1
|
Niebergall EB, Weekley D, Mazur A, Olszewski NA, DeSchepper KM, Radant N, Vijay AS, Risher WC. Abnormal Morphology and Synaptogenic Signaling in Astrocytes Following Prenatal Opioid Exposure. Cells 2024; 13:837. [PMID: 38786059 PMCID: PMC11119541 DOI: 10.3390/cells13100837] [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] [Received: 04/22/2024] [Revised: 05/09/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024] Open
Abstract
In recent decades, there has been a dramatic rise in the rates of children being born after in utero exposure to drugs of abuse, particularly opioids. Opioids have been shown to have detrimental effects on neurons and glia in the central nervous system (CNS), but the impact of prenatal opioid exposure (POE) on still-developing synaptic circuitry is largely unknown. Astrocytes exert a powerful influence on synaptic development, secreting factors to either promote or inhibit synapse formation and neuronal maturation in the developing CNS. Here, we investigated the effects of the partial µ-opioid receptor agonist buprenorphine on astrocyte synaptogenic signaling and morphological development in cortical cell culture. Acute buprenorphine treatment had no effect on the excitatory synapse number in astrocyte-free neuron cultures. In conditions where neurons shared culture media with astrocytes, buprenorphine attenuated the synaptogenic capabilities of astrocyte-secreted factors. Neurons cultured from drug-naïve mice showed no change in synapses when treated with factors secreted by astrocytes from POE mice. However, this same treatment was synaptogenic when applied to neurons from POE mice, indicating a complex neuroadaptive response in the event of impaired astrocyte signaling. In addition to promoting morphological and connectivity changes in neurons, POE exerted a strong influence on astrocyte development, disrupting their structural maturation and promoting the accumulation of lipid droplets (LDs), suggestive of a maladaptive stress response in the developing CNS.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - W. Christopher Risher
- Department of Biomedical Sciences, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV 25701, USA; (E.B.N.); (D.W.); (A.M.); (N.A.O.); (K.M.D.); (N.R.); (A.S.V.)
| |
Collapse
|
2
|
Miller JS, Bada HS, Westgate PM, Sithisarn T, Leggas M. Neonatal Abstinence Signs during Treatment: Trajectory, Resurgence and Heterogeneity. CHILDREN (BASEL, SWITZERLAND) 2024; 11:203. [PMID: 38397314 PMCID: PMC10887053 DOI: 10.3390/children11020203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 01/28/2024] [Accepted: 01/28/2024] [Indexed: 02/25/2024]
Abstract
Neonatal abstinence syndrome (NAS) presents with a varying severity of withdrawal signs and length of treatment (LOT). We examined the course and relevance of each of the NAS withdrawal signs during treatment in a sample of 182 infants with any prenatal opioid exposure, gestational age ≥ 35 weeks, without other medical conditions, and meeting the criteria for pharmacological treatment. Infants were monitored using the Finnegan Neonatal Abstinence Scoring Tool. Daily mean Finnegan scores were estimated using linear mixed models with random subject effects to account for repeated withdrawal scores from the same subject. Daily item prevalence was estimated using generalized estimating equations with a within-subject exchangeable correlation structure. The median LOT was 12.86 days. The prevalence of withdrawal signs decreased from day one to day three of treatment. However, certain central nervous system (CNS) and gastrointestinal (GI) signs showed sporadic increases in prevalence notable around two weeks of treatment, accounting for increases in Finnegan scores that guided pharmacotherapy. We question whether the resurgence of signs with a prolonged LOT is mainly a consequence of opioid tolerance or withdrawal. Monitoring CNS and GI signs throughout treatment is crucial. Future studies directed to better understand this clinical phenomenon may lead to the refining of NAS pharmacotherapy and perhaps the discovery of treatment alternatives.
Collapse
Affiliation(s)
- Jennifer S. Miller
- College of Nursing, University of Tennessee, Knoxville, TN 37996, USA;
- College of Medicine, University of Kentucky, Lexington, KY 40536, USA;
| | - Henrietta S. Bada
- College of Medicine, University of Kentucky, Lexington, KY 40536, USA;
| | - Philip M. Westgate
- College of Public Health, University of Kentucky, Lexington, KY 40536, USA;
| | | | - Markos Leggas
- Division of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN 38105, USA;
| |
Collapse
|
3
|
Mascarenhas M, Wachman EM, Chandra I, Xue R, Sarathy L, Schiff DM. Advances in the Care of Infants With Prenatal Opioid Exposure and Neonatal Opioid Withdrawal Syndrome. Pediatrics 2024; 153:e2023062871. [PMID: 38178779 PMCID: PMC10827648 DOI: 10.1542/peds.2023-062871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 01/06/2024] Open
Abstract
A significant number of advances have been made in the last 5 years with respect to the identification, diagnosis, assessment, and management of infants with prenatal opioid exposure and neonatal opioid withdrawal syndrome (NOWS) from birth to early childhood. The primary objective of this review is to summarize major advances that will inform the clinical management of opioid-exposed newborns and provide an overview of NOWS care to promote the implementation of best practices. First, advances with respect to standardizing the clinical diagnosis of NOWS will be reviewed. Second, the most commonly used assessment strategies are discussed, with a focus on presenting new quality improvement and clinical trial data surrounding the use of the new function-based assessment Eat, Sleep, and Console approach. Third, both nonpharmacologic and pharmacologic treatment modalities are reviewed, highlighting clinical trials that have compared the use of higher calorie and low lactose formula, vibrating crib mattresses, morphine compared with methadone, buprenorphine compared with morphine or methadone, the use of ondansetron as a medication to prevent the need for NOWS opioid pharmacologic treatment, and the introduction of symptom-triggered dosing compared with scheduled dosing. Fourth, maternal, infant, environmental, and genetic factors that have been found to be associated with NOWS severity are highlighted. Finally, emerging recommendations on postdelivery hospitalization follow-up and developmental surveillance are presented, along with highlighting ongoing and needed areas of research to promote infant and family well-being for families impacted by opioid use.
