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Implementation of a Universal Screening Process for Substance Use in Pregnancy. Obstet Gynecol 2021; 137:695-701. [PMID: 33706353 DOI: 10.1097/aog.0000000000004305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/10/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To implement a standardized universal substance use screening process in an outpatient prenatal clinic at an urban tertiary care hospital. METHODS Using a quality-improvement framework that involved process modeling, stakeholder analyses, and plan-do-study-act cycles, we implemented universal substance use screening for prenatal patients using a modified 5Ps screening tool (Parents, Peers, Partner, Past, Present). Implementation included an operational workflow based on the SBIRT (Screening, Brief Intervention, Referral to Treatment) model. The primary outcome measure was percentage of patients who were screened for substance use, with a goal of 90% screened. Secondary outcome measures were percentage who screened positive and percentage of the time a positive screen resulted in documentation of a brief intervention by a health care practitioner. RESULTS Over a 19-month implementation period, 733 patient encounters were sampled. A substance use screen was completed in 618 (84%). We exceeded our goal of screening 90% of eligible patients for the final 6 months of data collection. Of the 618 completed screens, 124 (20%) screened positive. Health care practitioner documentation of brief interventions for patients with a positive screen reached 80% in the final phase of implementation, but then declined to 50% by the completion of the study period. CONCLUSION A sustainable and generalizable process to carry out substance use screening within a large prenatal practice is feasible, and assisted with identification of patients not known to be at risk. Further efforts are needed to evaluate how to sustain health care practitioner documentation of intervention in response to positive screens.
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Cleary EM, Smid MC, Charles JE, Jones KM, Costantine MM, Saade G, Rood KM. Buprenorphine X-waiver exemption - beyond the basics for the obstetrical provider. Am J Obstet Gynecol MFM 2021; 3:100451. [PMID: 34320429 DOI: 10.1016/j.ajogmf.2021.100451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 07/20/2021] [Indexed: 11/17/2022]
Abstract
Buprenorphine is 1 of 3 medications approved by the US Food and Drug Administration for the treatment of opioid use disorder, and practitioners must obtain a federal waiver to prescribe buprenorphine. Until recently, physicians and advanced practice clinicians were required to complete 8 and 24 hours of training, respectively, before applying for this waiver and to provide psychosocial services when prescribing buprenorphine to ≤30 patients. The US Department of Health and Human Services announced in April 2021 that eligible providers would be exempt from the educational requirement for certification, making the waiver more accessible for those intending to prescribe to ≤30 patients. Here, we reviewed the historic background to the exemption and provided practical guidelines to practitioners caring for obstetrical patients with opioid use disorder who are considering applying for the waiver for the first time. Because the educational requirements will no longer be required for X-waiver application, we reviewed fundamental topics and challenging scenarios that are often reviewed in certification courses.
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Affiliation(s)
- Erin M Cleary
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH.
| | - Marcela C Smid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
| | - Jasmin E Charles
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
| | - Kaitlyn M Jones
- College of Nursing, University of Utah Health, Salt Lake City, UT
| | - Maged M Costantine
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH
| | - George Saade
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX
| | - Kara M Rood
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH
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203
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Holcomb DS, Pengetnze Y, Steele A, Karam A, Spong C, Nelson DB. Geographic barriers to prenatal care access and their consequences. Am J Obstet Gynecol MFM 2021; 3:100442. [PMID: 34245930 DOI: 10.1016/j.ajogmf.2021.100442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Although prenatal care has long been viewed as an important strategy toward improving maternal morbidity and mortality, limited data exist that support the premise that access to prenatal care impacts perinatal outcomes. Furthermore, little is known about geographic barriers that impact access to care in an underserved population and how this may influence perinatal outcomes. OBJECTIVE This study aimed to (1) evaluate perinatal outcomes among women with and without prenatal care and (2) examine barriers to receiving prenatal care according to block-level data of residence. We hypothesized that women without prenatal care would have worse outcomes and more barriers to receiving prenatal care services. STUDY DESIGN This was a retrospective cohort study of pregnant women delivering at ≥24 weeks' gestation in a large inner-city public hospital system. Maternal and neonatal data were abstracted from the electronic health record and a community-wide data initiative data set, which included socioeconomic and local geographic data from diverse sources. Maternal characteristics and perinatal outcomes were examined among women with and without prenatal care. Prenatal care was defined as at least 1 visit before delivery. Outcomes of interest were (1) preterm delivery at <37 weeks' gestation, (2) preeclampsia or eclampsia, and (3) days in the neonatal intensive care unit after delivery. Barriers to care were analyzed, including public transportation access and location of the nearest county-sponsored prenatal clinic according to block-level location of residence. Statistical analysis included chi-square test and analysis of variance with logistic regression performed for adjustment of demographic features. RESULTS Between January 1, 2019, and October 31, 2019, 9488 women received prenatal care and 326 women did not. Women without prenatal care differed by race and were noted to have higher rates of substance use (P=.004), preterm birth (P<.001), and longer lengths of newborn admission (P<.001). After adjustment for demographic features, higher rates of preterm birth in women without prenatal care persisted (adjusted odds ratio, 2.65; 95% confidence interval, 1.95-3.55). Women without prenatal care resided in areas that relied more on public transportation and required longer transit times (42 minutes vs 30 minutes; P=.005) with more bus stops (29 vs 17; P<.001) to the nearest county-sponsored prenatal clinic. CONCLUSION Women without prenatal care were at a significantly increased risk of adverse pregnancy outcomes. In a large inner city, women without prenatal care resided in areas with significantly higher demands for public transportation. Alternative resources, including telemedicine and ridesharing, should be explored to reduce barriers to prenatal care access.
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Affiliation(s)
- Denisse S Holcomb
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX (Drs Holcomb, Spong, and Nelson); Parkland Center for Clinical Innovation, Dallas, TX (Dr Pengetnze, Ms Steele, and Mr Karam).
| | - Yolande Pengetnze
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX (Drs Holcomb, Spong, and Nelson); Parkland Center for Clinical Innovation, Dallas, TX (Dr Pengetnze, Ms Steele, and Mr Karam)
| | - Ashley Steele
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX (Drs Holcomb, Spong, and Nelson); Parkland Center for Clinical Innovation, Dallas, TX (Dr Pengetnze, Ms Steele, and Mr Karam)
| | - Albert Karam
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX (Drs Holcomb, Spong, and Nelson); Parkland Center for Clinical Innovation, Dallas, TX (Dr Pengetnze, Ms Steele, and Mr Karam)
| | - Catherine Spong
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX (Drs Holcomb, Spong, and Nelson); Parkland Center for Clinical Innovation, Dallas, TX (Dr Pengetnze, Ms Steele, and Mr Karam)
| | - David B Nelson
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX (Drs Holcomb, Spong, and Nelson); Parkland Center for Clinical Innovation, Dallas, TX (Dr Pengetnze, Ms Steele, and Mr Karam)
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204
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Smid MC, Saitz R. Postpartum Treatment of Individuals With Opioid Use Disorder: Maternal Risk and Need for Evidence Do Not End When Pregnancy Ends. J Addict Med 2021; 15:267-268. [PMID: 34397779 DOI: 10.1097/adm.0000000000000878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Marcela C Smid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT (MCS), Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT (MCS), Department of Community Health Sciences, Boston University School of Public Health, Boston, MA (RS), Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, and the Grayken Center for Addiction, Boston Medical Center, Boston, MA (RS)
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205
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Pentecost R, Latendresse G, Smid M. Scoping Review of the Associations Between Perinatal Substance Use and Perinatal Depression and Anxiety. J Obstet Gynecol Neonatal Nurs 2021; 50:382-391. [PMID: 33773955 PMCID: PMC8286297 DOI: 10.1016/j.jogn.2021.02.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate published literature on the associations between perinatal substance use (PSU), perinatal depression and anxiety (PDA), and known maternal-newborn outcomes. DATA SOURCES We conducted a systematic search of health-related databases, including PubMed, CINAHL, MEDLINE, and Embase. Search terms included maternal mental health, substance use, postpartum, opioid, alcohol, methamphetamine, addiction, dependence, pregnancy, depression, and anxiety. STUDY SELECTION We included English-language, peer-reviewed reports of primary research and systematic reviews that were published between 2010 and 2020 and focused on PSU and PDA. We excluded commentaries, nonsystematic reviews, and articles on maternal mental health other than PDA. Fourteen of 379 articles met the inclusion criteria. DATA EXTRACTION We used the Joanna Briggs Institute Review Guidelines to guide extraction of the following data: author(s), year of publication, type of study, country of origin, study sample, targeted substance(s), mental health, key findings, and recommendation(s). DATA SYNTHESIS In studies of PSU, researchers identified a strong association with PDA. Likewise, researchers investigating PDA found a strong association with PSU. Findings from these articles suggest an increasing risk for PSU with increasing severity of PDA, depending on the specific substances of use. Findings also indicated that women with polysubstance use have greater odds for comorbid perinatal mental health conditions. A relationship between PSU and PDA and adverse newborn outcomes, such as low birth weight, was found. CONCLUSION There is a paucity of published research on co-occurring PSU and PDA. However, polysubstance use appears to be associated with the greatest risk for PDA. It is essential to address PSU and PDA together to better understand the effects on maternal and infant outcomes.
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206
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Anesthetic management of the parturient with opioid addiction. Int Anesthesiol Clin 2021; 59:28-39. [PMID: 34100798 DOI: 10.1097/aia.0000000000000323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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207
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Leyenaar JK, Schaefer AP, Wasserman JR, Moen EL, O’Malley AJ, Goodman DC. Infant Mortality Associated With Prenatal Opioid Exposure. JAMA Pediatr 2021; 175:706-714. [PMID: 33843963 PMCID: PMC8042571 DOI: 10.1001/jamapediatrics.2020.6364] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Knowledge of health outcomes among opioid-exposed infants is limited, particularly for those not diagnosed with neonatal opioid withdrawal syndrome (NOWS). OBJECTIVES To describe infant mortality among opioid-exposed infants and identify how mortality risk differs in opioid-exposed infants with and without a diagnosis of NOWS compared with infants without opioid exposure. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of maternal-infant dyads was conducted, linking health care claims with vital records for births from January 1, 2010, to December 31, 2014, with follow-up of infants until age 1 year (through 2015). Maternal-infant dyads were included if the infant was born in Texas at 22 to 43 weeks' gestational age to a woman aged 15 to 44 years insured by Texas Medicaid. Data analysis was performed from May 2019 to October 2020. EXPOSURE The primary exposure was prenatal opioid exposure, with infants stratified by the presence or absence of a diagnosis of NOWS during the birth hospitalization. MAIN OUTCOMES AND MEASURES Risk of infant mortality (death at age <365 days) was examined using Kaplan-Meier and log-rank tests. A series of logistic regression models was estimated to determine associations between prenatal opioid exposure and mortality, adjusting for maternal and neonatal characteristics and clustering infants at the maternal level to account for statistical dependence owing to multiple births during the study period. RESULTS Among 1 129 032 maternal-infant dyads, 7207 had prenatal opioid exposure, including 4238 diagnosed with NOWS (mean [SD] birth weight, 2851 [624] g) and 2969 not diagnosed with NOWS (mean [SD] birth weight, 2971 [639] g). Infant mortality was 20 per 1000 live births for opioid-exposed infants not diagnosed with NOWS, 11 per 1000 live births for infants with NOWS, and 6 per 1000 live births in the reference group (P < .001). After adjusting for maternal and neonatal characteristics, mortality in infants with a NOWS diagnosis was not significantly different from the reference population (odds ratio, 0.82; 95% CI, 0.58-1.14). In contrast, the odds of mortality in opioid-exposed infants not diagnosed with NOWS was 72% greater than the reference population (odds ratio, 1.72; 95% CI, 1.25-2.37). CONCLUSIONS AND RELEVANCE In this study, opioid-exposed infants appeared to be at increased risk of mortality, and the treatments and supports provided to those diagnosed with NOWS may be protective. Interventions to support opioid-exposed maternal-infant dyads are warranted, regardless of the perceived severity of neonatal opioid withdrawal.
