Drugs of abuse in pregnancy

Prevalence of Illicit Drug Use During Pregnancy: A Global Perspective

The World Drug Report 2019 presented an alarming figure to the world: more than 5% of the world's population has been using some type of illicit drug, and that number is growing every year. While its use increases, its abuse during pregnancy has become a global public health problem, resulting in medical and social challenges related to maternal and child health. In this context, the objective of this review was to determine the prevalence of illicit drug use during gestation across the globe, alongside with a critical review of the evaluated studies. Research was performed by simultaneously searching terms ("pregnant woman OR pregnant" OR "gestation" OR "pregnancy" AND "illicit drugs" OR "street drugs") in the databases of the Scientific Electronic Library Online, PubMed, and Web of Science. Comparisons between studies were performed in software Statistica 10.0. The data presented worrying results in relation to the variation in prevalence of illicit drug use during pregnancy, when comparing studies based on interviews or questionnaires (self-reported) (1.65%) and studies based on toxicological analysis (12.28%). In addition, we emphasize the high prevalence (5.16%) of illicit drug use among adolescent pregnant women and the low number of studies on this population. This study reveals worrying data about pregnant drug-user population, mainly the underestimation of prevalence in studies that use only questionnaires or similar methods in comparison to studies that use toxicological analysis of biological matrices. This scenario reveals necessity for health systems in different countries to establish specific public health policies for this population.

Involvement of mTOR, JNK and PI3K in the negative effect of ethanol and metformin on the human first-trimester extravillous trophoblast HTR-8/SVneo cell line

Our aim was to investigate the effect of two xenobiotics to which pregnant woman may be exposed, the drug of abuse ethanol (EtOH) (and its metabolite acetaldehyde (ACA)) and the therapeutic agent metformin (METF), on placentation-related processes in an extravillous trophoblastic (EVTs) cell line (HTR-8/SVneo cells). EtOH, ACA and METF (24 h) significantly reduced cell proliferation rates, culture growth, viability and migratory capacity of HTR-8/SVneo cells. Moreover, both EtOH (100 μM) and METF (1 mM) increased the apoptosis index and inhibited ³H-deoxy-D-glucose (³H-DG) and ³H-folic acid (³H-FA) uptake. mTOR, JNK and PI3K intracellular signaling pathways were involved in the effect of EtOH upon ³H-FA uptake and in the effect of METF upon cell viability, and mTOR and JNK in the effect of EtOH upon cell viability and ³H-DG uptake. We show that EtOH and METF have a detrimental effect in placentation-related processes of HTR-8/SVneo cells. Moreover, mTOR, JNK and PI3K appear to mediate some of these negative effects.

The Prevalence and Impact of Substance Use Disorder and Treatment on Maternal Obstetric Experiences and Birth Outcomes Among Singleton Deliveries in Massachusetts

Objectives Despite widely-known negative effects of substance use disorders (SUD) on women, children, and society, knowledge about population-based prevalence and impact of SUD and SUD treatment during the perinatal period is limited. Methods Population-based data from 375,851 singleton deliveries in Massachusetts 2003-2007 were drawn from a maternal-infant longitudinally-linked statewide dataset of vital statistics, hospital discharges (including emergency department (ED) visits), and SUD treatment records. Maternal SUD and SUD treatment were identified from 1-year pre-conception through delivery. We determined (1) the prevalence of SUD and SUD treatment; (2) the association of SUD with women's perinatal health service utilization, obstetric experiences, and birth outcomes; and (3) the association of SUD treatment with birth outcomes, using both bivariate and adjusted analyses. Results 5.5% of Massachusetts's deliveries between 2003 and 2007 occurred in mothers with SUD, but only 66% of them received SUD treatment pre-delivery. Women with SUD were poorer, less educated and had more health problems; utilized less prenatal care but more antenatal ED visits and hospitalizations, and had worse obstetric and birth outcomes. In adjusted analyses, SUD was associated with higher risk of prematurity (AOR 1.35, 95% CI 1.28-1.41) and low birth weight (LBW) (AOR 1.73, 95% CI 1.64-1.82). Women receiving SUD treatment had lower odds of prematurity (AOR 0.61, 95% CI 0.55-0.68) and LBW (AOR 0.54, 95% CI 0.49-0.61). Conclusions for Practice SUD treatment may improve perinatal outcomes among pregnant women with SUD, but many who need treatment don't receive it. Longitudinally-linked existing public health and programmatic records provide opportunities for states to monitor SUD identification and treatment.

