Opioid dependence during pregnancy. Effects and management

Evaluating the Effect of Maternal Opioid Maintenance Dose on the NOWS-COS Outcome Criteria: A Pilot Study

This retrospective cohort study included 77 mother-infant dyads that delivered term pregnancies at a single tertiary care institution. The primary objective was to investigate whether maternal dose of opioid maintenance therapy during pregnancy affects infant outcomes. All infants had prenatal exposure to opioid maintenance therapies. Maternal dose was converted into morphine milligram equivalents (MMEs) and stratified into high- (MME >1000 mg) and low-dose groups (MME ≤1000 mg). Associations between infant outcomes and MME dosage were examined using Wilcoxon rank-sum and Fisher's Exact tests. Days to symptom control were significantly higher in the high MME group (5 days vs 2.8 days, P = .016). Rates of developmental delay at 24 months were higher in the high MME group (21.2% vs 4.5%, P = .0335). Maternal MME did not predict need for NOWS treatment. Higher MME-exposed infants should have optimized nonpharmacologic interventions for consolation and be increasingly observed for signs of developmental delay.

Standard Versus Rapid Inpatient Methadone Titration for Pregnant Patients With Opioid Use Disorder: A Retrospective Cohort Study

OBJECTIVES

Our study evaluated if rapid inpatient titration of methadone for pregnant patients with opioid use disorder (OUD) improved outcomes without increasing the risk for overdose.

METHODS

This is a retrospective cohort study of pregnant patients admitted for inpatient methadone titration from January 2020 to June 2022. Outcomes were compared between standard versus rapid titration protocols. Standard titration involved an initial methadone dose with additional doses every 6 hours if clinical opiate withdrawal score (COWS) is >9. Rapid titration involved an initial methadone dose with additional doses every 4 hours if COWS is >9. The primary outcome was time required to achieve stable dose. Secondary outcomes included elopement prior to achieving stable dose, methadone-related readmission, opioid overdose, and final dose.

RESULTS

There were 97 patients in the standard titration (STP) and 97 patients in the rapid titration (RTP) groups. Demographic characteristics and substance use history did not differ between the 2 groups. Time to stable dose did not differ between the 2 groups (RTP, 5.0 days ±4.0; STP, 4.0 days ±3.0; P = 0.08). Patients in the rapid titration group were less likely to elope from the hospital prior to stabilization (RTP 23.0% vs STP 37.9%, P = 0.03) and had fewer methadone-related readmissions ( P < 0.001). One patient (1.0%) in the RTP group required naloxone treatment while inpatient for concern for overdose, while none did in the STP group ( P = 0.32). There was no difference in median final stable dose between the 2 groups ( P = 0.07).

CONCLUSIONS

Rapid titration of methadone for pregnant patients with OUD was associated with decreased medical elopement and methadone-related readmission, without increasing the risk for overdose.

Factors associated with receipt of medication for opioid use disorder among pregnant individuals entering treatment programs in the U.S

BACKGROUND

Opioid use disorder (OUD) among pregnant individuals in the U.S. has been on the rise, and carries significant health risks if left untreated. Despite the effectiveness of medication for opioid use disorder (MOUD), rates of treatment utilization remain low, and access varies by state. This study seeks to expand on what is known about the utilization of MOUD by estimating annual percentages of MOUD use among treatment admissions among pregnant individuals across all 50 states and U.S. regions. The study also examines how pregnant people experiencing OUD are referred to substance use treatment programs to better understand which referral sources are most effective at linking them to MOUD.

METHODS

This study estimated MOUD utilization among pregnant admissions over a 9-year period, identifying trends in the use of this treatment, using national and state level data from the Treatment Episode Dataset-Admissions (TEDS-A). The sample were pregnant females who admitted to treatment with opioids as a primary substance use problem, in all 50 states, from 2010 to 2018. The study examined the referral pathways through which pregnant individuals enter treatment, identifying variations in how they are linked with MOUD. A binary logistic regression was conducted to estimate significant sociodemographic characteristics and referral sources associated with MOUD receipt in treatment.

RESULTS

Among admissions who reported both pregnancy and OUD across nine years (n= 84,492), the average percentage of MOUD use was 50.8%. Average annual MOUD use was highest in the Northeast region (63.42%), and lowest in the South (34.01%). Maine had the highest MOUD use, for an average of 81.99% across all years. Pregnant individuals who were self-referred to treatment comprised the largest percentage of admissions leading to MOUD use (62.1%), and those referred by the criminal justice system or other legal entity resulted in the lowest MOUD use across years (23.6%). Binary logistic regression results found that race, education, employment status, and referral source were significantly associated with MOUD receipt in 2018; specifically, individuals with a higher education, those were unemployed, and those who were referred to treatment by another substance use or healthcare provider or from the criminal or legal system, were significantly less likely to receive MOUD.

CONCLUSION

This study estimated that an average of approximately half of admissions who were pregnant with OUD received MOUD as part of their treatment plans, and identified regional and state trends which can be further investigated to understand factors contributing to these geographical variations in MOUD access. Also notable were findings pertaining to low MOUD receipt among those referred from criminal or legal entities, warranting further investigation. These findings can lead to a better understanding of which referral sources to treatment can act as effective pathways to MOUD, and best practices to link pregnant individuals with evidence-based care.

Opioid, methamphetamine, and polysubstance use: perinatal outcomes for the mother and infant

The escalation in opioid pain relief (OPR) medications, heroin and fentanyl, has led to an increased use during pregnancy and a public health crisis. Methamphetamine use in women of childbearing age has now eclipsed the use of cocaine and other stimulants globally. Recent reports have shown increases in methamphetamine are selective to opioid use, particularly in rural regions in the US. This report compares the extent of our knowledge of the perinatal outcomes of OPRs, heroin, fentanyl, two long-acting substances used in the treatment of opioid use disorders (buprenorphine and methadone), and methamphetamine. The methodological limitations of the current research are examined, and two important initiatives that will address these limitations are reviewed. Current knowledge of the perinatal effects of short-acting opioids, OPRs, heroin, and fentanyl, is scarce. Most of what we know about the perinatal effects of opioids comes from research on the long-acting opioid agonist drugs used in the treatment of OUDs, methadone and buprenorphine. Both have better perinatal outcomes for the mother and newborn than heroin, but the uptake of these opioid substitution programs is poor (<50%). Current research on perinatal outcomes of methamphetamine is limited to retrospective epidemiological studies, chart reviews, one study from a treatment center in Hawaii, and the US and NZ cross-cultural infant Development, Environment And Lifestyle IDEAL studies. Characteristics of pregnant individuals in both opioid and MA studies were associated with poor maternal health, higher rates of mental illness, trauma, and poverty. Infant outcomes that differed between opioid and MA exposure included variations in neurobehavior at birth which could complicate the diagnosis and treatment of neonatal opioid withdrawal (NOWs). Given the complexity of OUDs in pregnant individuals and the increasing co-use of these opioids with MA, large studies are needed. These studies need to address the many confounders to perinatal outcomes and employ neurodevelopmental markers at birth that can help predict long-term neurodevelopmental outcomes. Two US initiatives that can provide critical research and treatment answers to this public health crisis are the US Environmental influences on Child Health Outcomes (ECHO) program and the Medication for Opioid Use Disorder During Pregnancy Network (MAT-LINK).

Brain circuits for maternal sensitivity and pain involving anterior cingulate cortex among mothers receiving buprenorphine treatment for opioid use disorder

Opioid-induced deficits in maternal behaviors are well-characterized in rodent models. Amid the current epidemic of opioid use disorder (OUD), prevalence among pregnant women has risen sharply. Yet, the roles of buprenorphine replacement treatment for OUD (BT/OUD) in the brain functions of postpartum mothers are unclear. Using functional magnetic resonance imaging (fMRI), we have developed an evolutionarily conserved maternal behavior neurocircuit (MBN) model to study human maternal care versus defensive/aggressive behaviors critical to mother-child bonding. The anterior cingulate gyrus (ACC) is not only involved in the MBN for mother-child bonding and attachment, but also part of an opioid sensitive "pain-matrix". The literature suggests that prescription opioids produce physical and emotional "analgesic" effects by disrupting specific resting-state functional connectivity (rs-FC) of ACC to regions related to MBN. Thus, in this longitudinal study, we report findings of overlapping MBN and pain matrix circuits, for mothers with chronic exposure of BT/OUD. A total of 32 mothers were studied with 6 min rs-FC at 1 month (T1) and 4 months postpartum (T2), including seven on BT/OUD and 25 non-BT/OUD mothers as a comparison group. We analyzed rs-FC between the insula, putamen, and the dorsal anterior cingulate cortex (DACC) and rostral ACC (RACC), as the regions of interest that mediate opioid analgesia. BT/OUD mothers, as compared to non-BT/OUD mothers, showed less left insula-RACC rs-FC but greater right putamen-DACC rs-FC at T1, with these between-group differences diminished at T2. Some of these rs-FC results were correlated with the scores of postpartum parental bonding questionnaire. We found time-by-treatment interaction effects on DACC and RACC-dependent rs-FC, potentially identifying brain mechanisms for beneficial effects of BT, normalizing dysfunction of maternal brain and behavior over the first four months postpartum. This study complements recent studies to ascertain how BT/OUD affects maternal behaviors, mother-child bonding, and intersubjectivity and reveals potential MBN/pain-matrix targets for novel interventions.

