the use of OBOT. The panel discussed results and agreed upon consensus recommendations for several facets of OBOT. RESULTS : On the basis of the literature review and consensus discussions, the panel developed a series of findings, conclusions, and recommendations regarding the use of buprenorphine in office-based treatment of opioid addiction. CONCLUSIONS Therapeutic outcomes for patients who self-select office-based treatment with buprenorphine are essentially comparable to those seen in patients treated with methadone programs. There are few absolute contraindications to the use of buprenorphine, although the experience and skill levels of treating physicians can vary considerably, as can access to the resources needed to treat comorbid medical or psychiatric conditions--all of which affect outcomes. It is important to conduct a targeted assessment of every patient to confirm that the provider has resources available to meet the patient's needs. Patients should be assessed for a broad array of biopsychosocial needs in addition to opioid use and addiction, and should be treated, referred, or both for help in meeting all their care needs, including medical care, psychiatric care, and social assistance. Current literature demonstrates promising efficacy of buprenorphine, though further research will continue to demonstrate its effectiveness for special populations, such as adolescents, pregnant women, and other vulnerable populations. Since the time of this review, several new studies have provided new data to continue to improve our understanding of the safety and efficacy of buprenorphine for special patient populations.
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Affiliation(s)
- Mark L Kraus
- Yale University School of Medicine, New Haven, USA.
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Development of a substance abuse program for opioid-dependent nonurban pregnant women improves outcome. J Addict Med 2013; 6:124-30. [PMID: 22517450 DOI: 10.1097/adm.0b013e3182541933] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The goal of this study was to determine whether improved access to medication assisted therapy in the general population, with improved coordination of ancillary services for pregnant women, improved perinatal outcomes in a nonurban area. METHODS The cohort of women treated for opioid dependence during pregnancy with medication-assisted therapy and delivered at a single institution between 2000 and 2006 were retrospectively identified (n = 149 women; n = 151 neonates). Access to opioid agonist therapy for the general population was determined as the combined number of available treatment positions for medication-assisted therapy. Treatment during pregnancy (interim substitution therapy vs opioid treatment program) and pregnancy outcomes were noted from chart review. The primary outcome of trend of prenatal care indices and newborn birth weight over time was determined by Kendall's tau. RESULTS As access to treatment in the general population expanded from 2000 to 2006, the number of women receiving treatment increased, the proportion of women receiving interim substitution therapy decreased (P < 0.001), gestational age at the initiation of treatment decreased (P < 0.001), and the proportion of women receiving treatment before pregnancy increased (P < 0.001). Infants delivered to mothers in a treatment program had improved birth weight z score compared with those receiving interim substitution therapy (P = 0.007). The proportion of infants discharged to the care of the mother and remaining in maternal care at 1 year improved both over time (P = 0.03; P = 0.004) and with treatment within a treatment program (P < 0.001; P = 0.004). CONCLUSIONS Improved access to opioid agonist treatment programs for the general population in nonurban areas improves perinatal outcome and retention of maternal guardianship.
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Terplan M, Smith EJ, Glavin SH. Trends in injection drug use among pregnant women admitted into drug treatment: 1994-2006. J Womens Health (Larchmt) 2013; 19:499-505. [PMID: 20136556 DOI: 10.1089/jwh.2009.1562] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE To describe trends in the regional and demographic characteristics of injection drug use (IDU) during pregnancy. METHODS Data were obtained from the Treatment Episode Data Set (TEDS), an administrative data set that captures admissions to federally funded treatment centers in the United States. Demographic and treatment-related measures were examined and compared between injection drug and noninjection drug admissions. The results were stratified by year of admission to assess trends over time. RESULTS From 1994 to 2006, there were 239,511 admissions of pregnant women, of whom 34,717 (14.4%) reported IDU. There was little change in the proportion of injecting from year to year. Compared with admissions of noninjecting pregnant women, a greater proportion of injection drug users were white (68.5 vs. 48.6%), reported heroin use (70.0% vs. 13.2%), and had no health insurance (48.2% vs. 40.2%). Over the time period, the proportion of injection drug users was seen to spread from the West to the South and Northeast for heroin and to the Midwest for amphetamines. CONCLUSIONS IDU among pregnant women in drug treatment remains a significant public health issue, especially among white women.