Refining Measurement of Substance Use Disorders Among Women of Child-Bearing Age Using Hospital Records: The Development of the Explicit-Mention Substance Abuse Need for Treatment in Women (EMSANT-W) Algorithm

Substance use disorder (SUD) in women of reproductive age is associated with adverse health consequences for both women and their offspring. US states need a feasible population-based, case-identification tool to generate better approximations of SUD prevalence, treatment use, and treatment outcomes among women. This article presents the development of the Explicit Mention Substance Abuse Need for Treatment in Women (EMSANT-W), a gender-tailored tool based upon existing International Classification of Diseases, 9th Edition, Clinical Modification diagnostic code-based groupers that can be applied to hospital administrative data. Gender-tailoring entailed the addition of codes related to infants, pregnancy, and prescription drug abuse, as well as the creation of inclusion/exclusion rules based on other conditions present in the diagnostic record. Among 1,728,027 women and associated infants who accessed hospital care from January 1, 2002 to December 31, 2008 in Massachusetts, EMSANT-W identified 103,059 women with probable SUD. EMSANT-W identified 4,116 women who were not identified by the widely used Clinical Classifications Software for Mental Health and Substance Abuse (CCS-MHSA) and did not capture 853 women identified by CCS-MHSA. Content and approach innovations in EMSANT-W address potential limitations of the Clinical Classifications Software, and create a methodologically sound, gender-tailored and feasible population-based tool for identifying women of reproductive age in need of further evaluation for SUD treatment. Rapid changes in health care service infrastructure, delivery systems and policies require tools such as the EMSANT-W that provide more precise identification methods for sub-populations and can serve as the foundation for analyses of treatment use and outcomes.

Pregnant and non-pregnant women with substance use disorders: the gap between treatment need and receipt

Differences in pregnant and non-pregnant women's alcohol and drug use, substance treatment need, and treatment receipt were examined using The National Survey of Drug Use and Health (2002-2006). Treatment need and receipt were defined by either self-report or DSM-IV criteria. Pregnant women were less likely to use alcohol and drugs than non-pregnant women. Among women who use drugs, pregnant women were more likely to need treatment (odds ratio (OR) = 1.92; 95% confidence interval (CI): 1.46, 2.52), however they were not more likely to receive treatment (OR = 0.90; 95% CI: 0.54, 1.51). Overall, there is an unmet need for treatment among reproductive-aged substance users.

Barriers to receiving substance abuse treatment among rural pregnant women in Kentucky

Research presenting outcomes for women who enter substance abuse treatment during pregnancy consistently shows benefits. While treatment has nearly universal benefits, there are many barriers to seeking substance abuse treatment for pregnant women. The purpose of this study is to explore barriers for rural pregnant women seeking substance abuse treatment. There were three eligibility criteria for study participation: (1) aged 18 and older, (2) pregnant, and (3) undergoing short-term inpatient detoxification at the University of Kentucky Chandler Medical Center. Eighty-five rural women (N = 85) were included in the analysis. Substance use history and previous treatment were assessed with measures adapted from the Addiction Severity Index. Treatment barriers were measured with three qualitative questions and were coded into four overarching categories: availability, accessibility, affordability, and acceptability barriers. This sample had an extensive substance use history. Almost all participants had used alcohol (98%), marijuana (98%), illicit opiates (99%), and cigarettes (97%). On average, participants reported about two barriers to receiving treatment (Mean = 1.8; SD = 1.3), with over 80% of the sample reporting having experienced any barrier to treatment. The majority experienced acceptability (51%) and accessibility (49%) barriers. Twenty-six percent (26%) of the sample reported availability barriers. A smaller percentage of participants reported affordability barriers (13%). Rural pregnant women seeking substance abuse treatment face many obstacles to receiving needed treatment. More studies on barriers to substance abuse treatment among rural pregnant women are needed. Identifying these barriers can help in improving treatment access and services.

