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Associations between Orofacial Clefting and Neonatal Abstinence Syndrome. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2095. [PMID: 30859050 PMCID: PMC6382228 DOI: 10.1097/gox.0000000000002095] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 11/07/2018] [Indexed: 12/21/2022]
Abstract
Background: Orofacial clefting (OFC) is the most common developmental craniofacial malformation, and causal etiologies largely remain unknown. The opioid crisis has led to a large proportion of infants recovering from neonatal abstinence syndrome (NAS) due to in-utero narcotics exposure. We sought to characterize the prevalence of OFC in infants with NAS. Methods: This cohort study analyzed live births at our institution from 2013 to 2017 to identify any association between OFC and NAS. Results: Prevalence of OFC was 6.79 and 1.63 (per 1,000 live births) in the NAS and general population, respectively. Odds ratios for NAS patients having developed OFC, isolated cleft palate, isolated cleft lip, and combined cleft lip and palate compared with the general population were found to be 4.18 (P = 0.001), 5.92 (P = 0.001), 3.79 (P = 0.05), and 2.94 (P = 0.35), respectively. Analyses performed comparing the NAS and general populations to control for potential confounding variables influencing the NAS population yielded no significant differences with exception of in-utero exposure to physician prescribed opioids. Conclusions: Prevalence of OFC in infants with NAS was higher than the general live birth population. Isolated cleft palate and isolated cleft lip, specifically, were significantly more prevalent in NAS patients compared with the general population and were associated with in-utero opioid exposure.
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Methadone Versus Buprenorphine for Opioid Use Dependence and Risk of Neonatal Abstinence Syndrome. Epidemiology 2019; 29:261-268. [PMID: 29112519 DOI: 10.1097/ede.0000000000000780] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Our objective was to estimate the association between methadone and neonatal abstinence syndrome compared with buprenorphine using a probabilistic bias analysis to account for unmeasured confounding by severity of addiction. METHODS We used a cohort of live-born infants exposed in utero to methadone or buprenorphine for maternal opioid maintenance therapy at Magee-Womens Hospital in Pittsburgh, PA, from 2013 to 2015 (n = 716). We determined exposure and outcome status using pharmacy billing claims. We used log-binomial regression models to assess association of treatment with neonatal abstinence syndrome after adjusting for parity, maternal race, age, delivery year, employment, hepatitis c, smoking, marital, and insurance status. We implemented probabilistic bias analysis, informed by an internal validation study, to assess the impact of unmeasured confounding by severity of addiction. RESULTS Infants exposed to methadone in utero were more likely to experience neonatal abstinence syndrome compared with those exposed to buprenorphine (RR, 1.3; 95% CI, 1.2, 1.5). After adjustment, infants exposed to methadone were more likely (adjusted RR, 1.3; 95% CI, 1.1, 1.5) than infants exposed to buprenorphine to have the syndrome. In the validation cohort (n = 200), severe addiction was more common in methadone- versus buprenorphine-exposed deliveries (77% vs. 32%). However, adjustment for severe addiction in the bias analysis only slightly attenuated the association (RR, 1.2; 95% CI, 1.0, 1.4), supporting conventional analysis. CONCLUSIONS Methadone is associated with increased risk of neonatal abstinence syndrome compared with buprenorphine in infants exposed in utero. This association is subject to minimal bias due to unmeasured confounding by severity of addiction.
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Patrick SW, Buntin MB, Martin PR, Scott TA, Dupont W, Richards M, Cooper WO. Barriers to accessing treatment for pregnant women with opioid use disorder in Appalachian states. Subst Abus 2018; 40:356-362. [PMID: 29949454 PMCID: PMC9069995 DOI: 10.1080/08897077.2018.1488336] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background and aims: Opioid agonist therapies (OATs) are highly effective treatments for opioid use disorders (OUDs), especially for pregnant women; thus, improving access to OAT is an urgent public policy goal. Our objective was to determine if insurance and pregnancy status were barriers to obtaining access to OAT in 4 Appalachian states disproportionately impacted by the opioid epidemic. Methods: Between April and May 2017, we conducted phone surveys of OAT providers, opioid treatment programs (OTPs), and outpatient buprenorphine providers, in Kentucky, North Carolina, Tennessee, and West Virginia. Survey response rates were 59%. Logistic models for dichotomous outcomes (e.g., patient acceptance) and negative binomial models were created for count variables (e.g., wait time), overall and for pregnant women. Results: The majority of OAT providers were accepting new patients; however, providers were less likely to treat pregnant women (91% vs. 75%; p < .01). OTPs were more likely to accept new patients than waivered buprenorphine providers (97% vs. 83%; p = .01); rates of accepting pregnant patients were lower in both (91% and 53%; p < .01). OTPs and buprenorphine providers accepted cash payments for services at high rates (OTP: 100%; buprenorphine: 89.4%; p < .01); Medicaid and private insurance were accepted at lower rates. In adjusted models, providers were less likely to accept pregnant women if they took any insurance (adjusted odds ratio [aOR] = 0.15, 95% confidence interval [CI]: 0.03-0.68) or were a buprenorphine provider (aOR = 0.09, 95% CI: 0.02-0.37). Conclusions: We found that OAT providers frequently did not accept any insurance and frequently did not treat pregnant women in an area of the country disproportionately affected by the opioid epidemic. Policymakers could prioritize improvements in provider training (e.g., training of obstetricians to become buprenorphine prescribers) as a means to enhance access to pregnant women or enhancing reimbursement rates as a means of improving insurance acceptance for OAT.