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Affiliation(s)
- Mishka Terplan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland, Baltimore, Maryland, USA.
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Winklbaur-Hausknost B, Jagsch R, Graf-Rohrmeister K, Unger A, Baewert A, Langer M, Thau K, Fischer G. Lessons learned from a comparison of evidence-based research in pregnant opioid-dependent women. Hum Psychopharmacol 2013; 28:15-24. [PMID: 23161599 DOI: 10.1002/hup.2275] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Revised: 08/03/2012] [Accepted: 09/23/2012] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Lessons learned in research and treatment of opioid dependence demonstrate the need to include pregnant women in clinical trials. METHODS Two double-blind, double-dummy, randomized controlled trials (Pilot study, European sample(†) of MOTHER-trial) comparing buprenorphine and methadone in opioid-dependent pregnant women were conducted. In both studies, participants received voucher-based incentives for attendance and completion of study assessments. In the MOTHER trial, participants additionally received escalating voucher incentives for drug-free urine samples. Neonatal abstinence syndrome was treated with oral morphine solution based on standardized modified Finnegan scores. RESULTS After a mean treatment period of 13.79 weeks in the Pilot study (PS, n = 18) and 20.78 weeks in the MOTHER-trial (MT, n = 41), respectively (p < 0.001), PS patients delivered at mean doses of 14.00 mg buprenorphine/52.50 mg methadone and MT participants at 13.44 mg buprenorphine/63.68 mg methadone. Nonsignificant differences regarding dropout rates were found (22% in PS versus 10% in MT), but dropout was significantly earlier in the MT (p = 0.013). Significantly higher rates of concomitant consumption of opioids and benzodiazepines occurred in the PS compared with the MT (p < 0.001), however, with no significant differences in neonatal data between both settings. CONCLUSIONS Early treatment enrolment combined with contingency management contributes to reduced illicit drug use throughout pregnancy, surprisingly without influencing neonatal outcome parameters.
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Welle-Strand GK, Skurtveit S, Jones HE, Waal H, Bakstad B, Bjarkø L, Ravndal E. Neonatal outcomes following in utero exposure to methadone or buprenorphine: a National Cohort Study of opioid-agonist treatment of Pregnant Women in Norway from 1996 to 2009. Drug Alcohol Depend 2013; 127:200-6. [PMID: 22841456 DOI: 10.1016/j.drugalcdep.2012.07.001] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 06/27/2012] [Accepted: 07/04/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND In Norway, most opioid-dependent women are in opioid maintenance treatment (OMT) with either methadone or buprenorphine throughout pregnancy. The inclusion criteria for both medications are the same and both medications are provided by the same health professionals in any part of the country. International studies comparing methadone and buprenorphine in pregnancy have shown differing neonatal outcomes for the two medications. METHOD This study compared the neonatal outcomes following prenatal exposure to either methadone or buprenorphine in a national clinical cohort of 139 women/neonates from 1996 to 2009. RESULTS After adjusting for relevant covariates, buprenorphine-exposed newborns had larger head circumferences and tended to be heavier and longer than methadone-exposed newborns. The incidence of neonatal abstinence syndrome (NAS) and length of treatment of NAS did not differ between methadone- and buprenorphine-exposed newborns. There was little use of illegal drugs and benzodiazepines during the pregnancies. However, the use of any drugs or benzodiazepines during pregnancy was associated with longer lasting NAS-treatment of the neonates. CONCLUSIONS The clinical relevance of these findings is that both methadone and buprenorphine are acceptable medications for the use in pregnancy, in line with previous studies. If starting OMT in pregnancy, buprenorphine should be considered as the drug of choice, due to more favorable neonatal growth parameters. Early confirmation of the pregnancy and systematic follow-up throughout the pregnancy are of importance to encourage the women in OMT to abstain from the use of tobacco, alcohol, illegal drugs or misuse of prescribed drugs.
