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Umer A, Lilly C, Hamilton C, Breyel J, Allen L, Rompala A, Moore C, O'Dierno P, John C. Disparities in neonatal abstinence syndrome and health insurance status: A statewide study using non-claims real-time surveillance data. Paediatr Perinat Epidemiol 2021; 35:330-338. [PMID: 33111385 PMCID: PMC8386694 DOI: 10.1111/ppe.12728] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 08/24/2020] [Accepted: 08/28/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Most studies examining the relationship between neonatal abstinence syndrome (NAS) and health insurance status in the United States (USA) have used administrative insurance claims data, which is subject to myriad limitations. We examined the association between NAS and health insurance status in a large geographically defined rural population in the United States, using non-claims data. METHODS We utilized data from a population-based cohort of all newborns born in 2017-2019 in the rural state of West Virginia (WV) and restricted analyses to WV residents' births (n = 46 213). NAS was defined as neonatal withdrawal from many substances, including opiates and not limited to those cases that require pharmacological treatment. RESULTS Medicaid covered more than half (52.6%) of all infants' births in the state of WV. The incidence of NAS was 85.8 and 12.7 per 1000 livebirths in the Medicaid and privately insured groups, respectively. Among all infants diagnosed with NAS, 86.1% were enrolled in the state's Medicaid programme. The risk of NAS in the Medicaid-insured newborns was higher than privately insured newborns in the unadjusted analysis (risk ratio (RR) 6.76, 95% confidence interval (CI) 5.95, 7.68) and the adjusted analysis RR 3.00, 95% CI 2.01, 4.49); adjusted risk difference 20.3 (95% CI 17.5, 23.1 cases per 1000 livebirths). CONCLUSIONS NAS is an important indicator of the immediate effect of the opioid crisis. This study shows the disparity in NAS by health insurance status for a large rural population in the United States, and its burden on the state's Medicaid programme. Providing timely and accurate estimates of NAS is important for public health policies and decision making.
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Affiliation(s)
- Amna Umer
- Department of Pediatrics, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Christa Lilly
- Department of Biostatistics, School of Public Health, West Virginia University, Morgantown, WV, USA
| | - Candice Hamilton
- Department of Pediatrics, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Janine Breyel
- West Virginia Perinatal Partnership, Department of Obstetrics and Gynecology, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Lindsay Allen
- Department Health Policy, Management, and Leadership, School of Public Health, West Virginia University, Morgantown, WV, USA
| | - Ancilla Rompala
- Department of Pediatrics, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Carrie Moore
- Department of Pediatrics, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Patricia O'Dierno
- Department of Pediatrics, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Collin John
- Department of Pediatrics, School of Medicine, West Virginia University, Morgantown, WV, USA
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Placek CD, Place JM, Wies J. Reflections and Challenges of Pregnant and Postpartum Participant Recruitment in the Context of the Opioid Epidemic. Matern Child Health J 2021; 25:1031-1035. [PMID: 33904023 DOI: 10.1007/s10995-021-03143-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Opioid use disorder among women of childbearing age has reached epidemic proportions. In rural regions of the United States, recruiting perinatal women who use nonmedical opioids to participate in research is wrought with challenges, including barriers such as community stigma, lack of transportation, and time constraints. The current study describes our process and challenges of recruiting pregnant and postpartum women in rural Indiana consisting of women who misuse opioids and those who do not. DESCRIPTION We employed multiple strategies to recruit participants. Methods included (1) sampling from healthcare facilities based on referrals from front-desk staff and frontline healthcare workers; (2) dissemination of flyers and brochures within healthcare facilities and the community, supported with onsite research assistant presence; (3) digital methods coupled with snowball sampling; and (4) local community talks that provided information about the study. ASSESSMENT Our multiple recruitment efforts revealed that building relationships with community stakeholders was key in recruiting women who use nonmedical opioids, but that digital methods were more effective in recruiting a larger sample of pregnant and postpartum women in a short amount of time. CONCLUSION We conclude by making several recommendations to enhance academic-community partnerships in order to bolster sample sizes for prolonged research studies. Furthermore, we highlight the need to destigmatize addiction in order to better serve hard-to-reach populations through research and practice.
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Affiliation(s)
- Caitlyn D Placek
- Department of Anthropology, Ball State University, Muncie, IN, 47306, USA.
| | - Jean Marie Place
- Department of Nutrition and Health Science, Ball State University, Muncie, IN, USA
| | - Jennifer Wies
- Department of Anthropology, Eastern Kentucky University, Richmond, KY, 40475, USA
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Moreland A, Guille C, McCauley JL. Increased availability of telehealth mental health and substance abuse treatment for peripartum and postpartum women: A unique opportunity to increase telehealth treatment. J Subst Abuse Treat 2021; 123:108268. [PMID: 33612199 PMCID: PMC9759701 DOI: 10.1016/j.jsat.2020.108268] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/19/2020] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
Since the onset of the COVID-19 pandemic, several federal, state, and payor policy changes have facilitated the uptake of telehealth service delivery. These changes have resulted in a significant uptick in the utilization of maternal mental health and substance use disorder screening and treatment services for pregnant and postpartum women. The Medical University of South Carolina's [MUSC] Women's Reproductive Behavioral Health Program provides outpatient mental health and substance use treatment to pregnant and postpartum women within obstetric practices. With the onset of COVID-19, our program converted all of its screening for and treatment of mental health and substance use disorders to remote platforms. Lessons learned during this time may lay the foundation for transitioning to sustainable telehealth-based referral and delivery of substance use treatment more broadly.
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Affiliation(s)
- Angela Moreland
- Medical University of South Carolina, United States of America.
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Wallin CM, Bowen SE, Brummelte S. Opioid use during pregnancy can impair maternal behavior and the Maternal Brain Network: A literature review. Neurotoxicol Teratol 2021; 86:106976. [PMID: 33812002 DOI: 10.1016/j.ntt.2021.106976] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/26/2021] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Abstract
Opioid Use Disorder (OUD) is a global epidemic also affecting women of reproductive age. A standard form of pharmacological treatment for OUD is Opioid Maintenance Therapy (OMT) and buprenorphine has emerged as the preferred treatment for pregnant women with OUD relative to methadone. However, the consequences of BUP exposure on the developing Maternal Brain Network and mother-infant dyad are not well understood. The maternal-infant bond is dependent on the Maternal Brain Network, which is responsible for the dynamic transition from a "nulliparous brain" to a "maternal brain". The Maternal Brain Network consists of regions implicated in maternal care (e.g., medial preoptic area, nucleus accumbens, ventral pallidum, ventral tegmentum area) and maternal defense (e.g., periaqueductal gray). The endogenous opioid system modulates many of the neurochemical changes in these areas during the transition to motherhood. Thus, it is not surprising that exogenous opioid exposure during pregnancy can be disruptive to the Maternal Brain Network. Though less drastic than misused opioids, OMTs may not be without risk of disrupting the neural and molecular structures of the Maternal Brain Network. This review describes the Maternal Brain Network as a framework for understanding how pharmacological differences in exogenous opioid exposure can disrupt the onset and maintenance of the maternal brain and summarizes opioid and OMT (in particular buprenorphine) use in the context of pregnancy and maternal behavior. This review also highlights future directions for evaluating exogenous opioid effects on the Maternal Brain Network in the hopes of raising awareness for the impact of the opioid crisis not only on exposed infants, but also on mothers and subsequent mother-infant bonds.
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Affiliation(s)
- Chela M Wallin
- Department of Psychology, Wayne State University, Detroit, MI 48202, USA.
| | - Scott E Bowen
- Department of Psychology, Wayne State University, Detroit, MI 48202, USA.
| | - Susanne Brummelte
- Department of Psychology, Wayne State University, Detroit, MI 48202, USA.
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Macleod ER, Tajbakhsh I, Hamilton-Wright S, Laliberte N, Wiese JL, Matheson FI. "They're not doing enough.": women's experiences with opioids and naloxone in Toronto. SUBSTANCE ABUSE TREATMENT PREVENTION AND POLICY 2021; 16:26. [PMID: 33743756 PMCID: PMC7980746 DOI: 10.1186/s13011-021-00360-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 03/04/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Amid increasing opioid overdose deaths in Canada since 2010 and a changing naloxone access landscape, there is a need for up-to-date research on Canadian women's experiences with opioids. Studies on Canadian take-home naloxone programs are promising, but research beyond these programs is limited. Our study is the first to focus on women's experiences and perspectives on the opioid crisis in Ontario, Canada's most populous province, since the opioid crisis began in 2010. OBJECTIVE Our objective was to address research knowledge gaps involving Canadian women with criminal justice involvement who use opioids, and identify flaws in current policies, responses, and practices. While the opioid overdose crisis persists, this lack of research inhibits our ability to determine whether overdose prevention efforts, especially involving naloxone, are meeting their needs. METHODS We conducted semi-structured, qualitative interviews from January to April 2018 with 10 women with experience of opioid use. They were recruited through the study's community partner in Toronto. Participants provided demographic information, experiences with opioids and naloxone, and their perceptions of the Canadian government's responses to the opioid crisis. Interviews were transcribed verbatim and inductive thematic analysis was conducted to determine major themes within the data. RESULTS Thematic analysis identified seven major concerns despite significant differences in participant life and opioid use experiences. Participants who had used illicit opioids since naloxone became available over-the-counter in 2016 were much more knowledgeable about naloxone than participants who had only used opioids prior to 2016. The portability, dosage form, and effects of naloxone are important considerations for women who use opioids. Social alienation, violence, and isolation affect the wellbeing of women who use opioids. The Canadian government's response to the opioid crisis was perceived as inadequate. Participants demonstrated differing needs and views on ideal harm reduction approaches, despite facing similar structural issues surrounding stigma, addiction management, and housing. CONCLUSIONS Participants experienced with naloxone use found it to be useful in preventing fatal overdose, however many of their needs with regards to physical, mental, and social health, housing, harm reduction, and access to opioid treatment remained unmet.
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Affiliation(s)
- Emilie R Macleod
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada
| | - Iren Tajbakhsh
- Elizabeth Fry Society Toronto, 215 Wellesley Street East, Toronto, ON, M4X 1G1, Canada
| | - Sarah Hamilton-Wright
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada
| | - Nancy Laliberte
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Jessica L Wiese
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada
| | - Flora I Matheson
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada. .,Dalla Lana School of Public Health, University of Toronto, 55 College St Room 500, Toronto, ON, M5T 3M7, Canada.
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Titus-Glover D, Shaya FT, Welsh C, Qato DM, Shah S, Gresssler LE, Vivrette R. Opioid use disorder in pregnancy: leveraging provider perceptions to inform comprehensive treatment. BMC Health Serv Res 2021; 21:215. [PMID: 33691677 PMCID: PMC7945667 DOI: 10.1186/s12913-021-06182-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 02/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Medications for opioid use disorder (MOUD) are recommended with adjuvant behavioral therapies, counseling, and other services for comprehensive treatment of maternal opioid use disorder. Inadequate access to treatment, lack of prescribing providers and complex delivery models are among known barriers to care. Multi-disciplinary provider input can be leveraged to comprehend factors that facilitate or inhibit treatment. The objective of this study is to explore provider perceptions of MOUD and factors critical to comprehensive treatment delivery to improve the care of pregnant women with opioid use disorder. METHODS A qualitative research approach was used to gather data from individual provider and group semi-structured interviews. Providers (n = 12) responded to questions in several domains related to perceptions of MOUD, treatment delivery, access to resources, and challenges/barriers. Data were collected, transcribed, coded (by consensus) and emerging themes were analyzed using grounded theory methodology. RESULTS Emerging themes revealed persistent gaps in treatment and challenges in provider, health systems and patient factors. Providers perceived MOUD to be a "lifeline" to women. CONCLUSIONS Inconsistencies in treatment provision, access and uptake can be improved by leveraging provider perceptions, direct experiences and recommendations for an integrated team-based, patient-centered approach to guide the care of pregnant women with opioid use disorder.
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Affiliation(s)
- Doris Titus-Glover
- Department of Pharmaceutical Health Services Research (PHSR), School of Pharmacy, University of Maryland, Baltimore, USA.