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Affiliation(s)
- JoAnna K. Leyenaar
- Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire,The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Andrew P. Schaefer
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Jared R. Wasserman
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - Erika L. Moen
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire,Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | - David C. Goodman
- Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire,The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
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208
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Harris M, Joseph K, Hoeppner B, Wachman EM, Gray JR, Saia K, Wakeman S, Bair-Merritt MH, Schiff DM. A Retrospective Cohort Study Examining the Utility of Perinatal Urine Toxicology Testing to Guide Breastfeeding Initiation. J Addict Med 2021; 15:311-317. [PMID: 33060464 PMCID: PMC8044259 DOI: 10.1097/adm.0000000000000761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE National guidelines advise against breastfeeding for women who use nonprescribed substances in the third trimester. This reduces the number of women who are supported in breastfeeding initiation despite limited evidence on the prognostic value of third trimester substance use. We sought to examine the degree to which prenatal nonprescribed substance use is associated with non-prescribed use postpartum. METHODS Retrospective cohort study of pregnant women with opioid use disorder on methadone or buprenorphine between 2006 and 2015. Nonprescribed use was defined by a positive urine drug testing (UDT). Sensitivity, specificity, positive predictive value, and negative predictive value were calculated comparing 3 prenatal periods with postpartum UDT results. Generalized estimating equations were used to examine the extent to which prenatal nonprescribed use was associated with postpartum use. RESULTS Included were 545 deliveries by 503 women. Mean age was 28.3 years, 88% were White/non-Hispanic, 93% had public insurance, and 43% received adequate prenatal care. The predictive value of UDT's 90 to 31 days before delivery, 30 to 0 days before delivery, and at delivery showed low sensitivity (44, 26, 27%, respectively) and positive predictive value (36, 36, 56%, respectively), but higher negative predictive value (80, 85, and 78%, respectively), P-values all <0.05. In the final adjusted model, only nonprescribed use at delivery was significantly associated with postpartum nonprescribed use. CONCLUSIONS Nonprescribed use at delivery was most strongly associated with postpartum use compared with earlier time periods currently prioritized in guidelines. In women with opioid use disorder prenatal UDT results alone are insufficient to guide breastfeeding decisions.
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Affiliation(s)
- Miriam Harris
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston MA, USA
| | - Kathleen Joseph
- Department Emergency Medicine, University of Indiana, Indianapolis, IN, USA
| | - Bettina Hoeppner
- Research Recovery Institute, Department of Psychiatry, Massachusetts General Hospital, Boston MA, USA
| | - Elisha M. Wachman
- Division of Neonatology, Department of Pediatrics, Boston Medical Center, Boston, MA, USA
| | - Jessica R. Gray
- Department of Internal Medicine, Massachusetts General Hospital, Boston MA, USA
| | - Kelley Saia
- Department of Obstetrics and Gynecology, Boston Medical Center, Boston, MA, USA
| | - Sarah Wakeman
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA
| | | | - Davida M. Schiff
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston, MA, USA
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209
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Unmet Mental Health Care Needs and Illicit Drug Use During Pregnancy. J Addict Med 2021; 15:233-240. [PMID: 33009165 DOI: 10.1097/adm.0000000000000752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The prevalence of drug use is at alarmingly high levels in the United States. Of particular concern is prenatal drug use, which exposes the underdeveloped organ systems of the fetus to harsh chemicals. Identifying factors associated with illicit drug use during pregnancy is critical to identify and treat at-risk pregnant women and improve maternal and infant health outcomes. The goal of this study was to examine the association between unmet mental health care needs and substance use during pregnancy. METHODS The present cross-sectional study analyzed secondary data from the 2002 to 2014 National Survey on Drug Use and Health (n = 10,516). The main outcome of interest was self-reported illicit drug use in the last 30 days. The independent variable was unmet mental health care needs in the last 12 months. RESULTS Overall, 6.4% of the participants reported a history of unmet mental health care needs and 4.5% used a substance during pregnancy. The odds of illicit drug use during pregnancy were higher among women who had an unmet mental health care needs compared to women without a history of unmet mental health care needs, multivariable-adjusted odds ratio (95% CI) 4.06 (3.01 to 5.48; P < 0.001). The observed association between unmet mental health care needs and illicit drug use persisted in subgroup analyses by age, race/ethnicity and education. CONCLUSION In a nationally representative cross-sectional sample of pregnant women, having unmet mental health care needs was positively associated with illicit drug use during pregnancy after adjusting for potential confounders.
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210
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Pocobelli G, Dublin S, Bobb JF, Albertson-Junkans L, Andrade S, Cheetham TC, Salgado G, Griffin MR, Raebel MA, Smith D, Li DK, Pawloski PA, Toh S, Taylor L, Hua W, Horn P, Trinidad JP, Boudreau DM. Prevalence of prescription opioid use during pregnancy in eight US health plans during 2001-2014. Pharmacoepidemiol Drug Saf 2021; 30:1541-1550. [PMID: 34169607 DOI: 10.1002/pds.5312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 05/18/2021] [Accepted: 06/07/2021] [Indexed: 11/07/2022]
Abstract
PURPOSE To estimate prevalence of prescription opioid use during pregnancy in eight US health plans during 2001-2014. METHODS We conducted a cohort study of singleton live birth deliveries. Maternal characteristics were ascertained from health plan and/or birth certificate data and opioids dispensed during pregnancy from health plan pharmacy records. Prevalence of prescription opioid use during pregnancy was calculated for any use, cumulative days of use, and number of dispensings. RESULTS We examined prevalence of prescription opioid use during pregnancy in each health plan. Tennessee Medicaid had appreciably greater prevalence of use compared to the seven other health plans. Thus, results for the two groups were reported separately. In the seven health plans (n = 587 093 deliveries), prevalence of use during pregnancy was relatively stable at 9%-11% throughout 2001-2014. In Tennessee Medicaid (n = 256 724 deliveries), prevalence increased from 29% in 2001 to a peak of 36%-37% in 2004-2010, and then declined to 28% in 2014. Use for ≥30 days during pregnancy was stable at 1% in the seven health plans and increased from 2% to 7% in Tennessee Medicaid during 2001-2014. Receipt of ≥5 opioid dispensings during pregnancy increased in the seven health plans (0.3%-0.6%) and Tennessee Medicaid (3%-5%) during 2001-2014. CONCLUSION During 2001-2014, prescription opioid use during pregnancy was more common in Tennessee Medicaid (peak prevalence in late 2000s) compared to the seven health plans (relatively stable prevalence). Although a small percentage of women had opioid use during pregnancy for ≥30 days or ≥ 5 dispensings, they represent thousands of women during 2001-2014.
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Affiliation(s)
- Gaia Pocobelli
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | | | - Susan Andrade
- Meyers Primary Care Institute, Worcester, Massachusetts, USA
| | - T Craig Cheetham
- Kaiser Permanente Southern California, Department of Research & Evaluation, Pasadena, CA, Chapman University, School of Pharmacy, Irvine, CA, USA
| | - Gladys Salgado
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Marie R Griffin
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marsha A Raebel
- Institute for Health Research, Kaiser Permanente Colorado, Colorado, USA
| | - David Smith
- Kaiser Permanente Center for Health Research, Portland, Oregon, USA
| | - De-Kun Li
- Kaiser Foundation Research Institute, Oakland, California, USA
| | | | - Sengwee Toh
- Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
| | | | - Wei Hua
- Food and Drug Administration, Silver Spring, Maryland, USA
| | - Pamela Horn
- Food and Drug Administration, Silver Spring, Maryland, USA
| | | | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
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211
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Hawk K, Hoppe J, Ketcham E, LaPietra A, Moulin A, Nelson L, Schwarz E, Shahid S, Stader D, Wilson MP, D'Onofrio G. Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department. Ann Emerg Med 2021; 78:434-442. [PMID: 34172303 DOI: 10.1016/j.annemergmed.2021.04.023] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Indexed: 12/17/2022]
Abstract
The treatment of opioid use disorder with buprenorphine and methadone reduces morbidity and mortality in patients with opioid use disorder. The initiation of buprenorphine in the emergency department (ED) has been associated with increased rates of outpatient treatment linkage and decreased drug use when compared to patients randomized to receive standard ED referral. As such, the ED has been increasingly recognized as a venue for the identification and initiation of treatment for opioid use disorder, but no formal American College of Emergency Physicians (ACEP) recommendations on the topic have previously been published. The ACEP convened a group of emergency physicians with expertise in clinical research, addiction, toxicology, and administration to review literature and develop consensus recommendations on the treatment of opioid use disorder in the ED. Based on literature review, clinical experience, and expert consensus, the group recommends that emergency physicians offer to initiate opioid use disorder treatment with buprenorphine in appropriate patients and provide direct linkage to ongoing treatment for patients with untreated opioid use disorder. These consensus recommendations include strategies for opioid use disorder treatment initiation and ED program implementation. They were approved by the ACEP board of directors in January 2021.
