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Siddappa AM, Morris E, Evans MD, Pelinka S, Adkisson C. Inpatient Growth in Infants Requiring Pharmacologic Treatment for Neonatal Opioid Withdrawal Syndrome. Int J Pediatr 2024; 2024:2212688. [PMID: 39220832 PMCID: PMC11366048 DOI: 10.1155/2024/2212688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 07/16/2024] [Accepted: 07/25/2024] [Indexed: 09/04/2024] Open
Abstract
Aim: To assess inpatient growth parameter trajectories and to identify the type of opioid exposure and treatment characteristics influencing growth parameters of infants admitted to the newborn intensive care unit (NICU) for pharmacological treatment of neonatal opioid withdrawal syndrome (NOWS). Methods: Charts of term infants with NOWS admitted to NICU from 2012 to 2019, who received pharmacologic treatment, were reviewed. Intake (volume: mL/kg/day; calorie: kcal/kg/day) and growth parameter trajectories (weight, head circumference, and length) were analyzed based on the type of prenatal opioid exposure (short-acting opioids (SAOs), long-acting opioids (LAOs), and polysubstance), pharmacologic treatment, and sex. Growth measurement patterns over time were compared between groups using longitudinal mixed-effects models. Results: One hundred nineteen infants were included in the study with median birth weight Z-score of -0.19 at birth and decreased to a median of -0.72 at discharge. Exposure to SAO was associated with an increase in Z-scores nearing discharge across all growth parameters (Z-score for weight p = 0.03). Polysubstance exposure was associated with a decrease in Z-scores for length and head circumference throughout hospitalization. Infants with adjunct clonidine treatment had an increase in Z-score for weight trends. Male infants had a decrease in Z-scores for weight (male -0.96, female -0.59, interaction p = 0.06) and length (male -1.17, female -0.57, interaction p = 0.003) at Day 28. Despite the difference in growth trajectories, intake in terms of amount (mL/kg/day) and calorie intake (kcal/kg/day) was similar based on prenatal exposure, treatment, and sex. Conclusion: Infants with NOWS requiring pharmacologic treatment have a decrease in Z-scores for weight, length, and head circumference at birth and at hospital discharge. Infants with prenatal polysubstance exposure were at particular risk for poorer inpatient growth relative to infants exposed to SAO and LAO, indicated by lower Z-scores for length and occipital frontal circumference (OFC).
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Affiliation(s)
- Ashajyothi M. Siddappa
- NeonatologyDepartment of PediatricsHennepin Healthcare, Minneapolis, Minnesota, USA
- Department of PediatricsUniversity of Minnesota, Minneapolis, Minnesota, USA
| | - Erin Morris
- Division of NeonatologyUniversity of Minnesota, Minneapolis, Minnesota, USA
| | - Michael D. Evans
- Clinical and Translational Science InstituteUniversity of Minnesota, Minneapolis, Minnesota, USA
| | - Sarah Pelinka
- NeonatologyDepartment of PediatricsHennepin Healthcare, Minneapolis, Minnesota, USA
| | - Constance Adkisson
- NeonatologyDepartment of PediatricsHennepin Healthcare, Minneapolis, Minnesota, USA
- Department of PediatricsUniversity of Minnesota, Minneapolis, Minnesota, USA
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Tarfa A, Lier AJ, Shenoi SV, Springer SA. Considerations when prescribing opioid agonist therapies for people living with HIV. Expert Rev Clin Pharmacol 2024; 17:549-564. [PMID: 38946101 PMCID: PMC11299801 DOI: 10.1080/17512433.2024.2375448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 06/28/2024] [Indexed: 07/02/2024]
Abstract
INTRODUCTION Medications for opioid use disorder (MOUD) include opioid agonist therapies (OAT) (buprenorphine and methadone), and opioid antagonists (extended-release naltrexone). All forms of MOUD improve opioid use disorder (OUD) and HIV outcomes. However, the integration of services for HIV and OUD remains inadequate. Persistent barriers to accessing MOUD underscore the immediate necessity of addressing pharmacoequity in the treatment of OUD in persons with HIV (PWH). AREAS COVERED In this review article, we specifically focus on OAT among PWH, as it is the most commonly utilized form of MOUD. Specifically, we delineate the intersection of HIV and OUD services, emphasizing their integration into the United States Ending the HIV Epidemic (EHE) plan by offering comprehensive screening, testing, and treatment for both HIV and OUD. We identify potential drug interactions of OAT with antiretroviral therapy (ART), address disparities in OAT access, and present the practical benefits of long-acting formulations of buprenorphine, ART, and pre-exposure prophylaxis for improving HIV prevention and treatment and OUD management. EXPERT OPINION Optimizing OUD outcomes in PWH necessitates careful attention to diagnosing OUD, initiating OUD treatment, and ensuring medication retention. Innovative approaches to healthcare delivery, such as mobile pharmacies, can integrate both OUD and HIV and reach underserved populations.