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Affiliation(s)
- Stephen W. Patrick
- Department of Pediatrics, Vanderbilt University, Nashville, TN
- Mildred Stahlman Division of Neonatology, Vanderbilt University, Nashville, TN
- Vanderbilt Center for Health Services Research, Nashville, TN
- Department of Health Policy, Vanderbilt University, Nashville, TN
| | | | - Peter R. Martin
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University, Nashville, TN
- Department of Pharmacology, Vanderbilt University, Nashville, TN
| | - Theresa A. Scott
- Department of Pediatrics, Vanderbilt University, Nashville, TN
- Mildred Stahlman Division of Neonatology, Vanderbilt University, Nashville, TN
| | - William Dupont
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - Michael Richards
- Department of Health Policy, Vanderbilt University, Nashville, TN
| | - William O. Cooper
- Department of Pediatrics, Vanderbilt University, Nashville, TN
- Department of Health Policy, Vanderbilt University, Nashville, TN
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Niethe M, Whitfield K. Psychotropic medication use during pregnancy. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2018. [DOI: 10.1002/jppr.1483] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Miranda Niethe
- School of Pharmacy; The University of Queensland; Woolloongabba Australia
| | - Karen Whitfield
- School of Pharmacy; The University of Queensland; Woolloongabba Australia
- Royal Brisbane and Women's Hospital; Brisbane Australia
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Brogly SB, Hernández-Diaz S, Regan E, Fadli E, Hahn KA, Werler MM. Neonatal Outcomes in a Medicaid Population With Opioid Dependence. Am J Epidemiol 2018; 187:1153-1161. [PMID: 29155919 DOI: 10.1093/aje/kwx341] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 08/24/2017] [Indexed: 12/17/2022] Open
Abstract
Confounding may account for the apparently improved infant outcomes after prenatal exposure to buprenorphine versus methadone. We used Massachusetts Medicaid Analytic eXtract (MAX) data to identify a cohort of opioid-dependent mother-infant pairs (2006-2011), supplemented with confounder data from an external Boston, Massachusetts, cohort (2015-2016). Associations between prenatal buprenorphine exposure versus methadone exposure and infant outcomes in the MAX cohort were adjusted for measured MAX confounders and were additionally adjusted for unmeasured confounders with bias analysis using external cohort data. A total of 477 women in MAX were treated with methadone and 543 with buprenorphine. More buprenorphine users than methadone users were white and used psychotropic medications. After adjustment for MAX confounders, risk ratios among infants exposed to buprenorphine versus those exposed to methadone were 0.45 (95% confidence interval (CI): 0.34, 0.61) for preterm birth (birth at <37 weeks) and 0.75 (95% CI: 0.51, 1.11) for low birth weight for gestational age. The mean difference in infant hospitalization was -7.35 days (95% CI: -9.16, -5.55). After further adjustment with bias analysis, the risk ratios were 0.53 (95% CI: 0.39, 0.71) for preterm birth and 1.14 (95% CI: 0.77, 1.69) for low birth weight for gestational age, and the mean difference in infant hospitalization was -3.66 days (95% CI: -5.46, -1.87). External confounder data can be used to adjust for unmeasured confounding in studies of prenatal outcomes among women on opioid agonist therapy based on administrative databases.
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Affiliation(s)
- Susan B Brogly
- Department of Surgery, Queen’s University, Kingston, Ontario, Canada
| | - Sonia Hernández-Diaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Emily Regan
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts
| | - Ela Fadli
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts
| | - Kristen A Hahn
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts
| | - Martha M Werler
- Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts
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Lemon LS, Naimi A, Caritis SN, Platt RW, Venkataramanan R, Bodnar LM. The Role of Preterm Birth in the Association Between Opioid Maintenance Therapy and Neonatal Abstinence Syndrome. Paediatr Perinat Epidemiol 2018; 32:213-222. [PMID: 29372750 PMCID: PMC5902412 DOI: 10.1111/ppe.12443] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Pregnant women treated with methadone as opioid maintenance therapy are more likely than women treated with buprenorphine to deliver preterm. Preterm birth is associated with less risk of neonatal abstinence syndrome (NAS). We sought to assess the role of preterm birth as a mediator of the relationship between in utero exposure to methadone and NAS compared with buprenorphine. METHODS We studied 716 women receiving methadone or buprenorphine and delivering liveborn infants at Magee-Womens Hospital, Pittsburgh, Pennsylvania (2013-15). We implemented inverse probability weighted marginal structural models to isolate the role of preterm birth (<37 weeks' gestation). Weights accounted for confounding by maternal age, race, insurance, parity, delivery year, marital, employment, hepatitis C, and smoking status. RESULTS Approximately 57% of the cohort were treated with methadone. Preterm birth was more common in methadone-exposed pregnancies (25% versus 14%). The incidence of NAS treatment was higher in methadone compared with buprenorphine-exposed infants (65% vs 49%), and term compared with preterm births (64% vs 36%). For every 100 infants liveborn to mothers treated for opioid dependence, there were 13 excess cases of NAS among infants exposed to methadone compared with buprenorphine (adjusted risk difference [RD] 13.3, 95% confidence interval [CI] 5.7, 20.9). Among term births, this increased to 17 excess cases of NAS in methadone- compared with buprenorphine-exposed (RD 16.7, 95% CI 9.3, 24.0). CONCLUSION The further increased risk of NAS associated with methadone use vs buprenorphine in term deliveries emphasises the utility of buprenorphine in clinical settings aimed at decreasing NAS.