Collapse
Affiliation(s)
| | - Elisha M. Wachman
- Department of Pediatrics, Boston Medical Center, and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Iyra Chandra
- Dana Farber Cancer Institute, Boston, Massachusetts
| | - Rachel Xue
- Department of Family Medicine, Boston Medical Center, Boston, Massachusetts
| | - Leela Sarathy
- Newborn Medicine, MassGeneral for Children, Boston, Massachusetts
| | | |
Collapse
|
4
|
Migliori C, Braga M, Siragusa V, Villa MC, Luzi L. The impact of gender medicine on neonatology: the disadvantage of being male: a narrative review. Ital J Pediatr 2023; 49:65. [PMID: 37280693 DOI: 10.1186/s13052-023-01447-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 03/20/2023] [Indexed: 06/08/2023] Open
Abstract
This narrative non-systematic review addresses the sex-specific differences observed both in prenatal period and, subsequently, in early childhood. Indeed, gender influences the type of birth and related complications. The risk of preterm birth, perinatal diseases, and differences on efficacy for pharmacological and non-pharmacological therapies, as well as prevention programs, will be evaluated. Although male newborns get more disadvantages, the physiological changes during growth and factors like social, demographic, and behavioural reverse this prevalence for some diseases. Therefore, given the primary role of genetics in gender differences, further studies specifically targeted neonatal sex-differences will be needed to streamline medical care and improve prevention programs.
Collapse
Affiliation(s)
- Claudio Migliori
- Department of Neonatology, Ospedale San Giuseppe MultiMedica, 20123, Milan, Italy.
| | - Marta Braga
- Department of Neonatology, Ospedale San Giuseppe MultiMedica, 20123, Milan, Italy
| | - Virginia Siragusa
- Department of Neonatology, Ospedale San Giuseppe MultiMedica, 20123, Milan, Italy
| | - Maria Cristina Villa
- Department of Neonatology, Ospedale San Giuseppe MultiMedica, 20123, Milan, Italy
| | - Livio Luzi
- Department of Endocrinology, Nutrition and Metabolic Diseases, IRCCS MultiMedica, 20099, Sesto San Giovanni, Milan, Italy
| |
Collapse
|
5
|
Gabapentin Use During Pregnancy and Lactation With and Without Concurrent Opioid Exposure: Considerations and Future Directions. J Addict Med 2023; 17:123-125. [PMID: 36069804 DOI: 10.1097/adm.0000000000001065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Gabapentin is a γ-aminobutyric acid analog formally indicated for the treatment of epilepsy and neuropathic pain that is gaining increased popularity. Gabapentin has been historically considered a safe medication, including during pregnancy and lactation, with low reported concerns for misuse and use disorders. However, new empirical efforts are revealing concerns regarding the safety of widespread gabapentin use, particularly in pregnancy and for individuals with a propensity toward substance misuse. The Food and Drug Administration's full prescribing information report on gabapentin provides concerning preclinical data and then states that gabapentin is potentially "developmentally toxic" and has an unknown risk of birth impacts. Concerns have also been raised surrounding in utero exposure to gabapentin due to the onset and presentation of atypical and/or difficult to control withdrawal signs and symptoms in neonates, including those dually exposed to opioids, as well as neonatal exposure to gabapentin via breastmilk. Moreover, nonprescribed gabapentin use has become an increasing problem, with opioid use disorder being the greatest risk factor for such misuse. This article summarizes the current literature regarding gabapentin use during pregnancy and related prenatal and neonatal exposure outcomes with special consideration for interactions between gabapentin and opioid use. Taken together, the current literature suggests that gabapentin use should be considered with caution during pregnancy and during the post-partum period. Well-controlled, prospective research studies are needed to determine the extent of the risks and benefits of prescribed and nonprescribed gabapentin exposure to pregnant people and their neonates.
Collapse
|
6
|
Morrison TM, MacMillan KDL, Melvin P, Singh R, Murzycki J, Van Vleet MW, Rothstein R, O'Shea TF, Gupta M, Schiff DM, Wachman EM. Neonatal Opioid Withdrawal Syndrome: A Comparison of As-Needed Pharmacotherapy. Hosp Pediatr 2022; 12:530-538. [PMID: 35403199 DOI: 10.1542/hpeds.2021-006301] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Methadone and morphine are commonly administered medications for neonatal opioid withdrawal syndrome (NOWS). Infants are increasingly treated with as-needed or "pro re nata" (PRN) medication. The optimal pharmacologic agent for PRN treatment of NOWS has not been examined. This study's objective is to compare NOWS hospital outcomes between infants treated with PRN methadone versus morphine. METHODS We performed a retrospective cohort study of infants pharmacologically treated for NOWS across 4 Massachusetts hospitals between January 2018 and February 2021. Infants born ≥36 weeks gestation with prenatal opioid exposure treated with PRN methadone or morphine were included. Mixed effects logistic and linear regression models were employed to evaluate differences in transition rates to scheduled dosing, length of stay, and number of PRN doses administered depending on PRN treatment agent. RESULTS There were 86 infants in the methadone group and 52 in the morphine group. There were no significant differences in NOWS hospital outcomes between groups in adjusted models: transition to scheduled dosing (methadone 31.6% vs morphine 28.6%, adjusted odds ratio 1.21, 95% confidence interval [CI] 0.87-1.19), mean length of stay (methadone 15.5 vs morphine 14.3 days, adjusted risk ratio 1.06, 95% CI 0.80-1.41), and the mean number of PRN doses (methadone 2.3 vs morphine 3.4, adjusted risk ratio 0.65, 95% CI 0.41-1.02). There was an association with nonpharmacologic care practices and improved NOWS hospital outcomes. CONCLUSIONS There were no significant differences in NOWS hospitalization outcomes based on pharmacologic agent type; nonpharmacologic care practices were most strongly associated with improved NOWS hospitalization outcomes.