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Affiliation(s)
- Kathryn Hawk
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
| | - Jason Hoppe
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Eric Ketcham
- Department of Emergency Medicine, Santa Fe & Espanola, Presbyterian Healthcare System, NM
| | - Alexis LaPietra
- Department of Emergency Medicine, Santa Fe & Espanola, Presbyterian Healthcare System, NM
| | - Aimee Moulin
- Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA
| | - Lewis Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ
| | - Evan Schwarz
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO
| | - Sam Shahid
- American College of Emergency Physicians, Dallas, TX
| | - Donald Stader
- Section of Emergency Medicine, Swedish Medical Center, Englewood, CO
| | - Michael P Wilson
- Department of Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Gail D'Onofrio
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
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212
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Prenatal Practice Staff Perceptions of Three Substance Use Screening Tools for Pregnant Women. J Addict Med 2021; 14:139-144. [PMID: 31090554 DOI: 10.1097/adm.0000000000000543] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE There is a need to identify an acceptable and comprehensive substance use screening tool for pregnant women in the United States. This qualitative study sought to better understand prenatal practice staff perceptions of three existing substance use screening tools for use among pregnant women in an outpatient practice setting. METHODS Eight focus groups with 40 total participants were conducted with clinical and administrative staff of 2 diverse Maryland prenatal practices to determine the acceptability and usability of 3 substance use screening tools (4P's Plus, NIDA-Modified Alcohol, Smoking and Substance Involvement Screening Test, and the Substance Use Risk Profile-Pregnancy scale). The focus groups were digitally recorded, transcribed, coded, and analyzed using thematic analysis. RESULTS Participant perceptions of screening tools were dependent upon screening tool length, tone, comprehensiveness, subjectivity, time frame of questions, and scoring and clinician instructions. Most participants preferred the 4P's Plus screening tool because it is brief, comprehensive, easy for the patient to understand, and excludes judgmental language and subjective questions. CONCLUSIONS These results provide valuable insight into the specific needs and preferences of prenatal practice staff as it relates to prenatal substance use screening and provides evidence that the 4P's Plus may be a preferred screening tool for standardized use in prenatal care.
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213
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Predictors of pharmacologic therapy for neonatal opioid withdrawal syndrome: a retrospective analysis of a statewide database. J Perinatol 2021; 41:1381-1388. [PMID: 33608626 DOI: 10.1038/s41372-021-00969-z] [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] [Received: 11/05/2020] [Revised: 01/13/2021] [Accepted: 01/27/2021] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Identify factors associated with the need for pharmacologic therapy (PT) among opioid exposed newborn (OENs). STUDY DESIGN Retrospective analysis of a statewide database of OENs from 2017 through 2019. Multivariable mixed-effects logistic regression modeled the association of maternal characteristics, infant characteristics, and family engagement practices on the receipt of PT. RESULTS Of 2098 OENs, 44.8% required PT for NOWS. Higher odds of PT were associated with in-utero exposure to medication treatment for opioid use disorder (MOUD) and non-prescribed opioids in addition to MOUD; nicotine, benzodiazepines, SSRIs; male; out-born infants and mother's ineligibility to provide breast-milk. Lower odds were associated with increasing birth year, skin-to-skin (STS) care, and rooming-in. CONCLUSION Male, out-born infants exposed to MOUD with additional non-prescribed opioids, nicotine, benzodiazepines and SSSRIs with mothers ineligible to provide breast-milk were more likely to require PT, while modifiable care practices including STS care, and rooming-in decreased the likelihood of PT.
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Ko JY, Yoon J, Tong VT, Haight SC, Patel R, Rockhill KM, Luck J, Shapiro-Mendoza C. Maternal opioid exposure, neonatal abstinence syndrome, and infant healthcare utilization: A retrospective cohort analysis. Drug Alcohol Depend 2021; 223:108704. [PMID: 33894458 PMCID: PMC8893024 DOI: 10.1016/j.drugalcdep.2021.108704] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/03/2021] [Accepted: 03/06/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND We sought to describe healthcare utilization of infants by maternal opioid exposure and neonatal abstinence syndrome (NAS) status. METHODS A longitudinal cohort of 81,833 maternal-infant dyads were identified from Oregon's 2008-2012 linked birth certificate and Medicaid eligibility and claims data. Chi-square tests compared term infants (≥37 weeks of gestational age) by maternal opioid exposure, defined using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes or prescription fills, and NAS, defined using ICD-9-CM codes, such that infants were categorized as Opioid+/ NAS+, Opioid+/NAS-, Opioid-/NAS+, and Opioid-/NAS-. Modified Poisson regression was used to calculate adjusted risk ratios (aRR) and 95 % confidence intervals (CI) for healthcare utilization for each infant group compared to Opioid-/NAS- infants. RESULTS The prevalence of documented maternal opioid exposure was 123.1 per 1000 dyads and NAS incidence was 5.8 per 1000 dyads. Compared to Opioid-/NAS- infants, infants with maternal opioid exposures were more likely to be hospitalized within 4 weeks (Opioid+/ NAS+: [aRR: 4.7; 95 % CI: 4.3-5.1]; Opioid+/ NAS-: [aRR: 3.7; 95 %CI: 3.1-4.5]) and a year after birth (Opioid+/ NAS+: [aRR: 3.7; 95 %CI: 3.4-4.0]; Opioid+/ NAS-: [aRR: 2.8; 95 %CI: 2.3-3.4]). Infants with maternal opioid exposure and/or NAS were more likely than Opioid-/NAS- infants to have ≥2 sick visits and any ED visits in the year after birth. CONCLUSIONS Infants with NAS and/or maternal opioid exposure had greater healthcare utilization than infants without NAS or opioid exposure. Efforts to mitigate future hospitalization risk and encourage participation in preventative services within the first year of life may improve outcomes.
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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, USA; United States Public Health Service, Commissioned Corps, Rockville, MD, USA.
| | - Jangho Yoon
- College of Public Health and Human Sciences, Oregon State University, USA
| | - Van T Tong
- Division of Congenital and Developmental Disorders, National Center for Birth Defects and Developmental Disorders, Centers for Disease Control and Prevention, USA
| | - Sarah C Haight
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, USA
| | - Roshni Patel
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, USA; DB Consulting Group, Atlanta, GA, USA
| | - Karilynn M Rockhill
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, USA; Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
| | - Jeff Luck
- College of Public Health and Human Sciences, Oregon State University, USA
| | - Carrie Shapiro-Mendoza
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, USA
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215
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Buprenorphine and Naloxone Versus Buprenorphine for Opioid Use Disorder in Pregnancy: A Cohort Study. J Addict Med 2021; 14:185-192. [PMID: 31567599 DOI: 10.1097/adm.0000000000000562] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To compare maternal and fetal outcomes among dyads prescribed buprenorphine and naloxone or buprenorphine during pregnancy. METHODS Retrospective cohort study of patients with opioid use disorder obtaining care in a comprehensive, perinatal program. Patients utilized medication for opioid use disorder: a buprenorphine and naloxone combination product or buprenorphine monotherapy. The primary outcome was neonatal abstinence syndrome requiring treatment. Maternal secondary outcomes included: negative urine drug screen at delivery, obstetrical care attendance, primary cesarean delivery, and preterm delivery. Neonatal secondary outcomes included neonatal biometry, admission to neonatal intensive care, appropriate findings on cord toxicology, and length of stay. Univariate analyses included Chi square, Fisher exact, t-, or Mann-Whitney tests, as appropriate. Multivariate binary logistic regressions examined the association of type of buprenorphine product with diagnosis of neonatal abstinence syndrome requiring treatment and adjusted for variables significantly different in between-group comparisons and correlates of treatments and the primary outcome. RESULTS The rate of neonatal abstinence syndrome was significantly higher (P = 0.007) among infants exposed in utero to buprenorphine versus buprenorphine and naloxone: 59/108 (54.6%) versus 30/85 (35.3%), respectively. The combined product, relative to the monoproduct, was associated with lower odds of neonatal abstinence syndrome: odds ratio (OR) = 0.453 (95% confidence interval [CI] 0.253-0.813; P = 0.008). Adjusting for dose of buprenorphine product at delivery, year of expected delivery, type of prescriber, diagnosis of hepatitis C, and preterm delivery negated these results: adjusted OR = 0.627 (95% CI 0.309-1.275). Secondary outcomes were similar. CONCLUSION Compared with buprenorphine monotherapy, the combined buprenorphine and naloxone product was an acceptable alternative pharmacologic treatment for opioid use disorder during pregnancy.
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216
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Abstract
Opioid use disorder (OUD) is a common, treatable chronic disease that can be effectively managed in primary care settings. Untreated OUD is associated with considerable morbidity and mortality-notably, overdose, infectious complications of injecting drug use, and profoundly diminished quality of life. Withdrawal management and medication tapers are ineffective and are associated with increased rates of relapse and death. Pharmacotherapy is the evidence based mainstay of OUD treatment, and many studies support its integration into primary care settings. Evidence is strongest for the opioid agonists buprenorphine and methadone, which randomized controlled trials have shown to decrease illicit opioid use and mortality. Discontinuation of opioid agonist therapy is associated with increased rates of relapse and mortality. Less evidence is available for the opioid antagonist extended release naltrexone, with a meta-analysis of randomized controlled trials showing decreased illicit opioid use but no effect on mortality. Treating OUD in primary care settings is cost effective, improves outcomes for both OUD and other medical comorbidities, and is highly acceptable to patients. Evidence on whether behavioral interventions improve outcomes for patients receiving pharmacotherapy is mixed, with guidelines promoting voluntary engagement in psychosocial supports, including counseling. Further work is needed to promote the integration of OUD treatment into primary care and to overcome regulatory barriers to integrating methadone into primary care treatment in the US.
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Affiliation(s)
- Megan Buresh
- Department of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Robert Stern
- Department of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Darius Rastegar
- Department of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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217
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Reproductive-Age Women's Experience of Accessing Treatment for Opioid Use Disorder: "We Don't Do That Here". Womens Health Issues 2021; 31:455-461. [PMID: 34090780 DOI: 10.1016/j.whi.2021.03.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 03/22/2021] [Accepted: 03/31/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE For reproductive-age women, medications for opioid use disorder (OUD) decrease risk of overdose death and improve outcomes but are underutilized. Our objective was to provide a qualitative description of reproductive-age women's experiences of seeking an appointment for medications for OUD. METHODS Trained female callers placed telephone calls to a representative sample of publicly listed opioid treatment clinics and buprenorphine providers in Florida, Kentucky, Massachusetts, Michigan, Missouri, North Carolina, Tennessee, Virginia, Washington, and West Virginia to obtain appointments to receive medication for OUD. Callers were randomly assigned to be pregnant or non-pregnant and have private or Medicaid-based insurance to assess differences in the experiences of access by these characteristics. The callers placed 28,651 uniquely randomized calls, 10,117 to buprenorphine-waivered prescribers and 754 to opioid treatment programs. Open-ended, qualitative data were obtained from the callers about the access experiences and were analyzed using a qualitative, iterative inductive-deductive approach. From all 28,651 total calls, there were 17,970 unique free-text comments to the question "Please give an objective play-by-play of the description of what happened in this conversation." FINDINGS Analysis demonstrated a common path to obtaining an appointment. Callers frequently experienced long hold times, multiple transfers, and difficult interactions. Clinic receptionists were often mentioned as facilitating or obstructing access. Pregnant callers and those with Medicaid noted more barriers. Obtaining an appointment was commonly difficult even for these persistent, trained callers. CONCLUSIONS Interventions are needed to improve the experiences of reproductive-age women as they enter care for OUD, especially for pregnant women and those with Medicaid coverage.