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Affiliation(s)
- Lara S. Lemon
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh
- Department of Pharmaceutical Science, School of Pharmacy, University of Pittsburgh, Pittsburgh
| | - Ashley Naimi
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh
| | - Steve N. Caritis
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh
| | - Robert W. Platt
- Departments of Pediatrics and Epidemiology, Biostatistics and Occupation Health, McGill University, Montreal, Canada
| | - Raman Venkataramanan
- Department of Pharmaceutical Science, School of Pharmacy, University of Pittsburgh, Pittsburgh
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lisa M. Bodnar
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh
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Klaman SL, Isaacs K, Leopold A, Perpich J, Hayashi S, Vender J, Campopiano M, Jones HE. Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance. J Addict Med 2018; 11:178-190. [PMID: 28406856 PMCID: PMC5457836 DOI: 10.1097/adm.0000000000000308] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 02/12/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The prevalence of opioid use disorder (OUD) during pregnancy is increasing. Practical recommendations will help providers treat pregnant women with OUD and reduce potentially negative health consequences for mother, fetus, and child. This article summarizes the literature review conducted using the RAND/University of California, Los Angeles Appropriateness Method project completed by the US Department of Health and Human Services Substance Abuse and Mental Health Services Administration to obtain current evidence on treatment approaches for pregnant and parenting women with OUD and their infants and children. METHODS Three separate search methods were employed to identify peer-reviewed journal articles providing evidence on treatment methods for women with OUD who are pregnant or parenting, and for their children. Identified articles were reviewed for inclusion per study guidelines and relevant information was abstracted and summarized. RESULTS Of the 1697 articles identified, 75 were included in the literature review. The perinatal use of medication for addiction treatment (MAT, also known as medication-assisted treatment), either methadone or buprenorphine, within comprehensive treatment is the most accepted clinical practice, as withdrawal or detoxification risks relapse and treatment dropout. Medication increases may be needed with advancing pregnancy, and are not associated with more severe neonatal abstinence syndrome (NAS). Switching medication prenatally is usually not recommended as it can destabilize opioid abstinence. Postnatally, breastfeeding is seen as beneficial for the infant for women who are maintained on a stable dose of opioid agonist medication. Less is known about ideal pain management and postpartum dosing regimens. NAS appears generally less severe following prenatal exposure to buprenorphine versus methadone. Frontline NAS medication treatments include protocol-driven methadone and morphine dosing in the context of nonpharmacological supports. CONCLUSIONS Women with OUD can be treated with methadone or buprenorphine during pregnancy. NAS is an expected and manageable condition. Although research has substantially advanced, opportunities to guide future research to improve maternal and infant outcomes are provided.
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Affiliation(s)
- Stacey L Klaman
- Department of Maternal and Child Health, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC (SLK); JBS International, Inc., North Bethesda, MD (KI, AL, JP, SH, JV); Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services, Rockville, MD (MC); UNC Horizons, Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC (HEJ); Departments of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, School of Medicine, Johns Hopkins University, Baltimore, MD (HEJ)
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Antenatal methadone vs buprenorphine exposure and length of hospital stay in infants admitted to the intensive care unit with neonatal abstinence syndrome. J Perinatol 2018; 38:75-79. [PMID: 29048415 DOI: 10.1038/jp.2017.157] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/17/2017] [Accepted: 08/28/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Antenatal exposure to methadone or buprenorphine often causes neonatal abstinence syndrome (NAS) in newborns. However, comparative effects on affected infants' hospital courses are inconclusive. We sought to estimate the relationship of antenatal exposure with methadone or buprenorphine and infants' length of stay among hospitalized infants with NAS. STUDY DESIGN This was a retrospective cohort study of hospitalized infants with NAS with either maternal exposure. Eligible infants were singleton infants born ⩾36 weeks' gestation and diagnosed with NAS<7 days of age between 2011 and 2014 in the Pediatrix Clinical Data Warehouse. Infant with congenital anomalies and those of multiple gestation were excluded. RESULTS Of 3364 eligible infants, 2202 (65%) were exposed to methadone and 1162 (34%) to buprenorphine. Infants exposed to buprenorphine had a lower rate of pharmacologic treatment for NAS (88 vs 91%, P<0.001). Median length of hospital stay was shorter among infants exposed to buprenorphine (21 days (inter-quartile range; 13-31) vs methadone (24 days (15-38), P<0.0001)). On multivariable Cox proportional hazard analyses, buprenorphine was associated with a shorter length of stay (hazard ratio (HR)=1.47 (95% confidence interval (CI): 1.32-1.62, P<0.001) after controlling for maternal age, parity, race or ethnicity, prenatal care, smoking status, use of antidepressants, use of benzodiazepines, and infant gestational age, small for gestational age status, cesarean delivery, sex, out born status, type of pharmacotherapy, breast milk use, year and center. We observed similar results in model using infants matched 1:1 with propensity scores for antenatal medication exposure (HR 1.39 for buprenorphine, CI 1.32-1.62, P<0.001). CONCLUSION Among infants born ⩾36 weeks' gestation with NAS, antenatal buprenorphine exposure was associated with a decreased length of stay relative to antenatal methadone exposure.