Collapse
Affiliation(s)
| | | | - Patrice Melvin
- Center for Applied Pediatric Quality Analytics, Boston Children's Hospital, Boston, Massachusetts
| | - Rachana Singh
- Department of Pediatrics, Tufts Children's Hospital, Boston, Massachusetts
| | - Jennifer Murzycki
- Department of Newborn Medicine, Lowell General Hospital, Lowell, Massachusetts
| | - Marcia W Van Vleet
- Department of Newborn Medicine, Baystate Franklin Medical Center, Greenfield, Massachusetts
| | - Robert Rothstein
- Department of Pediatrics, Baystate Medical Center, Springfield, Massachusetts
| | | | - Munish Gupta
- Department of Newborn Medicine, Beth Israel Hospital, Boston, Massachusetts
| | - Davida M Schiff
- Department of Pediatrics, MassGen Hospital for Children, Boston, Massachusetts
| | - Elisha M Wachman
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| |
Collapse
|
7
|
Morris E, Bardsley T, Schulte K, Seidel J, Shakib JH, Buchi KF, Fung CM. Hospital Outcomes of Infants with Neonatal Opioid Withdrawal Syndrome at a Tertiary Care Hospital with High Rates of Concurrent Nonopioid (Polysubstance) Exposure. Am J Perinatol 2022; 39:387-393. [PMID: 32892326 PMCID: PMC8632549 DOI: 10.1055/s-0040-1716490] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Neonatal opioid withdrawal syndrome (NOWS) describes infants' withdrawal signs and symptoms after birth due to an interruption of prenatal opioid exposure. Many infants with NOWS are also exposed to nonopioids, however. This study was to determine hospital outcomes of infants exposed to opioids alone or coexposed with nonopioid substances (polysubstance). STUDY DESIGN We reviewed infants of ≥34 weeks of gestation with prenatal opioid exposure from April 2015 to May 2018. We compared the median lengths of stay (LOS) and treatment (LOT) and the percentages of infants requiring pharmacologic and adjunctive treatment in infants exposed to opioids alone or polysubstance. We used Wilcoxon's test for continuous outcomes or Chi-squared test for categorical outcomes to determine statistical significance. We used multivariable regression model to calculate each drug category's estimates of adjusted mean ratios for LOS and LOT plus estimates of adjusted odds ratios for pharmacologic/adjunctive treatments. RESULTS Of the 175 infants, 33 (19%) infants had opioid exposure alone. Opioid exposure included short- and/or long-acting opioids. A total of 142 (81%) had polysubstance exposure with 47% of mothers using nicotine products. We saw similar hospital outcomes between infants exposed to opioids alone or polysubstance; however, a higher percentage of infants with both short- and long-acting opioid exposure required pharmacologic treatment compared with either opioid alone. Focusing on individual drug categories, we detected differential hospital outcomes in which short-acting opioids decreased LOT, whereas long-acting opioids increased LOS, LOT, and need for pharmacologic and adjunctive treatment. Coexposure of opioids with stimulants decreased LOT and reduced need for adjunctive treatment. Coexposures with antidepressants increased LOT, while with antiepilepetics increased LOS. CONCLUSION Because infants with NOWS often have coexposures to other nonopioid substances, appreciating the associated risks of individual or combination of drugs in modulating hospital outcomes may help counsel families on their infants' expected hospital course. KEY POINTS · Hospital outcomes were similar between infants exposed to opioids alone or polysubstance including opioids.. · Infants with short- and long-acting opioids required pharmacologic treatment more often than either opioid alone.. · Differential hospital outcomes exist for various co-exposures of opioids with nonopioids..
Collapse
Affiliation(s)
- Erin Morris
- Department of Pediatrics, Residency & Fellowship Program, Salt Lake City, Utah
| | - Tyler Bardsley
- Division of Epidemiology, University of Utah Study Design and Biostatistics Center, University of Utah School of Medicine, Salt Lake City, Utah
| | - Krista Schulte
- College of Nursing, University of Utah, Salt Lake City, Utah
| | - Jeanette Seidel
- College of Nursing, University of Utah, Salt Lake City, Utah
| | - Julie H. Shakib
- Division of General Pediatrics, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Karen F. Buchi
- Division of General Pediatrics, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Camille M. Fung
- Division of Pediatric Neonatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| |
Collapse
|
8
|
Miller JS, Anderson JG. Factors in children with a history of neonatal abstinence syndrome at 10 years of age: Evidence from the maternal lifestyle study. J SPEC PEDIATR NURS 2022; 27:e12358. [PMID: 34472206 DOI: 10.1111/jspn.12358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 07/26/2021] [Accepted: 08/23/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Few studies have addressed the impact of prior prenatal substance exposure and current household environment on neurodevelopmental health in children with a history of neonatal abstinence syndrome (NAS). This study aimed to describe the prenatal exposures, household environment, and neurodevelopmental health at 10 years of age among children with a history of NAS. DESIGN AND METHODS This study was a retrospective, descriptive design using data from the Maternal Lifestyle Study. Descriptive analyses were conducted. A total of 234 children with a history of NAS were included in this study. Variables selected based on the socio-ecological model included prenatal exposures, household environment, and neurodevelopmental health outcomes. RESULTS In this sample, most children were male (63%) with prenatal polysubstance exposure (80%). The majority lived in a home where substance use occurred (68%). Children experienced abnormal cognitive development (26%), language disorders (24%), learning disorders (23%), and abnormal behavioral development (16%). IMPLICATIONS This study extends the description of children with a history of NAS beyond 5 years of age. Pediatric nurses can ensure that children with a history of NAS receive neurodevelopmental screening up to and beyond 10 years of age.
Collapse
Affiliation(s)
| | - Joel G Anderson
- College of Nursing, University of Tennessee, Knoxville, Tennessee, USA
| |
Collapse
|
9
|
Schiff DM, Partridge S, Gummadi NH, Gray JR, Stulac S, Costello E, Wachman EM, Jones HE, Greenfield SF, Taveras EM, Bernstein JA. Caring for Families Impacted by Opioid Use: A Qualitative Analysis of Integrated Program Designs. Acad Pediatr 2022; 22:125-136. [PMID: 33901729 PMCID: PMC8542059 DOI: 10.1016/j.acap.2021.04.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 04/13/2021] [Accepted: 04/18/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE We sought to 1) identify models of integrated care that offer medical care and social services for children and families impacted by opioid use disorder (OUD) in the postpartum year; and 2) describe how each program was developed, designed, and sustained, and explore facilitators and barriers to implementation of a dyadic, two-generation approach to care. METHODS In-depth semi-structured interviews (n = 23) were conducted with programs for women and children affected by OUD across North America. Using a phenomenologic approach, key program components and themes were identified. Following thematic saturation, these results were triangulated with experts in program implementation and with a subset of key informants to ensure data integrity. RESULTS Five distinct types of programs were identified that varied in the degree of medical and behavioral care for families. Three themes emerged unique to the provision of dyadic care: 1) families require supportive, frequent visits with a range of providers, but constraints around billable services limit care integration across the perinatal continuum; 2) individual program champions are critical, but degree and reach of interdisciplinary care is limited by siloed systems for medical and behavioral care; and 3) addressing dual, sometimes competing, responsibilities for both parental and infant health following recurrence of parental substance use presents unique challenges. CONCLUSIONS The key components of dyadic care models for families impacted by OUD included prioritizing care coordination, removing barriers to integrating medical and behavioral services, and ensuring the safety of children in homes with ongoing parental substance use while maintaining parental trust.
