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Frankeberger J, Coulter RWS, Jarlenski M, Krans EE, Mair C. Co-occurring conditions during pregnancy and hospitalizations in the first year postpartum among persons with opioid use disorder. Prev Med 2024; 185:108057. [PMID: 38942123 DOI: 10.1016/j.ypmed.2024.108057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/15/2024] [Accepted: 06/25/2024] [Indexed: 06/30/2024]
Abstract
INTRODUCTION Pregnant persons with opioid use disorder (OUD) face a multitude of comorbid conditions that may increase the risk of adverse drug and health outcomes. This study characterizes typologies of comorbidities among pregnant persons with OUD and assesses the associations of these typologies with hospitalizations in the first year postpartum. METHODS A cohort of pregnant persons with OUD at delivery in 2018 were identified in a Pennsylvania statewide hospital dataset (n = 2055). Latent class analysis assessed 12 comorbid conditions including substance use disorders (SUDs), mental health conditions, and infections. Multivariable logistic regressions examined the association between comorbidity classes and hospitalizations (all-cause, OUD-specific, SUD-related, mental health-related) during early (0-42 days) and late (43-365 days) postpartum. RESULTS A three-class model best fit the data. Classes included low comorbidities (56.9% of sample; low prevalence of co-occurring conditions), moderate polysubstance/depression (18.4%; some SUDs, all with depression), and high polysubstance/bipolar disorder (24.7%; highest probabilities of SUDs and bipolar disorder). Overall, 14% had at least one postpartum hospitalization. From 0 to 42 days postpartum, the moderate polysubstance/depression and high polysubstance/bipolar disorder classes had higher odds of all-cause and mental health-related hospitalization, compared to the low comorbidities class. From 43 to 365 days postpartum, the high polysubstance/bipolar disorder class had higher odds of all-cause hospitalizations, while both the high polysubstance/depression and moderate polysubstance/bipolar disorder classes had higher odds of SUD-related and mental health-related hospitalizations compared to the low comorbidities class. CONCLUSIONS Findings highlight the need for long-term, multidisciplinary healthcare delivery interventions to address comorbidities and prevent adverse postpartum outcomes.
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Affiliation(s)
- Jessica Frankeberger
- Department of Behavioral and Community Health Sciences, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA; Department of Pediatrics, University of California San Diego, San Diego, CA, USA.
| | - Robert W S Coulter
- Department of Behavioral and Community Health Sciences, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Marian Jarlenski
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
| | - Elizabeth E Krans
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Magee-Womens Research Institute, Pittsburgh, PA, USA
| | - Christina Mair
- Department of Behavioral and Community Health Sciences, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA
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Koltenyuk V, Mrad I, Choe I, Ayoub MI, Kumaraswami S, Xu JL. Multimodal Acute Pain Management in the Parturient with Opioid Use Disorder: A Review. J Pain Res 2024; 17:797-813. [PMID: 38476879 PMCID: PMC10928917 DOI: 10.2147/jpr.s434010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 01/08/2024] [Indexed: 03/14/2024] Open
Abstract
The opioid epidemic in the United States has led to an increasing number of pregnant patients with opioid use disorder (OUD) presenting to obstetric units. Caring for this complex patient population requires an interdisciplinary approach involving obstetricians, anesthesiologists, addiction medicine physicians, psychiatrists, and social workers. The management of acute pain in the parturient with OUD can be challenging due to several factors, including respiratory depression, opioid tolerance, and opioid-induced hyperalgesia. Patients with a history of OUD can present in one of three categories: 1) those with untreated OUD; 2) those who are currently abstinent from opioids; 3) those being treated with medications to prevent withdrawal. A patient-centered, multimodal approach is essential for optimal peripartum pain relief and prevention of adverse maternal and neonatal outcomes. Medications for opioid use disorder (MOUD), previously referred to as medication-assisted therapy (MAT), include opioids like methadone, buprenorphine, and naltrexone. These are prescribed for pregnant patients with OUD, but appropriate dosing and administration of these medications are critical to avoid withdrawal in the mother. Non-opioid analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used in a stepwise approach, and regional techniques like neuraxial anesthesia and truncal blocks offer opioid-sparing options. Other medications like ketamine, clonidine, dexmedetomidine, nitrous oxide, and gabapentinoids show promise for pain management but require further research. Overall, a comprehensive pain management strategy is essential to ensure the well-being of both the mother and the fetus in pregnant patients with OUD.