Drug use in pregnancy in Ireland's capital city: A decade of trends and outcomes

OBJECTIVE

The aim of this study was to present contemporary trends in opiate use disorder (OUD) and substance use in pregnancy in Ireland, with associated obstetric outcomes, over the last ten years.

STUDY DESIGN

This retrospective observational cohort study was conducted at an Irish tertiary maternity unit. All women with OUD or substance use in pregnancy delivered under this service between 2010 and 2019 were included. Drug-exposure was self-reported. Data was collected by combining electronic and hand-held patient records. Trends and outcomes were analysed by year of delivery. Approval for the study was granted by the institution's clinical governance committee.

RESULTS

Of the 82,669 women delivered, 525 had OUD or substance use in pregnancy (1 in every 160 women booking). 11.6% were homeless, 20.0% were in full-time employment and 91.0% smoked tobacco in pregnancy. 66.3% had a history of psychiatric disorders. Over the ten years, there was a significant reduction in women delivered with OUD or substance use in pregnancy (0.8 % to 0.4 %, RR 0.55, 95 % CI 0.36-0.85), significant reduction in the proportion of women on Opioid-Substitute-Treatment (OST, RR 0.66 95 % CI 0.51-0.87) and an increase in mean maternal age (30.7to32.0 years). Rates of cocaine and cannabis consumption increased (20.6 %, RR 3.8, 95 % CI 1.57-9.44: 24.0 %, RR 3.7, 95 % CI 1.58-8.86 respectively). The maternal mortality rate was 380.9:100,000 births. The perinatal mortality rate was 15.6:1000 births. The preterm birth rate was 17.9 %, with a mean birth weight of 2832 g. The rate of NICU admission was 52.0 % and the mean length of stay was 22.4 days. Amongst the smaller OUD population, the rate of NICU admission for Neonatal Abstinence Syndrome (NAS) and treatment for NAS increased over the study timeframe (36.0 %, RR 2.97, 95 % CI 1.86-4.75: 28.5 %, RR 2.92, 95 % CI 1.70-5.0 respectively).

CONCLUSIONS

The obstetric population attending an Irish antenatal service with opiate use disorder or substance exposure is reducing in size with older patients, less opioid substitute therapy and increasing cocaine and cannabis use. These women have high rates of maternal and perinatal morbidity and mortality. Specialist antenatal addiction services, coordinated by the drug-liaison midwife, are critical in adapting care to respond to this dynamic and vulnerable patient cohort.

Evidence for the Normalization Effects of Medication for Opioid Use Disorder on Functional Connectivity in Neonates with Prenatal Opioid Exposure

Altered functional connectivity has been reported in infants with prenatal exposure to opioids, which significantly interrupts and influences endogenous neurotransmitter/receptor signaling during fetal programming. Better birth outcomes and long-term developmental outcomes are associated with medication for opioid use disorder (MOUD) during pregnancy, but the neural mechanisms underlying these benefits are largely unknown. We aimed to characterize effects of prenatal opioid/other drug exposure (PODE) and the neural basis for the reported beneficial effects of MOUD by examining neonatal brain functional organization. A cohort of 109 human newborns, 42 PODE, 39 with prenatal exposure to drugs excluding opioids (PDE), 28 drug-free controls (males and females) underwent resting-state fMRI at 2 weeks of age. To examine neural effects of MOUD, PODE infants were separated into subgroups based on whether mothers received MOUD (n = 31) or no treatment (n = 11). A novel heatmap analysis was designed to characterize PODE-associated functional connectivity alterations and MOUD-related effects, and permutation testing identified regions of interest with significant effects. PODE neonates showed alterations beyond those associated with PDE, particularly in reward-related frontal-sensory connectivity. MOUD was associated with a significant reduction of PODE-related alterations in key regions of endogenous opioid pathways including limbic and frontal connections. However, significant residual effects in limbic and subcortical circuitry were observed. These findings confirm altered brain functional organization associated with PODE. Importantly, widespread normalization effects associated with MOUD reveal, for the first time, the potential brain basis of the beneficial effects of MOUD on the developing brain and underscore the importance of this treatment intervention for better developmental outcomes.SIGNIFICANCE STATEMENT This is the first study to reveal the potential neural mechanisms underlying the beneficial effects on the neonate brain associated with MOUD during pregnancy. We identified both normalization and residual effects of MOUD on brain functional architecture by directly comparing neonates prenatally exposed to opioids with MOUD and those exposed to opioids but without MOUD. Our findings confirm altered brain functional organization associated with prenatal opioid exposure and demonstrate that although significant residual effects remain in reward circuitry, MOUD confers significant normalization effects on functional connectivity of regions associated with socioemotional development and reward processing. Together, our results highlight the importance of MOUD intervention for better neurodevelopmental outcomes.

Buprenorphine Exposure Alters the Development and Migration of Interneurons in the Cortex

The misuse of opioids has reached epidemic proportions over the last decade, with over 2.1 million people in the United States suffering from substance use disorders related to prescription opioid pain relievers. This increase in opioid misuse affects all demographics of society, including women of child-bearing age, which has led to a rise in opioid use during pregnancy. Opioid use during pregnancy has been associated with increased risk of obstetric complications and adverse neonatal outcomes, including neonatal abstinence syndrome. Currently, opioid use disorder in pregnant women is treated with long-acting opioid agonists, including buprenorphine. Although buprenorphine reduces illicit opioid use during pregnancy and improves infant outcomes at birth, few long-term studies of the neurodevelopmental consequences have been conducted. The goal of the current experiments was to examine the effects of buprenorphine on the development of the cortex using fetal brain tissue, 3D brain cultures, and rodent models. First, we demonstrated that we can grow cortical and subpallial spheroids, which model the cellular diversity, connectivity, and activity of the developing human brain. Next, we show that cells in the developing human cortex express the nociceptin opioid (NOP) receptor and that buprenorphine can signal through this receptor in cortical spheroids. Using subpallial spheroids to grow inhibitory interneurons, we show that buprenorphine can alter interneuron development and migration into the cortex. Finally, using a rodent model of prenatal buprenorphine exposure, we demonstrate that alterations in interneuron distribution can persist into adulthood. Together, these results suggest that more research is needed into the long-lasting consequences of buprenorphine exposure on the developing human brain.

Risk factors for preterm birth among gravid individuals receiving buprenorphine for opioid use disorder

OBJECTIVE

Pregnancies complicated by opioid use disorder (OUD) are at an increased risk for preterm birth (PTB), defined as delivery <37 weeks gestation. Limited literature is available on prevalence and risk factors for PTB in pregnancies complicated by OUD maintained on buprenorphine Therefore, we sought to determine rate of PTB and risk factors for PTB in this population.

STUDY DESIGN

We performed a retrospective cohort study of pregnant individuals with singleton gestation receiving buprenorphine for OUD, who delivered at a tertiary academic medical center between 7/1/2013 and 6/30/2018. Individuals who had at least three visits in our co-located clinic were included in analysis. Patients were divided into 2 groups, those delivered <37 weeks gestation were included in preterm group, while patient delivered ≥ 37 weeks were included in term group. We defined "supplements to buprenorphine" to include any illicit drugs found on antepartum urine toxicology. Variables evaluated as potential risk factors for PTB included medical and infectious comorbidities as well as illicit polysubstance use.

RESULTS

The overall PTB rate in this cohort was 22.7% (115/507). There was a non-significant trend towards decrease in overall PTB and provider-initiated PTB rate over study period. No differences found in spontaneous PTB or PTB< 34 weeks. There were no differences in use of tobacco, alcohol, number of prenatal visits or gestational age when prenatal care started between those who delivered preterm compared to term. Individuals with PTB in the index pregnancy were more likely to have history of PTB compared to those with term delivery (73% vs 16%; P<.01). No medical or infectious comorbidity nor any specific supplement increased risk of PTB. Among individuals using 0, 1, 2, or 3 or more illicit supplements in addition to confirmed buprenorphine for OUD, the PTB rate was 27.4% (reference), 18.0% (P=0.09), 18.1% (P=0.44), and 15.8% (P=0.77), respectively.

CONCLUSION

The PTB rate among individuals using buprenorphine for OUD (22.7%) is higher than national average but lower than the reported PTB rate in individuals using methadone for MOUD.. No medical or infectious comorbidity or use of additional illicit substances increased the risk of PTB.

Global Brain Functional Network Connectivity in Infants With Prenatal Opioid Exposure

BACKGROUND

Infants with prenatal opioid and substance exposure are at higher risk of poor neurobehavioral outcomes in later childhood. Early brain imaging in infancy has the potential to identify early brain developmental alterations that may help predict behavioral outcomes in these children. In this study, using resting-state functional MRI in early infancy, we aim to identify differences in global brain network connectivity in infants with prenatal opioid and substance exposure compared to healthy control infants.

METHODS AND MATERIALS

In this prospective study, we recruited 23 infants with prenatal opioid exposure and 29 healthy opioid naïve infants. All subjects underwent brain resting-state functional MRI before 3 months postmenstrual age. Covariate Assisted Principal (CAP) regression was performed to identify brain networks within which functional connectivity was associated with opioid exposure after adjusting for sex and gestational age. Associations of these significant networks with maternal comorbidities were also evaluated. Additionally, graph network metrics were assessed in these CAP networks.

RESULTS

There were four CAP network components that were significantly different between the opioid exposed and healthy control infants. Two of these four networks were associated with maternal psychological factors. Intra-network graph metrics, namely average flow coefficient, clustering coefficient and transitivity were also significantly different in opioid exposed infants compared to healthy controls.