- Present address: School of Nursing, University of Maryland, Baltimore, Universities at Shady Grove, 9640 Gudelsky Drive, Rockville, MD, 20850, USA.
| | - Fadia T Shaya
- Department of Pharmaceutical Health Services Research (PHSR), School of Pharmacy, University of Maryland, Baltimore, USA
| | - Christopher Welsh
- Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, USA
| | - Danya M Qato
- Department of Pharmaceutical Health Services Research (PHSR), School of Pharmacy, University of Maryland, Baltimore, USA
| | - Savyasachi Shah
- Department of Pharmaceutical Health Services Research (PHSR), School of Pharmacy, University of Maryland, Baltimore, USA
| | - Laura E Gresssler
- Department of Pharmaceutical Health Services Research (PHSR), School of Pharmacy, University of Maryland, Baltimore, USA
| | - Rebecca Vivrette
- Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, USA
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Yazdanfar N, Ali Mard S, Mahmoudi J, Bakhtiari N, Sarkaki A, Farnam A. Maternal Morphine Exposure and Post-Weaning Social Isolation Impair Memory and Ventral Striatum Dopamine System in Male Offspring: Is an Enriched Environment Beneficial? Neuroscience 2021; 461:80-90. [PMID: 33662528 DOI: 10.1016/j.neuroscience.2021.02.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 12/19/2022]
Abstract
Maternal opioids abuse has some deleterious consequences on next generations. Besides, children's rearing conditions can affect the behavioral states and brain plasticity in their later life. In the present study, we investigated the effects of maternal morphine (MOR) treatment and post-weaning rearing conditions on memory, pain threshold, and the ventral striatum dopaminergic activity in male offspring. Female Wistar rats were treated twice daily either with escalating doses of MOR or with normal saline (NS) one week before mating, during pregnancy and lactation. After weaning, the male pups were assigned to six groups and then raised for an 8-week period under three different conditions: standard (STD), isolated (ISO) or enriched environment (EE). The behavioral tests, including passive avoidance task, novel object recognition, and tail-flick test, were also performed. Moreover, the ventral striatum dopamine's content (DA), mRNA expressions of dopamine receptor 1(D1R) and dopamine receptor 2 (D2R), and dopamine transporter (DAT) were evaluated. The obtained data showed that maternal MOR exposure and post-weaning social isolation could dramatically impair memory in offspring, while EE could reverse these adverse outcomes. Moreover, results of tail flick latency indicated the increased pain threshold in EE animals. At molecular level, maternal MOR injections and social isolation reduced DA levels and altered expressions of D1R, D2R, and DAT within the ventral striatum of these male offspring. However, post-weaning EE partially buffered these changes. Our finding signified the effects of maternal MOR exposure and social isolation on the behaviors and neurochemistry of brain in next generation, and it also provided evidence on reversibility of these alterations following EE.
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Affiliation(s)
- Neda Yazdanfar
- Department of Neuroscience and Cognition, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran; Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Seyed Ali Mard
- The Persian Gulf Physiology Research Center, Medical Basic Sciences Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; Department of Physiology, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Javad Mahmoudi
- Neurosciences Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nima Bakhtiari
- Pain Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Alireza Sarkaki
- The Persian Gulf Physiology Research Center, Medical Basic Sciences Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; Department of Physiology, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Alireza Farnam
- Research Center of Psychiatry and Behavioral Sciences, Tabriz University of Medical Sciences, Tabriz, Iran.
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King Z, Kramer C, Latkin C, Sufrin C. Access to treatment for pregnant incarcerated people with opioid use disorder: Perspectives from community opioid treatment providers. J Subst Abuse Treat 2021; 126:108338. [PMID: 34116823 DOI: 10.1016/j.jsat.2021.108338] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 12/04/2020] [Accepted: 02/18/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Many jail facilities provide limited access to medications for opioid use disorder (MOUD) for pregnant people with opioid use disorder (OUD), despite it being the standard of care. We aim to explore the perspectives of opioid treatment providers (OTPs) on access to MOUD for pregnant people while incarcerated and postincarceration. METHODS We conducted 16 semistructured phone interviews with providers and administrators representing 16 unique OTPs in various U.S. states with high maternal opioid use rates. We developed the interview guide using the Consolidated Framework for Implementation Research, and we analyzed interview transcripts using a direct content analysis. RESULTS Nine participants reported having an arrangement with a carceral facility to provide care for pregnant people with OUD; however, others described how their local jail offered no OUD treatment for incarcerated pregnant people. Even if participants' clinics had arrangements to provide MOUD in a jail, most participants described significant barriers to continuity of care between jails and community providers as patients transition between jails and community settings. OTPs described their belief of how postincarceration, pregnant people experience barriers to OUD care such as lack of access to childcare, preparing for the baby, feeling unwell, in addition to the barriers that nonpregnant patients experience, such as transportation, housing, and financing. CONCLUSIONS OTPs perceive that pregnant people with OUD experience significant barriers to accessing treatment while incarcerated and in community settings due to discrimination, difficulties in continuity of care, and lack of treatment access while incarcerated. The implementation of evidence-based MOUD treatment for pregnant people in jail and continuation of treatment upon release is crucial to reduce health disparities.
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Affiliation(s)
- Zoe King
- Duke University, Trinity College of Arts & Sciences, 117 Physics Building, 120 Science Dr., Durham, NC 27708, United States.
| | - Camille Kramer
- Johns Hopkins University School of Medicine, Department of Gynecology and Obstetrics, Johns Hopkins Bayview Hospital, 4940 Eastern Ave, A121, Baltimore, MD 21224, United States.
| | - Carl Latkin
- Johns Hopkins University Bloomberg School of Public Health, Department of Health, Behavior and Society, 642 N Broadway, Baltimore, MD 21205, United States.
| | - Carolyn Sufrin
- Johns Hopkins University School of Medicine, Department of Gynecology and Obstetrics, Johns Hopkins Bayview Hospital, 4940 Eastern Ave, A121, Baltimore, MD 21224, United States; Johns Hopkins Bloomberg School of Public Health, Department of Health, Behavior and Society, 24 N. Broadway, Hampton House 737, Baltimore, MD 21205, United States.
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Currie CL, Tough SC. Adverse childhood experiences are associated with illicit drug use among pregnant women with middle to high socioeconomic status: findings from the All Our Families Cohort. BMC Pregnancy Childbirth 2021; 21:133. [PMID: 33583407 PMCID: PMC7882074 DOI: 10.1186/s12884-021-03591-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 01/26/2021] [Indexed: 11/10/2022] Open
Abstract
Background Adverse childhood experiences (ACEs) are associated with illicit drug use among pregnant women who are socioeconomically vulnerable. While it is assumed that the impact of ACEs on illicit drug use in pregnancy is reduced among women with higher socioeconomic status (SES), this assumption is not well tested in the literature. The objective of this study was to examine the impact of maternal ACEs on illicit drug use in a community-based sample of pregnant women with middle to high SES. Methods This study is a secondary analysis of a prospective cohort study that collected data from 1660 women during and after pregnancy in Calgary, Canada between 2008 and 2011 using mailed surveys. Illicit drug use in pregnancy was self-reported by women at 34–36 weeks gestation. An established scale examined maternal ACEs before 18 years. Logistic regression models and 95% confidence intervals tested associations between maternal ACE scores and illicit drug use in pregnancy. Results Overall, 3.1% of women in this predominantly married, well-educated, middle and upper middle income sample reported illicit drug use in pregnancy. Women with 2–3 ACEs had more than a two-fold increase, and women with 4 or more ACEs had almost a four-fold increase in illicit drug use in pregnancy, relative to women with 0–1 ACEs after adjustment for confounders. Exposure to child abuse was more consistently associated with illicit drug use in pregnancy than exposure to household dysfunction in childhood. Conclusions Maternal ACEs were common and associated with a moderate increase in the odds of illicit drug use in pregnancy among Canadian women with middle to high SES.
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Affiliation(s)
- Cheryl L Currie
- Faculty of Health Sciences, University of Lethbridge, M3083 Markin Hall, 4401 University Drive, Lethbridge, Alberta, T1K 3M4, Canada.
| | - Suzanne C Tough
- Cummings School of Medicine, University of Calgary, Calgary, Canada
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Darlington CK, Compton PA, Hutson SP. Revisiting the Fetal Assault Law in Tennessee: Implications and the Way Forward. Policy Polit Nurs Pract 2021; 22:93-104. [PMID: 33567969 DOI: 10.1177/1527154421989994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The rising prevalence of opioid use disorder (OUD) among those living in the United States has demanded a collaborative response from health care and policy spheres. Addressing OUD among pregnant women is especially difficult, given the controversies surrounding the medical and ethical balance between meeting maternal versus fetal/newborn needs. Most medical organizations discourage the criminalization of drug use in pregnancy due to the adverse public health outcomes of such an approach. Despite this recommendation, many states continue to use punitive law to address drug use in pregnancy. In 2014, the Fetal Assault Law in Tennessee (TN) became the first law in the United States to directly allow women to be prosecuted for drug use in pregnancy. Since its expiration in 2016, this law has been re-introduced several times to the TN legislature in support of permanent implementation. This article outlines the impact of the initial Fetal Assault Law on maternal/newborn health in TN and provides alternative immediate, short-term, and long-term health policy strategies through which health care providers and legislators can better advocate for the well-being of both mothers with OUD and their infants.
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Liang OS, Chen Y, Bennett DS, Yang CC. Identifying Self-Management Support Needs for Pregnant Women With Opioid Misuse in Online Health Communities: Mixed Methods Analysis of Web Posts. J Med Internet Res 2021; 23:e18296. [PMID: 33538695 PMCID: PMC7892281 DOI: 10.2196/18296] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 12/11/2020] [Accepted: 12/20/2020] [Indexed: 12/18/2022] Open
Abstract
Background The current opioid crisis in the United States impacts broad population groups, including pregnant women. Opioid use during pregnancy can affect the health and wellness of both mothers and their infants. Understanding women’s efforts to self-manage opioid use or misuse in pregnancy is needed to identify intervention points for improving maternal outcomes. Objective This study aims to identify the characteristics of women in an online health community (OHC) with opioid use or misuse during pregnancy and the self-management support needs of these mothers. Methods A total of 200 web posts by pregnant women with opioid use participating in an OHC were double coded. Concepts and their thematic connections were identified through an inductive process until theoretical saturation was reached. Statistical tests were performed to identify patterns. Results The majority of pregnant women (150/200, 75.0%) in the OHC exhibited signs of misuse, and 62.5% (125/200) of the participants were either contemplating or pursuing dosage reduction. Self-managed withdrawal was more common (P<.001) than professional treatment among the population. A total of 5 themes of self-management support needs were identified as women sought information about the potential adverse effects of gestational opioid use, protocols for self-managed withdrawal, pain management safety during pregnancy, hospital policies and legal procedures related to child protection, and strategies for navigating offline support systems. In addition, 58.5% (117/200) of the pregnant women expressed negative emotions, of whom only 10.2% (12/117) sought to address their emotional needs with the help of the OHC. Conclusions OHCs provide vital self-management support for pregnant women with opioid use or misuse. Women pursuing self-managed dosage reduction are prone to misinformation and repeated relapses, which can result in extreme measures to avoid testing positive for drug use at labor. The study findings provide evidence for public policy considerations, including universal screening of substance use for pregnant women, emphasis on treatment rather than legal punishment, and further expansion of the Drug Addiction Treatment Act waiver training program. The improvement of web-based platforms that can organize geo-relevant information, dispense clinically validated withdrawal schedules, and offer structured peer support is envisioned for harm reduction among pregnant women who opt for self-management of opioid misuse.
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Affiliation(s)
- Ou Stella Liang
- College of Computing and Informatics, Drexel University, Philadelphia, PA, United States
| | - Yunan Chen
- Donald Bren School of Information and Computer Sciences, University of California, Irvine, Irvine, CA, United States
| | - David S Bennett
- Department of Psychiatry, College of Medicine, Drexel University, Philadelphia, PA, United States
| | - Christopher C Yang
- College of Computing and Informatics, Drexel University, Philadelphia, PA, United States
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Abstract
At least one in seven pregnant or recently postpartum women will experience a mental illness such as an anxiety disorder, depressive disorder, or substance use disorder. These mental illnesses have detrimental effects on the health of the mother, child, and family, but little is known about the hypothalamic and other neural correlates of maternal mental health concerns. The transition to parenthood alone is a time of remarkable neural plasticity, so it is perhaps not surprising that current research is showing that maternal mental illness has unique neural profiles. Furthermore, the neural systems affected by peripartum mental illness overlap and interact with the systems involved in maternal caregiving behaviors, and mother-infant interactions are, therefore, highly susceptible to disruption. This review discusses what we know about the unique neural changes occurring during peripartum mental illness and the role of the hypothalamus in these illnesses. With an improved understanding of the neural correlates of maternal mental health and disease, we will be better equipped to predict risk, develop effective treatments, and ultimately prevent suffering for millions of parents during this critical time in life.