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O'Connor AB, Uhler B, O'Brien LM, Knuppel K. Predictors of treatment retention in postpartum women prescribed buprenorphine during pregnancy. J Subst Abuse Treat 2017; 86:26-29. [PMID: 29415847 DOI: 10.1016/j.jsat.2017.12.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 12/01/2017] [Accepted: 12/05/2017] [Indexed: 11/24/2022]
Abstract
AIM To determine variables related to treatment retention in women six and twelve months postpartum that were in medication treatment using buprenorphine during pregnancy. METHODS This retrospective cohort study of 190 maternal-infant dyads exposed to buprenorphine during pregnancy examines rates of treatment retention at six and twelve months postpartum and also analyzes a variety of potential predictors of treatment retention including illicit drug use in the third trimester, delayed entry into medication treatment and co-occurring mental health diagnoses requiring prescription medication. RESULTS At 12months postpartum, women appeared more likely to remain in medication treatment if they entered treatment early in pregnancy (defined as either being in treatment at the time of conception, p=0.001, or entering medication treatment prior to 13weeks gestation, p=0.037). Being prescribed an antidepressant medication during the third trimester was also associated with enhanced treatment retention at six months postpartum (p=0.005). At both six and twelve months postpartum, the use of illicit drugs (including opioids, cocaine and benzodiazepines) during the third trimester was negatively correlated with treatment retention (p=0.012 and p<0.001, respectively). CONCLUSIONS Early access to medication treatment is associated with treatment retention in women prescribed buprenorphine during pregnancy. This has important public health implications as access to treatment is limited in many parts of the country and many women are only able to obtain treatment after becoming pregnant. Being prescribed an antidepressant medication during pregnancy may enhance treatment retention, supporting the work of previous authors.
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Affiliation(s)
- Alane B O'Connor
- Dartmouth Medical School, Maine Dartmouth Family Medicine Residency, 149 North Street, Waterville, ME 04901, United States.
| | - Brett Uhler
- Maine Dartmouth Family Medicine Residency, 149 North Street, Waterville, ME 04901, United States
| | - Liam M O'Brien
- Department of Mathematics and Statistics, Colby College, School of Community and Population Health, University of New England, 5838 Mayflower Hill, Waterville, ME 04901, United States
| | - Kyle Knuppel
- Maine Dartmouth Family Medicine Residency, 149 North Street, Waterville, ME 04901, United States
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McHugh RK, Votaw VR, Sugarman DE, Greenfield SF. Sex and gender differences in substance use disorders. Clin Psychol Rev 2017; 66:12-23. [PMID: 29174306 DOI: 10.1016/j.cpr.2017.10.012] [Citation(s) in RCA: 478] [Impact Index Per Article: 68.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 10/26/2017] [Accepted: 10/30/2017] [Indexed: 12/18/2022]
Abstract
The gender gap in substance use disorders (SUDs), characterized by greater prevalence in men, is narrowing, highlighting the importance of understanding sex and gender differences in SUD etiology and maintenance. In this critical review, we provide an overview of sex/gender differences in the biology, epidemiology and treatment of SUDs. Biological sex differences are evident across an array of systems, including brain structure and function, endocrine function, and metabolic function. Gender (i.e., environmentally and socioculturally defined roles for men and women) also contributes to the initiation and course of substance use and SUDs. Adverse medical, psychiatric, and functional consequences associated with SUDs are often more severe in women. However, men and women do not substantively differ with respect to SUD treatment outcomes. Although several trends are beginning to emerge in the literature, findings on sex and gender differences in SUDs are complicated by the interacting contributions of biological and environmental factors. Future research is needed to further elucidate sex and gender differences, especially focusing on hormonal factors in SUD course and treatment outcomes; research translating findings between animal and human models; and gender differences in understudied populations, such as those with co-occurring psychiatric disorders and gender-specific populations, such as pregnant women.
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Affiliation(s)
- R Kathryn McHugh
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill Street, Belmont, MA 02478, United States; Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA 02155, United States.
| | - Victoria R Votaw
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill Street, Belmont, MA 02478, United States
| | - Dawn E Sugarman
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill Street, Belmont, MA 02478, United States; Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA 02155, United States
| | - Shelly F Greenfield
- Division of Alcohol and Drug Abuse, McLean Hospital, 115 Mill Street, Belmont, MA 02478, United States; Department of Psychiatry, Harvard Medical School, 401 Park Drive, Boston, MA 02155, United States
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O'Connor AB, Kelly BK, O'Brien LM. Maternal and infant outcomes following third trimester exposure to marijuana in opioid dependent pregnant women maintained on buprenorphine. Drug Alcohol Depend 2017; 180:200-203. [PMID: 28917206 DOI: 10.1016/j.drugalcdep.2017.08.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 08/05/2017] [Accepted: 08/14/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND To determine whether maternal and infant outcomes are associated with exposure to marijuana during the third trimester in a population of opioid dependent pregnant women maintained on buprenorphine. METHODS This retrospective cohort study of 191 maternal-infant dyads exposed to buprenorphine during pregnancy examines a variety of variables including gestational age, birthweight, method of delivery, Apgar scores at one and five minutes, duration of infant hospital stay, peak neonatal abstinence syndrome (NAS) score, duration of NAS and incidence of pharmacologic treatment of NAS in infants exposed to marijuana during the third trimester as compared to infants not exposed to marijuana during the third trimester. RESULTS Analyses failed to support any significant relationship between marijuana use in the third trimester and a variety of maternal and infant outcomes. Two important variables - the likelihood of requiring pharmacologic treatment for NAS (27.6% in marijuana exposed infants vs. 15.7% in non-marijuana exposed infants, p=0.066) and the duration of infant hospital stay (7.7days in marijuana exposed infants vs. 6.6days in non-exposed infants, p=0.053) trended toward significance. CONCLUSIONS Preliminary results indicate that marijuana exposure in the third trimester does not complicate the pregnancy or the delivery process. However, the severity of the infant withdrawal syndrome in the immediate postnatal period may be impacted by marijuana exposure. Because previous study of prenatal marijuana exposure has yielded mixed results, further analysis is needed to determine whether these findings are indeed significant.