CONCLUSION

Prenatal opioid exposure is associated with alterations in global brain functional networks compared to non-opioid exposed infants, with intra-network alterations in graph network modeling. These network alterations were also associated with maternal comorbidity, especially mental health. Large-scale longitudinal studies can help in understanding the clinical implications of these early brain functional network alterations in infants with prenatal opioid exposure.

Maternal Complications and Prescription Opioid Exposure During Pregnancy: Using Marginal Structural Models

INTRODUCTION

Prescription opioids are frequently used for pain management in pregnancy. Studies examining perinatal complications in mothers who received prescription opioids during pregnancy are still limited.

OBJECTIVES

The aim of this study was to assess the association of prescription opioid use and maternal pregnancy and obstetric complications.

METHODS

This retrospective cohort study with the Rhode Island (RI) Medicaid claims data linked to vital statistics throughout 2008-2015 included pregnant women aged 12-55 years with one or multiple live births. Women were excluded if they had cancer, opioid use disorder, or opioid dispensing prior to but not during pregnancy. Main outcomes included adverse pregnancy and obstetric complications. Marginal Structural Cox Models with time-varying exposure and covariates were applied to control for baseline and time-varying covariates. Analyses were conducted for outcomes that occurred 1 week after opioid exposure (primary) or within the same week as exposure (secondary). Sensitivity studies were conducted to assess the effects of different doses and individual opioids.

RESULTS

Of 9823 eligible mothers, 545 (5.5%) filled one or more prescription opioid during pregnancy. Compared with those unexposed, no significant risk was observed in primary analyses, while in secondary analyses opioid-exposed mothers were associated with an increased risk of cesarean antepartum depression (HR 3.19; 95% CI 1.22-8.33), and cardiac events (HR 9.44; 95% CI 1.19-74.83). In sensitivity analyses, results are more prominent in high dose exposure and are consistent for individual opioids.

CONCLUSIONS

Prescription opioid use during pregnancy is associated with an increased risk of maternal complications.

Acute psychiatric illness and drug addiction during pregnancy and the puerperium

Pregnancy and the puerperium do not protect against acute psychiatric illness. During puerperium, the chance of acute psychiatric illness, such as a psychotic episode or relapse of bipolar disorder, is greatly increased. Suicide is a leading cause of maternal death. Both psychiatric disease and ongoing drug addiction impact not only the pregnant woman's somatic and mental health but also impact short-term and long-term health of the child. Indeed, prompt recognition and expeditious treatment of acute psychiatric illness during pregnancy and the puerperium optimize health outcomes for two patients. Pregnancy and puerperium represent a stage of life of great physiologic adaptations, as well as emotional and social changes. This conjunction of changes in somatic, emotional health and social health may mitigate the occurrence, clinical presentation, and clinical course of acute psychiatric illness and call for a multidisciplinary approach, taking into account both the medical and social domains. This chapter describes acute psychiatric illnesses during pregnancy and the puerperium and illicit substance abuse, from a clinical perspective, while also describing general principles of diagnosis and clinical management during this stage of life, which is an important window of opportunity for both the pregnant woman and the child.

Precision dosing of methadone during pregnancy: A pharmacokinetics virtual clinical trials study

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.

Racial inequity in methadone dose at delivery in pregnant women with opioid use disorder

BACKGROUND

Medications for opioid use disorder, including methadone, combined with comprehensive wraparound services, are the gold standard for treatment in pregnancy. Higher methadone doses are associated with treatment retention in pregnancy and relapse prevention. Given known inequities where individuals of color tend to be prescribed lower doses of opioids for other conditions, the purpose of this study was to determine whether there is racial inequity in methadone dose at delivery in pregnant women with opioid use disorder.

METHODS

Retrospective review of medical charts identified pregnant women (N = 339) treated with methadone for opioid use disorder during pregnancy at one center from 2012 to 2017. Variables extracted from medical records included race, demographic and relevant clinical information (e.g., methadone dose at delivery, height, weight, etc.). Analyses used simple and multiple linear regressions to determine associations between these characteristics and methadone dose at delivery.

RESULTS

The mean methadone doses at delivery among women of color and white women were 105.8 mg and 144.9 mg, respectively (p < .0001). After adjusting for maternal age, gestational age at delivery, body mass index, type of opioid used, and parity, race was significantly and independently associated with methadone dose at delivery, with women of color receiving 36.2 mg less than white women (p = .0003).

CONCLUSIONS

Pregnant women of color with opioid use disorder received 67% of the dose of methadone at delivery that white women received. Antiracist responses to prevent provider bias in evaluating dose needs are needed to correct this inequity and prevent undertreatment of opioid use disorder among women of color.

Cleft Lip and Palate in Infants With Prenatal Opioid Exposure

OBJECTIVE

This study examines phenotypic presentation and perioperative outcomes of cleft-related procedures for infants with cleft lip and/or palate (CL/P) and prenatal opioid exposure.

DESIGN

This is a retrospective review of infants with prenatal opioid exposure treated for CL/P from 2008 to 2018.

SETTING

Patients cared for at a tertiary center from 2008 to 2018.

PATIENTS/PARTICIPANTS

Eighteen patients with documented prenatal opioid exposure and CL/P had primary repairs in our unit.

MAIN OUTCOME MEASURE(S)

The phenotypes of CL/P were characterized. Demographic data regarding additional exposures, as well as associated medical and social comorbidities were recorded. Outcome variables included operative delays, perioperative complications, and loss of follow-up.

RESULTS

Isolated cleft palate (CP; 67%) was overrepresented among patients with prenatal opioid exposure and CL/P, as was Robin sequence (50% in isolated CP). Fifty-six percent had exposure to additional substances. A majority (67%) had other medical conditions or anomalies, and 17% had known genetic syndromes. Seventy-two percent were in state custody. Thirty-nine percent of exposed patients had delays in their planned operative dates due to medical and/or social factors. There were no postoperative readmissions following cleft procedures. Lack of follow-up was noted in 33% of patients.

CONCLUSIONS

Infants with CL/P who have prenatal opioid exposure are likely to have additional medical conditions and complex social challenges.

Opioid use during pregnancy can impair maternal behavior and the Maternal Brain Network: A literature review

Opioid Use Disorder (OUD) is a global epidemic also affecting women of reproductive age. A standard form of pharmacological treatment for OUD is Opioid Maintenance Therapy (OMT) and buprenorphine has emerged as the preferred treatment for pregnant women with OUD relative to methadone. However, the consequences of BUP exposure on the developing Maternal Brain Network and mother-infant dyad are not well understood. The maternal-infant bond is dependent on the Maternal Brain Network, which is responsible for the dynamic transition from a "nulliparous brain" to a "maternal brain". The Maternal Brain Network consists of regions implicated in maternal care (e.g., medial preoptic area, nucleus accumbens, ventral pallidum, ventral tegmentum area) and maternal defense (e.g., periaqueductal gray). The endogenous opioid system modulates many of the neurochemical changes in these areas during the transition to motherhood. Thus, it is not surprising that exogenous opioid exposure during pregnancy can be disruptive to the Maternal Brain Network. Though less drastic than misused opioids, OMTs may not be without risk of disrupting the neural and molecular structures of the Maternal Brain Network. This review describes the Maternal Brain Network as a framework for understanding how pharmacological differences in exogenous opioid exposure can disrupt the onset and maintenance of the maternal brain and summarizes opioid and OMT (in particular buprenorphine) use in the context of pregnancy and maternal behavior. This review also highlights future directions for evaluating exogenous opioid effects on the Maternal Brain Network in the hopes of raising awareness for the impact of the opioid crisis not only on exposed infants, but also on mothers and subsequent mother-infant bonds.

Patient and Hospital Characteristics of Newborns with Neonatal Withdrawal Syndrome

OBJECTIVES

We sought to evaluate hospital resource usage patterns and determine risk factors for neonatal withdrawal syndrome (NWS) in the United States.

METHODS

Using the 2016 Kids' Inpatient Database (KID), we conducted a retrospective cross-sectional analysis of a nationally representative sample of neonates with NWS. The KID is the largest publicly available pediatric (20 years of age and younger) inpatient care database in the United States. We analyzed a stratified probability sampling of 3.1 million pediatric hospital discharges weighted to 6.3 million national discharges. Descriptive statistics for hospital and patient characteristics were identified and binary variables were analyzed using the Student t test. Multivariate regression was performed to assess the predictors of NWS. We excluded discharges if total cost or hospital length of stay (LOS) exceeded mean values by >3 standard deviations. Hospitalizations with NWS diagnosis were identified using the International Classification of Diseases, 10th Revision, Clinical Modification code P96.1 in any 1 of 30 discharge diagnostic fields.

RESULTS

We estimated that 25,394 pediatric discharges were associated with an NWS diagnosis, totaling 403,127 inpatient days at a cost of $1.8 billion. Compared with non-NWS newborns, neonates with NWS had higher mean hospital charges ($71,540 vs $15,765), longer mean hospital stays (16 days vs 3 days), and a significantly higher proportion of low birth weight (7.2% vs 1.9%), feeding problems (19.0% vs 3.5%), respiratory diagnoses (5.6% vs 2.5%), and seizure (0.3% vs 0.1%). Among newborns with NWS, 53% were boys, 80.0% were white, 7.2% were black, 7.4% were Hispanic, and 5.3% were of other races. Hispanic neonates had the highest mean hospital charges and LOS of any other ethnic group ($123,749, 21 days). The largest proportion (83.0%) of NWS-related hospital stays were billed to Medicaid, followed by private insurance (10.3%) and self-pay (4.8%). More than one-third of NWS-related discharges (39.3%) occurred in areas with the lowest mean household annual income (≤$42,999) compared with 28.4% of neonates without NWS. Most NWS cases (53%) had ≥5 diagnoses, compared with 11% of non-NWS neonates. In the multivariate analysis, neonates with a birth weight <2500 g, feeding problems, respiratory diagnoses, seizure, >4 diagnoses, LOS >5 days, rural hospitals, Medicaid, and low-income households were significantly associated with NWS. There was a statistically significant mean hospital charge difference of $55,775 between NWS and non-NWS neonates.