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89
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Janssen PA, Demorest LC, Kelly A, Thiessen P, Abrahams R. Auricular acupuncture for chemically dependent pregnant women: a randomized controlled trial of the NADA protocol. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2012; 7:48. [PMID: 23259913 PMCID: PMC3562266 DOI: 10.1186/1747-597x-7-48] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 12/10/2012] [Indexed: 01/06/2023]
Abstract
Background The prevalence of maternal drug use during pregnancy in North America has been estimated to be as high as 6-10%. The consequences for the newborn include increased risk for perinatal mortality and ongoing physical, neurobehavioral, and psychosocial problems. Methadone is frequently used to wean women off street drugs but is implicated as a cause of adverse fetal/neonatal outcomes itself. The purpose of our study was to test the ability of maternal acupuncture treatment among mothers who use illicit drugs to reduce the frequency and severity of withdrawal symptoms among their newborns. Methods We randomly assigned chemically dependent pregnant women at BC Women’s Hospital in Vancouver, British Columbia to daily acupuncture treatments versus usual care. By necessity, neither our participants nor acupuncturists were blinded as to treatment allocation. Our primary outcome was days of neonatal morphine treatment for symptoms of neonatal withdrawal. Secondary neonatal outcomes included admission to a neonatal ICU and transfer to foster care. Results We randomized 50 women to acupuncture and 39 to standard care. When analyzed by randomized groups, we did not find benefit of acupuncture; the average length of treatment with morphine for newborns in the acupuncture group was 2.7 (6.3) compared to 2.8 (7.0) in the control group. Among newborns of women who were compliant with the acupuncture regime, we observed a reduction of 2.1 and 1.5 days in length of treatment for neonatal abstinence syndrome compared to the non-compliant and control groups, respectively. These differences were not statistically significant. Conclusions Acupuncture may be a safe and feasible treatment to assist mothers to reduce their dosage of methadone. Our results should encourage ongoing studies to test the ability of acupuncture to mitigate the severity of neonatal abstinence syndrome among their newborns. Clinical Trial Registration http://www.clinicaltrials.gov registry: W05-0041
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Affiliation(s)
- Patricia A Janssen
- School of Population and Public Health, Child and Family Research Institute, University of British Columbia, 2206 East Mall, Vancouver, BC, Canada V6T-1Z3.
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Coyle MG, Salisbury AL, Lester BM, Jones HE, Lin H, Graf-Rohrmeister K, Fischer G. Neonatal neurobehavior effects following buprenorphine versus methadone exposure. Addiction 2012; 107 Suppl 1:63-73. [PMID: 23106928 PMCID: PMC4337995 DOI: 10.1111/j.1360-0443.2012.04040.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
AIM To determine the effects of in utero exposure to methadone or buprenorphine on infant neurobehavior. DESIGN Three sites from the Maternal Opioid Treatment: Human Experimental Research (MOTHER) study, a double-blind, double-dummy, randomized clinical trial participated in this substudy. SETTING Medical Centers that provided comprehensive maternal care to opioid-dependent pregnant women in Baltimore, MD, Providence, RI and Vienna, Austria. PARTICIPANTS Thirty-nine full-term infants. MEASUREMENTS The Neonatal Intensive Care Unit (NICU) Network Neurobehavioral Scale (NNNS) was administered to a subgroup of infants on postpartum days 3, 5, 7, 10, 14-15 and 28-30. FINDINGS While neurobehavior improved for both medication conditions over time, infants exposed in utero to buprenorphine exhibited fewer stress-abstinence signs (P < 0.001), were less excitable (P < 0.001) and less over-aroused (P < 0.01), exhibited less hypertonia (P < 0.007), had better self-regulation (P < 0.04) and required less handling (P < 0.001) to maintain a quiet alert state relative to in utero methadone-exposed infants. Infants who were older when they began morphine treatment for withdrawal had higher self-regulation scores (P < 0.01), and demonstrated the least amount of excitability (P < 0.02) and hypertonia (P < 0.02) on average. Quality of movement was correlated negatively with peak NAS score (P < 0.01), number of days treated with morphine for NAS (P < 0.01) and total amount of morphine received (P < 0.03). Excitability scores were related positively to total morphine dose (P < 0.03). CONCLUSION While neurobehavior improves during the first month of postnatal life for in utero agonist medication-exposed neonates, buprenorphine exposure results in superior neurobehavioral scores and less severe withdrawal than does methadone exposure.