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Affiliation(s)
| | | | - Liam M O'Brien
- Department of Mathematics and Statistics, Colby College, United States; School of Community and Population Health, University of New England, United States
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Johnson S, Martin PR. Transitioning from methadone to buprenorphine maintenance in management of opioid use disorder during pregnancy. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2017; 44:310-316. [DOI: 10.1080/00952990.2017.1363218] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Shakevia Johnson
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Peter R. Martin
- Department of Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA
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Kelty E, Hulse G. A Retrospective Cohort Study of Birth Outcomes in Neonates Exposed to Naltrexone in Utero: A Comparison with Methadone-, Buprenorphine- and Non-opioid-Exposed Neonates. Drugs 2017; 77:1211-1219. [PMID: 28536981 DOI: 10.1007/s40265-017-0763-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Naltrexone may provide a suitable alternative to methadone and buprenorphine in the treatment of pregnant opioid-dependent women; however, little is known about its effects on neonatal morbidity and mortality. OBJECTIVE The aim was to evaluate the health of neonates exposed to naltrexone in utero, and compare it with outcomes in neonates exposed to methadone or buprenorphine and a non-exposed control group. METHODS Sequential cohorts of Western Australian (WA) opioid-dependent women treated with implant naltrexone, oral methadone or sublingual buprenorphine were identified via records from a drug and alcohol clinic (Subiaco, WA) for naltrexone and state prescribing records for methadone and buprenorphine. A control cohort of non-opioid-dependent women was obtained from the WA electoral roll. Identifying information and treatment records for these women were linked against the Midwife Notification System records to identify exposed offspring born between 2001 and 2011. Birth characteristics, congenital anomalies and perinatal mortality for all neonates were extracted from state records. RESULTS The birth characteristics of naltrexone-exposed neonates (n = 68) were superior to methadone-exposed neonates (n = 199) in terms of birth size (birth weight, head circumference and length), hospital length of stay (5.5 vs. 11.3 days), and rates of neonatal abstinence syndrome (NAS) (7.5 vs. 51.5%). Naltrexone-exposed neonates were generally not significantly different to buprenorphine-exposed neonates (n = 124), with the exception of significantly lower rates of NAS (7.5 vs. 41.8%) and shorter hospital length of stay (5.5 vs. 8.0 days) in naltrexone-exposed neonates. Compared with the control group of neonates (n = 569), naltrexone-exposed neonates were not significantly different in terms of overall rates of congenital anomalies, stillbirths and neonatal mortality; however, they were significantly smaller (3137.1 vs. 3378.0 g), spent more time in hospital following birth (5.5 vs. 4.3 days) and had higher rates of NAS (7.5 vs. 0.2%). Exposure of neonates to prenatal methadone was associated with a high incidence of neonatal mortality (2.0 vs. 0.2 per 100 live births) and congenital anomalies (10.6 vs. 4.4 per 100 births) compared with the control group. Rates of neonatal mortality and congenital abnormalities in buprenorphine-exposed neonates were not significantly different to the control group. CONCLUSIONS The use of implant naltrexone during pregnancy was not associated with higher rates of negative birth outcomes compared with methadone- and buprenorphine-exposed neonates. Significantly, naltrexone and buprenorphine were not associated with the high rates of neonatal mortality or congenital anomalies seen in methadone-exposed neonates.
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Affiliation(s)
- Erin Kelty
- School of Psychiatry and Clinical Neurosciences, University of Western Australia, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia.
- School of Population and Global Health, University of Western Australia, Crawley, WA, 6009, Australia.
| | - Gary Hulse
- School of Psychiatry and Clinical Neurosciences, University of Western Australia, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia
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Tran TH, Griffin BL, Stone RH, Vest KM, Todd TJ. Methadone, Buprenorphine, and Naltrexone for the Treatment of Opioid Use Disorder in Pregnant Women. Pharmacotherapy 2017; 37:824-839. [PMID: 28543191 DOI: 10.1002/phar.1958] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pregnant women with opioid use disorder can be treated with methadone, buprenorphine, or naltrexone to reduce opioid use and improve retention to treatment. In this review, we compare the pregnancy outcomes of methadone, buprenorphine, and naltrexone in clinical trials and discuss the potential behavioral and developmental effects of these agents seen in offspring in animal studies. Important clinical considerations in the management of opioid use disorder in pregnant women and their infants are also discussed. Outside of pregnancy, buprenorphine is used in combination with naloxone to reduce opioid abuse and diversion. During pregnancy, however, the use of buprenorphine as a single agent is preferred to prevent prenatal naloxone exposure. Both methadone and buprenorphine are widely used to treat opioid use disorder; however, compared with methadone, buprenorphine is associated with shorter treatment duration, less medication needed to treat neonatal abstinence syndrome (NAS) symptoms, and shorter hospitalizations for neonates. Despite being the standard of care, medication-assisted treatment with methadone or buprenorphine is still underused, making it apparent that more options are necessary. Naltrexone is not a first-line treatment primarily because both detoxification and an opioid-free period are required. More research is needed to determine naltrexone safety and benefits in pregnant women. Animal studies suggest that changes in pain sensitivity, developmental processes, and behavioral responses may occur in children born to mothers receiving methadone, buprenorphine, or naltrexone and is an area that warrants future studies.
