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Ferrante JR, Blendy JA. Advances in animal models of prenatal opioid exposure. Trends Neurosci 2024; 47:367-382. [PMID: 38614891 PMCID: PMC11096018 DOI: 10.1016/j.tins.2024.03.005] [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: 01/05/2024] [Revised: 02/20/2024] [Accepted: 03/15/2024] [Indexed: 04/15/2024]
Abstract
Neonatal opioid withdrawal syndrome (NOWS) is a growing public health concern. The complexity of in utero opioid exposure in clinical studies makes it difficult to investigate underlying mechanisms that could ultimately inform early diagnosis and treatments. Clinical studies are unable to dissociate the influence of maternal polypharmacy or the environment from direct effects of in utero opioid exposure, highlighting the need for effective animal models. Early animal models of prenatal opioid exposure primarily used the prototypical opioid, morphine, and opioid exposure that was often limited to a narrow period during gestation. In recent years, the number of preclinical studies has grown rapidly. Newer models utilize both prescription and nonprescription opioids and vary the onset and duration of opioid exposure. In this review, we summarize novel prenatal opioid exposure models developed in recent years and attempt to reconcile results between studies while critically identifying gaps within the current literature.
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Affiliation(s)
- Julia R Ferrante
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Julie A Blendy
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Miller MR, MacMillan KDL. Growing together: Optimization of care through quality improvement for the mother/infant dyad affected by perinatal opioid use. Semin Perinatol 2024; 48:151907. [PMID: 38702266 DOI: 10.1016/j.semperi.2024.151907] [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] [Indexed: 05/06/2024]
Abstract
The care of the dyad affected by opioid use disorder (OUD) requires a multi-disciplinary approach that can be challenging for institutions to develop and maintain. However, over the years, many institutions have developed quality improvement (QI) initiatives aimed at improving outcomes for the mother, baby, and family. Over time, QI efforts targeting OUD in the perinatal period have evolved from focusing separately on the mother and baby to efforts addressing care of the dyad and family during pregnancy, delivery, and postpartum. Here, we review recent and impactful QI initiatives that serve as examples of work improving outcomes for this population. Further, we advocate that this work be done through a racial equity lens, given ongoing inequities in the care of particularly non-white populations with substance use disorders. Through QI frameworks, even small interventions can result in meaningful changes to the care of babies and families and improved outcomes.
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Affiliation(s)
- Megan R Miller
- Obstetrics & Gynecology, UMMS-Baystate Medical Center, United States.
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Bedrick BS, Cary C, O'Donnell C, Marx C, Friedman H, Carter EB, Raghuraman N, Stout MJ, Ku BS, Xu KY, Kelly JC. County-level neonatal opioid withdrawal syndrome rates and real-world access to buprenorphine during pregnancy: An audit ("secret shopper") study in Missouri. DRUG AND ALCOHOL DEPENDENCE REPORTS 2024; 10:100218. [PMID: 38380272 PMCID: PMC10877162 DOI: 10.1016/j.dadr.2024.100218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/22/2024]
Abstract
Background Amid rising rates of neonatal opioid withdrawal syndrome (NOWS) worldwide and in many regions of the USA, we conducted an audit study ("secret shopper study") to evaluate the influence of county-level buprenorphine capacity and rurality on county-level NOWS rates. Methods In 2019, up to three phone calls were made to buprenorphine prescribers in the state of Missouri (USA). County-level buprenorphine capacity was defined as the number of clinicians (across all specialties) accepting pregnant people divided by the number of births. Multivariable negative binomial regression models estimated associations between buprenorphine capacity, rurality, and county-level NOWS rates, controlling for potential confounders (i.e., poverty, unemployment, and physician shortages) that may correspond to higher rates of NOWS and lower rates of buprenorphine prescribing. Analyses were stratified using tertiles of county-level overdose rates (top, middle, and lowest 1/3 of overdose rates). Results Of 115 Missouri counties, 81(70 %) had no buprenorphine capacity, 17(15 %) were low-capacity (<0.5-clinicians/1,000 births), and 17(15 %) were high-capacity (≥0.5/1,000 births). The mean NOWS rate was 6.5/1,000 births. In Missouri counties with both the highest and lowest opioid overdose rates, higher buprenorphine capacity did not correspond to decreases in NOWS rates (incidence rate ratio[IRR]=1.23[95 %-confidence-interval[CI]=0.65-2.32] and IRR=1.57[1.21-2.03] respectively). Rurality did not correspond to greater NOWS burden in both Missouri counties with highest and lowest opioid overdose rates. Conclusions The vast majority of counties in Missouri have no capacity for buprenorphine prescribing during pregnancy. Rurality and lower buprenorphine capacity did not significantly predict elevated rates of NOWS.
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Affiliation(s)
- Bronwyn S. Bedrick
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caroline Cary
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO
| | - Carly O'Donnell
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Christine Marx
- Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Hayley Friedman
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Ebony B. Carter
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Nandini Raghuraman
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO
| | - Molly J. Stout
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI
| | - Benson S. Ku
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA
| | - Kevin Y Xu
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Jeannie C. Kelly
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO
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Suarez EA, Bateman BT, Straub L, Hernández-Díaz S, Jones HE, Gray KJ, Connery HS, Davis JM, Lester B, Terplan M, Zhu Y, Vine SM, Mogun H, Huybrechts KF. First Trimester Use of Buprenorphine or Methadone and the Risk of Congenital Malformations. JAMA Intern Med 2024; 184:242-251. [PMID: 38252426 PMCID: PMC10804281 DOI: 10.1001/jamainternmed.2023.6986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/12/2023] [Indexed: 01/23/2024]
Abstract
Importance Use of buprenorphine or methadone to treat opioid use disorder is recommended in pregnancy; however, their teratogenic potential is largely unknown. Objective To compare the risk of congenital malformations following in utero exposure to buprenorphine vs methadone. Design, Setting, and Participants This population-based cohort study used health care utilization data from publicly insured Medicaid beneficiaries in the US from 2000 to 2018. A total of 13 360 pregnancies with enrollment from 90 days prior to pregnancy start through 1 month after delivery and first trimester use of buprenorphine or methadone were included and linked to infants. Data were analyzed from July to December 2022. Exposure A pharmacy dispensing of buprenorphine or a code for administration of methadone in the first trimester. Main Outcomes and Measures Primary outcomes included major malformations overall and malformations previously associated with opioids (any cardiac malformations, ventricular septal defect, secundum atrial septal defect/nonprematurity-related patent foramen ovale, neural tube defects, clubfoot, and oral clefts). Secondary outcomes included other organ system-specific malformations. Risk differences and risk ratios (RRs) were estimated comparing buprenorphine with methadone, adjusting for confounders with propensity score overlap weights. Results The cohort included 9514 pregnancies with first-trimester buprenorphine exposure (mean [SD] maternal age, 28.4 [4.6] years) and 3846 with methadone exposure (mean [SD] maternal age, 28.8 [4.7] years). The risk of malformations overall was 50.9 (95% CI, 46.5-55.3) per 1000 pregnancies for buprenorphine and 60.6 (95% CI, 53.0-68.1) per 1000 pregnancies for methadone. After confounding adjustment, buprenorphine was associated with a lower risk of malformations compared with methadone (RR, 0.82; 95% CI, 0.69-0.97). Risk was lower with buprenorphine for cardiac malformations (RR, 0.63; 95% CI, 0.47-0.85), including both ventricular septal defect (RR, 0.62; 95% CI, 0.39-0.98) and secundum atrial septal defect/nonprematurity-related patent foramen ovale (RR, 0.54; 95% CI, 0.30-0.97), oral clefts (RR, 0.65; 95% CI, 0.35-1.19), and clubfoot (RR, 0.55; 95% CI, 0.32-0.94). Results for neural tube defects were uncertain given low event counts. In secondary analyses, buprenorphine was associated with a decreased risk of central nervous system, urinary, and limb malformations but a greater risk of gastrointestinal malformations compared with methadone. These findings were consistent in sensitivity and bias analyses. Conclusions and Relevance In this cohort study, the risk of most malformations previously associated with opioid exposure was lower in buprenorphine-exposed infants compared with methadone-exposed infants, independent of measured confounders. Malformation risk is one factor that informs the individualized patient decision regarding medications for opioid use disorder in pregnancy.
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Affiliation(s)
- Elizabeth A Suarez
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
- Center for Pharmacoepidemiology and Treatment Science, Rutgers Institute for Health, Health Care Policy and Aging Research, New Brunswick, New Jersey
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey
| | - Brian T Bateman
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - Loreen Straub
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sonia Hernández-Díaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Hendrée E Jones
- UNC Horizons Program, Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | - Kathryn J Gray
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Hilary S Connery
- Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Jonathan M Davis
- Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute, Boston, Massachusetts
| | - Barry Lester
- Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Alpert Medical School of Brown University and Women and Infants Hospital, Providence, Rhode Island
| | | | - Yanmin Zhu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Seanna M Vine
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Apsley HB, Brant K, Brothers S, Harrison E, Skogseth E, Schwartz RP, Jones AA. Pregnancy- and parenting-related barriers to receiving medication for opioid use disorder: A multi-paneled qualitative study of women in treatment, women who terminated treatment, and the professionals who serve them. WOMEN'S HEALTH (LONDON, ENGLAND) 2024; 20:17455057231224181. [PMID: 38362719 PMCID: PMC10874161 DOI: 10.1177/17455057231224181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/14/2023] [Accepted: 12/15/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND Women face unique barriers when seeking treatment for substance use disorders, often related to pregnancy and parenting. OBJECTIVES This study adds to the extant literature by elucidating the pregnancy- and parenting-related barriers women face when initiating or continuing medication for opioid use disorder, specifically. DESIGN This study is based on qualitative semi-structured interviews. METHODS Three subgroups participated in semi-structured interviews regarding their experiences (N = 42): women with current or past opioid use disorders who have used or were presently using medication for opioid use disorder, professionals working in substance use disorder treatment programs, and criminal justice professionals. RESULTS Three parenting-related subthemes were identified: (1) insufficient access to childcare to navigate appointments and meetings, (2) fear of losing custody of, or access to, one's children, and (3) prioritizing one's children's needs before one's own. Three subthemes were identified with regard to pregnancy as a barrier: (1) hesitancy among physicians to prescribe medication for opioid use disorder for pregnant patients, (2) limited access to resources in rural areas, and (3) difficulty navigating a complex, decentralized health system. CONCLUSION Systemic changes are needed to reduce pregnant and parenting women's barriers to seeking medication for opioid use disorder. These include improved childcare support at both in-patient and outpatient treatment programs, which would assuage women's barriers related to childcare, as well as their fears of losing access to their children if they spend time away from their children for treatment. An additional systemic improvement that may reduce barriers for these women is access to comprehensive, integrated care for their prenatal care, postpartum care, pediatric appointments, and appropriate substance use disorder treatment.