CONCLUSIONS

Since 2000, the number of infants treated for NWS in the US neonatal intensive care units has increased fivefold, accounting for an estimated $1.5 billion in annual hospital expenditures. The high hospital resource usage among NWS neonates raises the possibility that care for expectant mothers who use opiates and their newborns may be able to be delivered in a more efficient and effective manner. Because the majority of the study population was covered by Medicaid programs, state policy makers should be mindful of the impact the opioid crises continue to have on expectant mothers and their infants.

Temporal trends in rates of opioid misuse among delivery-related hospitalizations in North Carolina from 2000 to 2014

Opioid misuse during pregnancy is increasing at an alarming rate across the United States. To determine the prevalence, temporal trends, and resource usage of delivery-related hospitalizations of women who misuse opioids in North Carolina from 2000 to 2014. A retrospective, cross-sectional study was conducted using the State Inpatient Databases. Annual prevalence was calculated, and linear trends were assessed using logistic regression. Temporal trends in hospital charges and length of stay (LOS) were analyzed using ordinary least squares regression with a log_e-transformed response. Of 1,937,455 delivery-related hospitalizations in NC, 6,084 were associated with opioid misuse, a prevalence of 3.14 cases per 1,000 delivery-related discharges. During the study period, the prevalence of opioid misuse during pregnancy in NC increased 955%, from 0.9 cases per 1,000 discharges in 2000 to 9.5 cases per 1,000 discharges in 2014, an average annual rate increase of 1.18 cases (95% CI, 1.16-1.21; P < 0.0001). Median LOS for women who misuse opioids remained stable at three days, whereas the median charge per delivery-related hospitalization significantly increased from $6,311 in 2000 to $9,019 in 2010 (annual average change [AAC], 282.2; 95% CI, 182.9-381.5; P < 0.0001) and from $8,908 in 2011 to $10,864 in 2014 (AAC, 667.5; 95% CI, 275.2-1059.9; P < 0.0001). Health care providers and policymakers in NC are advised to introduce system-wide public health responses focused on prevention and increased access to evidence-based treatment that improves the health of the mothers and neonates who are exposed to opioids.

Prenatal Methamphetamine Exposure and Adverse Neonatal Outcomes: A Nationwide Cohort Study

BACKGROUND

There is limited knowledge on the adverse outcomes in newborns after maternal methamphetamine (MA) use during pregnancy.

OBJECTIVES

To compare neonatal outcomes in newborns exposed to MA with the newborns of opioid-exposed mothers and of mothers from the general population (GP).

METHOD

A cohort study using nationwide registries in Czechia (2000-2014). Women hospitalized with a main diagnosis of MA use disorder during pregnancy (n = 258) and their newborns were defined as MA-exposed. The comparison groups consisted of women (n = 199) diagnosed with opioid use disorder during pregnancy, defined as opioid-exposed, and women (n = 1,511,310) with no substance use disorder diagnosis (GP). The neonatal outcomes studied were growth parameters, gestational age, preterm birth, and Apgar score. To explore the associations between MA exposure and neonatal outcomes, regression coefficients (b) and odds ratios from multivariable linear and binary logistic regression were estimated.

RESULTS

MA-exposed women had similar socio-economic characteristics to opioid-exposed, both of which were worse than in the GP. After adjustment, MA exposure was associated with a more favourable birthweight when compared to the opioid-exposed (adjusted mean differences [aMD] b = 122.3 g, 95% CI: 26.0-218.5) and length (aMD b = 0.6 cm, 0.0-1.1). Unadjusted results from the comparison with the GP showed that the MA group had poorer neonatal outcomes, especially in the growth parameters. Adjustment for background characteristics had a profound effect on the comparison with the GP. After adjustment, MA exposure was associated only with a slightly reduced birthweight (aMD b = -63.0 g, -123.0 to -3.1) and birth length (aMD b = -0.3 cm, -0.6 to 0.0).

CONCLUSIONS

Although the observed negative outcomes were large in the MA-exposed newborns, the adjustment had a profound effect on the comparison with the GP, indicating the large influence of lifestyle and socio-economic factors in these high-risk pregnancies. MA-exposed newborns had better neonatal outcomes compared to opioids-exposed.

Model-Based Approach to Improve Clinical Outcomes in Neonates With Opioid Withdrawal Syndrome Using Real-World Data

At least 60% of the neonates with opioid withdrawal syndrome (NOWS) require morphine to control withdrawal symptoms. Currently, the morphine dosing strategies are empiric, not optimal and associated with longer hospital stay. The aim of the study was to develop a quantitative, model-based, real-world data-driven approach to morphine dosing to improve clinical outcomes, such as reducing time on treatment. Longitudinal morphine dose, clinical response (Modified Finnegan Score (MFS)), and baseline risk factors were collected using a retrospective cohort design from the electronic medical records of neonates with NOWS (N = 177) admitted to the University of Maryland Medical Center. A dynamic linear mixed effects model was developed to describe the relationship between MFS and morphine dose adjusting for baseline risk factors using a split-sample data approach (70% training: 30% test). The training model was evaluated in the test dataset using a simulation based approach. Maternal methadone and benzodiazepine use, and race were significant predictors of the MFS response. Positive autocorrelations of 0.56 and 0.12 were estimated between consecutive MFS responses. On an average, for a 1,000 μg increase in the morphine dose, the MFS decreased by 0.3 units. The model evaluation showed that observed and predicted median time on treatment were similar (13.0 vs. 13.8 days). A model-based framework was developed to describe the MFS-morphine dose relationship using real-world data that could potentially be used to develop an adaptive, individualized morphine dosing strategy to improve clinical outcomes in infants with NOWS.

Maintenance agonist treatments for opiate-dependent pregnant women

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.

Barriers to accessing opioid agonist therapy in pregnancy

BACKGROUND

The incidence of opioid use disorder during pregnancy has risen dramatically in the last couple of decades. Despite the safety and efficacy of treatment for opioid use during pregnancy, pregnant women often cannot access treatment.

OBJECTIVE

This study aimed to determine the availability of opioid agonist therapy to pregnant women in Missouri and Illinois and to compare different markers of treatment accessibility between opioid treatment programs and buprenorphine providers and between rural and urban practices.

STUDY DESIGN

Buprenorphine providers and opioid treatment programs in Missouri and Illinois were identified using the Substance Abuse and Mental Health Services Administration website. A phone audit was conducted to evaluate barriers to care, including whether clinics accepted new patients, pregnant patients, and insurance, and the time to the first appointment and appointment cost. Rural-urban commuting area codes and practice ZIP codes were used to determine whether practice location was rural or urban. Provider specialty was determined from state licensing databases.

RESULTS

There were 1363 buprenorphine providers and 98 opioid treatment programs listed. Clinics were clustered around metropolitan areas, and only 13% of buprenorphine providers (183 of 1363) and 5% of opioid treatment programs (5 of 98) were in rural areas. Despite 3 contact attempts for each clinic, we were unable to reach 42% of buprenorphine providers (401 of 965) and 14% of opioid treatment programs (14 of 98). Of those reached, 40% of buprenorphine providers (223 of 564) and 80% of opioid treatment programs (67 of 84) were accepting new pregnant patients (P=.01). Buprenorphine providers required more contact attempts (>2 attempts in 34% vs 15%; P<.0001) and had longer wait times for the first appointment (>7 days in 27% vs 4%; P=.002) than opioid treatment programs. Buprenorphine providers in urban areas required more attempts to reach (>2 attempts in 36% vs 24%; P=.03) and were less likely to accept Medicaid than those in rural areas (52% vs 74%; P=.008). More than 23% of buprenorphine provider listings (238 of 1038) contained incorrect information, whereas no opioid treatment program listing had incorrect information. Most buprenorphine providers were in primary care or psychiatry, whereas <5% of buprenorphine providers (43 of 1363) were obstetrician-gynecologists.

CONCLUSION

This is the first phone audit to evaluate access to opioid agonist therapy for pregnant women. Only a minority of buprenorphine providers offered care for this patient population, and a large proportion required multiple contact attempts and wait times of >7 days. Opioid treatment programs were more responsive and accepting of new pregnant patients but comprised a minority of clinics and were predominately located in urban areas. There is an urgent need for improved reliability of contact information for opioid agonist providers, timely intake and acceptance for treatment of pregnant patients, and overall improved access to clinics that are challenged by geographic and insurance status barriers.