Enhancement of tolerance development to morphine in rats prenatally exposed to morphine, methadone, and buprenorphine

Background

Abuse of addictive substances is a serious problem that has a significant impact on areas such as health, the economy, and public safety. Heroin use among young women of reproductive age has drawn much attention around the world. However, there is a lack of information on effects of prenatal exposure to opioids on their offspring. In this study, an animal model was established to study effects of prenatal exposure to opioids on offspring.

Methods

Female pregnant Sprague-Dawley rats were sub-grouped to receive (1) vehicle, (2) 2-4 mg/kg morphine (1 mg/kg increment per week), (3) 7 mg/kg methadone, and (4) 3 mg/kg buprenorphine, subcutaneously, once or twice a day from E3 to E20. The experiments were conducted on animals 8-12 weeks old and with body weight between 250 and 350 g.

Results

Results showed that prenatal exposure to buprenorphine caused higher mortality than other tested substance groups. Although we observed a significantly lower increase in body weight in all of the opioid-administered dams, the birth weight of the offspring was not altered in all treated groups. Moreover, no obvious behavioral abnormality or body-weight difference was noted during the growing period (8-12 weeks) in all offspring. When the male offspring received morphine injection twice a day for 4 days, the prenatally opioid-exposed rats more quickly developed a tolerance to morphine (as shown by the tail-flick tests), most notably the prenatally buprenorphine-exposed offspring. However, the tolerance development to methadone or buprenorphine was not different in offspring exposed prenatally to methadone or buprenorphine, respectively, when compared with that of the vehicle controlled group. Similar results were also obtained in the female animals.

Conclusions

Animals prenatally exposed to morphine, methadone, or buprenorphine developed tolerance to morphine faster than their controlled mates. In our animal model, prenatal exposure to buprenorphine also resulted in higher mortality and much less sensitivity to morphine-induced antinociception than prenatal exposure to morphine or methadone. This indicates that buprenorphine in higher doses may not be an ideal maintenance drug for treating pregnant women. This study provides a reference in selecting doses for clinical usage in treating pregnant heroin addicts.

Pharmacologic interventions for pregnant women enrolled in alcohol treatment

BACKGROUND

Excessive alcohol use during pregnancy has been associated with adverse maternal and neonatal effects. It is therefore important to develop and evaluate effective interventions during this important time in a woman's life. To our knowledge there have been no systematic reviews of randomised control trials (RCT) in this population.

OBJECTIVES

To evaluate the effectiveness of pharmacologic interventions in pregnant women enrolled in alcohol treatment programs for improving birth and neonatal outcomes, maternal abstinence and treatment retention.

SEARCH STRATEGY

We searched the Cochrane Drugs and Alcohol Group's Trial register (August 2008) ; MEDLINE (1.1950 to 6.2008) ; EMBASE (1.1974 - 8.2008); CINAHL (1.1982-6.2008); PsycInfo (1.1806-6.2008), and reference lists of articles.

SELECTION CRITERIA

We sought to include randomised or quasi-randomised studies comparing any pharmacologic intervention versus other pharmacologic treatment alone or in association with psychosocial treatment, placebo, non-intervention or psychosocial intervention.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion in the review. Included studies were to be assessed using standardized data extraction and quality assessment forms. No suitable trials were identified.

MAIN RESULTS

The search strategy identified 793 citations. Twenty-three citations were deemed relevant for full text review; an additional ten articles were retrieved through hand searching references, for a total of thirty-three articles. Following full text review no articles met the inclusion criteria. Data extraction and assessment of methodological quality were therefore not possible.