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Affiliation(s)
- Jodi L Pawluski
- Univ Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail), UMR S 1085, Rennes, France.
| | - James E Swain
- Department of Psychiatry and Behavioral Health, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, United States
| | - Joseph S Lonstein
- Neuroscience Program & Department of Psychology, Michigan State University, East Lansing, MI, United States
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Coulson CC, Lorencz E, Rittenhouse K, Ramage M, Lorenz K, Galvin SL. Association of Maternal Buprenorphine or Methadone Dose with Fetal Growth Indices and Neonatal Abstinence Syndrome. Am J Perinatol 2021; 38:28-36. [PMID: 31421639 DOI: 10.1055/s-0039-1694729] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Our objective was to compare fetal growth and incidence of neonatal abstinence syndrome requiring treatment across pregnant women with opioid use disorders on two types and two dose categories of medication-assisted treatment. STUDY DESIGN A retrospective cohort study was conducted in a comprehensive, perinatal program in western North Carolina comparing growth percentiles on third-trimester ultrasound and at birth, and diagnosis of neonatal abstinence syndrome requiring treatment. Singletons were exposed in utero to low- to moderate-dose buprenorphine (≤16 mg/day; n = 70), high-dose buprenorphine (≥17 mg/day; n = 36), low- to moderate-dose methadone (≤89 mg/day; n = 41), or high-dose methadone (≥90 mg/day; n = 74). Multivariate analysis of variance with posthoc Bonferroni comparisons (p ≤ 0.01) and multinomial logistic regressions (adjusted odds ratio, 99% confidence interval) were conducted. RESULTS Differences in neonatal outcomes reached statistical significance for larger head circumference for buprenorphine doses (p = 0.01) and for longer length (p < 0.01) and lower odds of neonatal abstinence syndrome requiring treatment (p < 0.01) with low- to moderate-dose buprenorphine versus high-dose methadone. CONCLUSION Among pregnant women using medication-assisted treatment for opioid use disorders, low- to moderate-dose buprenorphine (≤16 mg/day) was associated with the most favorable neonatal outcomes. However, more rigorous control of confounders with a larger sample is necessary to determine if low- to moderate-dose buprenorphine is the better treatment choice.
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Affiliation(s)
- Carol C Coulson
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina.,Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Erin Lorencz
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Katelyn Rittenhouse
- University of North Carolina School of Medicine-Asheville, Asheville, North Carolina
| | - Melinda Ramage
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Kathleen Lorenz
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Shelley L Galvin
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina.,Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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64
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Statler VA, Espinosa C. Management of Hepatitis C in Children and Adolescents. J Pediatric Infect Dis Soc 2020; 9:785-790. [PMID: 33043957 DOI: 10.1093/jpids/piaa114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/10/2020] [Indexed: 12/09/2022]
Abstract
The management of hepatitis C virus (HCV) infections has changed dramatically in recent years with the use of direct antiviral agents (AADs). New AADs have excellent safety profile and demonstrated to be highly effective. Interferon free regimens are now recommended for children and adolescents but significant barriers for treatment exist. Overcoming those barriers will facilitate HCV elimination. This review covers varied topics to familiarize providers with the current status of pediatric HCV management in light of newly available DAAs medications.
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Affiliation(s)
| | - Claudia Espinosa
- Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, USA
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Porter AC, Behrendt NJ, Zaretsky MV, Liechty KW, Wood C, Chow F, Galan HL. Continuous local bupivacaine wound infusion reduces oral opioid use for acute postoperative pain control following myelomeningocele repair. Am J Obstet Gynecol MFM 2020; 3:100296. [PMID: 33485023 DOI: 10.1016/j.ajogmf.2020.100296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/05/2020] [Accepted: 12/11/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND For pregnancies complicated by fetal myelomeningocele who meet the established criteria, prenatal closure is a viable management option. Prenatal closure is an open procedure, with some techniques requiring greater dissection of maternal tissue than cesarean delivery; pain control is an important postoperative goal. Given the rising rates of opioid dependence and concerns regarding the fetal and neonatal effects of opioid use, our practice has turned to nonopioid pain management techniques. OBJECTIVE This study aimed to compare postoperative opioid use and pain scores in women undergoing open fetal myelomeningocele repair with and without continuous local bupivacaine wound infusion. STUDY DESIGN This was a retrospective, single-center chart review of all consecutive patients who underwent open myelomeningocele repair from March 2013 to December 2019. Women were enrolled at the time of referral and locally followed for 2 weeks postoperatively. The control group received patient-controlled epidural analgesia for 48 hours with acetaminophen and oral and intravenous opioids as needed. The treatment group received patient-controlled epidural analgesia for 24 hours with acetaminophen, oral and intravenous opioids, and continuous local bupivacaine infusion. Pain scores, medication use, and postoperative milestones and complications through discharge were abstracted from the chart and compared. RESULTS Of 72 subjects, 51 were in the control group and 21 in the treatment group. Total opioid use, including intravenous doses (165 vs 52.5 mg; P=.001) and daily average oral opioid use (30 vs 10.5 mg; P=.002) were lower in the treatment group. In addition, 24% of women in the treatment group used no opioid postoperatively, compared with 4% in the control group. There was no difference in postoperative day 1 to 4 pain scores, antiemetic use, or bowel function; the treatment group was discharged significantly earlier. CONCLUSION Postoperative opioid use was reduced in women who received continuous local wound infusion of bupivacaine for incisional pain control after prenatal myelomeningocele repair. Pain control is paramount following open myelomeningocele repair; local bupivacaine wound infusion is an important adjunct to reduce opioid use postoperatively.
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Affiliation(s)
- Anne C Porter
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO.
| | - Nicholas J Behrendt
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Michael V Zaretsky
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Kenneth W Liechty
- Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO; Division of Pediatric Surgery; Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Cristina Wood
- Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Franklin Chow
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO
| | - Henry L Galan
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO; Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO
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66
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Chen G, Delcher C, Xiao H, Roussos-Ross D, Huo J, Chen X. Factors associated with opioid prescriptions among women proximal to pregnancy in the United States. Res Social Adm Pharm 2020; 17:1483-1488. [PMID: 33234451 DOI: 10.1016/j.sapharm.2020.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 09/08/2020] [Accepted: 11/11/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pregnant women are a vulnerable population exposed to opioids in the United States. OBJECTIVE To examine trends and factors associated with opioid prescribing to women proximal to pregnancy. METHODS The 2011 to 2015 Medical Expenditure Panel Survey (MEPS) was used to identify participants (n = 3020) with self-reported pregnancy or pregnancy-relevant events aged between 18 and 44 years old. To investigate factors associated with opioid prescriptions, we categorized participants into two subgroups: having one or more opioid prescription or having none during the observational period. We used survey multivariable logistic regression to identify factors associated with opioid prescribing accounting for the complex survey design in MEPS. RESULTS From 2011 to 2015, the prevalence of opioid prescribing among study participants was 31%. Opioids were more likely to be prescribed to women who had psychiatric conditions (odds ratio, 1,76, 95%CI: 1.27-2.44, p < 0.001). Other significant factors included being non-Hispanic white or black, living in the South, active tobacco users, and those with lower Physical Component Summary Scores. CONCLUSION Receipt of an opioid prescription in the perinatal period is associated with maternal psychiatric disorders in the United States. Study findings add new data to the literature on opioid use among pregnant women and provide evidence for healthcare providers and policy makers to tailor treatment and educational programs to avoid opioid overuse among pregnant women.
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Affiliation(s)
- Guanming Chen
- Department of Health Outcomes and Biomedical Informatics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Chris Delcher
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Hong Xiao
- Worldwide Health Economics and Outcomes Research, Bristol-Myers Squibb, New Jersey, USA
| | - Dikea Roussos-Ross
- Department of Obstetrics & Gynecology and Psychiatry, University of Florida College of Medicine, Gainesville, FL, USA
| | - Jinhai Huo
- Worldwide Health Economics and Outcomes Research, Bristol-Myers Squibb, New Jersey, USA
| | - Xinguang Chen
- Department of Epidemiology, College of Public Health, University of Florida, Gainesville, FL, USA.
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67
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Bryan MA, Smid MC, Cheng M, Fortenberry KT, Kenney A, Muniyappa B, Pendergrass D, Gordon AJ, Cochran G. Addressing opioid use disorder among rural pregnant and postpartum women: a study protocol. Addict Sci Clin Pract 2020; 15:33. [PMID: 33129355 PMCID: PMC7603672 DOI: 10.1186/s13722-020-00206-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/23/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Opioid use disorder (OUD) among women delivering at a hospital has increased 400% from 1999-2014 in the United States. From the years 2007 to 2016, opioid-related mortality during pregnancy increased over 200%, and drug-overdose deaths made up nearly 10% of all pregnancy-associated mortality in 2016 in the US. Disproportionately higher rates of neonatal opioid withdrawal syndrome (NOWS) have been reported in rural areas of the country, suggesting that perinatal OUD is a pressing issue among these communities. There is an urgent need for comprehensive, evidence-based treatment services for pregnant women experiencing OUD. The purpose of this article is to describe a study protocol aimed at developing and evaluating a perinatal OUD curriculum, enhancing evidence-based perinatal OUD treatment in a rural setting, and evaluating the implementation of such collaborative care for perinatal OUD. METHODS This two-year study employed a one group, repeated measures, hybrid type-1 effectiveness-implementation design. This study delivered interventions at 2 levels, both targeting improvement of care for pregnant women with OUD. The first area of focus was at the community healthcare provider-level, which aimed to evaluate the acceptability and feasibility of perinatal OUD education across time and to improve provider education by increasing knowledge specific to: MOUD provision; screening, brief intervention, and referral to treatment (SBIRT) utilization; and NOWS treatment. The second area of intervention focus was at the patient-level, which assessed the preliminary effect of perinatal OUD provider education in promoting illicit opioid abstinence and treatment engagement among pregnant women with OUD. We adopted constructs from the Consolidated Framework for Implementation Research (CFIR) to assess contextual factors that may influence implementation, and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model to comprehensively evaluate implementation outcomes. DISCUSSION This article presents the protocol of an implementation study that is employing the CFIR and RE-AIM frameworks to implement and evaluate a perinatal OUD education and service coordination program in two rural counties. This protocol could serve as a model for clinicians and researchers seeking to implement improvements in perinatal care for women with OUD in other rural communities. Trial registration NCT04448015 clinicaltrials.gov.
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Affiliation(s)
- M Aryana Bryan
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
| | - Marcela C Smid
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.,Department of Obstetrics and Gynecology, University of Utah School of Medicine, Division of Maternal Fetal Medicine, Salt Lake City, UT, 84132, USA
| | - Melissa Cheng
- Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way Ste. A, Salt Lake City, UT, 84108, USA
| | - Katherine T Fortenberry
- Department of Family and Preventive Medicine, University of Utah School of Medicine, 375 Chipeta Way Ste. A, Salt Lake City, UT, 84108, USA
| | - Amy Kenney
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Bhanu Muniyappa
- Department of Pediatrics, University of Utah School of Medicine, Division of General Pediatrics, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | | | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.,Greater Intermountain Node (GIN), NIH NIDA Clinical Trials Network, University of Utah, Salt Lake City, UT, USA.,Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Gerald Cochran
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.,Greater Intermountain Node (GIN), NIH NIDA Clinical Trials Network, University of Utah, Salt Lake City, UT, USA
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68
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Knittel AK, Zarnick S, Thorp JM, Amos E, Jones HE. Medications for opioid use disorder in pregnancy in a state women's prison facility. Drug Alcohol Depend 2020; 214:108159. [PMID: 32683223 PMCID: PMC7977476 DOI: 10.1016/j.drugalcdep.2020.108159] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/16/2020] [Accepted: 06/21/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Medication for opioid use disorder (MOUD) improves both maternal and neonatal outcomes for pregnant women with opioid use disorder (OUD). Although correctional policies often state that incarcerated pregnant women with OUD should receive MOUD, implementation data is scant. Our aims were to 1) quantify the extent to which pregnant women in a Southeastern prison received MOUD during their incarceration; 2) to describe the medications and doses used during incarceration and frequency of MOUD referral after incarceration; and 3) identify associations between maternal characteristics and receipt of MOUD in order to identify points of intervention for clinical policy change. METHODS We conducted a retrospective chart review of pregnant women with OUD in a North Carolina state women's prison from 2016-2018. We collected MOUD, demographic, custody, pregnancy, and pre-incarceration substance use data. We used descriptive statistics, chi square tests, and logistic regression. RESULTS There were 179 pregnant women with OUD. During incarceration, 11.7 % received buprenorphine, 17.8 % methadone, 22.8 % oxycodone, and 47.8 % did not receive any opioid medications. Of those who received buprenorphine, methadone, and no MOUD, respectively, 65 %, 51.2 %, and 3.2 % were referred for community MOUD. Women were more likely to receive MOUD during incarceration if they had received MOUD pre-incarceration. CONCLUSIONS There was significant unmet need for MOUD and MOUD referral among pregnant women imprisoned in North Carolina from 2016-2018. Our findings suggest that the initial assessment for MOUD and referral to a community MOUD provider may represent opportunities to improve MOUD access for this population.