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218
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Darlington F, Acha BM, Roshan T, Ikeanyionwu C, Kutse S, Abajue U, Osazuwa B, Gomez I, Spooner KK, Salemi JL, Dongarwar D, Olaleye OA, Salihu HM, Ndefo UA. Opioid-Related Disorders Among Pregnant Women with Sickle Cell Disease and Adverse Pregnancy Outcomes. PAIN MEDICINE 2021; 21:3087-3093. [PMID: 32710119 DOI: 10.1093/pm/pnaa188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Opioid use during pregnancy has increased in recent years, parallel with the opioid epidemic in the general population. Opioids are commonly used as an analgesic for pain crisis, a hallmark symptom of sickle cell disease (SCD). With the amplified frequency and severity of SCD pain crisis during pregnancy, the use of opioids may increase concurrently. The aim of this study was to examine trends in opioid-related disorders (ORDs) among pregnant women with and without SCD, as well as assess the risk for preterm labor, maternal sepsis, and poor fetal growth among patients with SCD and ORD. METHODS We conducted a retrospective analysis of inpatient pregnancy- and childbirth-related hospital discharge data from the 2002-2014 National (Nationwide) Inpatient Sample database. The primary outcome was the risk of ORD in pregnant women with SCD and its impact on threatened preterm labor, fetal growth, and maternal sepsis. RESULTS Among the >57 million pregnancy-related hospitalizations examined, 9.6 per 10,000 had SCD. ORD in mothers with SCD was four times as prevalent as in those without SCD (2% vs 0.5%). A significant rise in ORD occurred throughout the study period and was associated with an increased risk of maternal sepsis, threatened preterm labor, and poor fetal growth. CONCLUSIONS Pregnant women with SCD have a fourfold increased risk of ORD compared with their non-SCD counterparts. The current opioid epidemic continues to worsen in both groups, warranting a tailored and effective public health response to reduce the resulting adverse pregnancy outcomes.
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Affiliation(s)
- Francis Darlington
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
| | - Benjamina Mbah Acha
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
| | - Tasha Roshan
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
| | - Charles Ikeanyionwu
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
| | - Seun Kutse
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
| | - Uzoamaka Abajue
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
| | - Billy Osazuwa
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
| | - Ian Gomez
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
| | - Kiara K Spooner
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas
| | - Jason L Salemi
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas
| | - Deepa Dongarwar
- Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, Houston, Texas, USA
| | - Omonike A Olaleye
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
| | - Hamisu M Salihu
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas.,Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, Houston, Texas, USA
| | - Uche Anadu Ndefo
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
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219
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Wouldes TA, Crawford A, Stevens S, Stasiak K. Evidence for the Effectiveness and Acceptability of e-SBI or e-SBIRT in the Management of Alcohol and Illicit Substance Use in Pregnant and Post-partum Women. Front Psychiatry 2021; 12:634805. [PMID: 34025470 PMCID: PMC8131659 DOI: 10.3389/fpsyt.2021.634805] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 03/17/2021] [Indexed: 12/12/2022] Open
Abstract
Alcohol and illicit psychoactive drug use during pregnancy have increased worldwide, putting women and their children's health and development at risk. Multiple drug use, comorbid psychiatric disorders, sexual and physical abuse are common in women who use alcohol and drugs during pregnancy. The effects on the mother include poor reproductive and life-long health, legal, family, and social problems. Additionally, the exposed child is at increased risk of long-term physical health, mental health, and developmental problems. The stigma associated with substance use during pregnancy and some clinicians' reticence to inquire about substance use means many women are not receiving adequate prenatal, substance abuse, and mental health care. Evidence for mHealth apps to provide health care for pregnant and post-partum women reveal the usability and effectiveness of these apps to reduce gestational weight gain, improve nutrition, promote smoking cessation and manage gestational diabetes mellitus, and treat depression and anxiety. Emerging evidence suggests mHealth technology using a public health approach of electronic screening, brief intervention, or referral to treatment (e-SBIRT) for substance use or abuse can overcome the typical barriers preventing women from receiving treatment for alcohol and drug use during pregnancy. This brief intervention delivered through a mobile device may be equally effective as SBIRT delivered by a health care professional in preventing maternal drug use, minimizing the effects to the exposed child, and providing a pathway to therapeutic options for a substance use disorder. However, larger studies in more diverse settings with women who have co-morbid mental illness and a constellation of social risk factors that are frequently associated with substance use disorders are needed.
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Affiliation(s)
- Trecia A. Wouldes
- Department of Psychological Medicine, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| | - Andi Crawford
- Department of Psychological Medicine, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
- Te Ara Manapou, Parenting and Pregnancy Service, Hawke's Bay District Health Board, Hastings, New Zealand
| | - Suzanne Stevens
- Department of Psychological Medicine, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| | - Karolina Stasiak
- Department of Psychological Medicine, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
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220
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Abstract
PURPOSE OF REVIEW Opioid use disorder (OUD) in pregnancy has more than quadrupled in prevalence over the past two decades and continues to increase steadily every year. With no defined standard of care for the management of pain during the peripartum period, variability in treatment plans potentially leaves room for interrupted patient care, decreased patient satisfaction, and poorer outcomes. The impact of OUD and its management during the peripartum period has become more widely discussed over the past several years and is the focus of this review. RECENT FINDINGS Current recommendations including developing a detailed institutional plan for the management of pain for women with OUD during the intrapartum and postpartum periods. There is tremendous value in exploring partnerships with other specialties, including addiction medicine, and behavioral health and obstetrics in development of policies and procedures. Consistency within institutions is critical to improve patient outcomes. SUMMARY This review will address both pain management recommendations and best clinical practices regarding management of the parturient during the transition periods of the peripartum, intrapartum, and postpartum period. Novel approaches and perspectives from case reports and narrative experience will also be discussed. There are many opportunities in this field for further studies, research, and evidence-based guidelines that promote an established standard of care.
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221
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Cobb J, Craig W, Richard J, Snow E, Turcotte H, Warters R, Quaye A. Low-dose ketamine infusion for post-cesarean delivery analgesia in patients with opioid use disorder. Int J Obstet Anesth 2021; 47:103170. [PMID: 34090769 DOI: 10.1016/j.ijoa.2021.103170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/09/2021] [Accepted: 04/24/2021] [Indexed: 10/21/2022]
Affiliation(s)
- J Cobb
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - W Craig
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, ME, USA
| | - J Richard
- Department of Anesthesiology & Perioperative Medicine, Maine Medical Center, Portland, ME, USA
| | - E Snow
- Family Birth Center, Maine Medical Center, Portland, ME, USA
| | - H Turcotte
- Department of Anesthesiology & Perioperative Medicine, Maine Medical Center, Portland, ME, USA
| | - R Warters
- Department of Anesthesiology & Perioperative Medicine, Maine Medical Center, Portland, ME, USA; Spectrum Healthcare Partners, South Portland, ME, USA
| | - A Quaye
- Department of Anesthesiology & Perioperative Medicine, Maine Medical Center, Portland, ME, USA; Spectrum Healthcare Partners, South Portland, ME, USA
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222
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Forbes LA, Canner JK, Milio L, Halscott T, Vaught AJ. Association of Patient Sex and Pregnancy Status With Naloxone Administration During Emergency Department Visits. Obstet Gynecol 2021; 137:855-863. [PMID: 33831915 PMCID: PMC8058255 DOI: 10.1097/aog.0000000000004357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/28/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the association of sex and pregnancy status with rates of naloxone administration during opioid overdose-related emergency department (ED) visits by using the Nationwide Emergency Department Sample. METHODS A retrospective cohort study was conducted using the Nationwide Emergency Department Sample 2016 and 2017 data sets. Eligible records included men and women, 15-49 years of age, with an opioid overdose-related ED visit; records for women were stratified by pregnancy status (International Classification of Diseases, Tenth Revision O codes). A multivariable logistic regression model was used to assess the primary outcome of naloxone administration (Current Procedural Terminology code: J2310). Secondary outcomes included subsequent admission and mortality. A subgroup analysis compared pregnant women who did receive naloxone compared with those who did not receive naloxone. RESULTS Records from 443,714 men, 304,364 nonpregnant women, and 25,056 pregnant women were included. Nonpregnant women had lower odds for naloxone administration (1.70% vs 2.10%; adjusted odds ratio [aOR] 0.86 [95% CI 0.83-0.89]) and mortality (2.21% vs 2.99%; aOR 0.71 [95% CI 0.69-0.73]) but higher odds of subsequent admission (30.22% vs 27.18%; aOR 1.04 [95% CI 1.03-1.06]) compared with men. Pregnant women had lower odds for naloxone administration (0.27% vs 1.70%; aOR 0.16 [95% CI 0.13-0.21]) and mortality (0.41% vs 2.21%; aOR 0.28 [95% CI 0.23-0.35]) but higher odds of subsequent admission (40.50% vs 30.22%; aOR 2.04 [95% CI 2.00-2.10]) compared with nonpregnant women. Pregnant women who received naloxone had higher odds of mortality (14% vs 0.39%; aOR 6.30 [95% CI 2.11-18.78]) compared with pregnant women who did not receive naloxone. Pregnant women who did not receive naloxone were more likely to have Medicaid as their expected insurance payer, be in the lowest quartile of median household income for residence ZIP codes, and have a concurrent mental health diagnosis compared with pregnant women who did receive naloxone. CONCLUSION Reproductive-aged women who are nonpregnant and pregnant were less likely to receive naloxone during opioid overdose-related ED visits compared with reproductive-aged men. Naloxone administration for reproductive-aged women should be prioritized in the efforts to reduce opioid- and pregnancy-related morbidity and mortality in the United States.
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Affiliation(s)
- Lauren A. Forbes
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
- Brody School of Medicine, East Carolina University, Greenville, NC
| | - Joseph K. Canner
- Johns Hopkins School of Medicine Department of Surgery, Center for Outcomes Research, Baltimore, MD
| | - Lorraine Milio
- Johns Hopkins School of Medicine Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine, Baltimore, MD
| | - Torre Halscott
- Johns Hopkins School of Medicine Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine, Baltimore, MD
| | - Arthur Jason Vaught
- Johns Hopkins School of Medicine Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine, Baltimore, MD
- Johns Hopkins Hospital Department of Surgery, Division of Surgical Critical Care, Baltimore, MD
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223
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Asta D, Davis A, Krishnamurti T, Klocke L, Abdullah W, Krans EE. The influence of social relationships on substance use behaviors among pregnant women with opioid use disorder. Drug Alcohol Depend 2021; 222:108665. [PMID: 33775448 PMCID: PMC8627830 DOI: 10.1016/j.drugalcdep.2021.108665] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/26/2021] [Accepted: 01/31/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the social network characteristics of pregnant women with opioid use disorder (OUD) and explore how changes in social relationships during pregnancy may influence substance use behaviors. METHODS Between 2017 and 2018, we conducted an exploratory pilot study among 50 pregnant women with OUD. Participants completed a detailed social network inventory to describe the behaviors (e.g. substance-using), social support characteristics (e.g. financial, emotional, informational) and roles (e.g. family member, friend) of network members. The primary outcome was a self-reported decrease in substance use during pregnancy. Pearson correlations were used to test for associations between covariates reflecting different aspects of participants' social networks and decreased substance use during pregnancy. RESULTS Most participants (84.0 %) decreased substance use during pregnancy and stated that pregnancy motivated them to engage in treatment (94.0 %). Participants had a median of 8 (IQR: 4-18) network members with differing proportions of those who did and did not use substances. Pregnancy prompted participants to significantly increase contact with (26.4 % vs. 5.0 %), have increased support from (35.7 % vs. 7.5 %), and a have a feeling of increased closeness with (26.1 % vs. 3.3 %) network members who did not use substances. However, decreased substance use during pregnancy was most strongly (negatively) associated with the proportion of network members who used substances and provided informational support (r=-0.25, p = 0.08) and a feeling of closeness (r=-0.26, p = 0.08). CONCLUSIONS Our findings indicate that pregnancy has a profound influence on women's substance use behaviors and that changes in social relationships due to pregnancy may influence substance use.