Collapse
Affiliation(s)
- Davida M. Schiff
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, 125 Nashua St, Suite 860, Boston, MA, 02114
| | - Shayla Partridge
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, 125 Nashua St, Suite 860, Boston, MA, 02114
| | - Nina H. Gummadi
- Boston University School of Medicine, 72 E. Concord St, Boston, MA
| | - Jessica R. Gray
- Department of Medicine and Pediatrics, Massachusetts General Hospital, 55 Fruit St, Boston, MA
| | - Sara Stulac
- Boston University School of Medicine, 72 E. Concord St, Boston, MA,Department of Pediatrics, Boston Medical Center, 801 Albany Street, Boston, MA 02119, USA
| | - Eileen Costello
- Boston University School of Medicine, 72 E. Concord St, Boston, MA,Department of Pediatrics, Boston Medical Center, 801 Albany Street, Boston, MA 02119, USA
| | - Elisha M. Wachman
- Department of Pediatrics, Boston Medical Center, 801 Albany Street, Boston, MA 02119, USA
| | - Hendrée E. Jones
- UNC Florizons and Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, 410 North Greensboro St., Carrboro, NC
| | - Shelly F. Greenfield
- Boston University School of Medicine, 72 E. Concord St, Boston, MA,Division of Women’s Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, 115 Mill St, Belmont, MA 02478,Harvard Medical School, 25 Shattuck Street, Boston, MA 02115
| | - Elsie M. Taveras
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, 125 Nashua St, Suite 860, Boston, MA, 02114,Boston University School of Medicine, 72 E. Concord St, Boston, MA
| | - Judith A. Bernstein
- Division of Community Health Sciences, Boston University School of Public Health, 715 Albany St, Boston, MA 02118
| |
Collapse
|
10
|
Saito J, Ishii M, Miura Y, Yakuwa N, Kawasaki H, Suzuki T, Yamatani A, Sago H, Tachibana Y, Murashima A. Brotizolam During Pregnancy and Lactation: Brotizolam Levels in Maternal Serum, Cord Blood, Breast Milk, and Neonatal Serum. Breastfeed Med 2021; 16:579-582. [PMID: 33666494 DOI: 10.1089/bfm.2021.0013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Brotizolam is a sedative-hypnotic thienotriazolodiazepine that is a benzodiazepine analog used for debilitating insomnia. Anxiety, depression, and sleep disorders occur in about 15% of pregnant and lactating women; however, no studies have examined brotizolam transfer across the placenta or its excretion into breast milk. In this case report, we assessed brotizolam concentrations in maternal and neonatal blood, cord blood, and breast milk. Materials and Methods: Brotizolam concentrations in maternal serum, breast milk, cord blood, and neonatal serum were measured while the mother was taking oral brotizolam 0.25 mg once daily. Case Report: A 28-year-old woman diagnosed with bipolar II disorder received brotizolam during pregnancy (28-40 weeks' gestational age) and lactation, along with sertraline, alprazolam, and trazodone. A male infant weighing 3,412 g was born at 40 weeks of gestation. Neonatal abstinence syndrome manifested as fever, limb tremor, and central cyanosis, requiring oxygenation and intravenous phenobarbital administration for 4 days. No pulmonary dysfunction or birth defects were detected. Brotizolam concentrations in maternal serum at 7.0 and 14.0 hours after maternal dosing were 0.51 and 0.22 ng/mL, respectively. Brotizolam was not detected in cord blood or infant serum 9.2 hours after maternal dosing. The brotizolam concentration in breast milk collected 7.1 hours after maternal dosing was 0.12 ng/mL. The infant developed normally, with no drug-related adverse effects at the 1-, 3-, or 6-month postpartum checkups. Conclusion: Brotizolam transfer into placenta and breast milk was negligible. Further studies should assess the safety of brotizolam in fetuses and breastfed infants.
Collapse
Affiliation(s)
- Jumpei Saito
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan
| | - Mariko Ishii
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan
| | - Yoriko Miura
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan
| | - Naho Yakuwa
- Japan Drug Information Institute in Pregnancy, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroyo Kawasaki
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan
| | - Tomo Suzuki
- Division of Obstetrics, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Akimasa Yamatani
- Department of Pharmaceuticals, National Center for Child Health and Development, Tokyo, Japan
| | - Haruhiko Sago
- Division of Obstetrics, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Yoshiyuki Tachibana
- Maternal-Child Psychiatry, Department of Psychosocial Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Atsuko Murashima
- Japan Drug Information Institute in Pregnancy, National Center for Child Health and Development, Tokyo, Japan.,Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| |
Collapse
|
11
|
Abstract
Neonatal Abstinence Syndrome (NAS) has significantly increased worldwide secondary to a marked increase in the incidence of opioid use disorders (OUD) in women of childbearing age. Since first described in 1975, the Finnegan Neonatal Abstinence Scoring Tool (FNAST) remains the mainstay of monitoring NAS severity and its clinical management. The complexity of the tool (21 independent variables), the need for external validation, excessive subjectivity, poor inter-rater reliability, and uncertainty regarding the clinical relevance of some items has resulted in the need to develop an alternate scoring tool. A validated, simple, clinically relevant, and universally accepted approach to assessing opioid exposed neonates would facilitate high quality clinical care while assisting in the generation of generalizable data from future research studies conducted in this vulnerable population.