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Affiliation(s)
- Tran H Tran
- Pharmacy Practice, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois
| | - Brooke L Griffin
- Pharmacy Practice, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois
| | - Rebecca H Stone
- Pharmacy Practice, University of Georgia College of Pharmacy, Athens, Georgia
| | - Kathleen M Vest
- Pharmacy Practice, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois
| | - Timothy J Todd
- Pharmacy Practice, Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois
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Lind JN, Interrante JD, Ailes EC, Gilboa SM, Khan S, Frey MT, Dawson AL, Honein MA, Dowling NF, Razzaghi H, Creanga AA, Broussard CS. Maternal Use of Opioids During Pregnancy and Congenital Malformations: A Systematic Review. Pediatrics 2017; 139:e20164131. [PMID: 28562278 PMCID: PMC5561453 DOI: 10.1542/peds.2016-4131] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2017] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Opioid use and abuse have increased dramatically in recent years, particularly among women. OBJECTIVES We conducted a systematic review to evaluate the association between prenatal opioid use and congenital malformations. DATA SOURCES We searched Medline and Embase for studies published from 1946 to 2016 and reviewed reference lists to identify additional relevant studies. STUDY SELECTION We included studies that were full-text journal articles and reported the results of original epidemiologic research on prenatal opioid exposure and congenital malformations. We assessed study eligibility in multiple phases using a standardized, duplicate review process. DATA EXTRACTION Data on study characteristics, opioid exposure, timing of exposure during pregnancy, congenital malformations (collectively or as individual subtypes), length of follow-up, and main findings were extracted from eligible studies. RESULTS Of the 68 studies that met our inclusion criteria, 46 had an unexposed comparison group; of those, 30 performed statistical tests to measure associations between maternal opioid use during pregnancy and congenital malformations. Seventeen of these (10 of 12 case-control and 7 of 18 cohort studies) documented statistically significant positive associations. Among the case-control studies, associations with oral clefts and ventricular septal defects/atrial septal defects were the most frequently reported specific malformations. Among the cohort studies, clubfoot was the most frequently reported specific malformation. LIMITATIONS Variabilities in study design, poor study quality, and weaknesses with outcome and exposure measurement. CONCLUSIONS Uncertainty remains regarding the teratogenicity of opioids; a careful assessment of risks and benefits is warranted when considering opioid treatment for women of reproductive age.
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Affiliation(s)
- Jennifer N Lind
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia;
- US Public Health Service, Atlanta, Georgia
| | - Julia D Interrante
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
- Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - Elizabeth C Ailes
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Suzanne M Gilboa
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sara Khan
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
- Carter Consulting, Atlanta, Georgia; and
| | - Meghan T Frey
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - April L Dawson
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Margaret A Honein
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nicole F Dowling
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Hilda Razzaghi
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
- US Public Health Service, Atlanta, Georgia
| | - Andreea A Creanga
- Department of International Health and
- International Center for Maternal and Newborn Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Cheryl S Broussard
- Division of Congenital and Developmental Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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Abstract
The increase in opioid use among the general population is reflected in pregnant women and neonatal abstinence syndrome (NAS) statistics. This increase has produced an unprecedented focus on NAS from both the political-judicial sphere and the medical community. Under the banner of fetal protection, judges and prosecutors have implemented punitive approaches against women who use prescribed and nonprescribed opioids during pregnancy, including arrest, civil commitment, detention, prosecution, and loss of custody or termination of parental rights. Within the medical community, questions have been raised regarding protocols to detect prenatal drug exposure at delivery, NAS treatment protocols, the need for quality-improvement strategies to standardize care and reduce length of stay for mother and infant, and the benefits of engaging the mother in the care of her infant. It is not uncommon for the expression of strong discordant views on these issues both between and among these political-judicial and medical constituencies. Closely examining the issues often reveal a lack of understanding of substance use disorders, their treatment, and the occurrence and treatment of NAS. This study provides an in-depth examination of NAS, including variations in presentation and factors that impact the efficacy of treatment, and also identifying questions that remain unanswered. Finally, 4 key areas on which future research should focus to guide both medical care and public policy are discussed.