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Affiliation(s)
- Andrea K. Knittel
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | | | - John M. Thorp
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Elton Amos
- North Carolina Department of Public Safety, Raleigh, NC
| | - Hendree E. Jones
- UNC Horizons, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
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Patrick SW, Richards MR, Dupont WD, McNeer E, Buntin MB, Martin PR, Davis MM, Davis CS, Hartmann KE, Leech AA, Lovell KS, Stein BD, Cooper WO. Association of Pregnancy and Insurance Status With Treatment Access for Opioid Use Disorder. JAMA Netw Open 2020; 3:e2013456. [PMID: 32797175 PMCID: PMC7428808 DOI: 10.1001/jamanetworkopen.2020.13456] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Medications for opioid use disorder, including buprenorphine hydrochloride and methadone hydrochloride, are highly effective at improving outcomes for individuals with the disorder. For pregnant women, use of these medications also improves pregnancy outcomes, including the risk of preterm birth. Despite the known benefits of medications for opioid use disorder, many pregnant and nonpregnant women with the disorder are not receiving them. OBJECTIVE To determine whether pregnancy and insurance status are associated with a woman's ability to obtain an appointment with an opioid use disorder treatment clinician. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study with random assignment of clinicians and simulated-patient callers (performed in "secret shopper" format), outpatient clinics that provide buprenorphine and methadone were randomly selected from publicly available treatment lists in 10 US states (selected for variability in opioid-related outcomes and policies) from March 7 to September 5, 2019. Pregnant vs nonpregnant woman and private vs public insurance assigned randomly to callers to create unique patient profiles. Simulated patients called the clinics posing as pregnant or nonpregnant women to obtain an initial appointment with a clinician. MAIN OUTCOMES AND MEASURES Appointment scheduling, wait time, and out-of-pocket costs. RESULTS A total of 10 871 unique patient profiles were assigned to 6324 clinicians. Among all women, 2312 of 3420 (67.6%) received an appointment with a clinician who prescribed buprenorphine, with lower rates among pregnant vs nonpregnant callers (1055 of 1718 [61.4%] vs 1257 of 1702 [73.9%]; relative risk, 0.83; 95% CI, 0.79-0.87). For clinicians who prescribed methadone, there was no difference in appointment access for pregnant vs nonpregnant callers (240 of 271 [88.6%] vs 237 of 265 [89.4%]; relative risk, 0.99; 95% CI, 0.93-1.05). Insurance was frequently not accepted, with 894 of 3420 buprenorphine-waivered prescribers (26.1%) and 174 of 536 opioid treatment programs (32.5%) granting appointments only when patients agreed to pay cash. Median wait times did not differ between pregnant and nonpregnant callers among buprenorphine prescribers (3 days [interquartile range, 1-7 days] vs 3 days [interquartile range, 1-7 days]; P = .43) but did differ among methadone prescribers (1 day [interquartile range, 1-4 days] vs 2 days [interquartile range, 1-6 days]; P = .049). For patients agreeing to pay cash, the median out-of-pocket costs for initial appointments were $250 (interquartile range, $155-$300) at buprenorphine prescribers and $34 (interquartile range, $15-$120) at methadone prescribers. CONCLUSIONS AND RELEVANCE In this cross-sectional study with random assignment of clinicians and simulated-patient callers, many women, especially pregnant women, faced barriers to accessing treatment. Given the high out-of-pocket costs and lack of acceptance of insurance among many clinicians, access to affordable opioid use disorder treatment is a significant concern.
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Affiliation(s)
- Stephen W. Patrick
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - William D. Dupont
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elizabeth McNeer
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melinda B. Buntin
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Peter R. Martin
- Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew M. Davis
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital and Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Katherine E. Hartmann
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashley A. Leech
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kim S. Lovell
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Bradley D. Stein
- RAND Corporation, Pittsburgh, Pennsylvania
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - William O. Cooper
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
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Singh R, Rothstein R, Ricci K, Visintainer P, Shenberger J, Attwood E, Friedmann P. Partnering with parents to improve outcomes for substance exposed newborns-a pilot program. J Perinatol 2020; 40:1041-1049. [PMID: 32203180 DOI: 10.1038/s41372-020-0662-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/02/2020] [Accepted: 03/11/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Assess impact of parental involvement in care provision for term substance exposed newborns (SENs). STUDY DESIGN Prospective observational cohort study included mothers with opioid use disorder and their SENs over 4 year study period. Maternal-Infant dyads enrolled in EMPOWER and rooming-in (RI) programs were included and received care 24/7 in a private room until newborn's discharge. Outcomes were compared for dyads participating in EMPOWER/RI with historical controls. RESULTS Ninety of 156 historical SENs were RI eligible, while 49 of 108 SENs born during RI period had mothers enrolled in EMPOWER. EMPOWER/RI SENs had lower rates for and duration of pharmacotherapy, shorter neonatal intensive care unit (NICU) and hospital lengths of stay. EMPOWER/RI increased initiation and continuation of breastfeeding at discharge. CONCLUSIONS Parental participation was associated with a decrease in initiation and duration of pharmacotherapy, NICU admission, length of stay and hospital charges while increasing breastfeeding initiation and continuation at discharge.
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Affiliation(s)
- Rachana Singh
- Baystate Medical Center, Springfield, MA, USA. .,University of Massachusetts Medical School-Baystate, Springfield, MA, USA.
| | - Rachel Rothstein
- Baystate Medical Center, Springfield, MA, USA.,Penn State College of Medicine, Hershey, PA, USA
| | - Karen Ricci
- Baystate Medical Center, Springfield, MA, USA
| | - Paul Visintainer
- University of Massachusetts Medical School-Baystate, Springfield, MA, USA.,Office of Research, UMMS-Baystate, Springfield, MA, USA
| | - Jeffrey Shenberger
- Baystate Medical Center, Springfield, MA, USA.,Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Eilean Attwood
- Baystate Medical Center, Springfield, MA, USA.,University of Massachusetts Medical School-Baystate, Springfield, MA, USA
| | - Peter Friedmann
- Baystate Medical Center, Springfield, MA, USA.,Office of Research, UMMS-Baystate, Springfield, MA, USA
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Newville J, Maxwell JR, Kitase Y, Robinson S, Jantzie LL. Perinatal Opioid Exposure Primes the Peripheral Immune System Toward Hyperreactivity. Front Pediatr 2020; 8:272. [PMID: 32670993 PMCID: PMC7332770 DOI: 10.3389/fped.2020.00272] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/29/2020] [Indexed: 11/29/2022] Open
Abstract
The increased incidence of opioid use during pregnancy warrants investigation to reveal the impact of opioid exposure on the developing fetus. Exposure during critical periods of development could have enduring consequences for affected individuals. Particularly, evidence is mounting that developmental injury can result in immune priming, whereby subsequent immune activation elicits an exaggerated immune response. This maladaptive hypersensitivity to immune challenge perpetuates dysregulated inflammatory signaling and poor health outcomes. Utilizing an established preclinical rat model of perinatal methadone exposure, we sought to investigate the consequences of developmental opioid exposure on in vitro activation of peripheral blood mononuclear cells (PBMCs). We hypothesize that PBMCs from methadone-exposed rats would exhibit abnormal chemokine and cytokine expression at baseline, with exaggerated chemokine and cytokine production following immune stimulation compared to saline-exposed controls. On postnatal day (P) 7, pup PMBCs were isolated and cultured, pooling three pups per n. Following 3 and 24 h, the supernatant from cultured PMBCs was collected and assessed for inflammatory cytokine and chemokine expression at baseline or lipopolysaccharide (LPS) stimulation using multiplex electrochemiluminescence. Following 3 and 24 h, baseline production of proinflammatory chemokine and cytokine levels were significantly increased in methadone PBMCs (p < 0.0001). Stimulation with LPS for 3 h resulted in increased tumor necrosis factor (TNF-α) and C-X-C motif chemokine ligand 1 (CXCL1) expression by 3.5-fold in PBMCs from methadone-exposed PBMCs compared to PBMCs from saline-exposed controls (p < 0.0001). Peripheral blood mononuclear cell hyperreactivity was still apparent at 24 h of LPS stimulation, evidenced by significantly increased TNF-α, CXCL1, interleukin 6 (IL-6), and IL-10 production by methadone PMBCs compared to saline control PBMCs (p < 0.0001). Together, we provide evidence of increased production of proinflammatory molecules from methadone PBMCs at baseline, in addition to sustained hyperreactivity relative to saline-exposed controls. Exaggerated peripheral immune responses exacerbate inflammatory signaling, with subsequent consequences on many organ systems throughout the body, such as the developing nervous system. Enhanced understanding of these inflammatory mechanisms will allow for appropriate therapeutic development for infants who were exposed to opioids during development. Furthermore, these data highlight the utility of this in vitro PBMC assay technique for future biomarker development to guide specific treatment for patients exposed to opioids during gestation.
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Affiliation(s)
- Jessie Newville
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Jessie R. Maxwell
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM, United States
- Departments of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Yuma Kitase
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Shenandoah Robinson
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Lauren L. Jantzie
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Neurology, Kennedy Krieger Institute, Baltimore, MD, United States
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Morelli MK, Veve MP, Shorman MA. Maternal Bacteremia Caused by Staphylococcus Aureus With a Focus on Infective Endocarditis. Open Forum Infect Dis 2020; 7:ofaa239. [PMID: 32766382 PMCID: PMC7397833 DOI: 10.1093/ofid/ofaa239] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 06/11/2020] [Indexed: 11/13/2022] Open
Abstract
Background Sepsis is an important cause of morbidity and mortality in the pregnant patient. Injection drug use in pregnant populations has led to increased cases of bacteremia and infective endocarditis (IE) due to Staphylococcus aureus. We describe all cases of S. aureus bacteremia and IE among admitted pregnant patients at our hospital over a 6-year period. Methods This was a retrospective review of pregnant patients hospitalized with S. aureus bacteremia between April 2013 and November 2019. Maternal in-hospital mortality and fetal in-hospital mortality were the primary outcomes measured; the secondary outcome was the rate of 6-month maternal readmission. Results Twenty-seven patients were included; 15 (56%) had IE. The median (interquartile range [IQR]) age was 29 (25-33) years; 22 (82%) patients had methicillin-resistant S. aureus. Infection onset occurred at a median (IQR) of 29 (23-34) weeks' gestation. Twenty-three (85%) mothers reported active injection drug use, and 21 (78%) were hepatitis C seropositive. Fifteen (56%) mothers required intensive care unit (ICU) care. Twenty-two (81%) patients delivered 23 babies; of the remaining 5 mothers, 3 (11%) were lost to follow-up and 2 (7%) terminated pregnancy. Sixteen (73%) babies required neonatal ICU care, and 4/25 (16%) infants/fetuses died during hospitalization. One (4%) mother died during hospitalization, and 7/26 (27%) mothers were readmitted to the hospital within 6 months for infectious complications. Conclusions Injection drug use is a modifiable risk factor for S. aureus bacteremia in pregnancy. Fetal outcomes were poor, and mothers were frequently readmitted secondary to infection. Future targeted interventions are needed to curtail injection drug use in this population.
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Affiliation(s)
- Morgan K Morelli
- University of Tennessee Medical Center, Knoxville, Tennessee, USA
| | - Michael P Veve
- University of Tennessee Medical Center, Knoxville, Tennessee, USA.,Department of Clinical Pharmacy and Translational Science, College of Pharmacy, University of Tennessee Health Science Center, Knoxville, Tennessee, USA
| | - Mahmoud A Shorman
- University of Tennessee Medical Center, Knoxville, Tennessee, USA.,Department of Internal Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, USA
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Martinez A, Allen A. A review of nonpharmacological adjunctive treatment for postpartum women with opioid use disorder. Addict Behav 2020; 105:106323. [PMID: 32036191 DOI: 10.1016/j.addbeh.2020.106323] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 12/16/2019] [Accepted: 01/16/2020] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Over the past decade, opioid use disorder (OUD) among pregnant women has increased by over 400%. Although medication assisted treatment (MAT) provides necessary care for women with OUD, effective adjunctive nonpharmacological treatments have not been systematically identified. This is especially concerning for the postpartum period, which includes several unique risk factors (e.g., sleep deprivation, mood disturbances) for MAT non-adherence and relapse. This review summarizes the existing knowledge regarding nonpharmacological treatments for OUD during the postpartum period, as well as provides recommendations for the future. METHODS PubMed and PsycINFO were searched in July 2018 using combinations of 28 keywords. Eligibility criteria included: (1) coverage of postpartum period, (2) use of nonpharmacological treatment for OUD, (3) conducted in clinical samples, and (4) written in English. RESULTS A total of 4 out of 38 identified articles met eligibility criteria. Two of the studies offered weekly on-site group counseling, with one also offering monthly social worker meetings. The third study offered four sessions with a patient navigator during the postpartum period. The last offered an employment intervention. All four reported favorable effects on OUD at end of follow-up (range: 30 days postpartum to 1 year postpartum). However, the details of the interventions, methodologies, and abstinence rates were sparse. DISCUSSION Few published studies examine nonpharmacological OUD treatments specific to the postpartum period. Identification of adjunctive nonpharmacological treatments designed to the unique needs of postpartum women is of critical public health importance, and further research is needed.
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74
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Special High-Risk Populations in Dentistry: The Adolescent Patient, the Elderly Patient, and the Woman of Childbearing Age. Dent Clin North Am 2020; 64:585-595. [PMID: 32448461 DOI: 10.1016/j.cden.2020.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Comprehensive and compassionate treatment of vulnerable patients is an important service to the community, although dental treatment of special populations can represent a challenge. The dental provider must be able to recognize the issues surrounding substance use and abuse, coordinate care with medical providers, and build a trusting provider-patient relationship to achieve success. Open conversations regarding expectations of pain, and the risks, benefits, and alternatives to opioids are important aspects of the best care of these patients.