Functional dissection of prenatal drug effects on baby brain and behavioral development

Prenatal drug exposure (PDE) is known to affect fetal brain development with documented long‐term consequences. Most studies of PDE effects on the brain are based on animal models. In this study, based on a large sample of 133 human neonates and leveraging a novel linear mixed‐effect model designed for intersubject variability analyses, we studied the effects of six prenatally exposed drugs (i.e., nicotine, alcohol, selective serotonin reuptake inhibitor, marijuana, cocaine, and opioids) on neonatal whole‐brain functional organization and compared them with five other critical nondrug variables (i.e., gestational age at birth/scan, sex, birth weight, and maternal depression). The behavioral implications were also examined. Magnitude‐wise, through summing across individual drug effects, our results highlighted ~5% of whole‐brain functional connections (FCs) affected by PDE, which was highly comparable with the combined effects of the five nond rug variables. Spatially, the detected PDE effects featured drug‐specific patterns with a common bias in higher‐order brain regions/networks. Regarding brain–behavioral relationships, the detected connections showing significant drug effects also demonstrated significant correlations with 3‐month behavioral outcomes. Further mediation analyses supported a mediation role of the detected brain FCs between PDE status and cognitive/language outcomes. Our findings of widespread, and spatially biased PDE effect patterns coupled with significant behavioral implications may hopefully stimulate more human‐based studies into effects of PDE on long‐term developmental outcomes.

Buprenorphine-naloxone use in pregnancy: a systematic review and metaanalysis

OBJECTIVE

The goal of this systematic review and metaanalysis is to compare pregnancy outcomes between pregnant women undergoing treatment for opioid use disorder with buprenorphine-naloxone and those undergoing treatment for opioid use disorder with other forms of medication-assisted treatment.

STUDY DESIGN

PubMed, Embase, PsycINFO, Cochrane Clinical Trials, and Web of Science were searched to identify studies assessing the relationship between maternal buprenorphine-naloxone use and pregnancy outcomes. Outcomes assessed included neonatal abstinence syndrome diagnosis and treatment, neonatal intensive care unit admission, length of neonatal hospital stay, delivery complications, mode of delivery, labor analgesia, illicit drug use, medication-assisted treatment dosage, gestational age at delivery, breastfeeding status, miscarriage, congenital anomalies, intrauterine fetal demise, birthweight, head circumference, length, and Apgar scores.

RESULTS

Overall, 5 studies comprising 6 study groups met the inclusion criteria. Of the 1875 mother-baby dyads available for analysis, medications prescribed as part of the medication-assisted treatment included buprenorphine-naloxone, buprenorphine alone, methadone, or long-acting opioids. There were no serious adverse maternal or neonatal outcomes associated with maternal buprenorphine-naloxone use reported among any of the studies. Women prescribed with buprenorphine-naloxone for delivered neonates who were less likely to require treatment for neonatal abstinence syndrome were compared with pregnant women prescribed with other opioid agonist medications. Of the remaining outcomes assessed, metaanalysis did not detect any statistically significant differences when comparing the groups of women using buprenorphine-naloxone with the groups of women prescribed with other medications as part of the medication-assisted treatment.

CONCLUSION

Pregnant women undergoing treatment for opioid use disorder with buprenorphine-naloxone do not experience significantly different pregnancy outcomes than women undergoing treatment with other forms of opioid agonist medication-assisted therapy.

Methadone for Opioid Use Treatment during Pregnancy: Trends in Postpartum Dose Adjustments

Objective  This study examines methadone dose adjustment postpartum. Methods  A retrospective study of women with methadone for opioid use treatment (OUT) during pregnancy was performed. Patient charts were reviewed and data were extracted. Methadone doses from five temporal data points for each patient were used: starting dose, day of delivery, and 1, 2, and 6 months postpartum. Results  Over 26 months, 49 pregnancies to women using methadone for OUT were evaluated and 20 (41%) were included. The mean methadone starting dose was 47 mg, compared with 86 mg at the time of delivery. The mean dose postpartum remained unchanged from delivery and 75% of pregnancies required the same dose or higher 1 month postpartum. By 2 months postpartum, only 33% were able to decrease their methadone dose. Twelve pregnancies completed follow-up until 6 months postpartum; only 17% of patients were able to decrease their dose, with an overall mean dose decrease was 12%. There was no difference between the mean dose at delivery and the 6-month postpartum dose. Conclusion  Patients using methadone for OUT during pregnancy achieved minimal dose decreases postpartum. Patients should be counseled that postpartum dose tapers may be challenging and about alternatives to methadone for OUT.

Opioid use disorder among pregnant women in the 2000-2014 North Carolina state inpatient database

Background: The opioid epidemic's impact reached an increasing portion of the United States population, including pregnant women.Objectives: We sought to determine the prevalence and factors associated with opioid use disorders during pregnancy in North Carolina.Study Design: Using North Carolina's State Inpatient Sample, a retrospective study was conducted to identify pregnancy-related discharges between 2000 and 2014. Hospital discharge records associated with ICD-9-CM diagnoses codes for the use of opioids for all eligible pregnancy-related discharges were extracted. Logistic regression models were used to estimate unadjusted and adjusted bivariate and multivariate relationships.Results: Of 1,937,455 pregnancy-related hospitalization in North Carolina, 6,084 were associated with opioid use, a prevalence of 3.14 cases per 1,000 discharge. Maternal opioid use was associated with an increased odds of early onset delivery, threatened preterm labor, premature rupture of membranes, postpartum depression, stillbirth and poor fetal growth. Women who used opioids during pregnancy had prolonged hospital stays (>5 days) and were 2 times as likely to have more than 4 procedures performed during hospitalization. Compared to other racial groups, non-Hispanic whites had a notably higher prevalence of opioid use disorders (5.8/1,000 pregnancy-related discharges) (P < 0.05 for all).Conclusions: Very few health issues have garnered the attention of such diverse sectors of our society as the opioid epidemic. As the first state-level analysis of opioid use disorders among delivery hospitalizations, these findings suggest the need for a system-wide public health response such as improved funding for Medicaid and child welfare systems to improve the health of the opioid-exposed mother-infant dyad.

Methadone, Pierre Robin sequence and other congenital anomalies: case-control study

OBJECTIVE

Methadone is a vital treatment for women with opioid use disorder in pregnancy. Previous reports suggested an association between methadone exposure and Pierre Robin sequence (PRS), a rare craniofacial anomaly. We assessed the association between gestational methadone exposure and PRS.

DESIGN/SETTING

This case-malformed control study used European Surveillance of Congenital Anomalies population-based registries in Ireland, the Netherlands, Italy, Switzerland, Croatia, Malta, Portugal, Germany, Wales, Norway and Spain, 1995-2011.

PATIENTS

Cases included PRS based on International Classification of Disease (ICD), Ninth Edition-British Paediatric Association (BPA) code 75 603 or ICD, Tenth Edition-BPA code Q8708. Malformed controls were all non-PRS anomalies, excluding genetic conditions, among live births, fetal deaths from 20 weeks' gestation and terminations of pregnancy for fetal anomalies. An exploratory analysis assessed the association between methadone exposure and other congenital anomalies (CAs) excluding PRS. Methadone exposure was ascertained from medical records and maternal interview.

RESULTS

Among 87 979 CA registrations, there were 127 methadone-exposed pregnancies and 336 PRS cases. There was an association between methadone exposure and PRS (OR adjusted for registry 12.3, 95% CI 5.7 to 26.8). In absolute terms, this association reflects a risk increase from approximately 1-12 cases per 10 000 births. A raised OR was found for cleft palate (adjusted OR 5.0, 95% CI 2.7 to 9.2).

CONCLUSIONS

These findings suggest that gestational methadone exposure is associated with PRS. The association may be explained by unmeasured confounding factors. The small increased risk of PRS in itself does not alter the risk-benefit balance for gestational methadone use. The association with cleft palate, a more common CA, should be assessed with independent data.

Initial Management of Incarcerated Pregnant Women With Opioid Use Disorder

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.

Factors associated with treatment retention in pregnant women with opioid use disorders prescribed methadone or electing non-pharmacological treatment

Opioid use during pregnancy is rising, with an estimated 14-22% of women obtaining an opioid prescription during pregnancy. Methadone maintenance therapy (MMT) has been the gold standard for treatment of opioid use disorders during pregnancy; however, its use is limited in clinical practice due to availability, stigma, and reluctance on the part of clinicians. The present study compared against medical advice (AMA) treatment dropout from seven days of residential care between pregnant women diagnosed with opioid dependence who elected either MMT (n = 119) or non-pharmacological treatment (NPT) (n = 91) within the same treatment program in Baltimore, Maryland from 1996 to 1998. Multiple logistic regression analysis was conducted to compare the rate of AMA drop out between the two modalities. Patients who elected NPT were 2.77 times as likely to leave residential treatment as patients who elected MMT (adjusted odds ratio [OR = 2.77, 95% confidence interval [CI]: 1.23-6.17]. AMA was associated with interviewer-assessed drug severity and patient's rating of the importance of psychiatric treatment. The present findings further support the clinical utility of MMT and suggest that policies that facilitate the implementation of MMT in clinical practice would be beneficial to the engagement and retention of pregnant women with opioid use disorders.

Delivery dose of methadone, but not buprenorphine, is associated with the risk and severity of neonatal opiate withdrawal syndrome

BACKGROUND

Data on the relationship between the dose of opioid replacement therapy in pregnancy and the risk and severity of neonatal opioid withdrawal syndrome are conflicting and have methodological limitations.

OBJECTIVE

To assess the association of methadone and buprenorphine dose at delivery with neonatal opioid withdrawal syndrome in a large cohort.