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Affiliation(s)
- Mara G. Coyle
- Department of Pediatrics; The Warren Alpert Medical School of Brown University; Providence; RI; USA
| | | | | | | | - Hai Lin
- Department of Pediatrics; The Warren Alpert Medical School of Brown University; Providence; RI; USA
| | | | - Gabriele Fischer
- Addiction Clinic; Department of Psychiatry and Psychotherapy; Medical University of Vienna, Vienna Austria, Center of Public Health; Vienna; Austria
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91
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Abstract
PURPOSE OF REVIEW This article addresses the question of 'best treatment options', which clinicians face when treating pregnant women with alcohol and opioid dependence. RECENT FINDINGS Studies show that alcohol consumption is associated with fetal abnormalities and long-term cognitive problems depending on the amount consumed, drinking pattern, and time of gestation. Screening and evaluation of specific interventions are important to reduce alcohol consumption during pregnancy and associated problems in infants. Opioid detoxification is only recommended beyond the first trimester and only in those pregnant women who refuse opioid maintenance therapy. Methadone is the most established treatment of pregnant opioid-dependent women, though recent results indicate some advantages of buprenorphine, slow-release oral methadone and diamorphine compared with methadone. SUMMARY Benzodiazepines seem to be the most recommendable option for managing alcohol withdrawal, and psychosocial interventions succeed in reducing alcohol consumption or in maintaining abstinence in alcohol-dependent pregnant women. Regarding opioid dependence, current results suggest that factors like the health status of the mother, the need for additional medications (e.g. treatment for HIV), comorbid drug dependence, and concurrent drug use need to be considered in order to find the 'best opioid substitute'.
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92
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Benningfield MM, Dietrich MS, Jones HE, Kaltenbach K, Heil SH, Stine SM, Coyle MG, Arria AM, O’Grady KE, Fischer G, Martin PR. Opioid dependence during pregnancy: relationships of anxiety and depression symptoms to treatment outcomes. Addiction 2012; 107 Suppl 1:74-82. [PMID: 23106929 PMCID: PMC4315620 DOI: 10.1111/j.1360-0443.2012.04041.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
AIMS To examine the relationship of anxiety and depression symptoms with treatment outcomes (treatment discontinuation, rates of ongoing use of illicit drugs and likelihood of preterm delivery) in opioid-dependent pregnant women and describe their use of psychotropic medications. DESIGN AND SETTING Secondary data analysis from a randomized clinical trial of treatment for opioid dependence during pregnancy. PARTICIPANTS A total of 175 opioid-dependent pregnant women, of whom 131 completed treatment. MEASUREMENTS Symptoms of anxiety and depression were captured with the 15-item Mini International Neuropsychiatric Interview (MINI) screen. Use of illicit drugs was measured by urine drug screening. Preterm delivery was defined as delivery prior to 37 weeks' gestation. Self-reported use of concomitant psychotropic medication at any point during the study was recorded. FINDINGS Women reporting only anxiety symptoms at study entry were more likely to discontinue treatment [adjusted odds ratio (OR) = 4.56, 95% confidence interval (CI) : 1.91-13.26, P = 0.012], while those reporting only depression symptoms were less likely to discontinue treatment (adjusted OR = 0.14, 95% CI : 0.20-0.88, P = 0.036) compared to women who reported neither depression nor anxiety symptoms. No statistically significant between-group differences were observed for ongoing illicit drug use or preterm delivery. A majority (61.4%) of women reported use of concomitant psychotropic medication at some point during study participation. CONCLUSIONS Opioid agonist-treated pregnant patients with co-occurring symptoms of anxiety require additional clinical resources to prevent premature discontinuation.