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Laslo J, Brunner JM, Burns D, Butler E, Cunningham A, Killpack R, Pyeritz C, Rinard K, Childers J, Horzempa J. An overview of available drugs for management of opioid abuse during pregnancy. Matern Health Neonatol Perinatol 2017; 3:4. [PMID: 28203387 PMCID: PMC5303227 DOI: 10.1186/s40748-017-0044-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 02/06/2017] [Indexed: 12/15/2022] Open
Abstract
The prevalence of opioid abuse in the United States has been steadily increasing over the last several years among many major demographics, including pregnant women. Rise in prenatal opioid abuse has resulted in subsequent escalation of neonatal abstinence syndrome incidence, prompting the US Congress to pass the Protecting Our Infants Act of 2015. This act specifically calls for a critical review of current treatment options for prenatal opioid abuse which may ultimately lead to the development of better therapies and a decreased incidence of neonatal abstinence syndrome. Currently, the American College of Obstetricians and Gynecologists recommends methadone, buprenorphine, or buprenorphine/naloxone in the treatment of prenatal opioid abuse. In this review, each maintenance therapy treatment option is discussed and compared revealing inconsistencies in postpartum retention rates, effects on fetal development, and availability to patients due to restrictions in health care coverage. Although each of these treatment options reduces opioid abuse and potential negative outcomes for the fetus, the shortcomings of these drugs highlight the overarching need for an improved standard of care. Drug developers and lawmakers should consider that affordability, coverage by health insurance, and success in retention rates substantially impacts the decision of the patient and healthcare provider regarding utilization of a particular opioid maintenance therapy.
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Affiliation(s)
- Jillian Laslo
- Department of Graduate Health Sciences, West Liberty University, West Liberty, WV USA
| | - Jon-Michael Brunner
- Department of Graduate Health Sciences, West Liberty University, West Liberty, WV USA
| | - Daniel Burns
- Department of Graduate Health Sciences, West Liberty University, West Liberty, WV USA
| | - Emily Butler
- Department of Graduate Health Sciences, West Liberty University, West Liberty, WV USA
| | - Autumn Cunningham
- Department of Graduate Health Sciences, West Liberty University, West Liberty, WV USA
| | - Ryan Killpack
- Department of Graduate Health Sciences, West Liberty University, West Liberty, WV USA
| | - Courtney Pyeritz
- Department of Graduate Health Sciences, West Liberty University, West Liberty, WV USA
| | - Kimberly Rinard
- Department of Graduate Health Sciences, West Liberty University, West Liberty, WV USA
| | - Jennifer Childers
- Department of Graduate Health Sciences, West Liberty University, West Liberty, WV USA
| | - Joseph Horzempa
- Department of Graduate Health Sciences, West Liberty University, West Liberty, WV USA.,Department of Natural Sciences and Mathematics, West Liberty University, West Liberty, WV USA
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Zedler BK, Mann AL, Kim MM, Amick HR, Joyce AR, Murrelle EL, Jones HE. Buprenorphine compared with methadone to treat pregnant women with opioid use disorder: a systematic review and meta-analysis of safety in the mother, fetus and child. Addiction 2016; 111:2115-2128. [PMID: 27223595 PMCID: PMC5129590 DOI: 10.1111/add.13462] [Citation(s) in RCA: 155] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 02/16/2016] [Accepted: 05/06/2016] [Indexed: 12/25/2022]
Abstract
AIMS To assess the safety of buprenorphine compared with methadone to treat pregnant women with opioid use disorder. METHODS We searched PubMed, Embase and the Cochrane Library from inception to February 2015 for randomized controlled trials (RCT) and observational cohort studies (OBS) that compared buprenorphine with methadone for treating opioid-dependent pregnant women. Two reviewers assessed independently the titles and abstracts of all search results and full texts of potentially eligible studies reporting original data for maternal/fetal/infant death, preterm birth, fetal growth outcomes, fetal/congenital anomalies, fetal/child neurodevelopment and/or maternal adverse events. We ascertained each study's risk of bias using validated instruments and assessed the strength of evidence for each outcome using established methods. We computed effect sizes using random-effects models for each outcome with two or more studies. RESULTS Three RCTs (n = 223) and 15 cohort OBSs (n = 1923) met inclusion criteria. In meta-analyses using unadjusted data and methadone as comparator, buprenorphine was associated with lower risk of preterm birth [RCT risk ratio (RR) = 0.40, 95% confidence interval (CI) = 0.18, 0.91; OBS RR = 0.67, 95% CI = 0.50, 0.90], greater birth weight [RCT weighted mean difference (WMD) = 277 g, 95% CI = 104, 450; OBS WMD = 265 g, 95% CI = 196, 335] and larger head circumference [RCT WMD = 0.90 cm, 95% CI = 0.14, 1.66; OBS WMD = 0.68 cm, 95% CI = 0.41, 0.94]. No treatment differences were observed for spontaneous fetal death, fetal/congenital anomalies and other fetal growth measures, although the power to detect such differences may be inadequate due to small sample sizes. CONCLUSIONS Moderately strong evidence indicates lower risk of preterm birth, greater birth weight and larger head circumference with buprenorphine treatment of maternal opioid use disorder during pregnancy compared with methadone treatment, and no greater harms.