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75
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Woodruff K, Roberts SCM. "Alcohol During Pregnancy? Nobody Does That Anymore": State Legislators' Use of Evidence in Making Policy on Alcohol Use in Pregnancy. J Stud Alcohol Drugs 2020. [PMID: 31250804 DOI: 10.15288/jsad.2019.80.380] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE In recent years, U.S. states have passed many laws addressing alcohol use in pregnancy, despite limited evidence on the impact of such policies. This study explores how state legislators use evidence when making policy on alcohol use in pregnancy. METHOD Study data are drawn from semistructured interviews with 29 state lawmakers and their aides in Maryland, North Carolina, and Virginia, conducted in March through July 2017. Interview transcripts were coded and analyzed by inductive and deductive methods. RESULTS Despite evidence on the harms of alcohol use in pregnancy, most lawmakers did not express concern about this topic. Instead, they expressed concern about opioid use in pregnancy. Personal experiences, anecdotes, and known contacts influenced legislators' views on substance use in pregnancy, whereas evidence, for the most part, did not. The intermediaries who typically bring evidence about problems and solutions to legislators did not appear to be raising the issue of alcohol use in pregnancy on legislators' agenda. CONCLUSIONS Basic evidence on the prevalence and harms of alcohol use in pregnancy did not appear to influence state lawmakers' policy priorities. Concern over opioid use in general may provide a window of opportunity to educate legislators on the relative scope and harms of alcohol and opioid use in pregnancy. It remains unclear why states are passing alcohol-in-pregnancy policies. More research is needed to explore how state lawmakers form their understanding of substance use in pregnancy and related policies.
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Affiliation(s)
- Katie Woodruff
- Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, Oakland, California
| | - Sarah C M Roberts
- Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, Oakland, California
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Goodman DJ, Saunders EC, Wolff KB. In their own words: a qualitative study of factors promoting resilience and recovery among postpartum women with opioid use disorders. BMC Pregnancy Childbirth 2020; 20:178. [PMID: 32188411 PMCID: PMC7081623 DOI: 10.1186/s12884-020-02872-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 03/10/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Opioid use disorder (OUD) is associated with substantial morbidity and mortality for women, especially during the perinatal period. Opioid overdose has become a significant cause of maternal death in the United States, with rates highest in the immediate postpartum year. While pregnancy is a time of high motivation for healthcare engagement, unique challenges exist for pregnant women with OUD seeking both substance use treatment and maternity care, including managing change after birth. How women successfully navigate these barriers, engage in treatment, and abstain from substance use during pregnancy and postpartum is poorly understood. The aim of this study is to explore the experiences of postpartum women with OUD who successfully engaged in both substance use treatment and maternity care during pregnancy, to understand factors contributing to their ability to access care and social support. METHODS We conducted semi-structured, in-depth interviews with postpartum women in sustained recovery (n = 10) engaged in a substance use treatment program in northern New England. Interviews were analyzed using grounded theory methodology. RESULTS Despite multiple barriers, women identified pregnancy as a change point from which they were able to develop self-efficacy and exercise agency in seeking care. A shift in internal motivation enabled women to disclose need for OUD treatment to maternity care providers, a profoundly significant moment. Concurrently, women developed a new capacity for self-care, demonstrated through managing relationships with providers and family members, and overcoming logistical challenges which had previously seemed overwhelming. This transformation was also expressed in making decisions based on pregnancy risk, engaging with and caring for others, and providing peer support. Women developed resilience through the interaction of inner motivation and their ability to positively utilize or transform external factors. CONCLUSIONS Complex interactions occurred between individual-level changes in treatment motivation due to pregnancy, emerging self-efficacy in accessing resources, and engagement with clinicians and peers. This transformative process was identified by women as a key factor in entering recovery during pregnancy and sustaining it postpartum. Clinicians and policymakers should target the provision of services which promote resilience in pregnant women with OUD.
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Affiliation(s)
- Daisy J. Goodman
- Dartmouth Geisel School of Medicine, 46 Centerra Parkway, Office 338, Lebanon, NH 03766 USA
- The Dartmouth Institute for Health Policy and Clinical Practice, 74 College Street, Vail Building 709, Dartmouth College, Hanover, NH 03755 USA
| | - Elizabeth C. Saunders
- The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, 46 Centerra Parkway, Lebanon, NH 03766 USA
| | - Kristina B. Wolff
- The Dartmouth Institute for Health Policy and Clinical Practice, 74 College Street, Vail Building 709, Dartmouth College, Hanover, NH 03755 USA
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Ko JY, Tong VT, Haight SC, Terplan M, Stark L, Snead C, Schulkin J. Obstetrician-gynecologists' practices and attitudes on substance use screening during pregnancy. J Perinatol 2020; 40:422-432. [PMID: 31666646 PMCID: PMC7047638 DOI: 10.1038/s41372-019-0542-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/29/2019] [Accepted: 10/20/2019] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To describe obstetrician-gynecologists' practices and attitudes related to substance use screening in pregnant patients. STUDY DESIGN A 2017 cross-sectional survey assessed US obstetrician-gynecologists' (n = 462; response rate = 34%) practices (substance use screening frequency and methods) and attitudes (practice priority of screening, confidence in treating, and responsibility statements). Chi-squared tests and adjusted modified Poisson regression were used to estimate associations between practices and attitudes. RESULTS Of 353 respondents with screening information, 79% frequently screen for substance use and 11% used a validated instrument. Confidence was the highest for treating pregnant patients using tobacco (81%). Respondents whose practices make it a high priority to screen for all substances were 1.2 times as likely to frequently screen as their counterparts (95% CI: 1.1-1.3). CONCLUSIONS Four out of five obstetricians-gynecologists reported a high frequency of substance use screening in pregnant patients. Findings highlight the importance of increasing priority of substance use screening by obstetrician-gynecologists.
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Affiliation(s)
- Jean Y Ko
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS-S107-2, Atlanta, GA, 30341, USA.
- United States Public Health Service, Commissioned Corps, Rockville, MD, 20857, USA.
| | - Van T Tong
- Division of Congenital and Developmental Disorders, National Center for Birth Defects and Developmental Disorders, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS-S106-3, Atlanta, GA, 30341, USA
| | - Sarah C Haight
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS-S107-2, Atlanta, GA, 30341, USA
| | - Mishka Terplan
- Friends Research Institute, 1040 Park Ave Suite 103, Baltimore, MD, 21201, USA
| | - Lauren Stark
- Research Department, American College of Obstetricians and Gynecologists (ACOG), 409 12th Street SW, Washington, DC, 20024, USA
| | - Carrie Snead
- Research Department, American College of Obstetricians and Gynecologists (ACOG), 409 12th Street SW, Washington, DC, 20024, USA
| | - Jay Schulkin
- Department of Obstetrics and Gynecology, University of Washington School of Medicine, Box 356460, Seattle, WA, 98195, USA
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Poljak D, Chappelle J. The effect of a scheduled regimen of acetaminophen and ibuprofen on opioid use following cesarean delivery. J Perinat Med 2020; 48:153-156. [PMID: 31951589 DOI: 10.1515/jpm-2019-0322] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/13/2019] [Indexed: 11/15/2022]
Abstract
Objective The primary objective was to evaluate if the administration of ibuprofen and acetaminophen at regularly scheduled intervals impacts pain scores and total opioid consumption, when compared to administration based on patient demand. Methods A retrospective chart review was performed comparing scheduled vs. as-needed acetaminophen and ibuprofen regimens, with 100 women included in each arm. Demographics and delivery characteristics were collected in addition to pain scores and total ibuprofen, acetaminophen and oxycodone use at 24, 48 and 72 h postoperatively. Results The scheduled dosing group was found to have a statistically significant decrease in pain scores at all time intervals. Acetaminophen and ibuprofen usage were also noted to be higher in this group while narcotic use was reduced by 64%. Conclusion Scheduled dosing of non-narcotic pain medications can substantially decrease opioid usage after cesarean delivery and improve post-operative pain.
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Affiliation(s)
- Dijana Poljak
- Washington University, Mail Stop 8064-37-1005, 4901 Forest Park Ave, St Louis, MO 63108, USA
| | - Joseph Chappelle
- Stony Brook University Hospital, 101 Nicolls Rd, HSC 9-090, Stony Brook, NY 11794, USA
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Prenatal Opioid Maintenance in the United States and Its Effect on Neonatal Abstinence Syndrome: The Case of West Virginia's Opioid Epidemic. Health Care Manag (Frederick) 2020; 38:258-266. [PMID: 31261194 DOI: 10.1097/hcm.0000000000000268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
West Virginia's opioid epidemic has been the cause of more than 42 000 deaths each year. Opioid abuse has become an issue among pregnant mothers and has increased the effects of neonatal abstinence syndrome (NAS) in infants. The purpose of this study was to evaluate the participation of prenatal opioid maintenance to determine whether it has decreased the amount of treatment needed for NAS in infants in West Virginia. The methodology utilized a literature review complemented with a semistructured interview. Thirty-six sources were referenced for this literature review. It was found that buprenorphine maintenance therapy had the most positive effect on NAS after birth. This review also reported a lack of availability for addicted pregnant women to enroll in maintenance programs and a high dropout rate. Opioid maintenance therapy has permitted pregnant women to refrain from illicit drug use without experiencing withdrawal symptoms, and it has allowed the opportunity for their infants to have better health after birth.
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80
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Delker BC, Van Scoyoc A, Noll LK. Contextual influences on the perception of pregnant women who use drugs: Information about women's childhood trauma history reduces punitive attitudes. J Trauma Dissociation 2020; 21:103-123. [PMID: 31608822 DOI: 10.1080/15299732.2019.1675221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Punitive attitudes and consequences (e.g., incarceration) for prenatal illicit drug use persist in the United States despite evidence that these policies are ineffective and even harmful to women and children. For instance, the threat of these consequences can deter women from seeking healthcare, prenatal care, and drug treatment. Punitive responses may persist due to pejorative public perceptions of pregnant women who use illicit drugs. Although there is evidence that contextual information about prenatal drug use (e.g., drug type) can change such perceptions, other contextual influences are unknown. This experimental study tested whether receiving contextual information about a pregnant woman who uses drugs (specifically, her childhood trauma history) reduces punitive and increases supportive attitudes toward the woman. In a vignette-based 2(pregnancy status: pregnant/not pregnant) x 2(history of childhood trauma: interpersonal/non-interpersonal) between-subjects design, young adult university participants (N = 461) were randomly assigned to read a vignette about a woman who uses methamphetamine. Punitive attitudes were significantly reduced by information that the pregnant woman had a history of childhood trauma, especially interpersonal (versus non-interpersonal) trauma (ηp2 = .115). Supportive attitudes were not impacted (ηp2 = .005). Information about the pregnant woman's trauma history predicted less agreement with incarcerating her, only indirectly, through less punitive attitudes (R2 = .21). Reductions in punitive attitudes were on the order of 1.5-2 points on 5-point self-report scales and controlled for participant gender and political conservatism. Results have practical implications for interdisciplinary work aimed at unlocking greater support for policies that help pregnant women make safe, informed decisions with dignity and access to healthcare.
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Affiliation(s)
- Brianna C Delker
- Department of Psychology, University of Oregon, Eugene, Oregon, USA
| | | | - Laura K Noll
- Department of Psychology, University of Oregon, Eugene, Oregon, USA
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81
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Bowen EA, Irish A. A policy mapping analysis of goals, target populations, and punitive notions in the U.S. congressional response to the opioid epidemic. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 74:90-97. [DOI: 10.1016/j.drugpo.2019.09.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/26/2019] [Accepted: 09/23/2019] [Indexed: 11/29/2022]
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Chang G, Ondersma SJ, Blake-Lamb T, Gilstad-Hayden K, Orav EJ, Yonkers KA. Identification of substance use disorders among pregnant women: A comparison of screeners. Drug Alcohol Depend 2019; 205:107651. [PMID: 31683243 DOI: 10.1016/j.drugalcdep.2019.107651] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 09/11/2019] [Accepted: 09/12/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study is to evaluate five self-report, non-proprietary questionnaires in the identification of substance use disorders [including alcohol, cannabis, opioids, and stimulants] among pregnant women. PROCEDURES A total of 1220 pregnant women completed the NIDA Quick Screen, CRAFFT, Substance Use Risk Profile-Pregnancy (SURP-P), Wayne Indirect Drug Use Questionnaire (WIDUS), and the 5 Ps, as well as the MINI diagnostic interview for substance use disorders, which served as the reference standard. Measures of merit calculated for each screener included sensitivity, specificity, accuracy, and area under the receiver operating curve (AUROC). MAIN FINDINGS The participants were socioeconomically diverse, with a mean age of 29 years. Over 15% met diagnostic criteria for a substance use disorder. AUROCS for identifying any substance use disorder (including alcohol) ranged from a high of 0.75 for the CRAFFT (95% CI = 0.72-79) and 0.74 for the SURP-P (95% CI = 0.71-.78) to a low of 0.62 for the NIDA Quick Screen (95% CI = 0.59-.65). Overall accuracy of most tested measures was higher for identification of alcohol use disorders than for other substance use disorders (e.g., AUROCs for the CRAFFT and SURP-P for identifying alcohol use disorders were 0.78 and 0.77, respectively). PRINCIPAL CONCLUSIONS The CRAFFT and SURP-P showed modest ability to identify substance use disorders among pregnant women. Future research is needed to develop an ideal questionnaire set in the complicated societal context which includes increasing rates of use and potential sanction.