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Affiliation(s)
- Dena Asta
- Department of Statistics, The Ohio State University, 1958 Neil Ave, Columbus, OH, 43210, USA; Translational Data Analytics Institute, The Ohio State University, 1760 Neil Ave, Columbus, OH, 43210, USA.
| | - Alex Davis
- Department of Engineering and Public Policy, Carnegie Mellon University, 5000 Forbes Ave, Baker Hall 129, Pittsburgh, PA, 15213, USA
| | - Tamar Krishnamurti
- Department of General Internal Medicine, University of Pittsburgh School of Medicine, 200 Meyran Ave. Suite 200, Pittsburgh, PA, 15213, USA
| | - Leah Klocke
- Magee-Womens Research Institute, 204 Craft Ave, Pittsburgh, PA, 15213, USA
| | - Walitta Abdullah
- Magee-Womens Research Institute, 204 Craft Ave, Pittsburgh, PA, 15213, USA
| | - Elizabeth E. Krans
- Magee-Womens Research Institute, 204 Craft Ave, Pittsburgh, PA, 15213, USA,Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA, 15213, USA
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224
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Boden SL, Jones CW, Cabacungan ET. Improved Maternal and Infant Outcomes with Serial, Self-Reported Early Prenatal Substance Use Screening. Matern Child Health J 2021; 25:1118-1125. [PMID: 33904025 DOI: 10.1007/s10995-021-03127-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Most screening tools identifying women with substance use are not validated, used once in pregnancy, and are not reflective of continued substance use. We hypothesized that serial early prenatal substance screening leads to decreased substance use by the end of pregnancy and improved outcomes. METHODS This is a retrospective cohort study of mothers and their infants between 1/2015 and 12/2017. A self-reported substance screening tool was administered on the first prenatal visit and subsequent visits until delivery. For analysis, mothers were divided into three groups based on the trimester of their first screen and adjusted for demographics and risk factors. RESULTS Early first trimester screening resulted in 52% of mothers having ≥ 3 screens throughout pregnancy vs. 6% of mothers with late third trimester screens (p < 0.001). Compared to third trimester screening, there was a five-fold decrease of any substance use at second trimester, a seven-fold decrease at first trimester, and a nine-fold decrease for marijuana at first trimester. Compared to third trimester screening, there was a significant five-fold increase of negative maternal urine drug screen, 3 ½ -fold increase in well newborn diagnosis, and a five-fold increase of no infant morphine treatment at first trimester. DISCUSSION We identified improved maternal and infant outcomes with serial early prenatal substance use screening. Early maternal substance use identification is crucial for immediate referral for prevention and treatment, and for social and community services. Further research is needed on universal serial early prenatal screenings.
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Affiliation(s)
- Stacy L Boden
- Department of Pediatrics, West Bend Health Center, Froedtert Health & the Medical College of Wisconsin, 1700 W Paradise Drive, West Bend, WI, 53095, USA.
| | - Cresta W Jones
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, University of Minnesota Medical School, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Erwin T Cabacungan
- Division of Neonatology, Department of Pediatrics, Froedtert Health & the Medical College of Wisconsin, 8701 W Watertown Plank Rd, Wauwatosa, WI, 53226, USA
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225
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Dieter AA, Willis-Gray M, Carey ET. Opioid Education in Obstetrics and Gynecology Training Programs. South Med J 2021; 114:4-7. [PMID: 33398352 DOI: 10.14423/smj.0000000000001194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Our primary objective was to assess the current state of pain and opioid education in obstetrics and gynecology (OBGYN) by performing a detailed review of the national educational curricula guiding OBGYN residency and fellowship training programs in the United States. METHODS From 2019 to 2020 we reviewed seven documents created to guide learning and structure educational training for OBGYN residency and fellowship programs in the United States: the Council on Resident Education in Obstetrics and Gynecology (CREOG) Educational Objectives Core Curriculum in Obstetrics and Gynecology, the 2016 Educational Objectives-Fellowship in Minimally Invasive Gynecologic Surgery, and the 2018 Guides to Learning in Complex Family Planning, Female Pelvic Medicine & Reconstructive Surgery, Gynecologic Oncology, Maternal Fetal Medicine, and Reproductive Endocrinology and Infertility. Each document was reviewed by two authors to assess for items referring to pain or opioids. RESULTS The CREOG educational objectives, used to inform educational curricula for residency programs, were the most comprehensive, mentioning pain and/or opioid educational objectives the highest number of times and including the most categories. The CREOG document was followed by the Guides to Learning for Gynecologic Oncology and for Minimally Invasive Gynecologic Surgery. The Reproductive Endocrinology and Infertility Guide to Learning did not mention pain and/or opioids in the educational objectives. CONCLUSIONS Our study identifies an opportunity for consistent and appropriate opioid and pain management education in OBGYN training.
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Affiliation(s)
- Alexis A Dieter
- From the Department of Obstetrics & Gynecology, MedStar Washington Hospital Center/Georgetown University School of Medicine, Washington, DC, and the Department of Obstetrics & Gynecology, the University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Marcella Willis-Gray
- From the Department of Obstetrics & Gynecology, MedStar Washington Hospital Center/Georgetown University School of Medicine, Washington, DC, and the Department of Obstetrics & Gynecology, the University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Erin T Carey
- From the Department of Obstetrics & Gynecology, MedStar Washington Hospital Center/Georgetown University School of Medicine, Washington, DC, and the Department of Obstetrics & Gynecology, the University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Barriers to Breastfeeding: Supporting Initiation and Continuation of Breastfeeding: ACOG Committee Opinion, Number 821. Obstet Gynecol 2021; 137:e54-e62. [PMID: 33481532 DOI: 10.1097/aog.0000000000004249] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Breastfeeding has maternal, infant, and societal benefits. However, many parents experience obstacles to achieving their breastfeeding goals, leading to reduced rates of breastfeeding initiation and continuation. Despite efforts to increase rates of breastfeeding initiation and continuation, inequities still persist. The factors that influence an individual's desire and ability to breastfeed are varied and include individual parent considerations; practitioner influences; hospital barriers; societal factors, such as workplace and parental leave policies; access to lactation support; and social support of their breastfeeding goals. A multidisciplinary approach that involves community, family, parents, and health care professionals will strengthen the support for parents and help them achieve their breastfeeding goals.
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227
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Viera A, Gotham H, Cheng AL, Carlson K, Witt J. Barriers and Challenges to Making Referrals for Treatment and Services for Opioid Misuse in Family Planning Settings. J Womens Health (Larchmt) 2021; 31:38-46. [PMID: 33844948 DOI: 10.1089/jwh.2020.8761] [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: 11/13/2022] Open
Abstract
Background: In this opioid overdose epidemic, women are an overlooked group seeing increasing rates of overdose death. Implementation challenges have prevented evidence-based interventions from effectively reaching women who misuse opioids, with gaps in access to effective treatment and services. Family planning clinics could serve as important points of contact for referral to needed treatments and services. The study explores how family planning staff knowledge and attitudes related to opioid misuse serve as potential barriers and challenges in making referrals for evidence-based services and treatments. Methods: In 2018, we conducted a national online survey of family planning staff, assessing knowledge and attitudes of treatments and services for opioid misuse. Results: A total of 691 family planning staff completed the survey. Most respondents agreed that opioid misuse was a major problem in their community (86.0%) and identified challenges in responding to it, including a lack of treatment access (70.3%), the absence of in-house behavioral health staff (67.2%), and unfamiliarity with local treatment providers (54.1%). Respondents reported low levels of acceptability for syringe services programs (46.0%), medications such as methadone and buprenorphine (55.4%), and naloxone to reverse opioid overdose (60.1%). Controlling for other factors, race/ethnicity, urbanicity, workplace role, and substance use training were associated with differences in acceptability. Conclusions: Family planning settings could play a critical role in connecting women who misuse opioids to treatment and services. Strategies are needed to increase the acceptability of evidence-based interventions and the feasibility of having family planning staff play a linkage role.
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Affiliation(s)
- Adam Viera
- Department of Social and Behavioral Sciences, Yale University School of Public Health, New Haven, Connecticut, USA.,Yale University Center for Interdisciplinary Research on AIDS, New Haven, Connecticut, USA
| | - Heather Gotham
- Department of Psychiatry and Behavioral Sciences, Center for Behavioral Health Services and Implementation Research, Stanford University School of Medicine, Palo Alto, California, USA
| | - An-Lin Cheng
- Department of Biomedical and Health Informatics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri, USA
| | | | - Jacki Witt
- School of Nursing and Health Studies, University of Missouri Kansas City, Kansas City, Missouri, USA
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228
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Mark K, Pace L, Temkin SM, Crimmins S, Terplan M. Concordance and discordance between maternal and newborn drug test results. Am J Obstet Gynecol MFM 2021; 3:100366. [PMID: 33831588 DOI: 10.1016/j.ajogmf.2021.100366] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/28/2021] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Screening for substance use is recommended during pregnancy, and many clinicians rely on urine drug screening to identify newborns at potential risk for withdrawal. OBJECTIVE This study aimed to determine the concordance and discordance rates between maternal and neonatal drug testing at or near the time of delivery. STUDY DESIGN This retrospective chart review was performed at a single institution that employs universal testing for those who consent. Results of maternal and neonatal urine drug testing via immunoassay at delivery were compared. RESULTS Of 1573 singleton pregnancies, 233 mothers (14.8%) had a positive test result for any substance and 102 of their newborns (43.8%) had concordant positive test results. Of the 285 positive maternal test results for individual substances, 133 (46.7%) were concordant with newborn test results. After removing iatrogenic positives, there were 84 truly discordant pairs representing 5.9% of the total cohort of test pairs, but 29.5% of the pairs with maternal positive test results. When considering the outcome of a newborn positive test result, the overall sensitivity and specificity for the maternal test were 21.1% and 85.8%, respectively. The positive and negative predictive values were 46.7% and 96.4%, respectively. After excluding iatrogenic positive test results, the sensitivity and specificity for maternal testing were 97.8% and 99.4%, respectively, and the negative predictive value of maternal testing for all substances approached 100%. A total of 11 pairs of twins had at least 1 twin with a positive drug test result, and of these, 6 twin pairs (54.5%) had drug test results that were discordant from each other. CONCLUSION There is a high rate of iatrogenic discrepancy in maternal and neonatal drug testing. After adjusting for iatrogenic positive test results, the negative predictive value of maternal testing is high. Many discrepancies, such as those in twins, remained unexplained by medication administration, and potential reasons for these discrepancies warrant further investigation.