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Affiliation(s)
- Hannah B Apsley
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, USA
| | - Kristina Brant
- Department of Agricultural Economics, Sociology, and Education, The Pennsylvania State University, University Park, PA, USA
| | - Sarah Brothers
- Department of Sociology and Criminology, The Pennsylvania State University, University Park, PA, USA
| | - Eric Harrison
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, USA
| | - Emma Skogseth
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, USA
| | | | - Abenaa A Jones
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, USA
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Fryer K, Reid CN, Elmore AL, Mehra S, Carr C, Salemi JL, Cogle CR, Pelletier C, Pacheco Garrillo M, Sappenfield WS, Marshall J. Access to Prenatal Care Among Patients With Opioid Use Disorder in Florida: Findings From a Secret Shopper Study. Obstet Gynecol 2023; 142:1162-1168. [PMID: 37856854 DOI: 10.1097/aog.0000000000005315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/20/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE To evaluate access to prenatal care for pregnant patients receiving medication for opioid use disorder (MOUD) under Medicaid coverage in Florida. METHODS A cross-sectional, secret shopper study was conducted in which calls were made to randomly selected obstetric clinicians' offices in Florida. Callers posed as a 14-week-pregnant patient with Medicaid insurance who was receiving MOUD from another physician and requested to schedule a first-time prenatal care appointment. Descriptive statistics were used to report our primary outcome, the callers' success in obtaining appointments from Medicaid-enrolled physicians' offices. Wait time for appointments and reasons the physician offices refused appointments to callers were collected. RESULTS Overall, 2,816 obstetric clinicians are enrolled in Florida Medicaid. Callers made 1,747 attempts to contact 1,023 randomly selected physicians' offices from June to September 2021. Only 48.9% of medical offices (n=500) were successfully reached by phone, of which 39.4% (n=197) offered a prenatal care appointment to the caller. The median wait time until the first appointment was 15 days (quartile 1: 7; quartile 3: 26), with a range of 0-55 days. However, despite offering an appointment, 8.6% of the medical offices stated that they do not accept Medicaid insurance payment or would accept only self-pay. Among the 60.6% of callers unable to secure an appointment, the most common reasons were that the clinician was not accepting patients taking methadone (34.7%) or was not accepting any new patients with Medicaid insurance (23.8%) and that the pregnancy would be too advanced by the time of the first available appointment (7.3%). CONCLUSION This secret shopper study found that the majority of obstetric clinicians' offices enrolled in Florida Medicaid do not accept pregnant patients with Medicaid insurance who are taking MOUD. Policy changes are needed to ensure access to adequate prenatal care for patients with opioid use disorder.
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Affiliation(s)
- Kimberly Fryer
- Department of Obstetrics and Gynecology, College of Medicine, and the College of Public Health, University of South Florida, Tampa, and the Division of Hematology/Oncology, College of Medicine, University of Florida, Gainesville, Florida
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Knittel AK, Swartzwelder RA, Zarnick S, Tsujimoto TM, Horne T, Lin FC, Edwards J, Amos E, Alexander J, Thorp J, Jones HE. Neonatal Outcomes after Medications for Opioid Use Disorder during Pregnancy in a State Women's Prison Facility, 2016-2019. J Addict Med 2023; 17:587-591. [PMID: 37788614 PMCID: PMC10593980 DOI: 10.1097/adm.0000000000001184] [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: 06/03/2023]
Abstract
OBJECTIVE Although medications for opioid use disorder improve both maternal and neonatal outcomes, little is known about opioid-exposed infants born during episodes of incarceration. The study sought to examine birth outcomes for infants born with opioid exposure during perinatal incarceration. METHODS Participants were identified from clinic rosters in a Southeastern women's prison (2016-2019). Included infants born to pregnant people with opioid use disorder incarcerated in the study facility at the time of delivery. We abstracted hospital length of stay, neonatal opioid withdrawal syndrome (NOWS) severity, and discharge plan from hospital records and report descriptive statistics, analysis of variance F tests, and chi-square tests to compare outcomes by opioid exposure type. RESULTS There were 125 infants born after exposure to methadone (n = 34), buprenorphine (n = 15), oxycodone (n = 22), or no opioid medication (n = 54) during prenatal incarceration. Most infants exposed to methadone or buprenorphine had difficulty with eating, sleeping, or consoling (97% and 80%), and 59% and 47% were treated with medication for NOWS, respectively. The majority with prenatal opioid exposure required intervention for NOWS symptoms after their birthing parent was discharged to the prison. The average hospital length of stay was different for infants with no opioid, methadone, buprenorphine, and oxycodone exposure during incarceration (4, 15, 12, and 9 days, respectively, P < 0.001). CONCLUSIONS Neonatal hospitalization experiences of infants with perinatal opioid exposures during maternal incarceration mirror those of similarly exposed infants born outside the context of incarceration, except for hospital length of stay. Consideration of avoiding separation of the parent-infant dyad may be needed to improve outcomes for these infants.
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Affiliation(s)
- Andrea K Knittel
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Rita A Swartzwelder
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Samantha Zarnick
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Tamy Moraes Tsujimoto
- Department of Biostatistics, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Timeli Horne
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Feng Chang Lin
- Department of Biostatistics, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Elton Amos
- North Carolina Department of Public Safety, Raleigh, NC
| | | | - John Thorp
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Hendree E Jones
- UNC Horizons, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
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Vella A, Savona-Ventura C, Mahmood T. Harmful effects of opioid use in pregnancy: A scientific review commissioned by the European Board and College of obstetrics and gynaecology (EBCOG). Eur J Obstet Gynecol Reprod Biol 2023; 286:70-75. [PMID: 37216740 DOI: 10.1016/j.ejogrb.2023.05.019] [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: 05/24/2023]
Abstract
Caring for pregnant women who have a recreational opioid use disorder is a common clinical challenge in modern obstetric care. These are an elusive population who often have multiple social issues that complicate their pregnancy management. Comprehensive and supportive maternal care can motivate these mothers to change her lifestyle. Multidisciplinary non-judgemental approach with appropriate medication and management, can result in good pregnancy outcomes for mother and her baby.
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Affiliation(s)
| | - Charles Savona-Ventura
- Department of Obstetrics and Gynaecology, University of Malta, Member EBCOG Standing Committee on Standards of Care and Position Statements, Malta; Member of the EBCOG Standing Committee on Standards of Care and Position Statements, Malta
| | - Tahir Mahmood
- Victoria Hospital, Kirkcaldy and Spire Murrayfield Hospital, Edinburgh, United Kingdom; Member of the EBCOG Standing Committee on Standards of Care and Position Statements, Malta
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Wang S, Meador KJ, Pawasauskas J, Lewkowitz AK, Ward KE, Brothers TN, Hartzema A, Quilliam BJ, Wen X. Comparative Safety Analysis of Opioid Agonist Treatment in Pregnant Women with Opioid Use Disorder: A Population-Based Study. Drug Saf 2023; 46:257-271. [PMID: 36642778 PMCID: PMC10363992 DOI: 10.1007/s40264-022-01267-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2022] [Indexed: 01/17/2023]
Abstract
INTRODUCTION AND OBJECTIVE Receipt of opioid agonist treatment during early and late pregnancy for opioid use disorder may relate to varying perinatal risks. We aimed to assess the effect of time-varying prenatal exposure to opioid agonist treatment using buprenorphine or methadone on adverse neonatal and pregnancy outcomes. METHODS We conducted a retrospective cohort study of pregnant women with opioid use disorder using Rhode Island Medicaid claims data and vital statistics during 2008-16. Time-varying exposure was evaluated in early (0-20 weeks) and late (≥ 21 weeks) pregnancy. Marginal structural models with inverse probability of treatment weighting were applied. RESULTS Of 400 eligible pregnancies, 85 and 137 individuals received buprenorphine and methadone, respectively, during early pregnancy. Compared with 152 untreated pregnancies with opioid use disorders, methadone exposure in both periods was associated with an increased risk of preterm birth (adjusted odds ratio [aOR]: 2.52; 95% confidence interval [CI] 1.07-5.95), low birth weight (aOR: 2.99; 95% CI 1.34-6.66), neonatal intensive care unit admission (aOR, 5.04; 95% CI 2.49-10.21), neonatal abstinence syndrome (aOR: 11.36; 95% CI 5.65-22.82), respiratory symptoms (aOR, 2.71; 95% CI 1.17-6.24), and maternal hospital stay > 7 days (aOR, 14.51; 95% CI 7.23-29.12). Similar patterns emerged for buprenorphine regarding neonatal abstinence syndrome (aOR: 10.27; 95% CI 4.91-21.47) and extended maternal hospital stay (aOR: 3.84; 95% CI 1.83-8.07). However, differences were found favoring the use of buprenorphine for preterm birth versus untreated pregnancies (aOR: 0.17; 95% CI 0.04-0.77), and for several outcomes versus methadone. CONCLUSIONS Methadone and buprenorphine prescribed for the treatment of opioid use disorder during pregnancy are associated with varying perinatal risks. However, buprenorphine may be preferred in the setting of pregnancy opioid agonist treatment. Further research is necessary to confirm our findings and minimize residual confounding.
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Affiliation(s)
- Shuang Wang
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, 02881, USA
| | - Kimford J Meador
- Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Jayne Pawasauskas
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, 02881, USA
| | - Adam K Lewkowitz
- Department of Obstetrics and Gynecology, Women and Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, RI, USA
| | - Kristina E Ward
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, 02881, USA
| | - Todd N Brothers
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, 02881, USA
| | - Abraham Hartzema
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Brian J Quilliam
- College of Health Sciences, University of Rhode Island, Kingston, RI, USA
| | - Xuerong Wen
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, 02881, USA.
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Suarez EA, Huybrechts KF, Straub L, Hernández-Díaz S, Jones HE, Connery HS, Davis JM, Gray KJ, Lester B, Terplan M, Mogun H, Bateman BT. Buprenorphine versus Methadone for Opioid Use Disorder in Pregnancy. N Engl J Med 2022; 387:2033-2044. [PMID: 36449419 PMCID: PMC9873239 DOI: 10.1056/nejmoa2203318] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND Opioid agonist therapy is strongly recommended for pregnant persons with opioid use disorder. Buprenorphine may be associated with more favorable neonatal and maternal outcomes than methadone, but existing data are limited. METHODS We conducted a cohort study involving pregnant persons who were enrolled in public insurance programs in the United States during the period from 2000 through 2018 in which we examined outcomes among those who received buprenorphine as compared with those who received methadone. Exposure to the two medications was assessed in early pregnancy (through gestational week 19), late pregnancy (gestational week 20 through the day before delivery), and the 30 days before delivery. Risk ratios for neonatal and maternal outcomes were adjusted for confounders with the use of propensity-score overlap weights. RESULTS The data source for the study consisted of 2,548,372 pregnancies that ended in live births. In early pregnancy, 10,704 pregnant persons were exposed to buprenorphine and 4387 to methadone. In late pregnancy, 11,272 were exposed to buprenorphine and 5056 to methadone (9976 and 4597, respectively, in the 30 days before delivery). Neonatal abstinence syndrome occurred in 52.0% of the infants who were exposed to buprenorphine in the 30 days before delivery as compared with 69.2% of those exposed to methadone (adjusted relative risk, 0.73; 95% confidence interval [CI], 0.71 to 0.75). Preterm birth occurred in 14.4% of infants exposed to buprenorphine in early pregnancy and in 24.9% of those exposed to methadone (adjusted relative risk, 0.58; 95% CI, 0.53 to 0.62); small size for gestational age in 12.1% and 15.3%, respectively (adjusted relative risk, 0.72; 95% CI, 0.66 to 0.80); and low birth weight in 8.3% and 14.9% (adjusted relative risk, 0.56; 95% CI, 0.50 to 0.63). Delivery by cesarean section occurred in 33.6% of pregnant persons exposed to buprenorphine in early pregnancy and 33.1% of those exposed to methadone (adjusted relative risk, 1.02; 95% CI, 0.97 to 1.08), and severe maternal complications developed in 3.3% and 3.5%, respectively (adjusted relative risk, 0.91; 95% CI, 0.74 to 1.13). Results of exposure in late pregnancy were consistent with results of exposure in early pregnancy. CONCLUSIONS The use of buprenorphine in pregnancy was associated with a lower risk of adverse neonatal outcomes than methadone use; however, the risk of adverse maternal outcomes was similar among persons who received buprenorphine and those who received methadone. (Funded by the National Institute on Drug Abuse.).