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Affiliation(s)
- Grace Chang
- Department of Psychiatry, Harvard Medical School, Boston, MA, 02115, United States; VA Boston Healthcare System, Boston, MA, 02301, United States.
| | - Steven J Ondersma
- Merrill Palmer Skillman Institute and Department of Psychiatry and Behavioral Neurosciences, Wayne State University, Detroit, MI, 48202, United States
| | - Tiffany Blake-Lamb
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, 02114, United States; Department of Obstetrics and Gynecology, Harvard Medical School, Boston, MA, 02115, United States
| | - Kate Gilstad-Hayden
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, 06520, United States
| | - E John Orav
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, 02115, United States; Department of Medicine (Biostatistics), Harvard Medical School, Boston, MA, 02115, United States
| | - Kimberly A Yonkers
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, 06520, United States; Division of Chronic Disease, Yale University School of Epidemiology and Public Health, New Haven, CT, 06520, United States; Department of Obstetrics, Gynecology and Reproductive Medicine, Yale University School of Medicine, New Haven, CT, 06520, United States
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83
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Behura SK, Dhakal P, Kelleher AM, Balboula A, Patterson A, Spencer TE. The brain-placental axis: Therapeutic and pharmacological relevancy to pregnancy. Pharmacol Res 2019; 149:104468. [PMID: 31600597 PMCID: PMC6944055 DOI: 10.1016/j.phrs.2019.104468] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/23/2019] [Accepted: 09/27/2019] [Indexed: 12/22/2022]
Abstract
The placenta plays a critical role in mammalian reproduction. Although it is a transient organ, its function is indispensable to communication between the mother and fetus, and supply of nutrients and oxygen to the growing fetus. During pregnancy, the placenta is vulnerable to various intrinsic and extrinsic conditions which can result in increased risk of fetal neurodevelopmental disorders as well as fetal death. The placenta controls the neuroendocrine secretion in the brain as a means of adaptive processes to safeguard the fetus from adverse programs, to optimize fetal development and other physiological changes necessary for reproductive success. Although a wealth of information is available on neuroendocrine functions in pregnancy, they are largely limited to the regulation of hypothalamus-pituitary-adrenal/gonad (HPA/ HPG) axis, particularly the oxytocin and prolactin system. There is a major gap in knowledge on systems-level functional interaction between the brain and placenta. In this review, we aim to outline the current state of knowledge about the brain-placental axis with description of the functional interactions between the placenta and the maternal and fetal brain. While describing the brain-placental interactions, a special emphasis has been given on the therapeutics and pharmacology of the placental receptors to neuroligands expressed in the brain during gestation. As a key feature of this review, we outline the prospects of integrated pharmacogenomics, single-cell sequencing and organ-on-chip systems to foster priority areas in this field of research. Finally, we remark on the application of precision genomics approaches to study the brain-placental axis in order to accelerate personalized medicine and therapeutics to treat placental and fetal brain disorders.
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Affiliation(s)
- Susanta K Behura
- Division of Animal Sciences, University of Missouri, United States; Informatics Institute, University of Missouri, United States.
| | - Pramod Dhakal
- Division of Animal Sciences, University of Missouri, United States
| | | | - Ahmed Balboula
- Division of Animal Sciences, University of Missouri, United States
| | - Amanda Patterson
- Division of Animal Sciences, University of Missouri, United States; Department of Obstetrics, Gynecology and Women's Health, University of Missouri, United States
| | - Thomas E Spencer
- Division of Animal Sciences, University of Missouri, United States; Department of Obstetrics, Gynecology and Women's Health, University of Missouri, United States
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84
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Faherty LJ, Kranz AM, Russell-Fritch J, Patrick SW, Cantor J, Stein BD. Association of Punitive and Reporting State Policies Related to Substance Use in Pregnancy With Rates of Neonatal Abstinence Syndrome. JAMA Netw Open 2019; 2:e1914078. [PMID: 31722022 PMCID: PMC6902764 DOI: 10.1001/jamanetworkopen.2019.14078] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE Despite the rapidly changing policy environment regarding substance use during pregnancy, information is lacking on the association of state policies with neonatal abstinence syndrome (NAS). OBJECTIVE To determine if punitive or reporting state policies related to substance use during pregnancy are associated with NAS rates. DESIGN, SETTING, AND PARTICIPANTS This repeated cross-sectional study used retrospective, difference-in-difference analysis of live births in the State Inpatient Databases from 8 US states in varying years between January 1, 2003, and December 31, 2014. States without punitive or reporting policies were compared with states with policies before and after policy enactment using logistic regression models adjusted for individual and county-level factors and state and year fixed effects. Analyses were conducted from April 10, 2019, to July 30, 2019. EXPOSURES Time since enactment of state policies related to substance use in pregnancy, county-level rurality and unemployment, and presence of specialized treatment programs for pregnant and postpartum women in a county. MAIN OUTCOME AND MEASURES Rates of NAS. RESULTS Among 4 567 963 live births, 23 377 neonates (0.5%) received a diagnosis of NAS. Among neonates with NAS, 3394 (14.5%) lived in counties without any treatment programs specifically for pregnant and postpartum women, 20 323 (86.9%) lived in metropolitan counties, and 8135 (34.8%) lived in counties in the highest unemployment quartile. In adjusted analyses among neonates in states with punitive policies, odds of NAS were significantly greater during the first full calendar year after enactment (adjusted odds ratio, 1.25; 95% CI, 1.06-1.46; P = .007) and more than 1 full year after enactment (adjusted odds ratio, 1.33; 95% CI, 1.17-1.51; P < .001). After regression adjustment, the annual NAS rate was 46 (95% CI, 43-48) neonates with NAS per 10 000 live births in states without punitive policies; 57 (95% CI, 48-65) neonates with NAS per 10 000 live births in states with punitive policies during the first full year after enactment; and 60 (95% CI, 56-65) neonates with NAS per 10 000 live births in states with punitive policies in effect for more than 1 full year. There was no association between reporting policies and odds of NAS. CONCLUSIONS AND RELEVANCE In this repeated cross-sectional analysis of 8 states, states with punitive policies were associated with greater odds of NAS immediately and in the longer term, but there was no association between NAS and states with reporting policies.
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Affiliation(s)
- Laura J. Faherty
- RAND Corporation, Boston, Massachusetts
- School of Medicine, Boston University, Boston, Massachusetts
| | | | | | - Stephen W. Patrick
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee
- Mildred Stahlman Division of Neonatology, Vanderbilt University, Nashville, Tennessee
- Vanderbilt Center for Child Health Policy, Nashville, Tennessee
- Department of Health Policy, Vanderbilt University, Nashville, Tennessee
- RAND Corporation, Pittsburgh, Pennsylvania
| | | | - Bradley D. Stein
- RAND Corporation, Pittsburgh, Pennsylvania
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Serdarevic M, Striley CW, Gurka KK, Leeman RF, Cottler LB. Sex differences in prescription opioid use patterns assessed through a community engagement program in Florida. Drug Alcohol Depend 2019; 204:107568. [PMID: 31568932 PMCID: PMC6878203 DOI: 10.1016/j.drugalcdep.2019.107568] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 07/18/2019] [Accepted: 07/19/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Morbidity and mortality attributed to prescription opioids are a crisis in the US and spreading globally. Sex differences related to these conditions have not been adequately assessed. METHODS Through our community engagement program, data on demographics, health status, and substance use, including prescription opioids (e.g., Vicodin®, Oxycodone), were collected from community members in Florida (primarily North Central Florida) during a health needs assessment. Participants over 18 years of age were classified by opioid use: past 30-day, lifetime but not past 30-day, or no lifetime prescription opioid use. Descriptive statistics and chi-square tests were calculated, and multinomial logistic regression was used to calculate adjusted odds ratios (aOR; CI). Analyses were conducted for men and women separately to examine sex specific effects. RESULTS Among 9221 community members assessed, the mean age was 45 years, 60% were female, and 58% were black. Respondents who endorsed past 30-day use and lifetime use were more likely to be female. Prescription sedative use was the strongest risk factor for past 30-day (aOR = 3.96; 95% CI, 3.35-4.68) and lifetime (aOR = 2.67; 95% CI, 2.34-3.04) prescription opioid use, regardless of sex. Other factors including marijuana use and history of cancer were significantly associated with prescription opioid use; they varied by sex. CONCLUSIONS The risk factors identified in this community sample provide additional information not accounted for by national studies. Future examinations of the consequences of concomitant opioid and sedative use, especially among women, are needed.
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Affiliation(s)
- Mirsada Serdarevic
- Center for Outcomes Research, JPS Health Network, 1500 S. Main Street, Fort Worth, Texas 76104 USA.
| | - Catherine W Striley
- Department of Epidemiology, College of Public Health and Health Professions, College of Medicine, University of Florida, 2004 Mowry Road, Gainesville, Florida, 32610 USA
| | - Kelly K Gurka
- Department of Epidemiology, College of Public Health and Health Professions, College of Medicine, University of Florida, 2004 Mowry Road, Gainesville, Florida, 32610 USA
| | - Robert F Leeman
- Department of Health Education and Behavior, University of Florida, FLG 14, P.O. Box 118210, Gainesville, FL 32611-8210 USA
| | - Linda B Cottler
- Department of Epidemiology, College of Public Health and Health Professions, College of Medicine, University of Florida, 2004 Mowry Road, Gainesville, Florida, 32610 USA
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86
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Goldfarb SS, Stanwood GD, Flynn HA, Graham DL. Developmental opioid exposures: Neurobiological underpinnings, behavioral impacts, and policy implications. Exp Biol Med (Maywood) 2019; 245:131-137. [PMID: 31630569 DOI: 10.1177/1535370219883601] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The devastating impact of opioid abuse and dependence on the individual, family, and society are well known but extremely difficult to combat. During pregnancy, opioid drugs and withdrawal also affect fetal brain development and newborn neural functions, in addition to maternal effects. Neonatal Abstinence Syndrome/Neonatal Opioid Withdrawal Syndrome (NAS/NOWS) rates have drastically increased in the US in the past decade. Solutions to this complex problem must be multi-faceted, which would be greatly enhanced by a translational, multidisciplinary understanding. Therefore, this mini-review incorporates biomedical, clinical, and policy aspects of opioid use during pregnancy. We review the known roles for endogenous opioids in mediating circuit formation and function in the developing brain, discuss how exogenous opioid drug use and addiction impact these processes in animal models and humans, and discuss the implications of these data on public policy. We suggest that some current policy initiatives produce unintended harm on both mothers and their children and delineate recommendations for how legislation could better contribute to addiction recovery and increase neural resilience in affected children. Impact statement Opioid abuse is a critical epidemic affecting individuals, families, and communities. This mini-review summarizes current literature on the impact of opioid drugs—including prescription pain relievers and illicit opioids—on neurobiological and neurobehavioral development. Using concepts related to the medical model of addiction as a brain disease, we review the public policy implications of these data and identify needs for future investigations.
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Affiliation(s)
- Samantha S Goldfarb
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, FL 32306, USA
| | - Gregg D Stanwood
- Department of Biomedical Sciences, Florida State University College of Medicine, Tallahassee, FL 32306, USA.,Center for Brain Repair, Florida State University College of Medicine, Tallahassee, FL 32306, USA
| | - Heather A Flynn
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, FL 32306, USA.,Center for Brain Repair, Florida State University College of Medicine, Tallahassee, FL 32306, USA
| | - Devon L Graham
- Department of Biomedical Sciences, Florida State University College of Medicine, Tallahassee, FL 32306, USA.,Center for Brain Repair, Florida State University College of Medicine, Tallahassee, FL 32306, USA
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87
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Scott LF, Stone C, Duwve J. Policy perceptions of US state public health and child and family services regarding maternal opioid use and neonatal exposure. Arch Psychiatr Nurs 2019; 33:22-30. [PMID: 31711589 DOI: 10.1016/j.apnu.2019.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 03/12/2019] [Accepted: 04/09/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To explore how state legislatures and departments of health are responding to the public health and economic issues of increases in opioid use disorder and the impact on pregnant women and infants. DESIGN The design was a non-experimental descriptive study using a mixed methods survey research approach. SETTING Electronic and telephone survey of individuals from state departments of health associated with departments of behavioral health and substance use, or child and family services. PARTICIPANTS Fifty-two respondents employed by individual state departments of health and child and family services. METHODS Univariate analysis and frequency distribution of ordinal variables was completed. Thematic analysis was used to analyze free text questions and identify themes. RESULTS All states reported recent changes or plans to address the problem of opioid misuse in their state. Many respondents feel their state continues to lack adequate services for treatment. Some states are exploring unique methods for addressing this in a safe and timely fashion, such as moving medication-assisted treatment to primary care and expanding licensure to Primary Care Physicians (PCPs) and nurse practitioners. CONCLUSIONS Our findings demonstrate an increased commitment throughout the United States to enhance access to clinically appropriate treatment of substance use disorder particularly during pregnancy, consider unique methods for addressing the problem of opioid dependency, and increase education and primary prevention programs.