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Affiliation(s)
| | - Mary S. Dietrich
- Departments of Biostatistics and Psychiatry, Addiction Center, Vanderbilt University
| | - Hendrée E. Jones
- Departments of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, Johns Hopkins University; RTI International
| | - Karol Kaltenbach
- Departments of Pediatrics and Psychiatry and Human Behavior, Thomas Jefferson University
| | - Sarah H. Heil
- Departments of Psychiatry and Psychology, University of Vermont
| | - Susan M. Stine
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University
| | - Mara G. Coyle
- Department of Pediatrics, The Warren Alpert Medical School of Brown University
| | - Amelia M. Arria
- Center for Young Adult Health and Development, University of Maryland, College Park
| | | | - Gabriele Fischer
- Department of Psychiatry and Psychotherapy, Addiction Clinic, Medical University of Vienna
| | - Peter R. Martin
- Addiction Center, Departments of Psychiatry and Pharmacology, Vanderbilt University
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93
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Jones HE, Arria AM, Baewert A, Heil SH, Kaltenbach K, Martin PR, Coyle MG, Selby P, Stine SM, Fischer G. Buprenorphine treatment of opioid-dependent pregnant women: a comprehensive review. Addiction 2012; 107 Suppl 1:5-27. [PMID: 23106923 PMCID: PMC4506646 DOI: 10.1111/j.1360-0443.2012.04035.x] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
AIMS This paper reviews the published literature regarding outcomes following maternal treatment with buprenorphine in five areas: maternal efficacy, fetal effects, neonatal effects, effects on breast milk and longer-term developmental effects. METHODS Within each outcome area, findings are summarized first for the three randomized clinical trials and then for the 44 non-randomized studies (i.e. prospective studies, case reports and series and retrospective chart reviews), only 28 of which involve independent samples. RESULTS Results indicate that maternal treatment with buprenorphine has comparable efficacy to methadone, although difficulties may exist with current buprenorphine induction methods. The available fetal data suggest buprenorphine results in less physiological suppression of fetal heart rate and movements than methadone. Regarding neonatal effects, perhaps the single definitive conclusion is that prenatal buprenorphine treatment results in a clinically significant less severe neonatal abstinence syndrome (NAS) than treatment with methadone. The limited research suggests that, like methadone, buprenorphine is compatible with breastfeeding. Data available thus far suggest that there are no deleterious effects of in utero buprenorphine exposure on infant development. CONCLUSIONS While buprenorphine produces a less severe neonatal abstinence syndrome than methadone, both methadone and buprenorphine are important parts of a complete comprehensive treatment approach for opioid-dependent pregnant women.