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Affiliation(s)
- Elizabeth A Suarez
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Krista F Huybrechts
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Loreen Straub
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Sonia Hernández-Díaz
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Hendrée E Jones
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Hilary S Connery
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Jonathan M Davis
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Kathryn J Gray
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Barry Lester
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Mishka Terplan
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Helen Mogun
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
| | - Brian T Bateman
- From the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology (K.J.G.), Brigham and Women's Hospital, the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (E.A.S., K.F.H., L.S., H.M.), and the Department of Psychiatry (H.S.C.), Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health (S.H.-D.), and the Department of Pediatrics, Tufts Medical Center and the Tufts Clinical and Translational Science Institute (J.M.D.), Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont (H.S.C.) - all in Massachusetts; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill (H.E.J.); the Center for the Study of Children at Risk, Departments of Psychiatry and Pediatrics, Warren Alpert Medical School of Brown University, and Women and Infants Hospital - both in Providence, RI (B.L.); Friends Research Institute, Baltimore (M.T.); and the Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA (B.T.B.)
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Lim G, Soens M, Wanaselja A, Chyan A, Carvalho B, Landau R, George RB, Klem ML, Osmundson SS, Krans EE, Terplan M, Bateman BT. A Systematic Scoping Review of Peridelivery Pain Management for Pregnant People With Opioid Use Disorder: From the Society for Obstetric Anesthesia and Perinatology and Society for Maternal Fetal Medicine. Anesth Analg 2022; 135:912-925. [PMID: 36135926 PMCID: PMC9588509 DOI: 10.1213/ane.0000000000006167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The prevalence of pregnant people with opioid use disorder (OUD), including those receiving medications for opioid use disorder (MOUD), is increasing. Challenges associated with pain management in people with OUD include tolerance, opioid-induced hyperalgesia, and risk for return to use. Yet, there are few evidence-based recommendations for pain management in the setting of pregnancy and the postpartum period, and many peripartum pain management studies exclude people with OUD. This scoping review summarized the available literature on peridelivery pain management in people with OUD, methodologies used, and identified specific areas of knowledge gaps. PubMed and Embase were comprehensively searched for publications in all languages on peripartum pain management among people with OUD, both treated with MOUD and untreated. Potential articles were screened by title, abstract, and full text. Data abstracted were descriptively analyzed to map available evidence and identify areas of limited or no evidence. A total of 994 publications were imported for screening on title, abstracts, and full text, yielding 84 publications identified for full review: 32 (38.1%) review articles, 14 (16.7%) retrospective studies, and 8 (9.5%) case reports. There were 5 randomized controlled trials. Most studies (64%) were published in perinatology (32; 38.1%) journals or anesthesiology (22; 26.2%) journals. Specific areas lacking trial or systematic review evidence include: (1) methods to optimize psychological and psychosocial comorbidities relevant to acute pain management around delivery; (2) alternative nonopioid and nonpharmacologic analgesia methods; (3) whether or not to use opioids for severe breakthrough pain and how best to prescribe and monitor its use after discharge; (4) monitoring for respiratory depression and sedation with coadministration of other analgesics; (5) optimal neuraxial analgesia dosing and adjuncts; and (6) benefits of abdominal wall blocks after cesarean delivery. No publications discussed naloxone coprescribing in the labor and delivery setting. We observed an increasing number of publications on peripartum pain management in pregnant people with OUD. However, existing published works are low on the pyramid of evidence (reviews, opinions, and retrospective studies), with a paucity of original research articles (<6%). Opinions are conflicting on the utility and disutility of various analgesic interventions. Studies generating high-quality evidence on this topic are needed to inform care for pregnant people with OUD. Specific research areas are identified, including utility and disutility of short-term opioid use for postpartum pain management, role of continuous wound infiltration and truncal nerve blocks, nonpharmacologic analgesia options, and the best methods to support psychosocial aspects of pain management.
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Affiliation(s)
- Grace Lim
- University of Pittsburgh Department of Anesthesiology & Perioperative Medicine, Pittsburgh, PA
- University of Pittsburgh Department of Obstetrics & Gynecology, UPMC Magee-Women’s Hospital, Pittsburgh, PA
| | - Mieke Soens
- Brigham & Women’s Hospital, Department of Anesthesiology & Perioperative Medicine, Boston, MA
| | - Anne Wanaselja
- University of Pittsburgh Department of Anesthesiology & Perioperative Medicine, Pittsburgh, PA
| | - Arthur Chyan
- Brigham & Women’s Hospital, Department of Anesthesiology & Perioperative Medicine, Boston, MA
| | - Brendan Carvalho
- Stanford University Department of Anesthesiology, Perioperative & Pain Medicine, Palo Alto, CA
| | - Ruth Landau
- Columbia University Department of Anesthesiology & Perioperative Medicine, New York City, NY
| | - Ronald B. George
- University of California San Francisco Department of Anesthesiology & Perioperative Care, San Francisco, CA
| | - Mary Lou Klem
- University of Pittsburgh Health Sciences Library System, Pittsburgh, PA
| | - Sarah S. Osmundson
- Vanderbilt University, Department of Obstetrics & Gynecology, Nashville, TN
| | - Elizabeth E. Krans
- University of Pittsburgh Department of Obstetrics & Gynecology, UPMC Magee-Women’s Hospital, Pittsburgh, PA
| | | | - Brian T. Bateman
- Stanford University Department of Anesthesiology, Perioperative & Pain Medicine, Palo Alto, CA
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Medications for opioid use disorder during pregnancy: Access and continuity in a state women's prison facility, 2016-2019. Drug Alcohol Depend 2022; 232:109308. [PMID: 35074696 PMCID: PMC8946772 DOI: 10.1016/j.drugalcdep.2022.109308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/11/2022] [Accepted: 01/13/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Although medications to treat opioid use disorder (MOUD) are the standard of care during pregnancy, there are many potential gaps in the cascade of care for pregnant people experiencing incarceration. METHODS We conducted a retrospective cohort study of pregnant people with opioid use disorder incarcerated in a Southeastern women's prison from 2016 to 2019. The primary outcomes were access to MOUD during incarceration and continuity in the community. We used descriptive statistics to summarize aspects of our sample and logistic regression to identify predictors of MOUD receipt during incarceration. RESULTS Of the 279 pregnant people with OUD included in the analysis, only 40.1% (n = 112) received MOUD during incarceration, including 67 (59.8%) who received methadone and 45 (40.1%) who received buprenorphine. Less than one-third of the participants were referred to a community MOUD provider (n = 83, 30%) on return to the community. Significant predictors of MOUD receipt included medium/close custody level during incarceration, incarceration during the latter portion of the study period, pre-incarceration heroin use, and receipt of pre-incarceration MOUD. CONCLUSIONS Although prisons can serve as an important site of retention in MOUD for some pregnant people, there were substantial gaps in initiation of MOUD and retention in MOUD among pregnant people with OUD imprisoned in the Southeast during the study period.
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Tsuda-McCaie F, Kotera Y. A qualitative meta-synthesis of pregnant women's experiences of accessing and receiving treatment for opioid use disorder. Drug Alcohol Rev 2022; 41:851-862. [PMID: 35038366 DOI: 10.1111/dar.13421] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 11/30/2022]
Abstract
ISSUES Addressing opioid use disorder (OUD) among pregnant women is of growing importance, and substance use treatment positively impacts outcomes for mother and baby. Understanding substance use treatment experiences is important to improve access, and retention, and no review or synthesis of research addressing the treatment experiences of pregnant women exists. APPROACH Thus, a qualitative meta-synthesis was conducted, which investigated the psychological motivators and barriers of pregnant women with OUD trying to access treatment and their perceptions of treatment. KEY FINDINGS A total of 3844 articles were retrieved from the literature search. Nine articles met eligibility criteria, were appraised, then synthesised using a comparative thematic approach. Four themes: (i) Embodied Experiences; (ii) Institutional Pressures; (iii) Social Context; and (iv) Reconstructing Selves; indicate that women with OUD are motivated to engage in treatment to pursue the safety and custody of the unborn baby and to pursue and enact the changes necessary to claim 'normal' parenthood status. Pregnant women describe psychological and relational barriers to engaging in treatment, including anxieties about the baby's health, fears of authorities' involvement, stigma and experiencing relationships with treatment providers as constrictive or invalidating. IMPLICATIONS Identity theory's concepts of identity verification, closed environments and master status identities illuminate the findings. Implications include recognising the salience of bodily experiences, providing medication-assisted treatment support groups and promoting validating relationships in treatment using strengths-based approaches. CONCLUSIONS Pregnant women face unique psychological challenges in accessing and engaging in substance use treatment for OUD.
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Affiliation(s)
| | - Yasuhiro Kotera
- School of Health Sciences, University of Nottingham, Nottingham, UK
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Carpenter R, Smith MJ, Newhouse A. Mothering a child while participating in a substance use disorder program: A phenomenological study. Arch Psychiatr Nurs 2021; 35:577-582. [PMID: 34861948 DOI: 10.1016/j.apnu.2021.08.006] [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: 07/01/2021] [Revised: 08/07/2021] [Accepted: 08/10/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of this study is to describe what it is like to live the everyday moments of mothering while actively participating in a substance use disorder (SUD) program from the mother's perspective. This study was guided by the research question: What is the structure of meaning of the lived experience of mothering a child while participating in a substance use disorder program? METHOD This qualitative study integrated phenomenology and story theory in the gathering and analysis of the stories. The study setting included two ambulatory clinics that are part of a larger biobehavioral health center of a large south-eastern academic medical center. Nine mothers confirmed voluntary participation, beginning in October 2020 through February 2021, yet only 4 could meet for face to face story gathering sessions. Van Manen's approach to data analysis was used to determine themes in the gathered stories. RESULTS The finding revealed six themes, along with specific descriptors in the words of the mothers. The themes were synthesized into a structure of meaning that includes: 1. Living the tensions of the everyday; 2. being pressured in mother/family/community relationships; and 3. reflecting on moving forward. These findings could be established in practice protocols for mothers in SUD recovery programs. CONCLUSION To support the mental health of mothers in SUD recovery programs, it is essential to understand their situation from their perspective. To get that perspective, the nurse needs to encourage the mother to share her experiences in SUD recovery programs.
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Affiliation(s)
- Roger Carpenter
- West Virginia University School of Nursing, Morgantown, WV 26506, United States of America.
| | - Mary Jane Smith
- West Virginia University School of Nursing, Morgantown, WV 26506, United States of America.
| | - Amanda Newhouse
- WVU Medicine, Department of Behavioral Medicine and Psychiatry, Rockefeller Neuroscience Institute, Morgantown, WV 26508, United States of America.