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Affiliation(s)
- Katrina Mark
- University of Maryland School of Medicine, Baltimore, MD (Dr Mark, Ms Pace, and Dr Crimmins).
| | - Lauren Pace
- University of Maryland School of Medicine, Baltimore, MD (Dr Mark, Ms Pace, and Dr Crimmins)
| | | | - Sarah Crimmins
- University of Maryland School of Medicine, Baltimore, MD (Dr Mark, Ms Pace, and Dr Crimmins)
| | - Mishka Terplan
- Friend Social Research Institute, Baltimore, MD (Dr Terplan)
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229
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Link HM, Jones HE, Miller LA, Kaltenbach K, Seligman NS. Buprenorphine-naloxone use in pregnancy: a subgroup analysis of medication to treat opioid use disorder. Am J Obstet Gynecol MFM 2021; 3:100369. [PMID: 33831585 DOI: 10.1016/j.ajogmf.2021.100369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Heather M Link
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY; Maternal-Fetal Medicine Center, John R. Oishei Children's Hospital, Kaleida Health, 818 Ellicott St., Buffalo, NY 14203.
| | - Hendrée E Jones
- Department of Obstetrics and Gynecology, University of North Carolina, Raleigh, NC
| | - Lauren A Miller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY
| | - Karol Kaltenbach
- Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA
| | - Neil S Seligman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY
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230
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Renbarger KM, Draucker CB. Nurses' Approaches to Pain Management for Women With Opioid Use Disorder in the Perinatal Period. J Obstet Gynecol Neonatal Nurs 2021; 50:412-423. [PMID: 33823145 DOI: 10.1016/j.jogn.2021.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To identify how nurses approach pain management for women with opioid use disorder (OUD) in the perinatal period from the perspectives of nurses and women. DESIGN A secondary analysis of data from a qualitative descriptive study on the development of trust between nurses and women who use substances during the perinatal period. SETTING We interviewed the woman participants in a private conference room at a residential treatment center, and we interviewed the nurse participants over the phone. PARTICIPANTS Four women from a residential treatment center in the rural U.S. Midwest and nine nurses who were members of a local Midwestern Chapter of the Association of Women's Health, Obstetric and Neonatal Nurses. METHODS We used semistructured individual interviews, and participants were asked to describe positive, negative, and typical interactions they had with the other group to identify factors that helped or hindered the formation of trust. In the course of the interviews, four of the women and nine of the nurses described interactions centered on pain management. This information, which we summarized using content analysis, provided data related to the approaches to pain management that nurses use for women with opioid use disorder in the perinatal period. RESULTS Analysis showed that nurse participants used five approaches to pain management: Promoting Nonopioid Pain Management Strategies; Trying to Give Pain Medications on Time; Doubting or Judging Women; Withholding, Delaying, or Resisting Giving Pain Medications; and Responding to Women's Hostility. CONCLUSION Nurses should confront biases related to opioid use during pregnancy and receive training on how to manage aggressive behavior during the provision of maternity care.
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231
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Grecco GG, Mork BE, Huang JY, Metzger CE, Haggerty DL, Reeves KC, Gao Y, Hoffman H, Katner SN, Masters AR, Morris CW, Newell EA, Engleman EA, Baucum AJ, Kim J, Yamamoto BK, Allen MR, Wu YC, Lu HC, Sheets PL, Atwood BK. Prenatal methadone exposure disrupts behavioral development and alters motor neuron intrinsic properties and local circuitry. eLife 2021; 10:66230. [PMID: 33724184 PMCID: PMC7993998 DOI: 10.7554/elife.66230] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/11/2021] [Indexed: 12/18/2022] Open
Abstract
Despite the rising prevalence of methadone treatment in pregnant women with opioid use disorder, the effects of methadone on neurobehavioral development remain unclear. We developed a translational mouse model of prenatal methadone exposure (PME) that resembles the typical pattern of opioid use by pregnant women who first use oxycodone then switch to methadone maintenance pharmacotherapy, and subsequently become pregnant while maintained on methadone. We investigated the effects of PME on physical development, sensorimotor behavior, and motor neuron properties using a multidisciplinary approach of physical, biochemical, and behavioral assessments along with brain slice electrophysiology and in vivo magnetic resonance imaging. Methadone accumulated in the placenta and fetal brain, but methadone levels in offspring dropped rapidly at birth which was associated with symptoms and behaviors consistent with neonatal opioid withdrawal. PME produced substantial impairments in offspring physical growth, activity in an open field, and sensorimotor milestone acquisition. Furthermore, these behavioral alterations were associated with reduced neuronal density in the motor cortex and a disruption in motor neuron intrinsic properties and local circuit connectivity. The present study adds to the limited body of work examining PME by providing a comprehensive, translationally relevant characterization of how PME disrupts offspring physical and neurobehavioral development.
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Affiliation(s)
- Gregory G Grecco
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, United States.,Indiana University School of Medicine, Medical Scientist Training Program, Indianapolis, United States
| | - Briana E Mork
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, United States.,Program in Medical Neuroscience, Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, United States
| | - Jui-Yen Huang
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, United States.,The Linda and Jack Gill Center for Biomolecular Sciences, Department of Psychological and Brain Science, Program in Neuroscience, Indiana University, Bloomington, United States
| | - Corinne E Metzger
- Department of Anatomy, Cell Biology & Physiology, Indiana University School of Medicine, Indianapolis, United States
| | - David L Haggerty
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, United States
| | - Kaitlin C Reeves
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, United States
| | - Yong Gao
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, United States
| | - Hunter Hoffman
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, United States
| | - Simon N Katner
- Deparment of Psychiatry, Indiana University School of Medicine, Indianapolis, United States
| | - Andrea R Masters
- Clinical Pharmacology Analytical Core-Indiana University Simon Cancer Center, Indiana University School of Medicine, Indianapolis, United States
| | - Cameron W Morris
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, United States.,Department of Biology, Indiana University-Purdue University, Indianapolis, United States
| | - Erin A Newell
- Deparment of Psychiatry, Indiana University School of Medicine, Indianapolis, United States
| | - Eric A Engleman
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, United States
| | - Anthony J Baucum
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, United States.,Department of Biology, Indiana University-Purdue University, Indianapolis, United States.,Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, United States
| | - Jiuen Kim
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, United States.,Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, United States
| | - Bryan K Yamamoto
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, United States.,Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, United States
| | - Matthew R Allen
- Department of Anatomy, Cell Biology & Physiology, Indiana University School of Medicine, Indianapolis, United States.,Indiana Center for Musculoskeletal Health, Indiana University School of Medicine, Indianapolis, United States
| | - Yu-Chien Wu
- Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, United States.,Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, United States
| | - Hui-Chen Lu
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, United States.,Department of Psychological and Brain Sciences, Indiana University, Bloomington, United States
| | - Patrick L Sheets
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, United States.,Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, United States
| | - Brady K Atwood
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, United States.,Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, United States
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232
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Corsi DJ, Murphy MSQ. The Effects of opioids on female fertility, pregnancy and the breastfeeding mother-infant dyad: A Review. Basic Clin Pharmacol Toxicol 2021; 128:635-641. [PMID: 33650271 DOI: 10.1111/bcpt.13577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 02/24/2021] [Accepted: 02/25/2021] [Indexed: 11/29/2022]
Abstract
Opioids cover a broad class of natural, synthetic and semi-synthetic drugs that act on opioid receptors to produce powerful analgesic effects. Rates of opioid use and opioid agonist maintenance treatment have increased substantially in recent years, particularly among women. Trends and outcomes of opioids use on fertility, pregnancy and breastfeeding, and longer-term child developmental outcomes have not been well-described. Here, we review the existing literature on the health effects of opioid use on female fertility, pregnancy, breastmilk and the exposed infant. We find that the current literature is primarily concentrated on the impact of opioid use in pregnancy and neonatal outcomes, with little exploration of effects on fertility. Studies are limited in number, some with small sample sizes, and many are hampered by methodological challenges related to confounding and other potential biases. Opioid use is becoming more prevalent due to environmental pressures such as COVID-19. More research is needed to better elucidate its effects on reproductive health among younger women and support the development of evidence-based recommendations for safe prescription practices and public health messaging.
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Affiliation(s)
- Daniel J Corsi
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada.,Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Canada.,OMNI Research Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Malia S Q Murphy
- OMNI Research Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
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233
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Leziak K, Yee LM, Grobman WA, Badreldin N. Patient Experience with Postpartum Pain Management in the Face of the Opioid Crisis. J Midwifery Womens Health 2021; 66:203-210. [PMID: 33661564 DOI: 10.1111/jmwh.13212] [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: 08/11/2020] [Revised: 10/26/2020] [Accepted: 10/30/2020] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Professional societies have urged providers to reduce opioid use for pain management. Accordingly, the objective of this study was to assess patient experiences related to postpartum pain management in an effort to better understand potential paths to achieve such a reduction. METHODS This is a planned secondary analysis of a prospective observational study of opioid use following birth. In the primary study, women who received opioids as inpatients were queried about their pain management, including questions about pain experience, pain satisfaction, perceived areas for practice improvement, and the opportunity to leave additional comments. Participants who were prescribed opioids upon discharge completed postdischarge surveys with a similar opportunity for qualitative input. Data were analyzed using the constant comparative method to identify themes and subthemes. RESULTS Of the 493 women enrolled in the primary analysis, 125 provided qualitative data. Three overarching themes regarding pain management were identified: positive experiences (n = 22), negative experiences (n = 19), and beliefs and preferences on opioid use and pain management (n = 28). Women with positive experiences reported satisfaction with timely pain medication administration and appreciation of open dialogue with their care team. In contrast, several negative experiences centered on tardy administration of pain medications, resulting in increased pain. Patients also perceived judgment, accusation, and excessive lecturing by staff when requesting opioid medications. Finally, participants expressed the necessity for opioids for postpartum pain management, as well as their desires for limiting opioid use, improved options for multimodal pain management, and increased communication with providers about pain regimens. DISCUSSION Understanding women's perspectives and experiences regarding postpartum pain control is essential to improving care. Amid growing research on the role of maternity care providers in addressing the opioid crisis, women's voices are rarely solicited. These findings stress the importance of open and frequent dialogue between patients and providers and a need for multimodal pain management options.