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Affiliation(s)
- Hendrée E. Jones
- Department of Psychiatry, Johns Hopkins University School of Medicine
| | - Amelia M. Arria
- Center on Young Adult Health and Development, School of Public Health, University of Maryland, College Park
| | - Andjela Baewert
- Department of Psychiatry and Psychotherapy, Medical University Vienna
| | - Sarah H. Heil
- Departments of Psychiatry and Psychology, University of Vermont
| | - Karol Kaltenbach
- Department of Pediatrics, Jefferson Medical College, Thomas Jefferson University
| | | | - Mara G. Coyle
- Department of Pediatrics, The Warren Alpert Medical School of Brown University
| | - Peter Selby
- Departments of Family and Community Medicine, Psychiatry and Public Health Sciences, University of Toronto
| | - Susan M. Stine
- Department of Psychiatry & Behavior Neurosciences, Wayne State University
| | - Gabriele Fischer
- Department of Psychiatry and Psychotherapy, Medical University Vienna
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94
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“Subutex is safe”: Perceptions of risk in using illicit drugs during pregnancy. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2012; 23:365-73. [DOI: 10.1016/j.drugpo.2012.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Revised: 11/23/2011] [Accepted: 01/18/2012] [Indexed: 01/06/2023]
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95
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Park EM, Meltzer-Brody S, Suzuki J. Evaluation and management of opioid dependence in pregnancy. PSYCHOSOMATICS 2012; 53:424-32. [PMID: 22902085 DOI: 10.1016/j.psym.2012.04.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Revised: 03/30/2012] [Accepted: 04/02/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND Opioid use disorders are a growing public health problem in the United States. Most women who are opioid-dependent are of childbearing age, and management of opioid dependence during pregnancy poses unique challenges. Assessment includes evaluation for addiction, withdrawal syndromes, and comorbid psychiatric diagnoses. Consultation-liaison (C-L) psychiatrists may also be involved in acute pain management, perinatal medication management, buprenorphine induction, and stabilization. For the past four decades, the standard of care has included methadone maintenance, but the increasing use of buprenorphine creates new treatment issues and opportunities. OBJECTIVE To educate C-L psychiatrists in emergency and obstetrical settings about the appropriate approach toward the evaluation and basic management of women with opioid dependence in pregnancy. METHOD The authors reviewed the consensus literature and all new treatment options on opioid dependence during pregnancy. DISCUSSION In this review, the authors summarize known and emerging management strategies for opioid dependence in pregnancy pertinent to C-L psychiatrists.
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Affiliation(s)
- Eliza M Park
- Department of Psychiatry, University of North Carolina, Chapel Hill, NC 27599, USA.
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96
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Abstract
Opioid dependence in the setting of pregnancy provides a distinct set of challenges for providers. Treatment plans must take into consideration psychiatric and medical comorbidities while balancing risks and benefits for the maternal-fetal dyad. Treatment is best offered through a comprehensive treatment program designed to effectively deliver opioid agonist maintenance treatment along with psychosocial and obstetric care. As misuse of prescription analgesics increases in the United States, identification of the problem in pregnancy will become more important because this misuse is expected to lead to an increased prevalence of opioid dependence in pregnancy. Buprenorphine as maintenance treatment of opioid dependence during pregnancy has promise and may offer some benefits, but more research is needed, especially regarding induction of actively addicted women during pregnancy. For the present, methadone maintenance remains the standard of care for agonist treatment of opioid dependence in pregnancy against which other treatments must be compared.
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Affiliation(s)
- Jessica L Young
- Vanderbilt University Medical Center, Nashville, TN 37232, USA.
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97
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Black KI, Stephens C, Haber PS, Lintzeris N. Unplanned pregnancy and contraceptive use in women attending drug treatment services. Aust N Z J Obstet Gynaecol 2012; 52:146-50. [DOI: 10.1111/j.1479-828x.2012.01413.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2011] [Accepted: 12/25/2011] [Indexed: 01/06/2023]
Affiliation(s)
- Kirsten I. Black
- Discipline of Obstetrics, Gynaecology and Neonatology; Central Clinical School, Royal Prince Alfred Hospital, University of Sydney; Camperdown
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98
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Baewert A, Jagsch R, Winklbaur B, Kaiser G, Thau K, Unger A, Aschauer C, Weninger M, Metz V. Influence of Site Differences between Urban and Rural American and Central European Opioid-Dependent Pregnant Women and Neonatal Outcome Characteristics. Eur Addict Res 2012; 18:130-9. [PMID: 22354163 PMCID: PMC3696360 DOI: 10.1159/000335082] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 10/28/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND Multi-center trials enable the recruitment of larger study samples, although results might be influenced by site-specific factors. METHODS Site differences of a multi-center prospective double-blind, double-dummy randomized controlled trial (7 centers: Central Europe (Vienna)/USA (3 urban/3 rural centers)) comparing safety and efficacy of methadone and buprenorphine in pregnant opioid-dependent women and their neonates. RESULTS Urban US women had the highest rate of concomitant opioid (p = 0.050) and cocaine consumption (p = 0.003), the highest dropout rate (p = 0.001), and received the lowest voucher sums (p = 0.001). Viennese neonates had significantly higher Apgar scores 1 min (p = 0.001) and 5 min after birth (p < 0.001) and were more often born by cesarean section (p = 0.024). Rural US newborns had a significantly shorter neonatal abstinence syndrome treatment duration compared to Viennese and urban US sites (p = 0.006), in addition to other site-specific differences, suggesting a more severely affected group of women in the urban US sites. CONCLUSION This clinical trial represents a role model for pharmacological treatment in this unique sample of pregnant women and demonstrates the clinical importance of considering site-specific factors in research and clinical practice.