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15
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Cleary EM, Smid MC, Bokat C, Costantine MM, Rood KM. Indicated Opioids in Pregnancy: Guidance on Providing Comprehensive Care. Am J Perinatol 2021; 40:602-611. [PMID: 34768306 DOI: 10.1055/s-0041-1739427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
In modern obstetric practice, providers will encounter patients for whom opioid use in pregnancy is reasonable or even necessary. A "one-size-fits-all" approach to the counseling and management of such patients is misguided. Understanding indications for ongoing opioid use in pregnancy is essential to patient-centered care. Specifically, recognition of the nuanced differences between opioid dependence and opioid use disorder is crucial for appropriate diagnosis, screening for common concurrent conditions, adequately counseling about individualized maternal and perinatal risks, and accurate documentation of diagnoses and medical decision-making. In this paper, we explore the current typical scenarios in which opioid use in pregnancy may be encountered, ongoing opioid prescribing should be considered, and provide a guide for the obstetric provider to navigate the antepartum, intrapartum, and postpartum periods. KEY POINTS: · Opioid use in pregnant and postpartum individuals is not rare.. · Obstetric providers may elect to assume opioid prescribing.. · Obstetric providers are positioned to optimize outcomes for the mother-infant dyad..
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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, Ohio
| | - Marcela C Smid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Christina Bokat
- Department of Anesthesia, University of Utah Health, Salt Lake City, Utah
| | - Maged M Costantine
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Kara M Rood
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
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A Clinical Trial of a Program for Pain Management and Opioid Reduction During Pregnancy. Reprod Sci 2021; 29:606-613. [PMID: 34403125 DOI: 10.1007/s43032-021-00701-4] [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: 04/26/2021] [Accepted: 07/16/2021] [Indexed: 12/25/2022]
Abstract
A substantial proportion of pregnant women use prescription opioids. However, the lack of efficacy of chronic prescription opioid use for pain, combined with an increased risk of these medications in general and during pregnancy, suggests that the risks of these medications may outweigh the benefits of continued use. Though research has not evaluated non-pharmacological approaches to treat chronic pain during pregnancy, research conducted with the general population outside of pregnancy suggests that cognitive behavioral therapy (CBT) is an effective, non-pharmacological treatment. Therefore, the purpose of this study was to evaluate the effectiveness of CBT for chronic pain paired with shared decision-making for prescription opioid dose reduction among pregnant women with prescription opioid misuse. The study was an open-label, 8-week clinical trial of CBT for chronic pain and shared decision-making for prescription opioid dose reduction. Participants included a clinical sample of 20 pregnant women between the ages of 18 and 45 years who were misusing opioids but did not meet DSM-IV criteria for an opioid use disorder or other substance use disorder. Compared to baseline, at 8 weeks, participants had significant reductions in average prescription opioid morphine equivalent dose, prescription opioid misuse, worst pain ratings, and pain interference in general activity and at work. They did not report improvement in other pain ratings or areas of functioning. This study provides valuable information regarding the preliminary efficacy of CBT for chronic pain paired with shared decision-making among pregnant women misusing prescription opioids. ClinicalTrials.gov: NCT02804152.
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Cruden G, Karmali R. Opioid misuse as a coping behavior for unmet mental health needs among U.S. adults. Drug Alcohol Depend 2021; 225:108805. [PMID: 34174774 DOI: 10.1016/j.drugalcdep.2021.108805] [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] [Received: 06/26/2020] [Revised: 04/17/2021] [Accepted: 04/20/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Self-medication theory posits that opioids may be misused to cope with mental or emotional distress, especially if distress is not treated. Opioid misuse may lead to opioid use disorder, overdose, and death. We estimated the risk of opioid misuse associated with unmet mental health treatment needs (UMHN). METHODS We used 2015-2018 data on U.S. adults from the National Survey of Drug Use and Health (n = 165,767). UMHN was the perceived need for mental health services in the past year without service receipt. The primary dependent variable was past year prescription opioid misuse (POM). Secondary analyses estimated POM and/or heroin misuse risk. Logistic regressions estimated the predicted probability for POM, controlling for demographics, social factors, a major depressive episode (MDE), and overall health. We also tested whether the association of UMHN on the predicted probability of POM varied by MDE. RESULTS UMHN was associated with a 4.6 percentage point higher predicted probability of POM (p < 0.001; 95 % CI 0.04-0.05) and a 4.9 percentage point higher predicted probability of POM and/or heroin (p < 0.001; 95 % CI 0.04-0.06) compared to adults who accessed mental health services. MDE was associated with a significantly greater risk of POM (p < 0.001). POM risk was greater for adults potentially experiencing social isolation. CONCLUSION Targeted mental health support strategies may reduce the likelihood of POM initiation and episodes. Future research should investigate the relationship between unmet mental health needs and initiation of POM episodes.
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Affiliation(s)
- Gracelyn Cruden
- Oregon Social Learning Center, 10 Shelton McMurphey Blvd, Eugene, OR 97401, United States.
| | - Ruchir Karmali
- Kaiser Permanente Northern California, Division of Research, 2000 Broadway, Oakland, CA 94612, United States.
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Precision dosing of methadone during pregnancy: A pharmacokinetics virtual clinical trials study. J Subst Abuse Treat 2021; 130:108521. [PMID: 34118695 DOI: 10.1016/j.jsat.2021.108521] [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: 11/05/2020] [Revised: 04/05/2021] [Accepted: 05/28/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Methadone use for the management of opioid dependency during pregnancy is commonplace. Methadone levels are altered during pregnancy due to changes in maternal physiology. Despite this, a paucity of data exist regarding the most appropriate optimal dosing regimens during pregnancy. METHODS This study applied a pharmacokinetic modeling approach to examine gestational changes in R- and S-methadone concentrations in maternal plasma and fetal (cord) blood. This study did so to derive a theoretical optimal dosing regimen during pregnancy, and to identify the impact of Cytochromes P450 (CYP) 2B6 and 2C19 polymorphisms on methadone maternal and fetal pharmacokinetics. RESULTS The study noted significant decreases in maternal R- and S-methadone plasma concentrations during gestation, with concomitant increases in fetal levels. At a dose of 90 mg once daily, 75% (R-) and 94% (S-) of maternal methadone trough levels were below the lower therapeutic window at term (week 40). The developed optimal dosing regimen escalated doses to 110 mg by week 5, followed by 10 mg increments every 5 weeks up to a maximum of 180 mg once daily near term. This increase resulted in 27% (R-) and 11% (S-) of subjects with trough levels below the lower therapeutic window at term. CYP2B6 poor metabolizers (PM) and either CYP2C19 extensive metabolizers (EM), PM, or ultra-rapid (UM) metabolizer phenotypes demonstrated statistically significant increases in concentrations when compared to their matched CYP2B6 EM counterparts. CONCLUSIONS Specific and gestation-dependent dose titrations are required during pregnancy to reduce the risks associated with illicit drug use and to maintain fetal safety.
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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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Kelty E, Terplan M, Greenland M, Preen D. Pharmacotherapies for the Treatment of Alcohol Use Disorders During Pregnancy: Time to Reconsider? Drugs 2021; 81:739-748. [PMID: 33830479 DOI: 10.1007/s40265-021-01509-x] [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] [Accepted: 03/24/2021] [Indexed: 11/25/2022]
Abstract
It is generally recommended that medications only be used in pregnancy where the potential harms to both the mother and foetus are outweighed by the potential benefits. Despite the known harms associated with alcohol consumption during pregnancy, the use of medication for the treatment of pregnant women with an alcohol use disorder (AUD) appears to be rare. This is likely due to the lack of available data regarding the safety of these medications in pregnancy. We reviewed the literature and weighed up the harms associated with alcohol use and AUD during pregnancy with the potential benefits of medications for AUD in pregnancy, including acamprosate, naltrexone and disulfiram. There is little published evidence to support the safety of medications for AUD in pregnancy. However, from the research available it is likely that only disulfiram has the potential to cause serious foetal harm. While further research is required, acamprosate and naltrexone do not appear to be associated with substantial risks of congenital malformations or other serious consequences. Given the potential risks associated with alcohol consumption during pregnancy, the use of acamprosate and naltrexone should be considered for the treatment of pregnant women with AUD based on the current evidence base, although more research is warranted.
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Affiliation(s)
- Erin Kelty
- School of Population and Global Health, The University of Western Australia, Stirling Highway, Crawley, WA, 6009, Australia.
| | - Mishka Terplan
- University of California, San Francisco, San Francisco, California, USA
| | - Melanie Greenland
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - David Preen
- School of Population and Global Health, The University of Western Australia, Stirling Highway, Crawley, WA, 6009, Australia
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Maternal Opioid Exposure Culminates in Perturbed Murine Neurodevelopment and Hyperactive Phenotype in Adolescence. Neuroscience 2021; 463:272-287. [PMID: 33811940 DOI: 10.1016/j.neuroscience.2021.03.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/05/2021] [Accepted: 03/14/2021] [Indexed: 12/11/2022]
Abstract
Opioid use by women during pregnancy has risen dramatically since 2004, accompanied by a striking increase in the prevalence of neonatal opioid withdrawal syndrome (NOWS) and other long-term neurological deficits. However, the mechanisms underlying the impact of prenatal opioid exposure on fetal neurodevelopment are largely unknown. To translate from the clinical presentation, we developed a novel mouse model to study the neurodevelopmental consequences of maternal opioid use and management. Female mice were treated with oxycodone (OXY) before mating to mimic opioid use disorder (OUD) in humans. Following pregnancy confirmation, dams were switched to buprenorphine (BUP) via oral administration, simulating medication management of OUD (MOUD) in pregnant women. Here, we document critical changes in fetal brain development including reduced cortical thickness, altered corticogenesis, and ventriculomegaly in embryos from dams that were treated with opioids before and throughout pregnancy. Maternal care giving behavior was slightly altered without affecting gross growth of offspring. However, adolescent offspring exposed to maternal opioid use during pregnancy exhibited hyperactivity in late adolescence. Remarkably, we also show increased generation of dopaminergic neurons within the ventral tegmental area (VTA) of mice exposed to prenatal opioids. These data provide critical evidence of teratogenic effects of opioid use during pregnancy and suggest a causal relationship between maternal opioid use and neurodevelopmental/behavioral anomalies in adolescence.
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Neonatal Opioid Withdrawal Syndrome (NOWS): A Transgenerational Echo of the Opioid Crisis. Cold Spring Harb Perspect Med 2021; 11:cshperspect.a039669. [PMID: 32229609 DOI: 10.1101/cshperspect.a039669] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The incidence of neonatal opioid withdrawal syndrome (NOWS) has increased substantially in the setting of the opioid epidemic, a major public health problem in the United States. At present, NOWS has commonly used assessment and treatment protocols, but new protocols have questioned old practices. However, because of limited access to opioid use disorder (OUD) treatment and socioeconomic factors, many pregnant (and postpartum) women with OUD do not receive treatment. The pathophysiology of NOWS is not completely understood, although limited research studies have been conducted in humans and animals to better understand its etiology. Moreover, there is evidence that epigenetic and genetic factors play a role in the development of NOWS, but further study is needed. Animal models have suggested that there are deleterious effects of in utero opioid exposure later in life. Clinical research has revealed the harmful long-term sequelae of NOWS, with respect to cognitive function and childhood development. Many psychiatric disorders begin during adolescence, so as infants born with NOWS approach adolescence, additional clinical and molecular studies are warranted to identify biologic and psychosocial risk factors and long-term effects of NOWS. Additionally, access to specialized OUD treatment for pregnant women must be more readily available in the United States, especially in rural areas.