STUDY DESIGN

We performed a retrospective cohort study using data from a comprehensive perinatal opioid dependency program from 2000 through 2016. Women with a history of opioid use disorder enrolled in a medication-assisted treatment program were included. Strict neonatal opioid withdrawal syndrome case definition and neonatal treatment guidelines were utilized throughout the study epoch. Comparisons were made between women on methadone and buprenorphine. The dose of opioid replacement at delivery and the risk and severity of neonatal opioid withdrawal syndrome were assessed with univariable analysis and multivariable logistic regression. In all analyses, methadone and buprenorphine dosing were evaluated as a continuous variable.

RESULTS

Four hundred eighty two of 709 women (68.0%) met inclusion criteria including 344 on methadone (71.4%) and 138 on buprenorphine (28.6%). Nonopioid polysubstance abuse, body mass index, medication-assisted treatment compliance, birthweight, and other characteristics were similar between groups. Overall, the frequency of neonatal opioid withdrawal syndrome was not significantly different between the methadone and buprenorphine groups (56.8% vs 52.0%, P = .35). Dose at delivery ranged at 0-165 mg for methadone and 0-30 mg for buprenorphine. In a univariable analysis, methadone dose at delivery was associated with neonatal opioid withdrawal syndrome (83.0 ± 34.2 mg vs 71.9 ± 35.8 mg for neonatal opioid withdrawal syndrome vs nonneonatal opioid withdrawal syndrome neonates, P < .001), but buprenorphine dose at delivery was not (8.4 ± 4.4 vs 7.6 ± 4.8 mg for neonatal opioid withdrawal syndrome vs nonneonatal opioid withdrawal syndrome neonates, P = .30). Peak neonatal opioid withdrawal syndrome score, duration of neonatal opioid withdrawal syndrome treatment, and cumulative neonatal morphine exposure were significantly associated with delivery methadone dose but not buprenorphine dose. The association between delivery methadone dose and neonatal opioid withdrawal syndrome persisted in multivariable regression.

CONCLUSION

The dose of methadone at the time of delivery is associated with the frequency and severity of neonatal opioid withdrawal syndrome, with higher doses associated with more severe neonatal opioid withdrawal syndrome when analyzed continuously. These data may inform future prospective studies on methadone dosing in pregnancy. While medication-assisted treatment agent and dose may have an impact on pertinent neonatal outcomes related to neonatal opioid withdrawal syndrome, the provision of medication-assisted treatment in pregnancy should reflect the goal of prevention of recidivism and maternal mortality and utilize an approach that balances fetal and maternal risk to optimize outcomes.

Opioid use disorder in pregnancy

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.

Prenatal exposure to opioid maintenance treatment and neonatal outcomes: Nationwide registry studies from the Czech Republic and Norway

There is lack of knowledge about the safety of treatment with methadone and buprenorphine as part of opioid maintenance treatment (OMT) during pregnancy. The purpose of this study was to examine neonatal outcomes concerning the use of OMT during pregnancy. We used nationwide registry linkages from the Czech Republic (2000-2014) and Norway (2004-2013). We compared prenatally OMT-exposed newborns with (a) newborns of women hospitalized with opioid use disorder during pregnancy in the Czech sample and (b) newborns with neonatal abstinence syndrome (NAS) in Norway. We performed multivariate linear and binary logistic regression exploring the associations between OMT and neonatal outcomes (growth parameters, gestational age, fetal death, small for gestational age, Apgar score, and NAS). Regression coefficients (b) and odds ratios (ORs) were estimated. The cohorts consisted of 333 Czech, and 235 Norwegian OMT-exposed newborns, and 106 and 294 newborns in the comparison groups, respectively. In both countries, the neonatal growth parameters were similar in the OMT and the comparison groups. In Norway, OMT exposure prolonged gestational age (adjusted b = 0.96 weeks, 95% confidence interval [CI] =0.39-1.53) while the odds of preterm birth and Apgar score at 5 minutes were lower than in the comparison group (adjusted OR = 0.35, 0.16-0.75 and aOR = 0.21, 0.06-0.78, respectively). Newborns of women in OMT had similar growth parameters as newborns of women with opioid use disorders who were not in OMT during pregnancy. Overall, our findings do not suggest that OMT results in worse neonatal outcomes.

Early postpartum resting-state functional connectivity for mothers receiving buprenorphine treatment for opioid use disorder: A pilot study

Between 1999 and 2014, the prevalence of opioid use disorder (OUD) among pregnant women quadrupled in the USA. The standard treatment for peripartum women with OUD is buprenorphine. However, the maternal behavior neurocircuit that regulates maternal behavior and mother-infant bonding has not been previously studied for human mothers receiving buprenorphine treatment for OUD (BT). Rodent research shows opioid effects on reciprocal inhibition between maternal care and defence maternal brain subsystems: the hypothalamus and periaqueductal gray, respectively. We conducted a longitudinal functional magnetic resonance imaging (fMRI) pilot study in humans to specifically examine resting-state functional connectivity (rs-FC) between the periaqueductal gray and hypothalamus, as well as to explore associations with maternal bonding for BT. We studied 32 mothers who completed fMRI scans at 1 month (T1) and 4 months postpartum (T2), including seven mothers receiving buprenorphine for OUD and 25 non-OUD mothers as a comparison group (CG). The participants underwent a 6-minute resting-state fMRI scan at each time point. We measured potential bonding impairments using the Postpartum Bonding Questionnaire to explore how rs-FC with periaqueductal gray is associated with bonding impairments. Compared to CG, BT mothers differed in periaqueductal gray-dependent rs-FC with the hypothalamus, amygdala, insular cortex and other brain regions at T1, with many of these differences disappearing at T2, suggesting potential therapeutic effects of continuing buprenorphine treatment. In contrast, the "rejection and pathological anger" subscale of the Postpartum Bonding Questionnaire at T1 and T2 was associated with the T1-to-T2 increases in periaqueductal gray-dependent rs-FC with the hypothalamus and amygdala. Preliminary evidence links maternal bonding problems for mothers with OUD early in the postpartum to connectivity between specific care and defence maternal brain circuits, which may be mitigated by buprenorphine treatment. This exploratory study supports a potential mechanism for investigating both the therapeutic benefits and risks of opioids for maternal care and bonding with infants.

Analgesia, Opioids, and Other Drug Use During Pregnancy and Neonatal Abstinence Syndrome

When opioid misuse rises in the United States, pregnant women and their neonates are affected. This article summarizes the use of Food and Drug Administration-approved products, including methadone, buprenorphine, and the combination formulation of buprenorphine and naloxone to treat adult opioid use disorder during the perinatal period. All labels include pregnancy, neonatal, and lactation information and note the accepted use of these medications during the perinatal period if the benefits outweigh the risks. A summary of the neonatal abstinence syndrome definition, its assessment tools, treatment approaches, and future genetic directions are provided.

Association of Criminal Statutes for Opioid Use Disorder With Prevalence and Treatment Among Pregnant Women With Commercial Insurance in the United States

IMPORTANCE

Inadequate treatment of opioid use disorder (OUD) in pregnant women increases the risk of life-threatening consequences on maternal and fetal outcomes. Untreated OUD during pregnancy is associated with higher rates of adverse outcomes among newborns.

OBJECTIVE

To examine the variation in the prevalence of OUD and the use of medication-assisted treatment among commercially insured pregnant women according to region and state legislature.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study in which the patient cohort used was derived from a 10% random sample of enrollees within the IQVIA PharMetrics Plus adjudicated claims and enrollment database from 2007 to 2015. The database consists of a 10% random sample of private health insurance recipients in the United States and contains claims and enrollment data that are representative of the commercially insured US population. The cohort comprised women (n = 110 285) between 18 and 45 years of age with a code indicating a delivery and continuous insurance enrollment 9 months before and 12 months after delivery. Data analysis was performed from December 2017 to May 2018.

EXPOSURES

Based on their state of residence, the women were classified into 4 different regions: South, Midwest, West, and Northeast. Those residing in states with statutes that imposed civil or criminal penalties for OUD diagnosis during pregnancy were placed in a separate population from those residing in states without these statutes.

MAIN OUTCOMES AND MEASURES

Diagnosis of OUD in the 9 months before delivery and the receipt of medication-assisted treatment in the 9 months before or 12 months after delivery.

RESULTS

The 110 285 pregnant women included in the analysis had a mean (SD) age of 30.26 (5.59) years, with most (67 771 [61.5%]) falling within the 26- to 35-year age range. Of this cohort, 277 women (0.25%) had a diagnosis of OUD and 312 (0.28%) received treatment. Among the 277 women with OUD, 127 (45.9%) received treatment. The prevalence of an OUD diagnosis and receipt of treatment within regions was statistically significant (OUD diagnosis by region: Midwest, 0.05%; North, 0.09%; South, 0.06%; West, 0.06%; χ23 = 45.1148 [P < .001]; OUD treatment by region: Midwest, 0.05%; North, 0.08%; South, 0.10%; West, 0.05%; χ23 = 26.5654 [P < .001]). The prevalence of OUD diagnosis was also statistically significant when comparing women residing in states with statutes with those in states without statutes (OUD diagnosis by criminal statutes: criminalization, 0.07%; no criminalization, 0.18%; χ21 = 14.6456 [P < .001]; OUD treatment by criminal statutes: criminalization, 0.12%; no criminalization, 0.17%; χ21 = 0.0895); the receipt of treatment was not statistically significant (P = .76).

CONCLUSIONS AND RELEVANCE

These results appeared to show significant variations in the patterns of OUD diagnosis and receipt of medication-assisted treatment among pregnant women, suggesting the need to further explore the source of these variations.