Collapse
Affiliation(s)
- Rachana Singh
- Division of Newborn Medicine, Tufts Children's Hospital, Boston, MA, 02111, USA.
| | - Jonathan M Davis
- Division of Newborn Medicine, Tufts Children's Hospital, Boston, MA, 02111, USA; The Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA.
| |
Collapse
|
12
|
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.
Collapse
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
| |
Collapse
|
13
|
Wachman EM, Wang A, Isley BC, Boateng J, Beierle JA, Hansbury A, Shrestha H, Bryant C, Zhang H. Placental OPRM1 DNA methylation and associations with neonatal opioid withdrawal syndrome, a pilot study. EXPLORATION OF MEDICINE 2021; 1:124-135. [PMID: 33763662 PMCID: PMC7985727 DOI: 10.37349/emed.2020.00009] [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] [Indexed: 11/19/2022] Open
Abstract
Aims: Epigenetic variation of DNA methylation of the mu-opioid receptor gene (OPRM1) has been identified in the blood and saliva of individuals with opioid use disorder (OUD) and infants with neonatal opioid withdrawal syndrome (NOWS). It is unknown whether epigenetic variation in OPRM1 exists within placental tissue in women with OUD and whether it is associated with NOWS outcomes. In this pilot study, the authors aimed to 1) examine the association between placental OPRM1 DNA methylation levels and NOWS outcomes, and 2) compare OPRM1 methylation levels in opioid-exposed versus non-exposed control placentas. Methods: Placental tissue was collected from eligible opioid (n = 64) and control (n = 29) women after delivery. Placental DNA was isolated and methylation levels at six cytosine-phosphate-guanine (CpG) sites within the OPRM1 promoter were quantified. Methylation levels were evaluated for associations with infant NOWS outcome measures: need for pharmacologic treatment, length of hospital stay (LOS), morphine treatment days, and treatment with two medications. Regression models were created and adjusted for clinical co-variates. Methylation levels between opioid and controls placentas were also compared. Results: The primary opioid exposures were methadone and buprenorphine. Forty-nine (76.6%) of the opioid-exposed infants required pharmacologic treatment, 10 (15.6%) two medications, and average LOS for all opioid-exposed infants was 16.5 (standard deviation 9.7) days. There were no significant associations between OPRM1 DNA methylation levels in the six CpG sites and any NOWS outcome measures. No significant differences were found in methylation levels between the opioid and control samples. Conclusions: No significant associations were found between OPRM1 placental DNA methylation levels and NOWS severity in this pilot cohort. In addition, no significant differences were seen in OPRM1 methylation in opioid versus control placentas. Future association studies examining methylation levels on a genome-wide level are warranted.
Collapse
Affiliation(s)
- Elisha M Wachman
- Department of Pediatrics, Boston Medical Center, Boston, MA 02119, USA
| | - Alice Wang
- Department of Pediatrics, Boston Medical Center, Boston, MA 02119, USA
| | - Breanna C Isley
- Department of Pediatrics, Boston Medical Center, Boston, MA 02119, USA
| | - Jeffery Boateng
- Boston University School of Public Health, Boston, MA 02118, USA
| | - Jacob A Beierle
- Laboratory of Addiction Genetics, Department of Pharmacology and Experimental Therapeutics and Psychiatry, Boston University School of Medicine, Boston, MA 02118, USA
| | - Aaron Hansbury
- Boston University School of Public Health, Boston, MA 02118, USA
| | - Hira Shrestha
- Department of Pediatrics, Boston Medical Center, Boston, MA 02119, USA
| | - Camron Bryant
- Laboratory of Addiction Genetics, Department of Pharmacology and Experimental Therapeutics and Psychiatry, Boston University School of Medicine, Boston, MA 02118, USA
| | - Huiping Zhang
- Department of Psychiatry, Boston University School of Medicine, Boston, MA 02118, USA
| |
Collapse
|
14
|
Pahl A, Young L, Buus-Frank ME, Marcellus L, Soll R. Non-pharmacological care for opioid withdrawal in newborns. Cochrane Database Syst Rev 2020; 12:CD013217. [PMID: 33348423 PMCID: PMC8130993 DOI: 10.1002/14651858.cd013217.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The prevalence of substance use, both prescribed and non-prescribed, is increasing in many areas of the world. Substance use by women of childbearing age contributes to increasing rates of neonatal abstinence syndrome (NAS). Neonatal opioid withdrawal syndrome (NOWS) is a newer term describing the subset of NAS related to opioid exposure. Non-pharmacological care is the first-line treatment for substance withdrawal in newborns. Despite the widespread use of non-pharmacological care to mitigate symptoms of NAS, there is not an established definition of, and standard for, non-pharmacological care practices in this population. Evaluation of safety and efficacy of non-pharmacological practices could provide clear guidance for clinical practice. OBJECTIVES To evaluate the safety and efficacy of non-pharmacological treatment of infants at risk for, or having symptoms consistent with, opioid withdrawal on the length of hospitalization and use of pharmacological treatment for symptom management. Comparison 1: in infants at risk for, or having early symptoms consistent with, opioid withdrawal, does non-pharmacological treatment reduce the length of hospitalization and use of pharmacological treatment? Comparison 2: in infants receiving pharmacological treatment for symptoms consistent with opioid withdrawal, does concurrent non-pharmacological treatment reduce duration of pharmacological treatment, maximum and cumulative doses of opioid medication, and length of hospitalization? SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search CENTRAL (2019, Issue 10); Ovid MEDLINE; and CINAHL on 11 October 2019. We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs), quasi-RCTs, and cluster trials. SELECTION CRITERIA We included trials comparing single or bundled non-pharmacological interventions to no non-pharmacological treatment or different single or bundled non-pharmacological interventions. We assessed non-pharmacological interventions independently and in combination based on sufficient similarity in population, intervention, and comparison groups studied. We categorized non-pharmacological interventions as: modifying environmental stimulation, feeding practices, and support of the mother-infant dyad. We presented non-randomized studies identified in the search process narratively. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence. Primary outcomes in infants at risk for, or having early symptoms consistent with, opioid withdrawal included length of hospitalization and pharmacological treatment with one or more doses of opioid or sedative medication. Primary outcomes in infants receiving opioid treatment for symptoms consistent with opioid withdrawal included length of hospitalization, length of pharmacological treatment with opioid or sedative medication, and maximum and cumulative doses of opioid medication. MAIN RESULTS We identified six RCTs (353 infants) in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated between 1975 and 2018. We identified no RCTs in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. The certainty of evidence for all outcomes was very low to low. We also identified and excluded 34 non-randomized studies published between 2005 and 2018, including 29 in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated and five in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. We identified seven preregistered interventional clinical trials that may qualify for inclusion at review update when complete. Of the six RCTs, four studies assessed modifying environmental stimulation in the form of a mechanical rocking bed, prone positioning, non-oscillating waterbed, or a low-stimulation nursery; one study assessed feeding practices (comparing 24 kcal/oz to 20 kcal/oz formula); and one study assessed support of the maternal-infant dyad (tailored breastfeeding support). There was no evidence of a difference in length of hospitalization in the one study that assessed modifying environmental stimulation (mean difference [MD) -1 day, 95% confidence interval [CI) -2.82 to 0.82; 30 infants; very low-certainty evidence) and the one study of support of the maternal-infant dyad (MD -8.9 days, 95% CI -19.84 to 2.04; 14 infants; very low-certainty evidence). No studies of feeding practices evaluated the length of hospitalization. There was no evidence of a difference in use of pharmacological treatment in three studies of modifying environmental stimulation (typical risk ratio [RR) 1.00, 95% CI 0.86 to 1.16; 92 infants; low-certainty evidence), one study of feeding practices (RR 0.92, 95% CI 0.63 to 1.33; 49 infants; very low-certainty evidence), and one study of support of the maternal-infant dyad (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). Reported secondary outcomes included neonatal intensive care unit (NICU) admission, days to regain birth weight, and weight nadir. One study of support of the maternal-infant dyad reported NICU admission (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). One study of feeding practices reported days to regain birth weight (MD 1.10 days, 95% CI 2.76 to 0.56; 46 infants; very low-certainty evidence). One study that assessed modifying environmental stimulation reported weight nadir (MD -0.28, 95% CI -1.15 to 0.59; 194 infants; very low-certainty evidence) and one study of feeding practices reported weight nadir (MD -0.8, 95% CI -2.24 to 0.64; 46 infants; very low-certainty evidence). AUTHORS' CONCLUSIONS We are uncertain whether non-pharmacological care for opioid withdrawal in newborns affects important clinical outcomes including length of hospitalization and use of pharmacological treatment based on the six included studies. The outcomes identified for this review were of very low- to low-certainty evidence. Combined analysis was limited by heterogeneity in study design and intervention definitions as well as the number of studies. Many prespecified outcomes were not reported. Although caregivers are encouraged by experts to optimize non-pharmacological care for opioid withdrawal in newborns prior to initiating pharmacological care, we do not have sufficient evidence to inform specific clinical practices. Larger well-designed studies are needed to determine the effect of non-pharmacological care for opioid withdrawal in newborns.
Collapse
Affiliation(s)
- Adrienne Pahl
- Pediatrics, University of Vermont Medical Center, Burlington, VT, USA
| | - Leslie Young
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Madge E Buus-Frank
- The Children's Hospital at Dartmouth, Lebanon, New Hampshire, USA
- The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire, USA
| | | | - Roger Soll
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| |
Collapse
|
15
|
Tran EL, Kim SY, England LJ, Green C, Dang EP, Broussard CS, Fehrenbach N, Hudson A, Yowe-Conley T, Gilboa SM, Meaney-Delman D. The MATernaL and Infant NetworK to Understand Outcomes Associated with Treatment of Opioid Use Disorder During Pregnancy (MAT-LINK): Surveillance Opportunity. J Womens Health (Larchmt) 2020; 29:1491-1499. [PMID: 33227221 DOI: 10.1089/jwh.2020.8848] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Pregnant women with opioid use disorder (OUD) are at risk of overdose, infectious diseases, and inadequate prenatal care. Additional risks include adverse pregnancy and infant outcomes, such as preterm birth and neonatal abstinence syndrome. Management and treatment of OUD during pregnancy are associated with improved maternal and infant outcomes. Professional organizations, including the American College of Obstetricians and Gynecologists, recommend offering opioid agonist pharmacotherapy (i.e., methadone or buprenorphine) combined with behavioral therapy as standard treatment for pregnant women with OUD. Other medications and herbal supplements have also been used by pregnant women for OUD. Determining which OUD treatments optimize maternal and infant outcomes is challenging given the host of potential factors that affect these outcomes. The Centers for Disease Control and Prevention initiated the MATernaL and Infant NetworK to Understand Outcomes Associated with Treatment of Opioid Use Disorder during Pregnancy (MAT-LINK) to monitor more than 2000 mothers and their infants, using data collected from geographically diverse clinical sites. Information learned from MAT-LINK will inform the future management and treatment of pregnant women with OUD.
Collapse
Affiliation(s)
- Emmy L Tran
- Eagle Global Scientific LLC, San Antonio, Texas, USA.,Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Shin Y Kim
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lucinda J England
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Caitlin Green
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Elizabeth P Dang
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Cheryl S Broussard
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nicole Fehrenbach
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Amy Hudson
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Tineka Yowe-Conley
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Suzanne M Gilboa
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Dana Meaney-Delman
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| |
Collapse
|
16
|
Wachman EM, Houghton M, Melvin P, Isley BC, Murzycki J, Singh R, Minear S, MacMillan KDL, Banville D, Walker A, Mitchell T, Galimi-Hayes R, Jorgensen S, Gomes DR, Hodgins F, Whalen BL, Diop H, Gupta M. A quality improvement initiative to implement the eat, sleep, console neonatal opioid withdrawal syndrome care tool in Massachusetts' PNQIN collaborative. J Perinatol 2020; 40:1560-1569. [PMID: 32678314 DOI: 10.1038/s41372-020-0733-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/17/2020] [Accepted: 07/07/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To support hospitals in the Massachusetts PNQIN collaborative with adoption of the ESC Neonatal Opioid Withdrawal Syndrome (NOWS) Care Tool© and assess NOWS hospitalization outcomes. STUDY DESIGN Statewide QI study where 11 hospitals adopted the ESC NOWS Care Tool©. Outcomes of pharmacotherapy and length of hospital stay (LOS) and were compared in Pre- and Post-ESC implementation cohorts. Statistical Process Control (SPC) charts were used to examine changes over time. RESULTS The Post-ESC group had lower rates of pharmacotherapy (OR 0.35, 95% CI 0.26, 0.46) with shorter LOS (RR 0.79, 95% CI 0.76, 0.82). The 30-day NOWS readmission rate was 1.2% in the Pre- and 0.4% in the Post-ESC cohort. SPC charts indicate a shift in pharmacotherapy from 54.8 to 35.0% and LOS from 14.2 to 10.9 days Post-ESC. CONCLUSIONS The ESC NOWS Care Tool was successfully implemented across a state collaborative with improvement in NOWS outcomes without short-term adverse effects.