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Affiliation(s)
| | | | - Mimi M Kim
- Center for Biobehavioral Health Disparities Research, Division of Community Health, Duke University, Durham, NC, USA
| | | | | | | | - Hendrée E Jones
- UNC Horizons, Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Departments of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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69
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Wurst KE, Zedler BK, Joyce AR, Sasinowski M, Murrelle EL. A Swedish Population-based Study of Adverse Birth Outcomes among Pregnant Women Treated with Buprenorphine or Methadone: Preliminary Findings. SUBSTANCE ABUSE-RESEARCH AND TREATMENT 2016; 10:89-97. [PMID: 27679504 PMCID: PMC5026197 DOI: 10.4137/sart.s38887] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 05/10/2016] [Accepted: 05/18/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Untreated opioid dependence in pregnant women is associated with adverse birth outcomes. Buprenorphine and methadone are options for opioid agonist medication-assisted treatment during pregnancy. OBJECTIVE The aim of this study was to describe adverse birth outcomes observed with buprenorphine or methadone treatment compared to the general population in Sweden. METHODS Pregnant women and their corresponding births during 2005–2011 were identified in the Swedish Medical Birth Register. Data on stillbirth, neonatal/infant death, mode of delivery, gestational age at birth, Apgar score, growth outcomes, neonatal abstinence syndrome, and congenital malformations were examined. Frequencies were compared using two-sided Fisher’s exact tests. Unadjusted estimates of birth outcomes for women treated with buprenorphine or methadone were compared to the registered general population. RESULTS A total of 746,257 pregnancies among 538,178 unique women resulted in 746,485 live births. Among the 194 women treated with buprenorphine (N = 176) or methadone (N = 52), no stillbirths or neonatal/infant deaths occurred. Neonatal abstinence syndrome developed in 23.3% and 38.5% of infants born to mothers treated with buprenorphine and methadone, respectively. The frequency of the selected adverse birth outcomes assessed in women treated with buprenorphine as compared to the general population was not significantly different. However, a significantly higher frequency of preterm birth and congenital malformations was observed in women treated with methadone as compared to the general population. Compared with the general population, methadone-treated women were significantly older than buprenorphine-treated women, and both treatment groups began prenatal care later, were more likely to smoke cigarettes, and did not cohabitate with the baby’s father. CONCLUSIONS An increased frequency of the selected adverse birth outcomes was not observed with buprenorphine treatment during pregnancy. Twofold increased frequency of preterm birth [2.21 (1.11, 4,41)] and congenital malformations [2.05 (1.08, 3.87)] was observed in the methadone group, which may be partly explained by older average maternal age and differences in other measured and unmeasured confounders.
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70
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Martin PR, Finlayson AJR. Opioid use disorder during pregnancy in Tennessee: expediency vs. science. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2016; 41:367-70. [PMID: 26186388 DOI: 10.3109/00952990.2015.1047502] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Methadone and buprenorphine are highly effective and commonly prescribed for the treatment of opioid use disorder. Both medications are also efficacious for the treatment of pregnant women with this disorder. In one third of states, however, Medicaid reimbursement will cover the cost of buprenorphine, but not methadone, to treat opioid use disorder in pregnant women. This commentary will explore the clinical and policy rational and consequences of this policy, with the opinion that this approach is guided by political expediency rather than sound clinical research. The commentary will focus on the pharmacological management of prescription opioid dependence during pregnancy in Tennessee, one of the states that restrict Medicaid coverage of pregnant women to buprenorphine. Tennessee is also relevant in that this state ranks second nationally in the rate of prescriptions written for opioid pain relievers; in contrast to injection opioid use in urban populations, opioid addiction in rural and southeastern regions of the US is characterized by use of non-injection prescription opioids. Until recently, most research-based recommendations for the management of opioid use disorder during pregnancy have derived from studies of women using opioids intravenously. The lack of research in non-injection opioid-using pregnant women may partially explain why policy rather than scientific evidence guides Medicaid reimbursement. It is hoped that future research in pregnant women addicted to prescription opioids will clarify which opioid addicted pregnant women have better outcomes with buprenorphine or methadone treatment and these findings, in turn, will inform Medicaid reimbursement.
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Affiliation(s)
- Peter R Martin
- a Department of Psychiatry , Vanderbilt University , Nashville , TN , USA
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71
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Meyer M, Phillips J. Caring for pregnant opioid abusers in Vermont: A potential model for non-urban areas. Prev Med 2015; 80:18-22. [PMID: 26212632 PMCID: PMC4592470 DOI: 10.1016/j.ypmed.2015.07.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 07/13/2015] [Accepted: 07/16/2015] [Indexed: 11/25/2022]
Abstract
Opioid addiction is no longer a primarily urban problem. As dependence on heroin and prescription pain relievers has become a significant issue in rural areas, the need for effective treatment of opioid-dependent pregnant women and their neonates has grown accordingly. In addition to the adverse perinatal outcomes associated with opioid addiction in pregnant women, the high costs of caring for these mothers and their babies motivate efforts to develop appropriate treatment models. We found that integration and coordination of services that promote maternal recovery and ability to parent are key requirements for treatment of opioid dependence during pregnancy. Unfortunately, lack of experience and resources makes such coordination a real challenge in rural areas. In this review, we discuss how we managed the challenges of developing a comprehensive program for treatment of opioid dependence during pregnancy. In addition, we outline our approach for facilitating the development of community-based programs to help these patients and families in rural regions of Vermont. Close relationships between our tertiary care center, local hospitals, community health care infrastructure, and legislators bolstered our efforts. In particular, appreciation for the severity and importance of the opioid-dependence problem in Vermont among health care providers and state legislators was paramount for our success in developing a state-wide treatment program. This approach can inform similar efforts in other rural regions of the United States, and has great potential to improve both access and quality of care for women struggling with opioid dependence.
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Affiliation(s)
- Marjorie Meyer
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Vermont, Burlington, VT 05401, United States.
| | - Julie Phillips
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Vermont, Burlington, VT 05401, United States
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72
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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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Methadone and buprenorphine during pregnancy. J Addict Med 2015; 9:252. [PMID: 26020157 DOI: 10.1097/adm.0000000000000135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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