AUTHORS' CONCLUSIONS

The review question remains unanswered as there were no randomised control trials found relevant to the topic. There is a need for high quality research to determine the effectiveness of pharmacologic interventions in pregnant women enrolled in alcohol treatment program.

The impact of cocaine and heroin on the placental transfer of methadone

BACKGROUND

Methadone is the therapeutic agent of choice for the treatment of opiate addiction in pregnancy. The co-consumption (heroin, cocaine) which may influence the effects of methadone is frequent. Therefore, the impact of cocaine and heroin on the placental transfer of methadone and the placental tissue was investigated under in vitro conditions.

METHODS

Placentae (n = 24) were ex-vivo perfused with medium (m) (control, n = 6), m plus methadone (n = 6), m plus methadone and cocaine (n = 6) or m plus methadone and heroin (n = 6). Placental functionality parameters like antipyrine permeability, glucose consumption, lactate production, hormone production (hCG and leptin), microparticles release and the expression of P-glycoprotein were analysed.

RESULTS

Methadone accumulated in placental tissue. Methadone alone decreased the transfer of antipyrine from 0.60 +/- 0.07 to 0.50 +/- 0.06 (fetal/maternal ratio, mean +/- SD, P < 0.01), whereas the combination with cocaine or heroin increased it (0.56 +/- 0.08 to 0.68 +/- 0.13, P = 0.03 and 0.58 +/- 0.21 to 0.71 +/- 0.24; P = 0.18). Microparticles (MPs) released from syncytiotrophoblast into maternal circuit increased by 30% after cocaine or heroin (P < 0.05) and the expression of P-glycoprotein in the tissue increased by >or= 49% after any drug (P < 0.05). All other measured parameters did not show any significant effect when methadone was combined with cocaine or heroine.

CONCLUSION

The combination of cocaine or heroin with methadone increase antipyrine permeability. Changes of MPs resemble findings seen in oxidative stress of syncytiotrophoblast.

Psychosocial interventions for women enrolled in alcohol treatment during pregnancy

BACKGROUND

Excessive alcohol use during pregnancy has been associated with adverse maternal and neonatal effects. It is therefore important to develop and evaluate effective interventions during this important time in a woman's life. To our knowledge there have been no systematic reviews of randomised control trials (RCT) in this population.

OBJECTIVES

To evaluate the effectiveness of psychosocial interventions in pregnant women enrolled in alcohol treatment programs for improving birth and neonatal outcomes, maternal abstinence and treatment retention.

SEARCH STRATEGY

We searched the Cochrane Drugs and Alcohol Group's Trial register (December 2007); MEDLINE (1950 to 2007); PsycINFO (1806 to 2007); EMBASE (1974 to 2007); CINAHL (1982 to 2007)

SELECTION CRITERIA

We sought to include randomised or quasi-randomised studies comparing any psychosocial intervention versus pharmacological interventions or placebo or non-intervention or another psychosocial intervention for treating alcohol dependence in pregnancy.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion in review. Studies were to be assessed using standardized data extraction and quality assessment forms. No suitable trials were identified.

MAIN RESULTS

The search strategy identified 958 citations. 17 citations were deemed relevant for full text review, an additional 9 articles were retrieved through hand searching references, for a total of 26 articles. Following full text review no articles met the inclusion criteria. Data extraction and assessment of methodological quality were therefore not possible.

AUTHORS' CONCLUSIONS

The review question remains unanswered as there were no randomised control trials found relevant to the topic. There is a need for high quality randomised controlled trials to determine the effectiveness of psychosocial interventions in pregnant women enrolled in alcohol treatment programs.

The use of record linkage to examine illicit drug use in pregnancy

AIMS

To examine the obstetric and perinatal outcomes for women with a drug-related hospital admission during pregnancy.

DESIGN

Antenatal and birth admissions to New South Wales (NSW) hospitals from the NSW Inpatient Statistics Collection were linked to birth information from the NSW Midwives Data Collection over a 5-year period (1998-2002).