Association between prenatal opioid exposure, neonatal opioid withdrawal syndrome, and neurodevelopmental and behavioral outcomes at 5-8 months of age

BACKGROUND

While use of prescription opioids and medication assisted therapy (MAT) for opioid use disorder in pregnancy, as well as the incidence of neonatal opioid withdrawal syndrome (NOWS) continue to rise, little is known about outcomes for children with NOWS beyond the newborn period.

METHODS

We examined 1) prenatal MAT exposure vs. unexposed healthy controls [HC]; and 2) treatment for NOWS and NOWS severity on infant neurodevelopmental and behavioral outcomes at 5-8 months of age in 78 maternal-infant pairs from the ENRICH prospective cohort study. Data were obtained from 3 study visits: prenatal, delivery, and neurodevelopmental evaluation at 5-8 months of age. Neurodevelopmental outcomes included the Bayley Scales of Infant Development [BSID-III], caregiver questionnaires (Parenting Stress Index [PSI-SF], Infant Behavior Questionnaire [IBQ-R], Sensory Profile), and the experimental Still-Face Paradigm (SFP).

RESULTS

No differences in the BSID-III, PSI-SF, or IBQ-R scores were observed between MAT and HC groups; however, MAT-exposed and HC infants differed with respect to SFP self-regulation (β = -18.9; p = 0.01) and Sensory Profile sensation seeking (OR = 4.87; 95% CI: 1.55; 15.30) after adjusting for covariates. No significant differences between Treated-for-NOWS vs. not-Treated-for-NOWS were observed. Shorter timing to NOWS treatment initiation was associated with higher Total Stress (β = -9.08; p = 0.035), while longer hospitalization was associated with higher Parent-child dysfunctional interaction (p = 0.018) on PSI-SF.

CONCLUSIONS

Our results provide additional evidence of little-to-no effect of MAT and pharmacological treatment of NOWS on infant neurodevelopmental and behavioral outcomes at 5-8 months of age. However, prolonged hospitalization might increase family psychosocial stress and requires further examination.

Neonatal abstinence syndrome

Neonatal abstinence syndrome refers to the signs and symptoms attributed to the cessation of prenatal exposure (via placental transfer) to various substances. This Primer focuses on neonatal abstinence syndrome caused by opioid use during pregnancy - neonatal opioid withdrawal syndrome (NOWS). As the global prevalence of opioid use has alarmingly increased, so has the incidence of NOWS. NOWS can manifest with varying severity or not at all, for unknown reasons, but is likely to be associated with multiple factors, both maternal (for example, smoking and additional substance exposures) and neonatal (gestational age, sex and genetics). Care for the infant with NOWS begins with addressing the issues experienced by pregnant women with opioid use disorder. Co-occurring mental illness, economic hardship, intimate partner violence, infectious diseases and limited access to care are common in these women and can result in poor maternal and neonatal outcomes. Although there is no consensus regarding optimal NOWS management, non-pharmacological interventions (such as breastfeeding and rooming-in of the mother and the baby) have become a priority, as they can ameliorate symptoms without the need for further opioid exposure. Untreated NOWS can be associated with morbidity in early infancy, and the long-term consequences of fetal opioid exposure are only beginning to be understood.

Do Pregnant Inmates have a Constitutional Right to Opioid Replacement Therapy?

Changes in the national drug laws have resulted in a marked increase in the number of individuals who have been incarcerated in the United States over the past several decades; women have not been exempt from this trend. Incarcerated women who are pregnant and at risk of experiencing opioid withdrawal often lack access to opioid replacement therapy while in jails and prisons, although this treatment is necessary to prevent significant acute withdrawal that can be detrimental to maternal-fetal health. I contend that pregnant inmates who are at risk of experiencing opioid withdrawal possess a constitutional right to receive opioid replacement therapy while incarcerated and that failure to provide this treatment represents a violation of the Eighth Amendment's protection against cruel and unusual punishment.

Opium use during pregnancy and infant size at birth: a cohort study

BACKGROUND

The reported positive association between opiatic drug use during pregnancy and adverse pregnancy outcomes might be confounded by other factors related to high-risk behaviors, including the use of other harmful substances. In rural areas of Iran, opium use during pregnancy is relatively common among women who otherwise do not have a hazardous lifestyle, which reduces the risk of residual confounding and increasing the possibility to identify its effects. We aimed to examine the association of antenatal exposure to opium with risks of small for gestational age, short birth length, and small head circumference at birth.

METHOD

In this cohort study in the rural area of the Golestan province, Iran, we randomly selected 920 women who were exposed to opium during pregnancy and 920 unexposed women during 2008-2010. Log-binomial regression was used to estimate risk ratios (RR) and 95% confidence intervals (CI) for the associations between prenatal exposure to opium and risks of small for gestational age, short birth length, and small head circumference at birth.

RESULTS

Compared with non-use of opium and tobacco during pregnancy, using opium only and dual use of opium and tobacco were associated with increased risks of small for gestational age at births (RR = 1.71; 95% CI 1.34-2.18 and RR = 1.62; 95% CI 1.13-2.30, respectively). Compared with non-use of opium and tobacco, exposure to only opium or dual use of opium and tobacco were also associated with more than doubled increased risks of short birth length, and small head circumference in term infants.

CONCLUSION

Maternal opium use during pregnancy is associated with increased risks of giving birth to a small for gestational age infant, as well as a term infant with short birth length or small head circumference.

COGNITIVE AND SOCIOEMOTIONAL FUNCTIONING AT 4½ YEARS IN CHILDREN BORN TO MOTHERS WHO HAVE RECEIVED TREATMENT FOR SUBSTANCE-ABUSE PROBLEMS WHILE PREGNANT

Cognitive and socioemotional functioning at 4½ years of age were examined in children born to mothers with substance-abuse problems (n = 22) recruited from residential treatment institutions while pregnant, and then compared to children born to mothers with mental health problems (n = 18) and children from a low-risk group (n = 26). No significant group differences in cognitive functioning were found, but the children born to mothers with substance-abuse problems showed more caregiver-reported socioemotional problems than did the low-risk children, like the children born to mothers with mental health problems. Birth weight had an effect on internalizing problems at 4½ years and mediated the relation between group and socioemotional problems, although not when controlling for caregiver education, single parenthood, and anxiety and depression. At 4½ years, 7 children born to mothers with substance-abuse problems were placed in foster care. These children had lower birth weight and higher caregiver-rated internalizing problems. In addition to emphasizing the importance of the quality of the prenatal environment, this study suggests that families with previous substance abuse are in need of long-term follow-up to address socioemotional problems and enhance further positive child cognitive development. The foster-placed children may be in particular need of long-term follow-up.

Trends and disparities in receipt of pharmacotherapy among pregnant women in publically funded treatment programs for opioid use disorder in the United States

OBJECTIVE

To describe differences in geographic, demographic, treatment, and substance use characteristics by pharmacotherapy receipt among pregnant women entering publically funded treatment for opioid use disorder (OUD) in the United States.

METHODS

1996 to 2014 Treatment Episode Data Set-Admissions data from pregnant admissions with OUD, defined as reporting opioids as the primary substance of use leading to the treatment episode, were analyzed for this cross-sectional study. The proportion of all pregnant admissions with OUD who received pharmacotherapy was calculated by year and U.S. census region. Trends across time were assessed using the Cochrane-Armitage Trend test. Associations between demographic, substance use, and treatment characteristics and pharmacotherapy receipt were assessed using Chi-square tests and multivariable logistic regression.

RESULTS

The proportion of pregnant admissions where opioids were the primary substance of use increased from 16.9% to 41.6% during the study period, while the proportion of pregnant admissions with OUD who received pharmacotherapy remained relatively unchanged at around 50%. Overall, pharmacotherapy recipients were generally older and white, more likely to receive treatment in an outpatient setting, be self-referred, and report heroin as the primary substance, daily substance use, and intravenous drug use, and less likely to have a co-occurring psychiatric problem compared to those who did not receive pharmacotherapy. Regional differences in pharmacotherapy utilization exist; the South consistently had the fewest pregnant admissions with OUD receiving pharmacotherapy.

CONCLUSION

Although the proportion of pregnant admissions to substance use treatment centers with OUD has increased since the mid-1990s, the proportion receiving pharmacotherapy has not changed. Significant variations in pharmacotherapy utilization exist by geography and demographic, substance use and treatment characteristics. Utilization of pharmacotherapy at publically funded treatment centers providing care for pregnant women with OUD should be expanded.

Prenatal exposure to methadone or buprenorphine: Early childhood developmental outcomes

BACKGROUND

Methadone and buprenorphine are recommended to treat opioid use disorders during pregnancy. However, the literature on the relationship between longer-term effects of prenatal exposure to these medications and childhood development is both spare and inconsistent.

METHODS

Participants were 96 children and their mothers who participated in MOTHER, a randomized controlled trial of opioid-agonist pharmacotherapy during pregnancy. The present study examined child growth parameters, cognition, language abilities, sensory processing, and temperament from 0 to 36 months of the child's life. Maternal perceptions of parenting stress, home environment, and addiction severity were also examined.