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Affiliation(s)
- Lisa Fath Scott
- Indiana University School of Nursing, Neonatal Nurse Practitioner, Commonwealth Neonatology, 4428 Old Fox Trail, Richmond, VA 23112, United States of America.
| | - Cynthia Stone
- Fairbanks School of Public Health, Health Policy and Management, Indiana University at Indianapolis, 1050 Wishard Blvd RG 5128, Indianapolis, IN 46202, United States of America.
| | - Joan Duwve
- Richard M. Fairbanks School of Public Health at IUPUI, 1050 Wishard Blvd RG 6066, Indianapolis, IN 46202, United States of America.
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88
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Lilly CL, Ruhnke AM, Breyel J, Umer A, Leonard CE. Drug Free Moms and Babies: Qualitative and quantitative program evaluation results from a rural Appalachian state. Prev Med Rep 2019; 15:100919. [PMID: 31223561 PMCID: PMC6580012 DOI: 10.1016/j.pmedr.2019.100919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 05/01/2019] [Accepted: 06/04/2019] [Indexed: 02/06/2023] Open
Abstract
The main objective of this study is to present qualitative and quantitative results of the Drug Free Moms and Babies (DFMB) Project pilot program. The program was designed to integrate and evaluate treatment and recovery services for pregnant and postpartum women with substance use disorders. Qualitative assessment was conducted via interviews regarding programmatic design components (four West Virginia sites; 2012-2018). The quantitative assessment utilized a survey that included information on patients' (N = 550) demographic, medical and substance use histories, health care services, and maternal and infant health outcomes. The qualitative results noted that program development for this population is time- and resource-intensive, and implementation requires collaborative team work. A dedicated staff position and team flexibility were critical towards programmatic success. For quantitative results, among the 393 participants that completed the program, urine drug screen data showed a significant reduction of non-prescribed positive screens from 81% (N = 178) positive in the first trimester to 22% (n = 86) positive at delivery, p < 0.0001. The DFMB program reached high-risk, medically underserved women, and was associated with reducing drug use among program completers.
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Affiliation(s)
- Christa L. Lilly
- West Virginia University, School of Public Health, Department of Biostatistics, Morgantown, WV, United States of America
| | - Alice M. Ruhnke
- The Grant Advantage, Charleston, WV, United States of America
| | - Janine Breyel
- West Virginia Perinatal Partnership, Charleston, WV, United States of America
| | - Amna Umer
- West Virginia University, School of Medicine, Department of Pediatrics, Morgantown, WV, United States of America
| | - Cassie E. Leonard
- West Virginia University, School of Medicine, Department of Obstetrics and Gynecology, Morgantown, WV, United States of America
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89
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Liu SJ, Mair C, Songer TJ, Krans EE, Wahed A, Talbott E. Opioid-related hospitalizations in Pennsylvania: A latent class analysis. Drug Alcohol Depend 2019; 202:185-190. [PMID: 31352309 DOI: 10.1016/j.drugalcdep.2019.05.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 05/02/2019] [Accepted: 05/02/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Opioid abuse is associated with substantial morbidity and often results in hospitalization. Despite this, patient-level factors associated with opioid-related hospitalizations are not well understood. METHODS We used the Pennsylvania Health Care Cost Containment Council dataset (2000-2014) to identify opioid-related hospitalizations using primary and/or secondary ICD-9-CM hospital discharge codes for opioid use disorder (OUD), opioid poisoning, and heroin poisoning. Latent class analyses (LCA) of patient-level factors including sociodemographic characteristics, pregnancy, alcohol, tobacco, other substance use, and psychiatric disorders were used to identify common patterns within hospitalizations. RESULTS Among 28,538,499 hospitalizations, 430,569 (1.5%) were opioid-related. LCA identified five latent class (LC) patient groups associated with opioid-related hospitalizations: pregnant women with OUD (LC1); women over 65 with opioid overdose (LC2); OUD, polysubstance use and co-occurring psychiatric disorders (LC3); patients with opioid overdose without co-occurring polysubstance use (LC4); and African American patients with OUD and co-occurring cocaine use (LC5). LC3 was the largest latent class (58.2%) with annual hospitalizations doubling over time. DISCUSSION Among patients with opioid-related discharges, we identified five subpopulations among this sample. These findings suggest increased outpatient OUD treatment, mental health service support for patients with co-occurring psychiatric disorders and polysubstance use to prevent overdose and hospitalization.
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Affiliation(s)
- Stephen J Liu
- University of Pittsburgh, Graduate School of Public Health, 130 DeSoto St, Pittsburgh, 15261 PA, USA.
| | - Christina Mair
- University of Pittsburgh, Graduate School of Public Health, 130 DeSoto St, Pittsburgh, 15261 PA, USA
| | - Thomas J Songer
- University of Pittsburgh, Graduate School of Public Health, 130 DeSoto St, Pittsburgh, 15261 PA, USA
| | - Elizabeth E Krans
- University of Pittsburgh, Department of Obstetrics, Gynecology and Reproductive Sciences, 300 Halket Street, Pittsburgh, 15213 PA, USA; Magee-Womens Research Institute, 204 Craft Avenue, Pittsburgh, 15213 PA, USA
| | - Abdus Wahed
- University of Pittsburgh, Graduate School of Public Health, 130 DeSoto St, Pittsburgh, 15261 PA, USA
| | - Evelyn Talbott
- University of Pittsburgh, Graduate School of Public Health, 130 DeSoto St, Pittsburgh, 15261 PA, USA
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90
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Swain JE, Ho SS. Early postpartum resting-state functional connectivity for mothers receiving buprenorphine treatment for opioid use disorder: A pilot study. J Neuroendocrinol 2019; 31:e12770. [PMID: 31287922 PMCID: PMC7195812 DOI: 10.1111/jne.12770] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 07/03/2019] [Accepted: 07/03/2019] [Indexed: 12/14/2022]
Abstract
Between 1999 and 2014, the prevalence of opioid use disorder (OUD) among pregnant women quadrupled in the USA. The standard treatment for peripartum women with OUD is buprenorphine. However, the maternal behavior neurocircuit that regulates maternal behavior and mother-infant bonding has not been previously studied for human mothers receiving buprenorphine treatment for OUD (BT). Rodent research shows opioid effects on reciprocal inhibition between maternal care and defence maternal brain subsystems: the hypothalamus and periaqueductal gray, respectively. We conducted a longitudinal functional magnetic resonance imaging (fMRI) pilot study in humans to specifically examine resting-state functional connectivity (rs-FC) between the periaqueductal gray and hypothalamus, as well as to explore associations with maternal bonding for BT. We studied 32 mothers who completed fMRI scans at 1 month (T1) and 4 months postpartum (T2), including seven mothers receiving buprenorphine for OUD and 25 non-OUD mothers as a comparison group (CG). The participants underwent a 6-minute resting-state fMRI scan at each time point. We measured potential bonding impairments using the Postpartum Bonding Questionnaire to explore how rs-FC with periaqueductal gray is associated with bonding impairments. Compared to CG, BT mothers differed in periaqueductal gray-dependent rs-FC with the hypothalamus, amygdala, insular cortex and other brain regions at T1, with many of these differences disappearing at T2, suggesting potential therapeutic effects of continuing buprenorphine treatment. In contrast, the "rejection and pathological anger" subscale of the Postpartum Bonding Questionnaire at T1 and T2 was associated with the T1-to-T2 increases in periaqueductal gray-dependent rs-FC with the hypothalamus and amygdala. Preliminary evidence links maternal bonding problems for mothers with OUD early in the postpartum to connectivity between specific care and defence maternal brain circuits, which may be mitigated by buprenorphine treatment. This exploratory study supports a potential mechanism for investigating both the therapeutic benefits and risks of opioids for maternal care and bonding with infants.
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Affiliation(s)
- James E. Swain
- Department of Psychiatry and Behavioral Health & Psychology, Stony Brook University Medical Center, Stony Brook, NY, USA
- Department of Psychiatry, Psychology and Center for Human Growth and Development, University of Michigan, Ann Arbor, MI, USA
| | - S. Shaun Ho
- Department of Psychiatry and Behavioral Health & Psychology, Stony Brook University Medical Center, Stony Brook, NY, USA
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91
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Shearer JN, Erwin PC, Davis SK, Anderson JG, Lindley LC. Implications of Tennessee's Opioid Legislation for Neonatal Abstinence Syndrome. Policy Polit Nurs Pract 2019; 20:153-162. [PMID: 31390304 DOI: 10.1177/1527154419864540] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Opioid use during pregnancy is on the rise in the United States. Neonatal abstinence syndrome (NAS), also known as newborn drug withdrawal, is a public health epidemic. Between 2004 and 2014, Tennessee experienced a fivefold increase in NAS hospitalizations, from 1.5 to 8.0 per 1,000 live births. Soaring increases in the number of newborns with NAS nationwide have caught the attention of many federal and state lawmakers, especially given the unknown burdens associated with medical and social services needed by those affected over time. Tennessee opioid-related regulations and laws enacted between 2000 and 2018 were systematically reviewed and analyzed to identify each law's purpose; effects on families and individuals; pros and cons in terms of social, practical, and legal factors; and implications for nursing practice. Our findings were that Tennessee's laws are intended to decrease the number of opioids prescribed, ensure access to continued prenatal care and substance abuse management for mothers with substance use disorders, and reduce the ease of obtaining opioids. We also found that Tennessee lawmakers have enacted laws and regulations aimed at decreasing the abuse of opioids, but not reducing the incidence of NAS. As new laws are considered, it is critical that health care providers and lawmakers work together to ensure that the developed and enacted laws strike a balance between safely managing the care of both pregnant women and their newborns without producing negative outcomes.
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Affiliation(s)
| | | | - Sharon K Davis
- College of Nursing University of Tennessee, Knoxville, TN, USA
| | - Joel G Anderson
- College of Nursing University of Tennessee, Knoxville, TN, USA
| | - Lisa C Lindley
- College of Nursing University of Tennessee, Knoxville, TN, USA
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92
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Larson JJ, Graham DL, Singer LT, Beckwith AM, Terplan M, Davis JM, Martinez J, Bada HS. Cognitive and Behavioral Impact on Children Exposed to Opioids During Pregnancy. Pediatrics 2019; 144:peds.2019-0514. [PMID: 31320466 PMCID: PMC10106099 DOI: 10.1542/peds.2019-0514] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2019] [Indexed: 11/24/2022] Open
Abstract
The developmental impact of opioid use during pregnancy is a subject of ongoing debate. Short-term neonatal outcomes, such as lower birth weight and neonatal abstinence syndrome, are the most well-recognized outcomes. However, knowledge gaps exist regarding longer-term neurocognitive and mental health outcomes. In this article, we summarize an expert panel discussion that was held in April 2018 by the Substance Abuse and Mental Health Services Administration and attended by national experts in the field of perinatal opioid exposure and its impact on child development. Despite the challenges with research in this area, there is emerging literature revealing an association between neonates exposed to opioids in utero and longer-term adverse neurocognitive, behavioral, and developmental outcomes. Although adverse sequalae may not be apparent in the neonatal period, they may become more salient as children develop and reach preschool and school age. Multiple variables (genetic, environmental, and biological) result in a highly complex picture. The next steps and strategies to support families impacted by opioid use disorder are explored. Model programs are also considered, including integrated care for the child and mother, parenting supports, and augmentations to home visiting.