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Affiliation(s)
- Karolina Leziak
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lynn M Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - William A Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Nevert Badreldin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
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234
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Forinash AB, Yancey AM, Shyken J. Pharmacist led vaccination rates in opioid addicted obstetric patients. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Alicia B. Forinash
- Department of Pharmacy Practice St. Louis College of Pharmacy St. Louis Missouri USA
- WISH Center St. Louis Missouri USA
- SSM Health St. Mary's St. Louis Missouri USA
| | - Abigail M. Yancey
- Department of Pharmacy Practice St. Louis College of Pharmacy St. Louis Missouri USA
- SSM Health St. Mary's St. Louis Missouri USA
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235
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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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236
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Samiee-Zafarghandy S, van Donge T, Allegaert K, van den Anker J. Pharmacometric Evaluation of Umbilical Cord Blood Concentration-Based Early Initiation of Treatment in Methadone-Exposed Preterm Neonates. CHILDREN (BASEL, SWITZERLAND) 2021; 8:174. [PMID: 33668712 PMCID: PMC7996295 DOI: 10.3390/children8030174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/15/2021] [Accepted: 02/19/2021] [Indexed: 11/17/2022]
Abstract
In methadone-exposed preterm neonates, early identification of those at risk of severe neonatal abstinence syndrome (NAS) and use of a methadone dosing regimen that can provide effective and safe drug exposure are two important aspects of optimal care. To this end, we reviewed 17 methadone dosing recommendations in the international guidelines and literature and explored their variability in key dosing strategies. We selected three of the reviewed dosing regimens for their pharmacokinetics (PK) characteristics and their exposure-response relationship in three gestational age groups of preterm neonates (28, 32 and 36 gestational age weeks) at risk for development of severe NAS (defined as an umbilical cord methadone concentration of ≤60 ng/mL, following fetal exposure). We applied early (12 h after birth) vs. typical (36 h after birth) initiation of treatment. We observed that use of universally recommended dosing regimens in preterm neonates can result in under- or over-exposure. Use of a PK-guided dosing regimen resulted in effective target exposures within 24 h after birth with early initiation of treatment (12 h after birth). Future prospective studies should explore the incorporation of umbilical cord methadone concentrations for early identification of preterm neonates at risk of developing severe NAS and investigate the use of a PK-guided methadone dosing regimen, so that treatment failure, prolonged length of stay and opioid over-exposure can be avoided.
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Affiliation(s)
- Samira Samiee-Zafarghandy
- Division of Neonatology, Department of Paediatrics, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Tamara van Donge
- Division of Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel (UKBB), University of Basel, 4056 Basel, Switzerland; (T.v.D.); (J.v.d.A.)
| | - Karel Allegaert
- Department of Clinical Pharmacy, Erasmus MC, Postbus 2040, 3000 CA Rotterdam, The Netherlands;
- Department of Development and Regeneration, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - John van den Anker
- Division of Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel (UKBB), University of Basel, 4056 Basel, Switzerland; (T.v.D.); (J.v.d.A.)
- Division of Clinical Pharmacology, Children’s National Health Hospital, Washington, DC 20010, USA
- Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children’s Hospital, 3015 GD Rotterdam, The Netherlands
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238
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Abstract
Before the COVID-19 pandemic, many pregnant patients experienced barriers in accessing opioid use disorder (OUD) medication. This project surveyed buprenorphine treatment clinics to determine how many accepted pregnant women before and then during the pandemic. Of those clinics accepting pregnant patients during the pandemic, respondents were asked what services were provided and what forms of payment they accepted.
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239
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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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McMillin GA, Johnson-Davis KL, Kelly BN, Scott B, Yang YK. Impact of the Opioid Epidemic on Drug Testing. Ther Drug Monit 2021; 43:14-24. [PMID: 33230043 DOI: 10.1097/ftd.0000000000000841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/20/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND This review provides a description of how the opioid epidemic has impacted drug testing. METHODS Four major service areas of drug testing were considered, including emergency response, routine clinical care, routine forensics, and death investigations. RESULTS Several factors that the opioid epidemic has impacted in drug testing are discussed, including specimens, breadth of compounds recommended for testing, time to result required for specific applications, analytical approaches, interpretive support requirements, and examples of published practice guidelines. CONCLUSIONS Both clinical and forensic laboratories have adapted practices and developed new testing approaches to respond to the opioid epidemic. Such changes are likely to continue evolving in parallel with changes in both prescription and nonprescription opioid availability and use patterns, as well as emerging populations that are affected by the "waves" of the opioid epidemic.
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Affiliation(s)
| | | | - Brian N Kelly
- Department of Pathology, University of Utah and ARUP Laboratories; and
| | | | - Yifei K Yang
- Department of Pathology, University of Utah and ARUP Laboratories; and
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241
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Case Report of Cardiopulmonary Arrest During Pregnancy due to Opioid Overdose. J Obstet Gynecol Neonatal Nurs 2021; 50:205-213. [PMID: 33482106 DOI: 10.1016/j.jogn.2020.11.003] [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: 11/01/2020] [Indexed: 11/20/2022] Open
Abstract
In the United States, the number of deaths related to overdose of heroin and other opioids, specifically among women of reproductive age, has been rising. This case report adds new knowledge to the limited scientific literature currently available. We describe the care of a 30-year-old pregnant (31.4 weeks gestation) woman who was found unresponsive from a suspected opioid overdose in a friend's home. In response to an unwitnessed cardiopulmonary arrest, the team initiated therapeutic hypothermia 12 hours after the event. Multiple interdisciplinary teams came together to care for this woman and fetus. Information sharing among care providers from multiple disciplines is needed to build expertise in managing the care of pregnant women who experience opioid overdose.
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242
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Kitsantas P, Adams AR, Cheema J, Kornides ML. Opioid use in pregnant women with mental health-related disabilities. Arch Gynecol Obstet 2021; 303:1531-1537. [PMID: 33423110 DOI: 10.1007/s00404-020-05953-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 12/26/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of this study was to examine associations between opioid use and the degree of mental health-related disability due to emotional/behavioral problems as measured by the World Health Organization Disability Assessment Schedule (WHODAS) instrument in a national sample of pregnant women. METHODS We used data from the National Survey on Drug Use and Health 2014-2017 which included 2,888 pregnant women 18 years or older. The WHODAS instrument was utilized to measure disability as the degree of functional impairment due to emotional/behavioral problems experienced by the respondent. Multinomial logistic regression models were built to assess the magnitude and direction of the association between severity of mental health-related disability with opioid use and abuse/dependency in the past year. RESULTS Approximately 30% of pregnant women suffered from moderate/severe mental health-related disability, and 2% reported opioid abuse/dependency. Compared to those with no opioid use, the odds of opioid use in the past year for individuals with moderate/severe mental health-related disability were 1.73 (95% CI 1.36, 2.21) times higher than those with no/mild disability. Similarly, the odds of opioid abuse/dependency were at least three times higher (OR 3.51; 95% CI 1.80, 6.84) among those with moderate/severe mental health-related disability relative to pregnant women with no/mild disability. CONCLUSIONS Clinicians should consider screening for both opioid use and mental health conditions and related disabilities using screening tools such as the WHODAS during the initial prenatal visits.
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Affiliation(s)
- Panagiota Kitsantas
- Department of Health Administration and Policy, George Mason University, 4400 University Dr, Fairfax, VA, MS 1J322030-4444, USA.
| | - Amy R Adams
- Department of Global and Community Health, George Mason University, 4400 University Dr., Fairfax, VA, 22030, USA
| | - Jehanzeb Cheema
- Department of Information Systems and Operations Management, School of Business, George Mason University, Enterprise Hall 239, 4400 University Dr., Fairfax, VA, 22030, USA
| | - Melanie L Kornides
- Department of Family and Community Health, School of Nursing, University of Pennsylvania, 418 Curie Blvd, Philadelphia, PA, 19104, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
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243
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Reno JL, Kushelev M, Coffman JH, Prasad MR, Meyer AM, Carpenter KM, Palettas MS, Coffman JC. Post-Cesarean Delivery Analgesic Outcomes in Patients Maintained on Methadone and Buprenorphine: A Retrospective Investigation. J Pain Res 2021; 13:3513-3524. [PMID: 33408510 PMCID: PMC7779306 DOI: 10.2147/jpr.s284874] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/03/2020] [Indexed: 12/30/2022] Open
Abstract
Background Despite the increasing prevalence of opioid use disorder (OUD) in pregnant women, there are limited studies on their anesthesia care and analgesic outcomes after cesarean delivery (CD). Methods Patients with OUD on either buprenorphine or methadone maintenance therapy who underwent CD at our institution from 2011 to 2018 were identified. Anesthetic details and analgesic outcomes, including daily opioid consumption and pain scores, were compared between patients maintained on buprenorphine and methadone. Analgesic outcomes were also evaluated according to anesthetic type (neuraxial or general anesthesia) and daily buprenorphine/methadone dose to determine if these factors impacted pain after delivery. Results A total of 146 patients were included (buprenorphine n=99 (67.8%), methadone n=47 (32.2%)). Among all patients: 74% had spinal/CSE, 15% epidural, and 11% general anesthesia. Anesthesia types were similar among buprenorphine and methadone patients. For spinal anesthetics, intrathecal fentanyl (median 15 µg) and morphine (median 100 µg) were commonly given (97.2% and 96.3%, respectively), and dosed similarly between groups. Among epidural anesthetics, epidural morphine (median 2 mg) was commonly administered (90.9%), while fentanyl (median 100 µg) was less common (54.5%). Buprenorphine and methadone groups consumed similar amounts of oxycodone equivalents per 24 hours of hospitalization (80.6 vs 76.3 mg; p=0.694) and had similar peak pain scores (8.3 vs 8.0; p=0.518). Daily methadone dose correlated weakly with opioid consumption (R=0.3; p=0.03), although buprenorphine dose did not correlate with opioid consumption or pain scores. General anesthesia correlated with greater oxycodone consumption in the first 24 hours (median 156.1 vs 91.7 mg; p=0.004) and greater IV PCA use (63% vs 7%; p<0.001) compared to neuraxial anesthesia. Conclusion Patients on buprenorphine and methadone had similar high opioid consumption and pain scores after CD. The anesthetic details and analgesic outcomes reported in this investigation may serve as a useful reference for future prospective investigations and aid in the clinical care of these patients.