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Prenatal opioid exposure and vulnerability to future substance use disorders in offspring. Exp Neurol 2021; 339:113621. [PMID: 33516730 DOI: 10.1016/j.expneurol.2021.113621] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 01/06/2023]
Abstract
The heightened incidence of opioid use during pregnancy has resulted in unprecedented rates of neonates prenatally exposed to opioids. Prenatal opioid exposure (POE) results in significantly adverse medical, developmental, and behavioral outcomes in offspring. Of growing interest is whether POE contributes to future vulnerability to substance use disorders. The effects of POE on brain development is difficult to assess in humans, as the timing, dose, and route of drug exposure together with complex genetic and environmental factors affect susceptibility to addiction. Preclinical models of POE have allowed us to avoid methodological difficulties and confounding factors of POE in humans. Here, we review the effects of maternal opioid exposure on the developing brain with an emphasis on the neurobiological basis of drug addiction and on preclinical models of POE and their limitations. These studies have indicated that POE increases self-administration of drugs, reward-driven behaviors in the conditioned place paradigm, and locomotor sensitization. While addiction is multifaceted and vulnerability to drug addiction is still inconclusive in human studies of prenatally exposed infants, animal studies do provide a noteworthy corroboration of negative behavioral outcomes.
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What's in an "ASAM-based Assessment?" Variations in Assessment and Level of Care Determination in Systems Required to Use ASAM Patient Placement Criteria. J Addict Med 2020; 16:18-26. [PMID: 33395145 DOI: 10.1097/adm.0000000000000804] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES When clients begin substance use disorder (SUD) treatment, it is critical to ensure that they receive treatment that matches their needs and preferences. A growing number of payors are requiring the use of multidimensional assessments such as assessments based on the American Society of Addiction Medicine (ASAM) criteria, which describe 6 dimensions that should be used to inform decisions about patient placement. However, ASAM guidance does not list specific questions to ask or instruments to use to elicit this information. This paper evaluates differences among the assessment tools being used by SUD service systems that are required to use ASAM-based assessments to make patient placement decisions. METHODS We analyzed 29 different ASAM-based assessments being used by California counties to make patient placement decisions using conventional and summative content analysis techniques. RESULTS All assessments were organized by the 6 ASAM dimensions. However, some of them only ask 1 or 2 questions per dimension, while others ask over 20, and some ask over 100 depending on patient responses. There is significant heterogeneity in the information the assessments collect and how it is used to generate patient placement decisions. Among the 29 assessments examined, there are 8 different algorithms or instructions on how to translate information from assessments into level of care recommendations. CONCLUSIONS The differences among the ASAM-based assessments examined in this paper suggest a need to implement fidelity standards, enhance training, and create resources to help systems create and utilize assessment and patient placement tools that are consistent across the SUD treatment field.
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Minozzi S, Amato L, Jahanfar S, Bellisario C, Ferri M, Davoli M. Maintenance agonist treatments for opiate-dependent pregnant women. Cochrane Database Syst Rev 2020; 11:CD006318. [PMID: 33165953 PMCID: PMC8094273 DOI: 10.1002/14651858.cd006318.pub4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The prevalence of opiate use among pregnant women can range from 1% to 2% to as high as 21%. Just in the United States alone, among pregnant women with hospital delivery, a fourfold increase in opioid use is reported from 1999 to 2014 (Haight 2018). Heroin crosses the placenta, and pregnant, opiate-dependent women experience a six-fold increase in maternal obstetric complications such as low birth weight, toxaemia, third trimester bleeding, malpresentation, puerperal morbidity, fetal distress and meconium aspiration. Neonatal complications include narcotic withdrawal, postnatal growth deficiency, microcephaly, neuro-behavioural problems, increased neonatal mortality and a 74-fold increase in sudden infant death syndrome. This is an updated version of the original Cochrane Review first published in 2008 and last updated in 2013. OBJECTIVES To assess the effectiveness of any maintenance treatment alone or in combination with a psychosocial intervention compared to no intervention, other pharmacological intervention or psychosocial interventions alone for child health status, neonatal mortality, retaining pregnant women in treatment, and reducing the use of substances. SEARCH METHODS We updated our searches of the following databases to February 2020: the Cochrane Drugs and Alcohol Group Specialised Register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science. We also searched two trials registers and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). SELECTION CRITERIA Randomised controlled trials which assessed the efficacy of any pharmacological maintenance treatment for opiate-dependent pregnant women. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We found four trials with 271 pregnant women. Three compared methadone with buprenorphine and one methadone with oral slow-release morphine. Three out of four studies had adequate allocation concealment and were double-blind. The major flaw in the included studies was attrition bias: three out of four had a high dropout rate (30% to 40%), and this was unbalanced between groups. Methadone versus buprenorphine: There was probably no evidence of a difference in the dropout rate from treatment (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.37 to 1.20, three studies, 223 participants, moderate-quality evidence). There may be no evidence of a difference in the use of primary substances between methadone and buprenorphine (RR 1.81, 95% CI 0.70 to 4.68, two studies, 151 participants, low-quality evidence). Birth weight may be higher in the buprenorphine group in the two trials that reported data MD;-530.00 g, 95%CI -662.78 to -397.22 (one study, 19 particpants) and MD: -215.00 g, 95%CI -238.93 to -191.07 (one study, 131 participants) although the results could not be pooled due to very high heterogeneity (very low-quality of evidence). The third study reported that there was no evidence of a difference. We found there may be no evidence of a difference in the APGAR score (MD: 0.00, 95% CI -0.03 to 0.03, two studies,163 participants, low-quality evidence). Many measures were used in the studies to assess neonatal abstinence syndrome. The number of newborns treated for neonatal abstinence syndrome, which is the most critical outcome, may not differ between groups (RR 1.19, 95% CI 0.87 to1.63, three studies, 166 participants, low-quality evidence). Only one study which compared methadone with buprenorphine reported side effects. We found there may be no evidence of a difference in the number of mothers with serious adverse events (AEs) (RR 1.69, 95% CI 0.75 to 3.83, 175 participants, low-quality evidence) and we found there may be no difference in the numbers of newborns with serious AEs (RR 4.77, 95% CI 0.59, 38.49,131 participants, low-quality evidence). Methadone versus slow-release morphine: There were no dropouts in either treatment group. Oral slow-release morphine may be superior to methadone for abstinence from heroin use during pregnancy (RR 2.40, 95% CI 1.00 to 5.77, one study, 48 participants, low-quality evidence). In the comparison between methadone and slow-release morphine, no side effects were reported for the mother. In contrast, one child in the methadone group had central apnoea, and one child in the morphine group had obstructive apnoea (low-quality evidence). AUTHORS' CONCLUSIONS Methadone and buprenorphine may be similar in efficacy and safety for the treatment of opioid-dependent pregnant women and their babies. There is not enough evidence to make conclusions for the comparison between methadone and slow-release morphine. Overall, the body of evidence is too small to make firm conclusions about the equivalence of the treatments compared. There is still a need for randomised controlled trials of adequate sample size comparing different maintenance treatments.
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Affiliation(s)
- Silvia Minozzi
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Laura Amato
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Shayesteh Jahanfar
- Department of Public Health, School of Population and Public Health, University of British Columbia, Vancouver, Canada
- School of Health Sciences, Central Michigan University, Mount Pleasant, Michigan, USA
- MPH Program, School of Public Health, Central Michigan University, Michigan, USA
| | - Cristina Bellisario
- CPO Piemonte, Dipartimento Interaziendale di Prevenzione Secondaria dei Tumori S.C. Epidemiologia dei Tumori, AO Città della Salute e della Scienza di Torino Via San Francesco da Paola 31, Torino, Italy
| | - Marica Ferri
- Best practices, knowledge exchange and economic issues, European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
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Reising VA, Horne A, Bennett AC. The interaction of neonatal abstinence syndrome and opioid use disorder treatment availability for women insured by medicaid. Public Health Nurs 2020; 38:98-105. [PMID: 33025600 DOI: 10.1111/phn.12816] [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: 04/22/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This paper will discuss the process of mapping opioid use disorder (OUD) treatment resources for pregnant women and discuss the intersection between treatment resources and rates of neonatal abstinence syndrome (NAS). DESIGN A resource manual was developed through a systematic process with stakeholders across Illinois. Resources were mapped by county and overlaid with county rates of NAS, using hospital discharge data. RESULTS Across Illinois, 89 treatment resources were identified for pregnant women insured by Medicaid. Resources were concentrated in 36% of Illinois' counties. Counties with limited treatment resources generally had high rates of NAS. Sixty-six percent of NAS cases among rural Illinois residents had no OUD treatment resources in their county. Rural counties had less access to medication-assisted treatment (MAT), the standard of care for treatment of OUD, compared with other counties across the state. CONCLUSIONS Efforts to increase OUD treatment options for pregnant women insured by Medicaid should concentrate on geographic areas with limited access and high need.
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Affiliation(s)
| | - Ashley Horne
- Illinois Department of Public Health, Chicago, IL, USA.,University of Illinois at Chicago, Chicago, IL, USA
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Knittel AK, Zarnick S, Thorp JM, Amos E, Jones HE. Medications for opioid use disorder in pregnancy in a state women's prison facility. Drug Alcohol Depend 2020; 214:108159. [PMID: 32683223 PMCID: PMC7977476 DOI: 10.1016/j.drugalcdep.2020.108159] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/16/2020] [Accepted: 06/21/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Medication for opioid use disorder (MOUD) improves both maternal and neonatal outcomes for pregnant women with opioid use disorder (OUD). Although correctional policies often state that incarcerated pregnant women with OUD should receive MOUD, implementation data is scant. Our aims were to 1) quantify the extent to which pregnant women in a Southeastern prison received MOUD during their incarceration; 2) to describe the medications and doses used during incarceration and frequency of MOUD referral after incarceration; and 3) identify associations between maternal characteristics and receipt of MOUD in order to identify points of intervention for clinical policy change. METHODS We conducted a retrospective chart review of pregnant women with OUD in a North Carolina state women's prison from 2016-2018. We collected MOUD, demographic, custody, pregnancy, and pre-incarceration substance use data. We used descriptive statistics, chi square tests, and logistic regression. RESULTS There were 179 pregnant women with OUD. During incarceration, 11.7 % received buprenorphine, 17.8 % methadone, 22.8 % oxycodone, and 47.8 % did not receive any opioid medications. Of those who received buprenorphine, methadone, and no MOUD, respectively, 65 %, 51.2 %, and 3.2 % were referred for community MOUD. Women were more likely to receive MOUD during incarceration if they had received MOUD pre-incarceration. CONCLUSIONS There was significant unmet need for MOUD and MOUD referral among pregnant women imprisoned in North Carolina from 2016-2018. Our findings suggest that the initial assessment for MOUD and referral to a community MOUD provider may represent opportunities to improve MOUD access for this population.
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Affiliation(s)
- Andrea K. Knittel
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | | | - John M. Thorp
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Elton Amos
- North Carolina Department of Public Safety, Raleigh, NC
| | - Hendree E. Jones
- UNC Horizons, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
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Abstract
The growing opioid crisis in the United States affects childbearing women and their infants at an alarming rate. Substance use disorders in pregnancy have transitioned from a topic barely addressed to one that has become mainstream in the issue of pregnancy management. Opioid use can include appropriate use of a prescribed medication, the misuse of street drugs, and maintenance on an opioid agonist treatment such as methadone. Identifying this population of childbearing women is critical to be able to organize the appropriate resources and to provide a comprehensive multidisciplinary evidence-based plan of care. All clinicians need to be educated in identifying and caring for the growing population of women with substance use disorders. Each component of the continuum from prenatal care, labor and birth, and postpartum has challenges and issues that can have a positive or negative impact on the outcome of the pregnancy and the mother-infant relationship. Risk assessment, medication-assisted treatment, pain management, and fostering maternal-infant bonding are important considerations in the care of the woman with substance use disorder. Unbiased empathetic nurses are well positioned to strongly advocate and intervene on behalf of women with substance use disorder, which in turn will help to create positive outcomes for the mother and her baby.