Collapse
Affiliation(s)
- Elisha M Wachman
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA.
| | - Mary Houghton
- Newborn Medicine, Beth Israel Deaconness Medical Center, Boston, MA, USA
| | - Patrice Melvin
- Center for Applied Pediatric Quality Analytics, Children's Hospital Boston, Boston, MA, USA
| | - Breanna C Isley
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA
| | | | - Rachana Singh
- Department of Pediatrics, Baystate Children's Hospital, Springfield, MA, USA
| | - Susan Minear
- Department of Pediatrics, Boston Medical Center, Boston, MA, USA
| | | | | | - Amy Walker
- Cooley Dickinson Hospital, Northampton, MA, USA
| | - Teresa Mitchell
- Department of Pediatrics, Mercy Medical Center, Springfield, MA, USA
| | | | - Selena Jorgensen
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Daphne Remy Gomes
- Department of Neonatology, Boston Children's Hospital, Boston, MA, USA
| | - Fran Hodgins
- Massachusetts Health Policy Commission, Boston, MA, USA
| | - Bonny L Whalen
- Department of Pediatrics, Children's Hospital at Dartmouth-Hitchcock, Lebanon, NH, USA
| | - Hafsatou Diop
- Massachusetts Department of Public Health, Boston, MA, USA
| | - Munish Gupta
- Newborn Medicine, Beth Israel Deaconness Medical Center, Boston, MA, USA
| |
Collapse
|
17
|
Singh R, Rothstein R, Ricci K, Visintainer P, Shenberger J, Attwood E, Friedmann P. Partnering with parents to improve outcomes for substance exposed newborns-a pilot program. J Perinatol 2020; 40:1041-1049. [PMID: 32203180 DOI: 10.1038/s41372-020-0662-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/02/2020] [Accepted: 03/11/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Assess impact of parental involvement in care provision for term substance exposed newborns (SENs). STUDY DESIGN Prospective observational cohort study included mothers with opioid use disorder and their SENs over 4 year study period. Maternal-Infant dyads enrolled in EMPOWER and rooming-in (RI) programs were included and received care 24/7 in a private room until newborn's discharge. Outcomes were compared for dyads participating in EMPOWER/RI with historical controls. RESULTS Ninety of 156 historical SENs were RI eligible, while 49 of 108 SENs born during RI period had mothers enrolled in EMPOWER. EMPOWER/RI SENs had lower rates for and duration of pharmacotherapy, shorter neonatal intensive care unit (NICU) and hospital lengths of stay. EMPOWER/RI increased initiation and continuation of breastfeeding at discharge. CONCLUSIONS Parental participation was associated with a decrease in initiation and duration of pharmacotherapy, NICU admission, length of stay and hospital charges while increasing breastfeeding initiation and continuation at discharge.
Collapse
Affiliation(s)
- Rachana Singh
- Baystate Medical Center, Springfield, MA, USA. .,University of Massachusetts Medical School-Baystate, Springfield, MA, USA.
| | - Rachel Rothstein
- Baystate Medical Center, Springfield, MA, USA.,Penn State College of Medicine, Hershey, PA, USA
| | - Karen Ricci
- Baystate Medical Center, Springfield, MA, USA
| | - Paul Visintainer
- University of Massachusetts Medical School-Baystate, Springfield, MA, USA.,Office of Research, UMMS-Baystate, Springfield, MA, USA
| | - Jeffrey Shenberger
- Baystate Medical Center, Springfield, MA, USA.,Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Eilean Attwood
- Baystate Medical Center, Springfield, MA, USA.,University of Massachusetts Medical School-Baystate, Springfield, MA, USA
| | - Peter Friedmann
- Baystate Medical Center, Springfield, MA, USA.,Office of Research, UMMS-Baystate, Springfield, MA, USA
| |
Collapse
|
18
|
Leinaar E, Brooks B, Johnson L, Alamian A. Perceived Barriers to Contraceptive Access and Acceptance among Reproductive-Age Women Receiving Opioid Agonist Therapy in Northeast Tennessee. South Med J 2020; 113:213-218. [PMID: 32358615 DOI: 10.14423/smj.0000000000001095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Women with substance use disorders experience unique challenges to contraceptive obtainment and user-dependent method adherence, contributing to higher than average rates of unintended pregnancy. This study estimated the prevalence of barriers to contraception and their associations with contraceptive use and unwanted pregnancies among women receiving opioid agonist therapy (OAT) in northeast Tennessee. METHODS A cross-sectional survey was piloted among female patients aged 18 to 55 years from 2 OAT clinics. Logistic regression was used to evaluate associations between contraceptive barriers and current contraceptive use and previous unwanted pregnancies among women receiving OAT. RESULTS Of 91 participants, most experienced previous pregnancies (97.8%), with more than half reporting unwanted pregnancies (52.8%). Although 60% expressed a strong desire to avoid pregnancy, ambivalence toward becoming pregnant was common (30.0%). Most experienced ≥1 barriers to contraceptive use or obtainment (75.8%), the most prevalent being aversion to adverse effects (53.8%), healthcare provider stigmatization (30.7%), scheduled appointment compliance (30.3%), and prohibitive cost (25.0%). Experience of any contraceptive barrier (adjusted odds ratio [AOR] 8.64, 95% confidence interval [CI] 2.03-36.79) and access to a contraceptive provider (AOR 5.01, 95% CI 1.34-18.77) were positively associated with current use of prescribed contraceptives, whereas prohibitive cost was negatively associated (AOR 0.28, 95% CI 0.08-0.94). CONCLUSIONS Although most participants desired to avoid pregnancy, ambivalence or uncertainty of pregnancy intention was common. Most experienced barriers to contraception, which were more strongly associated with previous unwanted pregnancy than current contraceptive use. The provision of long-acting reversible contraceptives and contraceptive education at OAT clinics represents an opportunity to reduce the incidence of neonatal abstinence syndrome.