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Affiliation(s)
| | - Ismat Mrad
- Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, NY, USA
| | - Ian Choe
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Mohamad Ibrahim Ayoub
- Department of Anesthesiology, New York University Grossman School of Medicine, New York, NY, USA
| | - Sangeeta Kumaraswami
- Department of Anesthesiology, Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Jeff L Xu
- Department of Anesthesiology, Westchester Medical Center/New York Medical College, Valhalla, NY, USA
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Junn S, Tugarinov N, Mark K. Low-dose Induction of Buprenorphine in Pregnancy: A Case Series. J Addict Med 2024; 18:62-64. [PMID: 37862120 DOI: 10.1097/adm.0000000000001233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
BACKGROUND Because of a risk of precipitated withdrawal occurring from buprenorphine induction in people who use fentanyl, low-dose inductions are becoming increasingly common. However, little evidence exists on the use of this method in pregnant people. METHODS We conducted a case series of all pregnant people treated for opioid use disorder with low-dose buprenorphine induction at the University of Maryland Medical Center between January 1, 2021, and August 22, 2022. Primary outcome was completion of induction regimen. Secondary outcomes were self-report of withdrawal, continuation of buprenorphine until delivery, and return to or continuation of illicit opioid use. RESULTS Six pregnant people were prescribed a total of 10 buprenorphine inductions. Five of the 6 pregnant people (83.3%) completed at least 1 induction, none of whom experienced precipitated withdrawal. Two of 6 (33.3%) continued buprenorphine until the time of delivery, and 1 of 6 (16.7%) abstained from illicit opioid use. CONCLUSIONS The low-dose buprenorphine induction regimen described was successful in 5 of 6 pregnant individuals. Further research, particularly regarding continuation rates, is needed.
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Affiliation(s)
- Sue Junn
- From the University of Maryland School of Medicine, College Park, MD
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Bates JN, Getsy PM, Coffee GA, Baby SM, MacFarlane PM, Hsieh YH, Knauss ZT, Bubier JA, Mueller D, Lewis SJ. L-cysteine ethyl ester prevents and reverses acquired physical dependence on morphine in male Sprague Dawley rats. Front Pharmacol 2023; 14:1303207. [PMID: 38111383 PMCID: PMC10726967 DOI: 10.3389/fphar.2023.1303207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 10/31/2023] [Indexed: 12/20/2023] Open
Abstract
The molecular mechanisms underlying the acquisition of addiction/dependence on morphine may result from the ability of the opioid to diminish the transport of L-cysteine into neurons via inhibition of excitatory amino acid transporter 3 (EAA3). The objective of this study was to determine whether the co-administration of the cell-penetrant L-thiol ester, L-cysteine ethyl ester (L-CYSee), would reduce physical dependence on morphine in male Sprague Dawley rats. Injection of the opioid-receptor antagonist, naloxone HCl (NLX; 1.5 mg/kg, IP), elicited pronounced withdrawal phenomena in rats which received a subcutaneous depot of morphine (150 mg/kg) for 36 h and were receiving a continuous infusion of saline (20 μL/h, IV) via osmotic minipumps for the same 36 h period. The withdrawal phenomena included wet-dog shakes, jumping, rearing, fore-paw licking, 360° circling, writhing, apneas, cardiovascular (pressor and tachycardia) responses, hypothermia, and body weight loss. NLX elicited substantially reduced withdrawal syndrome in rats that received an infusion of L-CYSee (20.8 μmol/kg/h, IV) for 36 h. NLX precipitated a marked withdrawal syndrome in rats that had received subcutaneous depots of morphine (150 mg/kg) for 48 h) and a co-infusion of vehicle. However, the NLX-precipitated withdrawal signs were markedly reduced in morphine (150 mg/kg for 48 h)-treated rats that began receiving an infusion of L-CYSee (20.8 μmol/kg/h, IV) at 36 h. In similar studies to those described previously, neither L-cysteine nor L-serine ethyl ester (both at 20.8 μmol/kg/h, IV) mimicked the effects of L-CYSee. This study demonstrates that 1) L-CYSee attenuates the development of physical dependence on morphine in male rats and 2) prior administration of L-CYSee reverses morphine dependence, most likely by intracellular actions within the brain. The lack of the effect of L-serine ethyl ester (oxygen atom instead of sulfur atom) strongly implicates thiol biochemistry in the efficacy of L-CYSee. Accordingly, L-CYSee and analogs may be a novel class of therapeutics that ameliorate the development of physical dependence on opioids in humans.