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Living a normal life? Follow-up study of women who had been in opioid maintenance treatment during pregnancy. J Subst Abuse Treat 2020; 113:108004. [PMID: 32359675 DOI: 10.1016/j.jsat.2020.108004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/04/2020] [Accepted: 03/28/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND There are few longitudinal follow-up studies of patients in opioid maintenance treatment (OMT). For this reason we performed a follow-up study of a cohort of 67 women who had used OMT-medications during pregnancy an average of ten years earlier. The aim of our study was to explore how the women were doing over time regarding OMT medication adherence and use of other legal and illegal substances, as well as to evaluate the mortality for the women and custody situation for the children in the cohort. METHODS Participants were recruited from two cohorts in our previous pregnancy study covering women who gave birth from 2004 to 2009. Sixty-seven women agreed to be interviewed, which is 73% of the eligible women from our original study. We developed a questionnaire, which we used in the interview, that focused primarily on these women's current life situation (custody of child they had delivered, the use of medications in OMT and other legal and illegal substances, and several other health and social aspects of the participants' lives). RESULTS Two women had died prior to the follow-up. Eighty-one percent of the women had custody of the child they had delivered in our pregnancy study and half the women were single parents. Fifty-four percent of the women were employed. At follow-up, 42% of the women were in methadone maintenance treatment (MMT), 39% were in buprenorphine maintenance treatment (BMT), and 19% had left OMT. One-third of the women had changed their OMT medication during the follow-up period. The majority (77%) were satisfied with their current OMT medication. The women in MMT seemed to be more severe substance dependent than the rest of the participants. There was little use of legal and illegal substances at follow-up, especially among women with custody of their child. The frequency of substance use was low. Fourteen percent of the women were in the process of leaving OMT and another half of the women wanted to leave OMT, but had no plan for how and when. CONCLUSION This follow-up study describes a predominantly well rehabilitated cohort of women who had given birth while in OMT ten years earlier. The majority of the women had custody of their children and used very few legal and illegal drugs. Our findings may be explained partly from a life course perspective, with the women having experienced turning points when starting OMT or becoming mothers.
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Obstetrician-gynecologists' practice patterns related to opioid use during pregnancy and postpartum-United States, 2017. J Perinatol 2020; 40:412-421. [PMID: 31616051 PMCID: PMC7047516 DOI: 10.1038/s41372-019-0535-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/29/2019] [Accepted: 10/01/2019] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To describe obstetrician-gynecologists' practices and attitudes related to opioid use among pregnant and postpartum women. STUDY DESIGN A 2017 cross-sectional survey assessed U.S. obstetrician-gynecologists' (N = 462; response rate = 34%) practices (management) and attitudes (knowledge, preparedness, confidence, barriers, and resources needed) related to opioid use among pregnant and postpartum women. Modified Poisson regression determined adjusted prevalence ratios (aPR) for advising medication-assisted therapy (MAT) for pregnant women with opioid use disorder (OUD) by knowledge, confidence, and preparedness. RESULTS Of respondents, 33% always or usually advised MAT to pregnant women with OUD. Confidence in treating pregnant women who use opioids (aPR: 1.3, 95% CI: 1.0-1.8) and knowledge that substance use services were covered under the Affordable Care Act (aPR: 1.4, 95% CI: 1.1-1.8) were associated with advising MAT. CONCLUSION Evidence suggests that efforts are needed to enhance physician confidence to manage pregnant and postpartum patients who use opioids, which may increase optimal care of this patient population.
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O'Connor A, Bowling N. Initial Management of Incarcerated Pregnant Women With Opioid Use Disorder. JOURNAL OF CORRECTIONAL HEALTH CARE 2020; 26:17-26. [PMID: 31960750 DOI: 10.1177/1078345819897063] [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] [Indexed: 01/06/2023]
Abstract
The epidemic of opioid and other drug use and related arrests are a growing public health crisis in the United States. The national prevalence of pregnant women with opioid use disorder (OUD) has increased dramatically from 1.5 per 1,000 delivery hospitalizations in 1999 to 6.5 in 2014. The combination of these factors has led to an increased frequency of pregnant women with OUDs in the correctional health care system. This protocol provides evidence-based treatment recommendations including the initiation of methadone and buprenorphine in the inpatient or jail setting. It also explores many of the nuances around caring for this vulnerable patient population and discusses ways in which the medical and correctional health care teams can efficiently collaborate to improve patient outcomes.
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Affiliation(s)
- Alane O'Connor
- Maine-Dartmouth Family Medicine Residency, Maine General Medical Center, Waterville, ME, USA
| | - Nathaniel Bowling
- Maine-Dartmouth Family Medicine Residency, Maine General Medical Center, Waterville, ME, USA
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Meinhofer A, Hinde JM, Ali MM. Substance use disorder treatment services for pregnant and postpartum women in residential and outpatient settings. J Subst Abuse Treat 2019; 110:9-17. [PMID: 31952630 DOI: 10.1016/j.jsat.2019.12.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 10/28/2019] [Accepted: 12/05/2019] [Indexed: 12/22/2022]
Abstract
The increasing prevalence of opioid use disorders among pregnant and postpartum women (PPW) has generated a need for greater availability of specialized programs offering evidence-based and comprehensive substance use disorder treatment services tailored to this population. In this study, we used data from the 2007 to 2018 National Survey of Substance Abuse Treatment Services to describe recent time trends and the geographic distribution of treatment facilities with specialized programs for PPW. We also compared differences in the availability of opioid agonist medication treatments (MT), key ancillary services, and health insurance acceptance between PPW Programs and Other Programs, overall and by residential and outpatient settings. We found that the prevalence of PPW Programs increased from 17% in 2007 to 23% in 2018, for a total of 3,429 PPW Programs and 11,230 Other Programs in 2018. The prevalence of PPW Programs was lowest in some states in the South and Midwest. Compared to Other Programs, PPW Programs were more likely to accept Medicaid (75% vs. 64%) and offer opioid agonist MTs methadone (24% vs. 6%), buprenorphine (44% vs. 30%), or both (18% vs. 4%). PPW Programs were also more likely to offer other key ancillary services such as childcare (16% vs. 3%), transportation (50% vs. 42%), and domestic violence assistance (51% vs. 35%). Compared to PPW Programs in outpatient settings, PPW Programs in residential settings were more likely to offer these key ancillary services but less likely to offer methadone or accept Medicaid. Our findings reflect considerable variation in the availability of PPW Programs over time and across states, as well as substantial gaps in key services offered in PPW Programs, let alone in Other Programs.
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Affiliation(s)
- Angélica Meinhofer
- Weill Cornell Medicine, Department of Healthcare Policy & Research, New York, NY, United States of America.
| | - Jesse M Hinde
- RTI International, Behavioral Health Research Division, Research Triangle Park, NC, United States of America
| | - Mir M Ali
- Office of the Assistant Secretary for Planning and Evaluation, US Department of Health & Human Services, Washington, DC, United States of America
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Singleton R, Slaunwhite A, Herrick M, Hirschfeld M, Brunner L, Hallas C, Truit S, Hanson S, Young M, Rider E. Research and policy priorities for addressing prenatal exposure to opioids in Alaska. Int J Circumpolar Health 2019; 78:1599275. [PMID: 31020919 PMCID: PMC6493296 DOI: 10.1080/22423982.2019.1599275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 02/24/2019] [Accepted: 03/15/2019] [Indexed: 12/18/2022] Open
Abstract
The current opioid crisis in Alaska and the USA will negatively affect the health and wellbeing of future generations. The increasing number of infants born with neonatal opioid withdrawal syndrome (NOWS) has had a profound impact on families, health care providers and the child welfare system. This manuscript summarises the main themes of a Symposium held in Anchorage, Alaska with health care providers, researchers, elders and public health officials that focused on identifying emerging challenges, trends and potential solutions to address the increasing number of infants and children affected by maternal opioid use. Five areas of importance for research and policy development that would direct improvement in the care of infants with NOWS in Alaska are outlined with the goal of supporting a research agenda on opioid misuse and child health across the circumpolar north. Abbreviations: NOWS - neonatal opioid withdrawal syndrome; NAS - neonatal abstinence syndrome; MAT - medication-assisted treatment; NICU - neonatal intensive care unit; OATs - opioid agonist treatments; OCS - office of children's services; ANTHC - Alaska Native Tribal Health Consortium; OUD - opioid use disorder; SBIRT - screening, brief intervention and referral to treatment; ISPCTN - IDeA States Pediatric Clinical Trials Network; NIH - National Institutes of Health; ANMC - Alaska Native Medical Center; DHSS - Department of Health and Social Services; AAPP - All Alaska Pediatric Partnership.
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Affiliation(s)
| | | | | | | | | | - Christine Hallas
- Alaska Native Tribal Health Consortium, Anchorage, AK, USA
- Southcentral Foundation, Anchorage, AK, USA
| | | | | | - Margaret Young
- Division of Public Health, Department of Health and Social Services, State of Alaska, Anchorage, AK, USA
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Practitioners' Views on Nicotine Replacement Therapy in Pregnancy during Lapse and for Harm Reduction: A Qualitative Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16234791. [PMID: 31795347 PMCID: PMC6926779 DOI: 10.3390/ijerph16234791] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 11/22/2019] [Accepted: 11/23/2019] [Indexed: 11/17/2022]
Abstract
Many countries, including the UK, recommend nicotine replacement therapy (NRT) for smoking cessation during pregnancy. However, adherence to NRT is generally low, smoking lapse or relapse is common and using NRT to reduce the harm from the number of cigarettes smoked is only advocated in non-pregnant smokers. Two focus groups were conducted with 13 professionals involved in antenatal stop smoking services (SSS). The data were analysed thematically. Two themes were extracted that describe health professionals' attitudes towards using NRT either during lapses or to reduce smoking in women who cannot quit (harm reduction). These are presented around a social-ecological framework describing three hierarchical levels of influence within smoking cessation support: (1) Organizational: providing NRT during lapses could be expensive for SSS though harm reduction could result in services helping a wider range of clients. (2) Interpersonal: participants felt using NRT for harm reduction was not compatible with cessation-orientated messages practitioners conveyed to clients. (3) Individual: practitioners' advice regarding using NRT during smoking lapses varied; many were generally uncomfortable about concurrent smoking and NRT use and had strong reservations about recommending NRT when smoking during all but the briefest lapses. Further evidence is required to guide policy and practice.
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Abstract
The number of pregnant people affected by the opioid epidemic in the United States continues to rise. The following key aspects of opioid use disorder in pregnancy are explored through the progression of a pregnancy via a patient case: treatment options, treatment decisions, substance use screening, dosing modifications, and other aspects of peripartum care. Many factors affect opioid use disorder treatment choices during pregnancy; however, when a pregnant person is medically eligible for a therapy and multiple options are available locally, the ultimate decision regarding treatment selection should be left up to the patient and strong support services provided. This approach to treatment results in optimal maternal and neonatal outcomes and long-term maternal engagement and retention in care.