MEASUREMENTS

Birth admissions were flagged as positive for drug use where a birth admission or any pregnancy admission for that birth involved an opioid, cannabis or stimulant-related International Classification of Diseases version 10 Australian modification (ICD-10AM) code.

FINDINGS

A total of 416 834 live births were analysed over a 5-year period (1998-2002). Of these, 1974 pregnancies had an opioid ICD-10AM diagnosis recorded, 552 a stimulant-related ICD-10AM and 2172 a cannabis ICD-10AM diagnosis. Births in each of the drug groups were to women who were younger, had a higher number of previous pregnancies, were indigenous, smoked heavily and were not privately insured. These women also presented later in their pregnancy to antenatal services and were more likely to arrive at hospital unbooked. Neonates born to women in each of the drug groups were more likely to be premature and were admitted to neonatal intensive care and special care nursery more often, with neonates born to women in the opioid group admitted most often.

CONCLUSIONS

Linked population level administrative data is a powerful method for examining the maternal and neonatal outcomes associated with the use of specific illicit drugs during pregnancy.

Discrete opioid gene expression impairment in the human fetal brain associated with maternal marijuana use

Fetal development is a period sensitive to environmental influences such as maternal drug use. The most commonly used illicit drug by pregnant women is marijuana. The present study investigated the effects of in utero marijuana exposure on expression levels of opioid-related genes in the human fetal forebrain in light of the strong interaction between the cannabinoid and opioid systems. The study group consisted of 42 midgestation fetuses from saline-induced voluntary abortions. The opioid peptide precursors (preprodynorphin and preproenkephalin (PENK)) and receptor (mu, kappa and delta) mRNA expression were assessed in distinct brain regions. The effect of prenatal cannabis exposure was analyzed by multiple regression controlling for confounding variables (maternal alcohol and cigarette use, fetal age, sex, growth measure and post-mortem interval). Prenatal cannabis exposure was significantly associated with increased mu receptor expression in the amygdala, reduced kappa receptor mRNA in mediodorsal thalamic nucleus and reduced preproenkephalin expression in the caudal putamen. Prenatal alcohol exposure primarily influenced the kappa receptor mRNA with reduced levels in the amygdala, claustrum, putamen and insula cortex. No significant effect of prenatal nicotine exposure could be discerned in the present study group. These results indicate that maternal cannabis and alcohol exposure during pregnancy differentially impair opioid-related genes in distinct brain circuits that may have long-term effects on cognitive and emotional behaviors.

Substance use during pregnancy: risk factors and obstetric and perinatal outcomes in South Australia

OBJECTIVE

To determine the prevalence of self-reported substance use during pregnancy in South Australia, the characteristics of substance users, their obstetric outcomes and the perinatal outcomes of their babies.

METHODS

Multivariable logistic regression with STATA statistical software was undertaken using the South Australian perinatal data collection 1998-2002. An audit was conducted on every fifth case coded as substance use to identify the actual substances used.

RESULTS

Substance use was reported by women in 707 of 89 080 confinements (0.8%). Marijuana (38.9%), methadone (29.9%), amphetamines (14.6%) and heroin (12.5%) were most commonly reported, with polydrug use among 18.8% of the women audited. Substance users were more likely than non-users to be smokers, to have a psychiatric condition, to be single, indigenous, of lower socio-economic status and living in the metropolitan area. The outcome models had poor predictive powers. Substance use was associated with increased risks for placental abruption (OR 2.53) and antepartum haemorrhage from other causes (OR 1.41). The exposed babies had increased risks for preterm birth (OR 2.63), small for gestational age (OR 1.79), congenital abnormalities (1.52), nursery stays longer than 7 days (OR 4.07), stillbirth (OR 2.54) and neonatal death (OR 2.92).

CONCLUSIONS

Substance use in pregnancy is associated with increased risks for antepartum haemorrhage and poor perinatal outcomes. However, only a small amount of the variance in outcomes can be explained by the substance use alone. Recent initiatives to improve identification and support of women exposed to adverse health, psychosocial and lifestyle factors will need evaluation.