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Affiliation(s)
- Andjela Baewert
- Department of Psychiatry and Psychotherapy, Medical University Vienna, Austria,*Andjela Baewert, Department of Psychiatry and Psychotherapy, Medical University Vienna, Währinger Gürtel 18–20, AT–1090 Vienna (Austria), Tel. +43 1 40400 3547, E-Mail
| | | | | | - Gerda Kaiser
- Department of Psychiatry and Psychotherapy, Medical University Vienna, Austria
| | - Kenneth Thau
- Department of Psychiatry and Psychotherapy, Medical University Vienna, Austria
| | - Annemarie Unger
- Department of Psychiatry and Psychotherapy, Medical University Vienna, Austria
| | - Constantin Aschauer
- Department of Psychiatry and Psychotherapy, Medical University Vienna, Austria
| | - Manfred Weninger
- Department of Neonatology, Medical University Vienna, Vienna, Austria
| | - Verena Metz
- Department of Psychiatry and Psychotherapy, Medical University Vienna, Austria
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99
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Cigarette Smoking and Neonatal Outcomes in Depressed and Non-Depressed Opioid-Dependent Agonist-Maintained Pregnant Patients. ADDICTIVE DISORDERS & THEIR TREATMENT 2011; 10:180-187. [PMID: 22833702 DOI: 10.1097/adt.0b013e31821cadbd] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
AIMS: To investigate whether cigarette smoking and/or depression contribute to neonatal abstinence syndrome (NAS) severity. DESIGN: Cohort study analyzing data from a randomized, controlled trial of methadone versus buprenorphine. SETTING: Seven study sites that randomized patients to study conditions and provided comprehensive addiction treatment to pregnant patients. PARTICIPANTS: 119 of 131 opioid-dependent pregnant patients who completed the MOTHER study. MEASUREMENTS: Smoking data and depression status were obtained from the Addiction Severity Index and Mini International Neuropsychiatric Interview, respectively. Neonatal outcomes (birth weight, preterm delivery and NAS pharmacologic treatment) were collected from the medical charts. Study site was a fixed-effect factor in all analyses. FINDINGS: Cigarette smoking was reported by 94% of participants and depression identified in 35%. Smoking was associated with low birth weight, preterm delivery, and NAS pharmacologic treatment in both depressed and non-depressed participants. The association between smoking and NAS treatment differed significantly between depressed and non-depressed participants. Among non-depressed participants, adjusting for site and illicit drug use, each additional average cigarette per day (CPD) increased the odds of NAS treatment by 12% [95%CI: (1.02-1.23), p=0.02]. Among depressed participants, each additional average CPD did not statistically increase the odds of NAS treatment [OR: 0.94, 95% CI: (0.84-1.04), p=0.23]. CONCLUSIONS: These results are consistent with the hypothesis that NAS expression is influenced by many factors. The relationship between CPD and NAS pharmacologic treatment is attenuated among depressed women in this study for reasons currently unknown. Further investigations are needed to clarify the complex relationships among maternal smoking, depression, and NAS.
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100
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Albright B, de la Torre L, Skipper B, Price S, Abbott P, Rayburn W. Changes in methadone maintenance therapy during and after pregnancy. J Subst Abuse Treat 2011; 41:347-53. [DOI: 10.1016/j.jsat.2011.05.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Revised: 04/29/2011] [Accepted: 05/09/2011] [Indexed: 10/18/2022]
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