RESULTS

Tests of mean differences between children prenatally exposed to methadone vs. buprenorphine over the three-year period yielded 2/37 significant findings for children. Similarly, tests of mean differences between children treated for NAS relative to those not treated for NAS yielded 1/37 significant finding. Changes over time occurred for 27/37 child outcomes including expected child increases in weight, head and height, and overall gains in cognitive development, language abilities, sensory processing, and temperament. For mothers, significant changes over time in parenting stress (9/17 scales) suggested increasing difficulties with their children, notably seen in increasing parenting stress, but also an increasingly enriched home environment (4/7 scales) CONCLUSIONS: Findings strongly suggest no deleterious effects of buprenorphine relative to methadone or of treatment for NAS severity relative to not-treated for NAS on growth, cognitive development, language abilities, sensory processing, and temperament. Moreover, findings suggest that prenatal opioid agonist exposure is not deleterious to normal physical and mental development.

The Impact of Early Substance Use Disorder Treatment Response on Treatment Outcomes Among Pregnant Women With Primary Opioid Use

OBJECTIVES

This study examined the impact of early patient response on treatment utilization and substance use among pregnant participants enrolled in substance use disorder (SUD) treatment.

METHODS

Treatment responders (TRs) and treatment nonresponders (TNRs) were compared on pretreatment and treatment measures. Regression models predicted treatment utilization and substance use.

RESULTS

TR participants attended more treatment and had lower rates of substance use relative to TNR participants. Regression models for treatment utilization and substance use were significant. Maternal estimated gestational age (EGA) and baseline cocaine use were negatively associated with treatment attendance. Medication-assisted treatment, early treatment response, and baseline SUD treatment were positively associated with treatment attendance. Maternal EGA was negatively associated with counseling attendance; early treatment response was positively associated with counseling attendance. Predictors of any substance use at 1 month were maternal education, EGA, early treatment nonresponse, and baseline cocaine use. The single predictor of any substance use at 2 months was early treatment nonresponse. Predictors of opioid use at 1 month were maternal education, EGA, early treatment nonresponse, and baseline SUD treatment. Predictors of opioid use at 2 months were early treatment nonresponse, and baseline cocaine and marijuana use. Predictors of cocaine use at 1 month were early treatment nonresponse, baseline cocaine use, and baseline SUD treatment. Predictors of cocaine use at 2 months were early treatment nonresponse and baseline cocaine use.

CONCLUSIONS

Early treatment response predicts more favorable maternal treatment utilization and substance use outcomes. Treatment providers should implement interventions to maximize patient early response to treatment.

Prenatal buprenorphine exposure and neonatal neurobehavioral functioning

AIMS

Assessments of effects of prenatal opioid exposure on the neonate have consisted principally of evaluations of neonatal abstinence syndrome (NAS) to determine the need for pharmacotherapy. The purpose of this study was to comprehensively evaluate the effects of gestational maternal buprenorphine maintenance on newborn neurobehavioral functioning.

STUDY DESIGN

Maternal substance use history and psychosocial demographics that can contribute to the neurobehavioral functioning of the infant were explored. Infants were assessed using the NICU Network Neurobehavioral Scale (NNNS) to measure their neurologic and behavioral functioning and signs of stress/abstinence on days 3, 14 and 30 of life.

SUBJECTS

Participants were 41 pregnant buprenorphine-maintained women and their infants.

RESULTS

Maternal buprenorphine dose at delivery was negatively correlated with infant quality of movement and self-regulation, and positively correlated with the central nervous system parameters of stress/abstinence at day 3 of life. As maternal buprenorphine dose increased, the mean morphine dose that the infant required for NAS treatment significantly increased. No differences were found when comparing the NNNS domain scores between infants who required pharmacotherapy for NAS versus those who did not at day 3 of life.

CONCLUSIONS

Buprenorphine exposure during pregnancy can alter neonatal neurobehavioral and physiological responses to stimuli. A systematic evaluation of the newborn's functional domains above NAS assessment alone is crucial to address the challenges created by neurobehavioral dysregulation associated with substance exposure, improve caregiver/infant interaction and developmental trajectory. Comprehensive pre/postnatal treatment of buprenorphine-maintained mothers can lead to healthier outcomes for the dyad.

Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance

OBJECTIVES

The prevalence of opioid use disorder (OUD) during pregnancy is increasing. Practical recommendations will help providers treat pregnant women with OUD and reduce potentially negative health consequences for mother, fetus, and child. This article summarizes the literature review conducted using the RAND/University of California, Los Angeles Appropriateness Method project completed by the US Department of Health and Human Services Substance Abuse and Mental Health Services Administration to obtain current evidence on treatment approaches for pregnant and parenting women with OUD and their infants and children.

METHODS

Three separate search methods were employed to identify peer-reviewed journal articles providing evidence on treatment methods for women with OUD who are pregnant or parenting, and for their children. Identified articles were reviewed for inclusion per study guidelines and relevant information was abstracted and summarized.

RESULTS

Of the 1697 articles identified, 75 were included in the literature review. The perinatal use of medication for addiction treatment (MAT, also known as medication-assisted treatment), either methadone or buprenorphine, within comprehensive treatment is the most accepted clinical practice, as withdrawal or detoxification risks relapse and treatment dropout. Medication increases may be needed with advancing pregnancy, and are not associated with more severe neonatal abstinence syndrome (NAS). Switching medication prenatally is usually not recommended as it can destabilize opioid abstinence. Postnatally, breastfeeding is seen as beneficial for the infant for women who are maintained on a stable dose of opioid agonist medication. Less is known about ideal pain management and postpartum dosing regimens. NAS appears generally less severe following prenatal exposure to buprenorphine versus methadone. Frontline NAS medication treatments include protocol-driven methadone and morphine dosing in the context of nonpharmacological supports.

CONCLUSIONS

Women with OUD can be treated with methadone or buprenorphine during pregnancy. NAS is an expected and manageable condition. Although research has substantially advanced, opportunities to guide future research to improve maternal and infant outcomes are provided.

Management of drug misuse in pregnancy

Use of both licit and illicit drugs can lead to a range of medical, psychiatric and social problems, and the situation becomes further complicated if the user is pregnant. Prescribed and non-prescribed substances can affect a pregnancy, and substances are seldom used in isolation. In this review we focus on users of illicit drugs (including prescribed drugs used illicitly) during pregnancy and describe some of the issues in managing such cases. We consider the impact of subtance use on the foetus, the mother and the newborn child, and highlight the importance of multidisciplinary working in this area. Space precludes a detailed account of the issues surrounding the use of legal substances such as alcohol and tobacco during pregnancy, but we note their significant impact in this group.

Medicaid Coverage of Methadone Maintenance and the Use of Opioid Agonist Therapy Among Pregnant Women in Specialty Treatment

BACKGROUND

Opioid agonist therapy (OAT) is the standard of care for pregnant women with opioid use disorder (OUD). Medicaid coverage policies may strongly influence OAT use in this group.

OBJECTIVE

To examine the association between Medicaid coverage of methadone maintenance and planned use of OAT in the publicly funded treatment system.

RESEARCH DESIGN

Retrospective cross-sectional analysis of treatment admissions in 30 states extracted from the Treatment Episode Data Set (2013 and 2014).

SUBJECTS

Medicaid-insured pregnant women with OUD (n=3354 treatment admissions).

MEASURES

The main outcome measure was planned use of OAT on admission. The main exposure was state Medicaid coverage of methadone maintenance. Using multivariable logistic regression models adjusting for sociodemographic, substance use, and treatment characteristics, we compared the probability of planned OAT use in states with Medicaid coverage of methadone maintenance versus states without coverage.

RESULTS

A total of 71% of pregnant women admitted to OUD treatment were 18-29 years old, 85% were white non-Hispanic, and 56% used heroin. Overall, 74% of admissions occurred in the 18 states with Medicaid coverage of methadone maintenance and 53% of admissions involved planned use of OAT. Compared with states without Medicaid coverage of methadone maintenance, admissions in states with coverage were significantly more likely to involve planned OAT use (adjusted difference: 32.9 percentage points, 95% confidence interval, 19.2-46.7).

CONCLUSIONS

Including methadone maintenance in the Medicaid benefit is essential to increasing OAT among pregnant women with OUD and should be considered a key policy strategy to enhance outcomes for mothers and newborns.

Buprenorphine for Medication-Assisted Treatment of Opioid Use Disorder in Pregnancy: Relationship to Neonatal Opioid Withdrawal Syndrome

Objective  To examine the relationship between antepartum buprenorphine dose for medication-assisted treatment (MAT) of opioid use disorder (OUD) and incident neonatal opioid withdrawal syndrome (NOWS). Study Design  We performed a prospective cohort study of pregnant women with a singleton gestation diagnosed with OUD and receiving buprenorphine for MAT at a tertiary care academic institution from July 2015 to January 2017. We divided the study cohort into two groups-pregnancies with versus without NOWS. Substance abuse patterns in pregnancy, maternal, and neonatal clinical outcomes were compared. Results  The incidence of NOWS was 31.11% ( n  = 28/90) in our study cohort. Pregnancies with NOWS had a significantly higher rate of benzodiazepine positive urine tests and number of positive urine drug screen (UDS) results for illicit opioids. The group without NOWS had significantly higher number of patients with an appropriate UDS result at delivery through postpartum. Rates of neonatal intensive care unit (NICU) admission, length of NICU stay, and maximum Finnegan score were significantly higher in the group with NOWS. Neither the initial (10.6 ± 5.2 versus 10.3 ± 4.8 mg, p  = 0.80) nor the final buprenorphine doses (13.3 ± 5.1 versus 13.0 ± 4.6 mg, p  = 0.81) were significantly different between study groups. Conclusion  The occurrence of NOWS was not related to buprenorphine dose used for MAT.