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Goldfarb SS, Stanwood GD, Flynn HA, Graham DL. Developmental opioid exposures: Neurobiological underpinnings, behavioral impacts, and policy implications. Exp Biol Med (Maywood) 2019; 245:131-137. [PMID: 31630569 DOI: 10.1177/1535370219883601] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The devastating impact of opioid abuse and dependence on the individual, family, and society are well known but extremely difficult to combat. During pregnancy, opioid drugs and withdrawal also affect fetal brain development and newborn neural functions, in addition to maternal effects. Neonatal Abstinence Syndrome/Neonatal Opioid Withdrawal Syndrome (NAS/NOWS) rates have drastically increased in the US in the past decade. Solutions to this complex problem must be multi-faceted, which would be greatly enhanced by a translational, multidisciplinary understanding. Therefore, this mini-review incorporates biomedical, clinical, and policy aspects of opioid use during pregnancy. We review the known roles for endogenous opioids in mediating circuit formation and function in the developing brain, discuss how exogenous opioid drug use and addiction impact these processes in animal models and humans, and discuss the implications of these data on public policy. We suggest that some current policy initiatives produce unintended harm on both mothers and their children and delineate recommendations for how legislation could better contribute to addiction recovery and increase neural resilience in affected children. Impact statement Opioid abuse is a critical epidemic affecting individuals, families, and communities. This mini-review summarizes current literature on the impact of opioid drugs—including prescription pain relievers and illicit opioids—on neurobiological and neurobehavioral development. Using concepts related to the medical model of addiction as a brain disease, we review the public policy implications of these data and identify needs for future investigations.
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Affiliation(s)
- Samantha S Goldfarb
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, FL 32306, USA
| | - Gregg D Stanwood
- Department of Biomedical Sciences, Florida State University College of Medicine, Tallahassee, FL 32306, USA.,Center for Brain Repair, Florida State University College of Medicine, Tallahassee, FL 32306, USA
| | - Heather A Flynn
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, FL 32306, USA.,Center for Brain Repair, Florida State University College of Medicine, Tallahassee, FL 32306, USA
| | - Devon L Graham
- Department of Biomedical Sciences, Florida State University College of Medicine, Tallahassee, FL 32306, USA.,Center for Brain Repair, Florida State University College of Medicine, Tallahassee, FL 32306, USA
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Lambert JE, Peeler CE. Visual and oculomotor outcomes in children with prenatal opioid exposure. Curr Opin Ophthalmol 2019; 30:449-453. [PMID: 31449086 DOI: 10.1097/icu.0000000000000604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To summarize the visual and oculomotor outcomes in children with prenatal opioid exposure and review the effects of opioids on the developing central nervous system. RECENT FINDINGS Animal models and imaging studies in children suggest that prenatal opioid exposure may affect neuronal survival and result in delayed maturation of white matter tracts and decreased volumes in certain brain areas. Visual evoked potential testing in children demonstrates delayed maturation of the afferent visual system in opioid-exposed groups compared with controls, though 'catch-up' development is seen with longitudinal follow-up. Strabismus and nystagmus are also more common in exposed children, and these findings appear to persist. SUMMARY As rates of opioid dependence and prenatal opioid exposure continue to increase, it is important to evaluate the short-term and long-term effects of opioids on the developing visual system. An understanding of these risks is important when counseling the parents or guardians of opioid-exposed children, though larger studies with more long-term follow-up will improve our prognostic abilities.
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Affiliation(s)
| | - Crandall E Peeler
- Department of Ophthalmology.,Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
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Guille C, Aujla R. Developmental Consequences of Prenatal Substance Use in Children and Adolescents. J Child Adolesc Psychopharmacol 2019; 29:479-486. [PMID: 31038354 DOI: 10.1089/cap.2018.0177] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective: Prenatal substance use is increasing and is a major public health concern due to its impact on women's health and child development. Prior studies demonstrate an association between prenatal substance use and deficits in children's physical, cognitive, behavioral, and emotional development. Many studies, however, have significant methodological limitations that hinder our understanding of the impact of substance use on child development. The goal of this review is to describe the risks of prenatal substance use on child development among studies that have overcome major study limitations to inform the development of targeted interventions to improve child health. Methods: Studies investigating the relationship between prenatal substance use and its impact on child development are identified. Studies employing a prospective, longitudinal study design with appropriate comparison groups and methods accounting for potentially confounding variables are reviewed. Results: Prenatal tobacco or alcohol use has the most well-established adverse impact on child development, including an increased risk for behavioral problems and deficits in academic performance, resulting in significant functional impairment. Prenatal marijuana use is associated with deficits in executive and intellectual functioning among school-age children and adolescents. Prenatal opioid use and child development findings are conflicting, but treatment with opioid agonist therapy for opioid use disorder (e.g., methadone or buprenorphine) does not appear to have a negative impact on child growth, cognition, language abilities, sensory processing, or temperament. Prenatal amphetamine and cocaine use may have a negative impact on child development, but effects, in part, are mediated by childhood environment and adversity. Conclusions: Preventative efforts in women's health are needed to reduce substance use and unplanned pregnancies. Early interventions for children exposed to substances are needed as well as interventions targeting the myriad of issues that co-occur with substance use, including poverty, mental health problems, and childhood adversity.
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Affiliation(s)
- Constance Guille
- Department of Psychiatry, Behavioral Sciences and Medical University of South Carolina, Charleston, South Carolina.,Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina
| | - Rubin Aujla
- Department of Psychiatry, Behavioral Sciences and Medical University of South Carolina, Charleston, South Carolina
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Bruneau J, Ahamad K, Goyer MÈ, Poulin G, Selby P, Fischer B, Wild TC, Wood E. Management of opioid use disorders: a national clinical practice guideline. CMAJ 2019; 190:E247-E257. [PMID: 29507156 DOI: 10.1503/cmaj.170958] [Citation(s) in RCA: 263] [Impact Index Per Article: 52.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Julie Bruneau
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Keith Ahamad
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Marie-Ève Goyer
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Ginette Poulin
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Peter Selby
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Benedikt Fischer
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - T Cameron Wild
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
| | - Evan Wood
- Centre hospitalier de l'Université de Montréal (Bruneau), Université de Montréal; Département de médecine de famille et de médecine d'urgence (Bruneau, Goyer), Faculté de médecine, Université de Montréal, Montréal, Que.; British Columbia Centre on Substance Use (Ahamad), St. Paul's Hospital; Department of Family Medicine (Ahamad), University of British Columbia, Vancouver, BC; Centre de recherche et d'aide pour narcomanes, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (Goyer), Montréal, Que.; Addictions Foundation of Manitoba (Poulin); Max Rady College of Medicine, Postgraduate Medical Education (Poulin), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Man.; Addictions Division (Selby), Centre for Addiction and Mental Health; Department of Family and Community Medicine, Dalla Lana School of Public Health (Selby); Department of Psychiatry (Selby, Fischer), University of Toronto, Toronto, Ont.; Institute for Mental Health Policy Research (Fischer), Centre for Addiction and Mental Health, Toronto, Ont.; School of Public Health (Wild), Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alta.; British Columbia Centre on Substance Use (Wood), St. Paul's Hospital; Department of Medicine (Wood), University of British Columbia, Vancouver, BC
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Swain JE, Ho SS, Fox H, Garry D, Brummelte S. Effects of opioids on the parental brain in health and disease. Front Neuroendocrinol 2019; 54:100766. [PMID: 31128130 PMCID: PMC8318357 DOI: 10.1016/j.yfrne.2019.100766] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/20/2019] [Accepted: 05/21/2019] [Indexed: 12/20/2022]
Abstract
The epidemic of opioid use disorder (OUD) directly affects millions of women of child-bearing age. Unfortunately, parenting behaviors - among the most important processes for human survival - are vulnerable to the effects of OUD. The standard of care for pregnant women with OUD is opioid maintenance therapy (OMT), of which the primary objective is to mitigate addiction-related stress. The aim of this review is to synthesize current information specific to pregnancy and parenting that may be affected by OUD. We first summarize a model of the parental brain supported by animal research and human neuroimaging. We then review animal models of exogenous opioid effects on parental brain and behavior. We also present preliminary data for a unifying hypothesis that may link different effects of exogenous opioids on parenting across species and in the context of OMT. Finally, we discuss future directions that may inform research and clinical decision making for peripartum women with OUD.
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Affiliation(s)
- James E Swain
- Department of Psychiatry and Behavioral Health, and Psychology, Stony Brook University, Stony Brook, NY, United States; Department of Psychiatry, Psychology, and Center for Human Growth & Development, University of Michigan, Ann Arbor, MI, United States.
| | - S Shaun Ho
- Department of Psychiatry and Behavioral Health, and Psychology, Stony Brook University, Stony Brook, NY, United States
| | - Helen Fox
- Department of Psychiatry and Behavioral Health, and Psychology, Stony Brook University, Stony Brook, NY, United States
| | - David Garry
- Department of Obstetrics and Gynecology, Stony Brook University, Stony Brook, NY, United States
| | - Susanne Brummelte
- Department of Psychology, Wayne State University, Detroit, MI, United States.
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Klaman SL, Andringa K, Horton E, Jones HE. Concurrent Opioid and Alcohol Use Among Women Who Become Pregnant: Historical, Current, and Future Perspectives. SUBSTANCE ABUSE-RESEARCH AND TREATMENT 2019; 13:1178221819852637. [PMID: 31210730 PMCID: PMC6545650 DOI: 10.1177/1178221819852637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 05/02/2019] [Indexed: 01/07/2023]
Abstract
The numbers of women using opioids who become pregnant have captured the
attention of media, research, policy, and community. At the same time, there is
an ever-growing use of alcohol among women who continue drinking during
pregnancy that has received less focus. Although both untreated opioid use
disorder and alcohol misuse pose risks for maternal, fetal, and child
morbidities, alcohol is the substance with the most significant documentation of
harms. As we focus on the opioid epidemic in the United States, it is critical
that we do not overlook alcohol use during pregnancy. Both opioid use and
alcohol use during pregnancy are important public health challenges and often
happen concurrently. Thus, this commentary aims to (1) highlight the historical
and current context of opioid and alcohol use during pregnancy; (2) summarize
the current knowledge of opioids and alcohol use during pregnancy; and (3)
detail future directions in how health care providers can help identify and
therapeutically respond to women with concurrent opioid and alcohol use
disorder.
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Affiliation(s)
- Stacey L Klaman
- Department of Maternal and Child Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,UNC Horizons, Carrboro, NC, USA
| | | | | | - Hendrée E Jones
- Department of Obstetrics & Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Departments of Psychiatry & Behavioral Sciences and Gynecology & Obstetrics, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Abstract
The United States opioid epidemic is a nationwide public health crisis. Initially driven by increased consumption and availability of pharmaceutical opioids, an increasing number of opioid overdoses are now related to heroin and illicitly manufactured fentanyl and fentanyl analogs. Addressing this epidemic requires addressing the stigma associated with opioid use disorders and its treatment, improving access to efficacious treatment options, specifically methadone and buprenorphine, and reducing opioid overdose fatalities with distribution of the opioid antagonist and overdose reversal agent naloxone.