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Affiliation(s)
- Joseph L Reno
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Michael Kushelev
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, USA
| | - Julie H Coffman
- Department of Internal Medicine, Riverside Methodist Hospital, Columbus, OH, USA
| | | | - Avery M Meyer
- Department of Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Kristen M Carpenter
- Department of Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - John C Coffman
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, USA
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244
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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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245
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Bader MY, Zaghloul N, Repholz A, Nagy N, Ahmed MN, Thompson L, Kylat RI. A Retrospective Review Following the Addition of Clonidine to a Neonatal Abstinence Syndrome Treatment Algorithm. Front Pediatr 2021; 9:632836. [PMID: 34164354 PMCID: PMC8215153 DOI: 10.3389/fped.2021.632836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 05/05/2021] [Indexed: 11/25/2022] Open
Abstract
Objective: To investigate the outcomes associated with the implementation of a neonatal abstinence syndrome (NAS) treatment algorithm utilizing dual therapy with morphine sulfate and clonidine in a level four neonatal intensive care unit (NICU). Study Design: A cohort of neonates (≥35 weeks gestation) born at an academic tertiary medical center between January 1, 2015 and December 31, 2018 who were diagnosed with NAS were retrospectively evaluated following the implementation of a new NAS treatment algorithm. Neonates were categorized in two groups based on if they were treated pre- or post-implementation of the protocol. The primary efficacy outcome was length of hospital stay. Secondary outcomes included the incidence of adverse drug reactions, length of treatment for NAS, and maximum as well as total cumulative dose of each medication used to treat NAS. Results: The implementation of this NAS treatment algorithm significantly reduced the length of hospital stay (30 days vs. 20 days, p = 0.001). In addition, there was a significant decrease in duration of morphine sulfate exposure as well as cumulative dose of morphine required to successfully treat a neonate with NAS in the post-implementation group (26 days vs. 15 days, p = 0.002 and 6.9 mg/kg vs. 3.4 mg/kg, p = 0.031). Conclusion: Addition of clonidine to morphine sulfate as initial therapy for NAS significantly reduced the cumulative exposure as well as duration of exposure to morphine sulfate compared to morphine monotherapy and decrease length of hospital stay.
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Affiliation(s)
- Mohammad Y Bader
- Department of Pediatrics, University of Arizona Health Sciences, Tucson, AZ, United States.,Banner University Medical Center, Tucson, AZ, United States
| | - Nahla Zaghloul
- Department of Pediatrics, University of Arizona Health Sciences, Tucson, AZ, United States.,Banner University Medical Center, Tucson, AZ, United States
| | - Ashley Repholz
- Las Vegas Children's Hospital, Las Vegas, NV, United States
| | - Nadia Nagy
- Department of Pediatrics, University of Arizona Health Sciences, Tucson, AZ, United States.,Banner University Medical Center, Tucson, AZ, United States
| | - Mohamed N Ahmed
- Department of Pediatrics, University of Arizona Health Sciences, Tucson, AZ, United States.,Banner University Medical Center, Tucson, AZ, United States
| | | | - Ranjit I Kylat
- Department of Pediatrics, University of Arizona Health Sciences, Tucson, AZ, United States.,Banner University Medical Center, Tucson, AZ, United States
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246
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Contraception After Surgical Abortion in Patients With Opioid Use Disorder. Womens Health Issues 2020; 31:271-276. [PMID: 33380374 DOI: 10.1016/j.whi.2020.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/06/2020] [Accepted: 11/25/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study describes the prevalence of medications for opioid use disorder (MOUD) among surgical abortion patients, evaluates long-acting reversible contraception (LARC) uptake after surgical abortion among patients on MOUD, and identifies predictors of immediate postabortion LARC uptake among individuals on MOUD. METHODS We performed a secondary analysis of data from a retrospective observational cohort study of LARC uptake immediately after surgical abortion up to 210/7 weeks gestation at Planned Parenthood League of Massachusetts between October 2012 and April 2017. We estimated proportions and analyzed predictors of LARC uptake among women on MOUD using logistic regression analysis to control for possible confounders. RESULTS During the study period, 26,858 patients had an abortion procedure; 768 (2.9%; 95% confidence interval, 2.7%-3.1%) used MOUD. In the primary study, controlling for demographic factors, MOUD was not an independent predictor of LARC uptake. In this analysis, patients on MOUD differed demographically from non-MOUD users and were significantly more likely to initiate a LARC method immediately after their procedure: 30.1% versus 25.3% (p = .002), including 22.7% who obtained an intrauterine device and 7.4% who obtained an implant. Among patients on MOUD, a prior live birth and public insurance predicted LARC uptake at the time of abortion. CONCLUSION Women on MOUD had higher postabortion LARC uptake compared with those not on MOUD in a setting with easy access to postabortion LARC. Public insurance coverage for abortion was associated with LARC uptake among women on MOUD.
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247
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Yossuck P, Tacker DH. Drug Positivity Findings from a Universal Umbilical Cord Tissue Drug Analysis Program in Appalachia. J Appl Lab Med 2020; 6:285-297. [PMID: 33324976 DOI: 10.1093/jalm/jfaa196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 10/14/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND West Virginia has high rates of opioid-related health crises and deaths that extend to pregnant women and newborns. Our institutional screening approach has included universal umbilical cord tissue drug analysis (UCTDA) since 2013. The objective of this study was to retrospectively report incidence of in utero drug exposure using UCTDA data. METHODS Two sequential UCTDA data sets (October 2013 to September 2015, and October 2016 to September 2018) represent interrupted epochs given changes in interfaced data availability. UCTDA positivity (by drug class and parent drug) and numbers of drugs detected in each specimen were retrospectively analyzed. THC was removed from the analysis because of discontinuous testing, and 4 opioids were separated from the data set given the potential for both therapeutic and illicit use. RESULTS UCTDA specimens that were positive for drugs (22% overall) decreased between Epochs 1 and 2, from 25% to 20%. Increased positivity was noted for hydrocodone (+407%), oxycodone (+240%), amphetamines (+506%), and cocaine (+417%). Fentanyl and morphine positivity decreased by 75% and 18%, respectively, whereas buprenorphine detection increased 195%. Most positive specimens (80% overall) had 1 drug present, but specimens positive for 2 to 6 discrete drugs were found. CONCLUSION Universal UCTDA allows for unbiased assessment of drug exposure in infants. With the additional knowledge of therapeutic indications for drug use, UCTDA may allow for analysis of trends in illicit drug use and the impact of interventions to curb neonatal abstinence syndrome.
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Affiliation(s)
- Panitan Yossuck
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, WV.,Department of Pathology, Anatomy, and Laboratory Medicine, West Virginia University School of Medicine, Morgantown, WV
| | - Danyel H Tacker
- Department of Pediatrics, West Virginia University School of Medicine, Morgantown, WV.,Department of Pathology, Anatomy, and Laboratory Medicine, West Virginia University School of Medicine, Morgantown, WV
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248
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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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249
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Vallejo MC, Shapiro RE, Lippy MW, Lilly CL, Brancazio LR. Independent risk factors for chronic illicit substance use during pregnancy. J Opioid Manag 2020; 16:351-356. [PMID: 33226092 DOI: 10.5055/jom.2020.0590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE We aimed to determine the incidence of chronic illicit substance use during pregnancy and to identify associated risk factors. DESIGN A 2-year time-matched retrospective maternal quality control database (n = 4,470) analysis of parturients with chronic illicit substance use compared to controls. SETTING A tertiary academic medical center located in a rural setting. RESULTS The rate of chronic illicit substance use was 1.95 percent. Demographic factors associated with chronic illicit substance use in pregnancy-included lower body mass index (BMI; OR: 0.93; 95 percent CI: 0.89-0.96, p < 0.0001), higher gravidity (OR: 1.24; 95 percent CI: 1.13-1.36, p < 0.0001), higher parity (OR: 1.38; 95 percent CI: 1.22-1.57, p < 0.0001), and more live births (OR: 1.30; 95 percent CI: 1.16-1.46, p < 0.0001). A history of smoking (OR: 10.51; 95 percent CI: 5.69-19.42, p < 0.0001), alcohol use (OR: 48.98; 95 percent CI: 17.33-138.40, p < 0.0001), anxiety (OR: 1.88; 95 percent CI: 1.16-3.05, p = 0.01), depression (OR: 2.44; 95 percent CI: 1.55-3.85, p = 0.0001), transfer on admission (OR: 2.12; 95 percent CI: 1.16-3.87, p = 0.01), payor insurance (OR: 2.12, 95 percent CI: 2.10-5.04, p < 0.0001), and Apgar scores < 7 at 1 minute (OR: 0.50; 95 percent CI: 0.25-1.00, p = 0.049) were significant. Multiple variable logistic regression-revealed BMI, smoking, alcohol use, and Apgar score <7 at 1 minute as significant factors. CONCLUSIONS Awareness of these factors can assist in identifying and treating parturients with chronic illicit substance use.
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Affiliation(s)
- Manuel C Vallejo
- Department of Medical Education, Health Science Center North, West Virginia University, Morgantown, West Virginia; Department of Anesthesiology, West Virginia University, Morgantown, West Virginia; Department of Obstetrics and Gynecology, West Virginia University, Morgantown, West Virginia; West Virginia University School of Medicine, West Virginia Univer-sity, Morgantown, West Virginia
| | - Robert E Shapiro
- Department of Obstetrics and Gynecology, West Virginia University, Morgantown, West Virginia; West Vir-ginia University School of Medicine, West Virginia University, Morgantown, West Virginia
| | - Mitchell W Lippy
- West Virginia University School of Medicine, Morgantown, West Virginia
| | - Christa L Lilly
- Department of Biostatistics, West Virginia University, Morgantown, West Virginia; West Virginia University School of Public Health, West Virginia University, Morgantown, West Virginia
| | - Leo R Brancazio
- Department of Obstetrics and Gynecology, West Virginia University, Morgantown, West Virginia; West Vir-ginia University School of Medicine, West Virginia University, Morgantown, West Virginia
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250
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Stone RH, Griffin B, Fusco RA, Vest K, Tran T, Gross S. Factors Affecting Contraception Access and Use in Patients With Opioid Use Disorder. J Clin Pharmacol 2020; 60 Suppl 2:S63-S73. [PMID: 33274509 DOI: 10.1002/jcph.1772] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 10/06/2020] [Indexed: 01/23/2023]
Abstract
Maternal opioid use disorder increased > 4-fold from 1999 to 2014 and is associated with poor maternal and fetal outcomes. Women with opioid use disorder are at 2 to 3 times greater risk for unintended pregnancy than the general population and may face additional barriers to accessing and effectively using contraception compared to women without opioid use disorder, particularly highly effective long-acting reversible contraception. Additionally, women with opioid use disorder tend to use less effective forms of contraception such as condoms alone. Barriers to contraceptive access include patient misconceptions or knowledge gaps regarding reproductive health and family planning, cost, intimate partner violence, fear of criminalization, difficulty accessing care, comorbid health conditions, and health care provider misconceptions or practice limitations. Strategies that may assist women with opioid use disorder in achieving their family planning goals include colocation of family planning services within opioid treatment facilities, optimization of patient care services to minimize the need for costly and/or time consuming follow-up, increasing provider education and awareness of best practices in family planning and opioid use disorder treatment, and providing patient-centered family planning education and counseling. Additional research is needed to identify and develop strategies that empower women who use opioids to effectively access and use their preferred contraceptive method.
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Affiliation(s)
- Rebecca H Stone
- University of Georgia College of Pharmacy, Athens, Georgia, USA
| | - Brooke Griffin
- Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois, USA
| | - Rachel A Fusco
- University of Georgia School of Social Work, Athens, Georgia, USA
| | - Kathy Vest
- Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois, USA
| | - Tran Tran
- Midwestern University Chicago College of Pharmacy, Downers Grove, Illinois, USA
| | - Savannah Gross
- University of Georgia College of Pharmacy, Athens, Georgia, USA
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