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Affiliation(s)
- James N. Bates
- Department of Anesthesiology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Paulina M. Getsy
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
| | - Gregory A. Coffee
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
| | - Santhosh M. Baby
- Section of Biology, Galleon Pharmaceuticals, Inc., Horsham, PA, United States
| | - Peter M. MacFarlane
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
| | - Yee-Hsee Hsieh
- Division of Pulmonary, Critical Care and Sleep Medicine, Case Western Reserve University, Cleveland, OH, United States
| | - Zackery T. Knauss
- Department of Biological Sciences, Kent State University, Kent, OH, United States
| | | | - Devin Mueller
- Department of Biological Sciences, Kent State University, Kent, OH, United States
| | - Stephen J. Lewis
- Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States
- Department of Pharmacology, Case Western Reserve University, Cleveland, OH, United States
- Functional Electrical Stimulation Center, Case Western Reserve University, Cleveland, OH, United States
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West BS, Choi S, Terplan M. In our responses to the overdose epidemic, we cannot forget pregnant and postpartum people. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 120:104153. [PMID: 37572587 DOI: 10.1016/j.drugpo.2023.104153] [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: 04/02/2023] [Revised: 07/10/2023] [Accepted: 07/27/2023] [Indexed: 08/14/2023]
Abstract
In 2021, there were over 100,000 drug overdose deaths in the United States (US). Death rates have increased faster among women than men, particularly among Black and Indigenous people. Although drug overdose is a leading cause of pregnancy-associated deaths, birthing people are rarely emphasized in discussions of overdose and research and services remain limited. Data show increases in drug use and deaths among women of child-bearing age, with risks continuing in the postpartum period. Harms experienced by birthing people who use drugs occur in the context of broader inequities in maternal morbidity and mortality that lead to disparate reproductive health outcomes. Shared structural antecedents (e.g. intersecting sexism and racism, stigma, and punitive policies) underlie overlapping epidemics of overdose and maternal morbidity and mortality. Here we discuss the unique challenges placed on birthing people who use drugs and make recommendations on how to mitigate harms by improving access to and delivery of quality care and addressing unjust policies and practices. We highlight the need for integrated health services, clearer guidelines rooted in equity, and the need for changes to policy and practice that support rather than punish. To better serve individuals and families impacted by substance use, we need multilevel solutions that advance gender equity and racial justice to reshape and/or dismantle the systems that undergird oppression.
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Affiliation(s)
- Brooke S West
- Columbia University School of Social Work, United States.
| | - Sugy Choi
- Department of Population Health, New York University Langone Health, United States
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Szlyk HS, Constantino-Pettit A, Li X, Kasson E, Maranets E, Worku Y, Montayne M, Banks DE, Kelly JC, Cavazos-Rehg PA. Self-Identified Stage in Recovery and Substance-Use Behaviors among Pregnant and Postpartum Women and People with Opioid Use Disorder. Healthcare (Basel) 2023; 11:2392. [PMID: 37685426 PMCID: PMC10486579 DOI: 10.3390/healthcare11172392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/09/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Opioid use among pregnant and postpartum women and people (PPWP) has significant health repercussions. This study explores how substance-use behaviors may vary by stage in recovery among PPWP with opioid use disorder (OUD). We recruited 29 PPWP with OUD. "High-risk" participants self-identified as "not being engaged in treatment" or "new or early in their recovery" (n = 11); "low-risk" participants self-identified as being "well-established" or "in long-term recovery" (n = 18). Participants were queried regarding sociodemographic, mental health, and drug-misuse factors; urine drug screens were collected at baseline. Univariate group comparisons between high-risk and low-risk PPWP were conducted. High-risk PPWP were more likely to self-identify as non-Hispanic African American and more likely to report current opioid use, other illicit drugs, and tobacco. High-risk PPWP had higher opioid cravings versus low-risk PPWP. High-risk PPWP were more likely to screen positive on urine tests for non-opioid drugs and on concurrent use of both non-opioid drugs and opioids versus low-risk participants. PPWP earlier in recovery are at higher-risk for opioid and other illicit drug misuse but are willing to disclose aspects of their recent use. PPWP early in recovery are an ideal population for interventions that can help facilitate recovery during the perinatal period and beyond.
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Affiliation(s)
- Hannah S. Szlyk
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
| | - Anna Constantino-Pettit
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
- Brown School, Washington University in St. Louis, 1 Brookings Dr., St. Louis, MO 63130, USA
| | - Xiao Li
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
| | - Erin Kasson
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
| | - Emily Maranets
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
| | - Yoseph Worku
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
| | - Mandy Montayne
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
| | - Devin E. Banks
- Department of Psychological Sciences, University of Missouri–St. Louis, One University Blvd., 325 Stadler Hall, St. Louis, MO 63121, USA;
| | - Jeannie C. Kelly
- Department of Obstetrics & Gynecology, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO 63110, USA;
| | - Patricia A. Cavazos-Rehg
- Department of Psychiatry, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA; (A.C.-P.); (X.L.); (E.K.); (E.M.); (Y.W.); (M.M.); (P.A.C.-R.)
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