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Affiliation(s)
- Jennifer Lyden
- Denver Health and Hospital Authority, Denver, CO, United States; Department of Medicine, University of Colorado School of Medicine, Denver, CO, United States.
| | - Ingrid A Binswanger
- Department of Medicine, University of Colorado School of Medicine, Denver, CO, United States; Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, United States; Colorado Permanente Medical Group, Aurora, CO, United States
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Abstract
Pharmacotherapy, or medication-assisted treatment (MAT), is a critical component of a comprehensive treatment plan for the pregnant woman with opioid use disorder (OUD). Methadone and buprenorphine are two types of opioid-agonist therapy which prevent withdrawal symptoms and control opioid cravings. Methadone is a long-acting mu-opioid receptor agonist that has been shown to increase retention in treatment programs and attendance at prenatal care while decreasing pregnancy complications. However methadone can only be administered by treatment facilities when used for OUD. In contrast, buprenorphine is a mixed opioid agonist-antagonist medication that can be prescribed outpatient. The decision to use methadone vs buprenorphine for MAT should be individualized based upon local resources and a patient-specific factors. There are limited data on the use of the opioid antagonist naltrexone in pregnancy. National organizations continue to recommend MAT over opioid detoxification during pregnancy due to higher rates of relapse with detoxification.
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Affiliation(s)
| | - Kaylin A Klie
- University of Colorado, Department of Family Medicine, 1693 N Quentin Street, Aurora, CO, USA.
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Sutter MB, Watson H, Bauers A, Johnson K, Hatley M, Yonke N, Leeman L. Group Prenatal Care for Women Receiving Medication-Assisted Treatment for Opioid Use Disorder in Pregnancy: An Interprofessional Approach. J Midwifery Womens Health 2019; 64:217-224. [PMID: 30864287 DOI: 10.1111/jmwh.12960] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 12/05/2018] [Accepted: 12/06/2018] [Indexed: 01/06/2023]
Abstract
Opioid use disorder among pregnant women is common and rapidly increasing nationwide. Group prenatal care is an innovative alternative to individual care for pregnant women and has been shown to improve women's and health care providers' satisfaction and adherence to care. We describe a novel group prenatal care program colocated in an opioid treatment program that integrates prenatal care, substance use disorder counseling, and medication-assisted treatment. Our interprofessional model draws on the unique contributions of physicians, midwives, nurses, and mental health professionals to address the complex needs of pregnant women with opioid use disorder. Participants reported increased trust and engagement with health care providers and peers, improved prenatal care and birth experience, and increased resilience for relapse prevention. Group prenatal care is an accepted and promising model for women with opioid use disorder in pregnancy and has the potential to improve outcomes for women and newborns.
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Affiliation(s)
- Mary Beth Sutter
- Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | | | - Kate Johnson
- University of New Mexico, Albuquerque, New Mexico
| | - Mandy Hatley
- University of New Mexico, Albuquerque, New Mexico
| | - Nicole Yonke
- Health Sciences Center, University of New Mexico, Albuquerque, New Mexico.,Department of Family and Community Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Lawrence Leeman
- Health Sciences Center, University of New Mexico, Albuquerque, New Mexico.,Department of Family and Community Medicine, University of New Mexico, Albuquerque, New Mexico.,Department of Obstetrics, University of New Mexico, Albuquerque, New Mexico
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Lawlor ML, Shook LA, McQuerry K, Srinivasan A, Johnson QB, Chavan NR, Critchfield AS. Care-by-parent model as a tool for reduction of neonatal opioid withdrawal syndrome in neonates exposed to buprenorphine maintenance therapy in-utero. J Matern Fetal Neonatal Med 2019; 33:2718-2722. [PMID: 30563376 DOI: 10.1080/14767058.2018.1558201] [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: 10/27/2022]
Abstract
Objective: To determine if a structured care-by-parent (CBP) protocol is associated with a reduction in diagnosis of treatment-requiring Neonatal Opioid Withdrawal Syndrome (NOWS).Study design: We performed a pilot retrospective, case control study of pregnant women enrolled in a comprehensive prenatal care program for opioid-dependent patients during which they received buprenorphine for Medication Assisted Treatment (MAT) for Opioid Use Disorder (OUD). Patients who participated in the CBP program actively roomed-in with their infants even after maternal hospital discharge while infants continued to be monitored for development of treatment-requiring NOWS. The primary outcome was the rate of treatment-requiring NOWS in the CBP grouping.Results: Thirty-two (32) cases that were enrolled in the CBP model were compared with 32 matched controls that were not enrolled in this model. There was a significant reduction in the rate of treatment-requiring NOWS among cases compared to the controls (OR = 0.10; p = .001). Neonates undergoing CBP had a decreased length of stay and lower Finnegan scores compared to those who did not undergo CBPConclusion: Among infants born to mothers with OUD in pregnancy, CBP significantly reduces the rate of treatment-requiring NOWS.
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Affiliation(s)
- Megan L Lawlor
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Lori A Shook
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Kristen McQuerry
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Aarthi Srinivasan
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Quinetta B Johnson
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Niraj R Chavan
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Agatha S Critchfield
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Kentucky College of Medicine, Lexington, KY, USA
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Miller CB, Wright T. Investigating Mechanisms of Stillbirth in the Setting of Prenatal Substance Use. Acad Forensic Pathol 2018; 8:865-873. [PMID: 31240077 DOI: 10.1177/1925362118821471] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 10/22/2018] [Indexed: 01/03/2023]
Abstract
Introduction Intrauterine fetal demise affects between 0.4-0.8% of pregnancies worldwide. This significant adverse pregnancy outcome continues to be poorly understood. In utero exposure to substances increases the risk of stillbirth to varying degrees according to the type of substance and degree of exposure. The aim of this qualitative narrative review is to investigate common biologic relationships between stillbirth and maternal substance use. Methods A PubMed literature search was conducted to query the most commonly used substances and biologic mechanisms of stillbirth. Search terms included "stillbirth," "intrauterine fetal demise," "placenta," "cocaine," "tobacco," "alcohol," "methamphetamines," "opioids/ opiates," and "cannabis." Results There are very few studies identifying a direct link between substance use and stillbirth. Several studies demonstrate associations with placental lesions of insufficiency including poor invasion, vasoconstriction, and sequestration of toxic substances that inhibit nutrient transport. Restricted fetal growth is the most common finding in pregnancies complicated by all types of substance use. Discussion More research is needed to understand the biologic mechanisms of stillbirth. Such knowledge will be foundational to understanding how to prevent and treat the adverse effects of substances during pregnancy.
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Maternal and neonatal characteristics of a Canadian urban cohort receiving treatment for opioid use disorder during pregnancy. J Dev Orig Health Dis 2018; 10:132-137. [PMID: 30113278 DOI: 10.1017/s2040174418000478] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The epidemic of prescription and non-prescription opioid misuse is of particular importance in pregnancy. The Society of Obstetricians and Gynaecologists of Canada currently recommends opioid replacement therapy with methadone or buprenorphine for opioid-dependent women during pregnancy. This vulnerable segment of the population has been shown to be at increased risk of blood-borne infectious diseases, nutritional insecurity and stress. The objective of this study was to describe an urban cohort of pregnant women on opioid replacement therapy and to evaluate potential effects on the fetus. A retrospective chart review of all women on opioid replacement therapy and their infants who delivered at The Ottawa Hospital General and Civic campuses between January 1, 2013 and March 24, 2017 was conducted. Data were collected on maternal characteristics, pregnancy outcomes, neonatal outcomes and corresponding placental pathology. Maternal comorbidities identified included high rates of infection, tobacco use and illicit substance use, as well as increased rates of placental abruption compared with national averages. Compared with national baseline averages, the mean neonatal birth weight was low, and the incidence of small for gestational age infants and congenital anomalies was high. The incidence of NAS was comparable with estimates from other studies of similar cohorts. Findings support existing literature that calls for a comprehensive interdisciplinary risk reduction approach including dietary, social, domestic, psychological and other supports to care for opioid-dependent women in pregnancy.
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Walker ZW, Vinson AR, Babcock D, Benjamin T, Haas DM. Determining the Initiation of Opiate Misuse Resulting in Opioid Use Disorder in Pregnant Women. J Psychoactive Drugs 2018; 50:331-338. [PMID: 30089441 DOI: 10.1080/02791072.2018.1497235] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The aim of this study was to explore the "opiate misuse footprint" made by obstetrics and gynecology physicians in prescribing opioid medications for postpartum pain control that led to opioid misuse and opioid use disorder. Data were collected using intake information and anonymous surveys administered to pregnant women at local methadone clinics in Indianapolis, Indiana, in 2016-2017. Results from this study revealed that 40% of the 33 participants stated that the first drug they became addicted to was prescription opioids; 71% stated that the first opiate they became addicted to was a prescription pain medication. Prescription opioids were mainly obtained from emergency medicine physicians and friends. Reported use of opioids within the past four months was high, with the most commonly used drugs being methadone (57.6%) and heroin (42.4%). A majority of participants also endorsed a history of sexual and physical abuse, recent incarceration, and mental health disorders. As a large number of pregnant women with opioid use disorder reported their initial drug of misuse as prescription pain medications, it is important to avoid overprescribing opioids in reproductive-age women.
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Affiliation(s)
- Zachary W Walker
- a Department of OB/GYN , Indiana University School of Medicine , Indianapolis , IN, USA
| | - Abigail R Vinson
- a Department of OB/GYN , Indiana University School of Medicine , Indianapolis , IN, USA
| | - Dean Babcock
- b Department of Psychiatry , Midtown Community Mental Health Clinic, Eskenazi Health, Indianapolis, IN, USA
| | - Tara Benjamin
- a Department of OB/GYN , Indiana University School of Medicine , Indianapolis , IN, USA
| | - David M Haas
- a Department of OB/GYN , Indiana University School of Medicine , Indianapolis , IN, USA
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Problematisation and regulation: Bodies, risk, and recovery within the context of Neonatal Abstinence Syndrome. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 68:139-146. [PMID: 30025899 DOI: 10.1016/j.drugpo.2018.06.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 05/01/2018] [Accepted: 06/11/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Neonatal Abstinence Syndrome (NAS) is an anticipated effect of maternal drug use during pregnancy. Yet it remains a contested area of policy and practice. In this paper, we contribute to ongoing debates about the way NAS is understood and responded to, through different treatment regimes, or logics of care. Our analysis examines the role of risk and recovery discourses, and the way in which the bodies of women and babies are conceptualised within these. METHODS Qualitative interviews with 16 parents (9 mothers, 7 fathers) and four focus groups with 27 health and social care professionals based in Scotland. All the mothers were prescribed opioid replacement therapy and parents were interviewed after their baby was born. Data collection explored understandings about the causes and consequences of NAS and experiences of preparing for, and caring for, a baby with NAS. Data were analysed using a narrative and discursive approach. RESULTS Parent and professional accounts simultaneously upheld and subverted logics of care which govern maternal drug use and the assessment and care of mother and baby. Despite acknowledging the unpredictability of NAS symptoms and the inability of the women who are opioid-dependent to prevent NAS, logics of care centred on 'proving' risk and recovery. Strategies appealed to the need for caution, intervening and control, and obscured alternative logics of care that focus on improving support for mother-infant dyads and the family as a whole. CONCLUSION Differing notions of risk and recovery that govern maternal drug use, child welfare and family life both compel and trouble all logics of care. The contentious nature of NAS reflects wider socio-political and moral agendas that ultimately have little to do with meeting the needs of mothers and babies. Fundamental changes in the principles, quality and delivery of care could improve outcomes for families affected by NAS.
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