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Affiliation(s)
- Justine J Larson
- Substance Abuse and Mental Health Services Administration, Rockville, Maryland;
| | - Devon L Graham
- College of Medicine, Florida State University, Tallahassee, Florida
| | | | | | - Mishka Terplan
- School of Medicine, Tufts University, Boston, Massachusetts
| | | | - Juan Martinez
- School of Public Health, University of Colorado Denver, Denver, Colorado; and
| | - Henrietta S Bada
- College of Medicine, University of Kentucky, Lexington, Kentucky
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93
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Clark RRS. Breastfeeding in Women on Opioid Maintenance Therapy: A Review of Policy and Practice. J Midwifery Womens Health 2019; 64:545-558. [PMID: 31294522 DOI: 10.1111/jmwh.12982] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 03/24/2019] [Accepted: 03/25/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Opioid use is epidemic in the United States. Opioid use disorder (OUD) in pregnancy, as well as neonatal abstinence syndrome, has quadrupled in the last decade, and opioid maintenance therapy is recommended for pregnant women with OUD. Breastfeeding is an important means of improving outcomes for these vulnerable women and newborns. The purpose of this study was to review current policy on breastfeeding and opioid maintenance therapy, the rates of breastfeeding among women in this population, and facilitators and barriers to implementing policy recommendations. METHODS CINAHL, PubMed, the Cochrane Database of Systematic Reviews, Embase, and Web of Science were searched. Inclusion criteria included publication between 2013 and 2018, English language, human only, and original data (except for policy statements). Studies were excluded if they did not report original data and did not examine breastfeeding for women on opioid maintenance therapy. RESULTS Eight policy statements and 17 original research studies were identified that met the search criteria. All the policy statements support breastfeeding for women who are stable on opioid maintenance therapy and do not have HIV. Despite this, rates of breastfeeding among women receiving opioid maintenance therapy remain low compared with women in the general population. Results of qualitative research indicates that women on opioid maintenance therapy face numerous barriers to breastfeeding, including misinformation from health care professionals. Quantitative research has only begun to identify interventions to improve breastfeeding outcomes in this population. Research was conducted primarily with white women receiving care at urban health care centers. DISCUSSION Practice lags behind policy in terms of supporting breastfeeding in women receiving opioid maintenance therapy. There is a need for more research that includes African American and rural women on opioid maintenance therapy, as well as quantitative research that uses findings from qualitative research to identify the best possible interventions for improving breastfeeding outcomes for women on opioid maintenance therapy and their newborns. One significant need is for health care provider education regarding these policies as well as best practices for providing breastfeeding education and support to this population.
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Affiliation(s)
- Rebecca R S Clark
- Department of Community and Public Health, Johns Hopkins University, Baltimore, Maryland
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94
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Crowley DM, Connell CM, Jones D, Donovan MW. Considering the child welfare system burden from opioid misuse: research priorities for estimating public costs. THE AMERICAN JOURNAL OF MANAGED CARE 2019; 25:S256-S263. [PMID: 31361428 PMCID: PMC7895335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The negative impact of opioids on those who misuse them has been widely documented. Despite significant spillover effects in the form of elevated rates of child maltreatment and child welfare system (CWS) involvement for children affected by parental opioid misuse, the public costs of opioid misuse to the CWS remain largely undocumented. This work seeks to understand the value and limitations of public data in estimating the costs of the opioid epidemic on the CWS. National data from federal sources are combined with best estimates of the association between opioid misuse and child services system utilization. The limitations of this work are explored, and future research priorities are outlined. Ultimately, this work illustrates the need to (1) improve data quality related to parental opioid misuse and CWS linkages; (2) better estimate the number of children and families coming into contact with the CWS as a result of parental opioid misuse; (3) improve predictions of CWS trajectories, including investigation, service provision, and foster care entry among this population; and (4) better estimate the CWS costs associated with patterns of system involvement resulting from parental opioid misuse. This information is crucial to ensuring the production of high-quality system involvement and cost projections related to the opioid crisis.
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95
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Swain JE, Ho SS, Fox H, Garry D, Brummelte S. Effects of opioids on the parental brain in health and disease. Front Neuroendocrinol 2019; 54:100766. [PMID: 31128130 PMCID: PMC8318357 DOI: 10.1016/j.yfrne.2019.100766] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/20/2019] [Accepted: 05/21/2019] [Indexed: 12/20/2022]
Abstract
The epidemic of opioid use disorder (OUD) directly affects millions of women of child-bearing age. Unfortunately, parenting behaviors - among the most important processes for human survival - are vulnerable to the effects of OUD. The standard of care for pregnant women with OUD is opioid maintenance therapy (OMT), of which the primary objective is to mitigate addiction-related stress. The aim of this review is to synthesize current information specific to pregnancy and parenting that may be affected by OUD. We first summarize a model of the parental brain supported by animal research and human neuroimaging. We then review animal models of exogenous opioid effects on parental brain and behavior. We also present preliminary data for a unifying hypothesis that may link different effects of exogenous opioids on parenting across species and in the context of OMT. Finally, we discuss future directions that may inform research and clinical decision making for peripartum women with OUD.
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Affiliation(s)
- James E Swain
- Department of Psychiatry and Behavioral Health, and Psychology, Stony Brook University, Stony Brook, NY, United States; Department of Psychiatry, Psychology, and Center for Human Growth & Development, University of Michigan, Ann Arbor, MI, United States.
| | - S Shaun Ho
- Department of Psychiatry and Behavioral Health, and Psychology, Stony Brook University, Stony Brook, NY, United States
| | - Helen Fox
- Department of Psychiatry and Behavioral Health, and Psychology, Stony Brook University, Stony Brook, NY, United States
| | - David Garry
- Department of Obstetrics and Gynecology, Stony Brook University, Stony Brook, NY, United States
| | - Susanne Brummelte
- Department of Psychology, Wayne State University, Detroit, MI, United States.
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96
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van Donge T, Samiee‐Zafarghandy S, Pfister M, Koch G, Kalani M, Bordbar A, van den Anker J. Methadone dosing strategies in preterm neonates can be simplified. Br J Clin Pharmacol 2019; 85:1348-1356. [PMID: 30805946 PMCID: PMC6533437 DOI: 10.1111/bcp.13906] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/14/2019] [Accepted: 02/21/2019] [Indexed: 01/11/2023] Open
Abstract
AIMS A dramatic increase in newborn infants with neonatal abstinence syndrome has been observed and these neonates are frequently treated with complex methadone dosing schemes to control their withdrawal symptoms. Despite its abundant use, hardly any data on the pharmacokinetics (PK) of methadone is available in preterm neonates. Therefore we investigated developmental PK of methadone and evaluated current dosing strategies and possible simplification in this vulnerable population. METHODS A single-centre open-label prospective study was performed to collect PK data after a single oral dose of methadone in preterm neonates. A population PK model was built to characterize developmental PK of (R)- and (S)-methadone. Model-based simulations were performed to identify a simplified dosing strategy to reach and maintain target methadone exposure. RESULTS A total of 121 methadone concentrations were collected from 31 preterm neonates. A one-compartment model with first order absorption and elimination kinetics best described PK data for (R)- and (S)-methadone. Clearance increases with advancing gestational age and differs between R- and S-enantiomer, being slightly higher for the former (0.244 vs 0.167 L/h). Preterm neonates reached target exposure after 48 hours with currently used dosing schedules. Output from simulations revealed that target exposures can be achieved with a simplified dosing strategy during the first 4 days of treatment. CONCLUSION Methadone clearance in preterm neonates increases with advancing gestational age and its disposition is influenced by its chirality. Simulations that account for developmental PK changes indicate a shorter methadone dosing strategy can maintain target exposure to control withdrawal symptoms.
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Affiliation(s)
- Tamara van Donge
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital BaselUniversity of BaselBaselSwitzerland
| | | | - Marc Pfister
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital BaselUniversity of BaselBaselSwitzerland
- Certara LPPrincetonNJUSA
| | - Gilbert Koch
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital BaselUniversity of BaselBaselSwitzerland
| | - Majid Kalani
- Department of Pediatrics, Shahid Akbarabadi HospitalIran University of Medical SciencesTehranIran
| | - Arash Bordbar
- Department of Pediatrics, Shahid Akbarabadi HospitalIran University of Medical SciencesTehranIran
| | - John van den Anker
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital BaselUniversity of BaselBaselSwitzerland
- Intensive Care and Department of Pediatric SurgeryErasmus MC‐Sophia Children's HospitalRotterdamThe Netherlands
- Division of Clinical PharmacologyChildren's National Health SystemWashingtonDCUSA
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97
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Crane D, Marcotte M, Applegate M, Massatti R, Hurst M, Menegay M, Mauk R, Williams S. A statewide quality improvement (QI) initiative for better health outcomes and family stability among pregnant women with opioid use disorder (OUD) and their infants. J Subst Abuse Treat 2019; 102:53-59. [PMID: 31202289 DOI: 10.1016/j.jsat.2019.04.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/12/2019] [Accepted: 04/25/2019] [Indexed: 12/12/2022]
Abstract
A collaborative led by state health and human service agencies, academic leaders, and stakeholders tested interventions to expand use of medication assisted treatment (MAT) through a maternal medical home (MMH) model that coordinated behavioral health and prenatal care with social supports for pregnant women with opioid use disorder (OUD) enrolled in Medicaid. The program was anchored in four clinical organizations with distinct models of care: community behavioral health, residential behavioral health, hospital-based obstetrical practice, and co-located obstetrical and behavioral health. A modified version of the Institute for Healthcare Improvement Breakthrough Series Model for Improvement was implemented using monthly performance data feedback to conduct small tests of change and improve care. Administrative data from the state's Medicaid, vital statistics, and child welfare systems were linked to evaluate the impact of MOMS on 252 mother-infant dyads compared to a sample of 846 Medicaid beneficiaries with OUD in the third trimester of pregnancy. MOMS participation was associated with increased likelihood of MAT in trimesters one, two and three (AOR = 2.30, 4.40, 2.75, respectively), behavioral health counseling during trimesters two and three (AOR = 3.75 and 2.07, respectively), retention in MAT during postpartum months one through three and four through six (AOR = 2.86, 2.40, respectively), and marginally lower out-of-home placement of infants born to mothers with OUD (AOR = 0.66). Within the MOMS program, greater participation in behavioral health treatment and MAT (χ2(3) ≥ 12.09) was observed in the co-located behavioral health/obstetrical care practice site compared to behavioral health-led and obstetrical provider-led sites.
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Affiliation(s)
- Dushka Crane
- Ohio Colleges of Medicine Government Resource Center, Ohio State University Medical Center, United States of America.
| | - Michael Marcotte
- Tri-State Maternal-Fetal Medicine Associates, United States of America.
| | - Mary Applegate
- FACP - NASHP, Ohio Department of Medicaid, United States of America.
| | - Richard Massatti
- Ohio Department of Mental Health and Addiction Services, United States of America.
| | - Mark Hurst
- Ohio Department of Mental Health and Addiction Services, United States of America.
| | - Michelle Menegay
- Ohio Colleges of Medicine Government Resource Center, Ohio State University Medical Center, United States of America.
| | - Rachel Mauk
- Ohio Colleges of Medicine Government Resource Center, Ohio State University Medical Center, United States of America.
| | - Susan Williams
- Ohio Department of Job and Family Services, United States of America.
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98
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Blanco C, Volkow ND. Management of opioid use disorder in the USA: present status and future directions. Lancet 2019; 393:1760-1772. [PMID: 30878228 DOI: 10.1016/s0140-6736(18)33078-2] [Citation(s) in RCA: 256] [Impact Index Per Article: 51.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 11/15/2018] [Accepted: 11/26/2018] [Indexed: 02/06/2023]
Abstract
Opioid use disorder is characterised by the persistent use of opioids despite the adverse consequences of its use. The disorder is associated with a range of mental and general medical comorbid disorders, and with increased mortality. Although genetics are important in opioid use disorder, younger age, male sex, and lower educational attainment level and income, increase the risk of opioid use disorder, as do certain psychiatric disorders (eg, other substance use disorders and mood disorders). The medications for opioid use disorder, which include methadone, buprenorphine, and extended-release naltrexone, significantly improve opioid use disorder outcomes. However, the effectiveness of medications for opioid use disorder is limited by problems at all levels of the care cascade, including diagnosis, entry into treatment, and retention in treatment. There is an urgent need for expanding the use of medications for opioid use disorder, including training of health-care professionals in the treatment and prevention of opioid use disorder, and for development of alternative medications and new models of care to expand capabilities for personalised interventions.
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Affiliation(s)
- Carlos Blanco
- National Institute on Drug Abuse, Bethesda, MD, USA.
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99
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Abstract
Pregnancy presents a window of opportunity for effecting positive change in the lives of women with opioid use disorder (OUD). Care should be empathetic and nonjudgmental with a focus on counseling for initiation and maintenance of beneficial health behaviors as well as development of a strong patient-provider relationship.1 These include adherence to treatment of OUD through pharmacotherapy and behavioral counseling, smoking cessation, healthy nutrition, treatment of coexisting medical and psychosocial conditions, as well as preparation for the postpartum period through breastfeeding education and antenatal discussion of contraception. Women will also benefit from anticipatory guidance with regard to neonatal abstinence syndrome (see Chapter 7). This may include a consultation with pediatric or neonatal providers who will be caring for their infants. In the absence of other obstetric indications, minimal additional fetal assessment outside that of standard prenatal care is recommended for OUD.
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Affiliation(s)
- Emily W Rosenthal
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, 833 Chestnut Street, Philadelphia, PA, United States.
| | - Jason K Baxter
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, 833 Chestnut Street, Philadelphia, PA, United States
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100
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Rodriguez JJ, Smith VC. Epidemiology of perinatal substance use: Exploring trends in maternal substance use. Semin Fetal Neonatal Med 2019; 24:86-89. [PMID: 30777708 DOI: 10.1016/j.siny.2019.01.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Over the last two decades, the prevalence of substance use among women of childbearing age has risen dramatically in the United States making substance use during pregnancy a significant public health concern. This article offers a general overview of the epidemiology of perinatal substance use focusing primarily on the United States but when available international trends will be presented as well.
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Affiliation(s)
| | - Vincent C Smith
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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