Collapse
Affiliation(s)
- Edward Leinaar
- From the Department of Health Services Management and Policy, College of Public Health, the Center for Prescription Drug Abuse Prevention and Treatment, the Department of Family Medicine, Quillen College of Medicine, and the Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City
| | - Bill Brooks
- From the Department of Health Services Management and Policy, College of Public Health, the Center for Prescription Drug Abuse Prevention and Treatment, the Department of Family Medicine, Quillen College of Medicine, and the Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City
| | - Leigh Johnson
- From the Department of Health Services Management and Policy, College of Public Health, the Center for Prescription Drug Abuse Prevention and Treatment, the Department of Family Medicine, Quillen College of Medicine, and the Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City
| | - Arsham Alamian
- From the Department of Health Services Management and Policy, College of Public Health, the Center for Prescription Drug Abuse Prevention and Treatment, the Department of Family Medicine, Quillen College of Medicine, and the Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City
| |
Collapse
|
19
|
Shen Y, Lo-Ciganic WH, Segal R, Goodin AJ. Prevalence of substance use disorder and psychiatric comorbidity burden among pregnant women with opioid use disorder in a large administrative database, 2009-2014. J Psychosom Obstet Gynaecol 2020:1-7. [PMID: 32067526 DOI: 10.1080/0167482x.2020.1727882] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 01/30/2020] [Accepted: 02/05/2020] [Indexed: 10/25/2022] Open
Abstract
Objectives: Using data from the Healthcare Cost and Utilization Project (HCUP), we estimated prevalence of individual substance use disorders (SUDs) and psychiatric comorbidities among pregnant women with opioid use disorder (OUD) in the New York State from 2009 to 2014.Methods: In this cross-sectional study, pregnancy outcome and gestational age at delivery were estimated, and OUD diagnosis during pregnancy or at delivery discharge was identified. Prevalence of SUDs and psychiatric comorbidities were then calculated.Results: Among 1,463,302 pregnant women, 8324 (0.57%) were diagnosed with OUD during pregnancy or at delivery. The most frequent SUDs or psychiatric comorbidities among pregnant women with OUD were non-opioid SUD (78.2%), followed by tobacco use disorder (74.9%), generalized anxiety disorder (38.0%), major depressive disorder (36.9%), cannabis use disorder (28.3%) and cocaine use disorder (27.4%).Conclusions: Most pregnant women with OUD were diagnosed with at least one non-opioid SUD and tobacco use disorder. Generalized anxiety disorder and major depressive disorder were also common, suggesting that mental health screenings should be prioritized for pregnant women with OUD.
Collapse
Affiliation(s)
- Yun Shen
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL, USA
| | - Richard Segal
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL, USA
| | - Amie J Goodin
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL, USA
| |
Collapse
|
20
|
Minear S, Wachman EM. Management of Newborns with Prenatal Opioid Exposure: One Institution's Journey. Clin Ther 2019; 41:1663-1668. [DOI: 10.1016/j.clinthera.2019.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/28/2019] [Accepted: 07/02/2019] [Indexed: 10/26/2022]
|
21
|
Abstract
As increasing resources are now being directed towards addressing the growing U.S. opioid epidemic, the long-term care of children from opioid-affected families has been relatively neglected. While an array of evidence suggests long-term negative developmental, medical, and social impacts to children related to their parents' opioid use, there remains much to be learned about how best to support children and families to promote healthy outcomes. Here, we report on the launch of an innovative family-centered pediatric medical home for opioid-affected families in Boston. We describe the program, the patient cohort, and early lessons learned. Important themes include the vulnerability of families with infants whose parents are in early recovery, and the need for compassionate, high-touch, high-continuity, team-based care that views the needs of the family as a whole. We recommend a future emphasis on non-stigmatizing, trauma-informed care; centering the needs of the family by addressing social and logistics barriers and by expanding models of parent-child dyadic care; investing in attachment and mental health interventions; developing strategies for prevention of opioid use disorder (OUD) in the next generation; and grounding our advocacy and actions in a social justice approach.
Collapse
|
22
|
Bogen DL, Whalen BL. Breastmilk feeding for mothers and infants with opioid exposure: What is best? Semin Fetal Neonatal Med 2019; 24:95-104. [PMID: 30922811 DOI: 10.1016/j.siny.2019.01.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
With rare exception, breastfeeding is the optimal way to feed infants, and has special benefits for women and infants with perinatal opioid exposure. Infants breastfed and/or fed their mother's own breastmilk experience less severe opioid withdrawal symptoms, have shorter hospital stays, and are less likely to be treated with medication for withdrawal. The specific impact of mothers' milk feeding on opioid withdrawal may be related to the act of breastfeeding and associated skin-to-skin contact, qualities of breastmilk, healthier microbiome, small amounts of opioid drug in breastmilk, or a combination of these. Women with opioid use disorder face significant breastfeeding obstacles, including psychosocial, behavioral, concomitant medications, and tobacco use and thus may require high levels of support to achieve their breastfeeding goals. They often don't receive information to make informed infant feeding decisions. Hospital practices such as prenatal education, rooming-in and having a policy that minimizes barriers to breastfeeding are associated with increased breastfeeding rates.
Collapse
Affiliation(s)
- Debra L Bogen
- University of Pittsburgh School of Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, 3414 Fifth Ave, Pittsburgh, PA, 15213, USA.
| | - Bonny L Whalen
- Geisel School of Medicine at Dartmouth, Children's Hospital at Dartmouth-Hitchcock, Dartmouth-Hitchcock Medical Center, DHMC Pediatrics, One Medical Center Drive, Lebanon, NH, 03756, USA.
| |
Collapse
|