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Affiliation(s)
- Adati Tarfa
- Yale University School of Medicine; 135 College Street, Suite 280, New Haven, New Haven, CT 06510
| | - Audun J. Lier
- Renaissance School of Medicine at Stony Brook University; Northport VA Medical Center, 79 Middleville Road, Northport, NY 11768
| | - Sheela V. Shenoi
- Yale School of Medicine, VA Connecticut Health System, 950 Campbell Avenue, West Haven, CT 06516
| | - Sandra A. Springer
- Yale University School of Medicine; 135 College Street, Suite 280, New Haven, New Haven, CT 06510
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Dempsey S, O' Grady MJ. Current management of neonatal abstinence syndrome: a survey of practice in the UK and Ireland. Arch Dis Child Fetal Neonatal Ed 2024; 109:261-264. [PMID: 37879885 DOI: 10.1136/archdischild-2023-326204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/11/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE To study the current management practices of neonatal abstinence syndrome (NAS) throughout the UK and Ireland and identify changes in practice from the most recent survey in 2008. DESIGN Postal questionnaire to a consultant paediatrician or neonatologist in all 215 neonatal units in the UK and Ireland in January 2020. RESULTS Response rate was 62%. An objective scoring tool was used in 97% of units and the Finnegan score was favoured by 70%. Morphine sulfate use as first line for the treatment of opiate withdrawal was almost universal and 70% used a dose of 40 µg/kg every 4 hours (240 µg/kg/day). Phenobarbitone administration as a second-line agent for opiate withdrawal increased to 61% of units with significant reductions in chloral hydrate and chlorpromazine use compared with the previous survey. Morphine sulfate and phenobarbitone remain the preferred first-line and second-line agents, respectively, for polysubstance withdrawal. There was a significant increase in chlorpromazine use as first line for polydrug withdrawal (1.5-14.2%). The practice of units discharging infants' home on medication increased to 46% from 29%. All units now permit breastfeeding in mothers taking methadone, compared with 81% previously. CONCLUSION AND RELEVANCE Compared with the previous survey, improvements in evidence-based practices were noted, highlighting the benefits of this type of research. Nonetheless, significant variation still exists in some aspects of the management of NAS. Post-discharge follow-up varies widely, with particular deficits in ophthalmology follow-up.
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Affiliation(s)
- Sharon Dempsey
- Department of Paediatrics, Regional Hospital Mullingar, Mullingar, Westmeath, Ireland
| | - Michael J O' Grady
- Department of Paediatrics, Regional Hospital Mullingar, Mullingar, Westmeath, Ireland
- Women's and Children's Health, University College Dublin, Dublin, Ireland
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Smith D, Sullivan R, Allen EC, Pradhan S, Zhu J, Oji-Mmuo CN. Evaluating the Effect of Maternal Opioid Maintenance Dose on the NOWS-COS Outcome Criteria: A Pilot Study. Clin Pediatr (Phila) 2024:99228241246647. [PMID: 38629767 DOI: 10.1177/00099228241246647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2024]
Abstract
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.
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Affiliation(s)
- Danielle Smith
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Rhea Sullivan
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Emma C Allen
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Penn State College of Medicine, Hershey, PA, USA
| | - Sandeep Pradhan
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Junjia Zhu
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Christiana N Oji-Mmuo
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
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Hite MK, Chroust AJ, Proctor-Williams K, Lowe JL. Newborn Hearing Screening Results for Infants With Prenatal Opioid Exposure in Southern Appalachia. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2024; 67:1268-1280. [PMID: 38517271 DOI: 10.1044/2024_jslhr-23-00492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
PURPOSE Infants prenatally exposed to opioids exhibit withdrawal symptomology that introduce physiological noise and can impact newborn hearing screening results. This study compared the referral rate and physiological noise interpreted by number of trials rejected due to artifact on initial newborn hearing screenings of infants with prenatal opioid exposure (POE) and infants with no opioid exposure (NOE). Furthermore, within the POE group, it examined the relationship of referral rates with severity of withdrawal symptomology, and with maternal and infant risk factors. METHOD This study used a retrospective cohort design of electronic medical records from six delivery hospitals in South-Central Appalachia. Newborn hearing screenings were conducted using automated auditory brainstem response (ABR) for 334 infants with POE and 226 infants with NOE. Severity of withdrawal symptomology was measured using the Modified Finnegan Neonatal Abstinence Scoring Tool, which includes observation of behaviors that introduce physiological noise. RESULTS There was no significant difference in newborn hearing screening referral rate between infants with POE and infants with NOE. Referral rate was not affected by maternal or infant risk factors. Infants with POE had statistically significant higher artifact (defined as rejected ABR sweeps) than infants with NOE. There was a strong positive correlation between Finnegan scores and artifact but not referral rates. Sensitivity and specificity analysis indicated artifact decreased substantially after Day 4 of life. CONCLUSIONS Referral rates of infants with POE were similar to those of infants with NOE. Nevertheless, the withdrawal symptomology of infants with POE introduces physiological noise reflected as artifact on ABR, which can affect efficiency of newborn hearing screenings.
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Affiliation(s)
- Marcy K Hite
- Department of Audiology and Speech Language Pathology, East Tennessee State University, Johnson City
| | - Alyson J Chroust
- Department of Psychology, East Tennessee State University, Johnson City
| | - Kerry Proctor-Williams
- Department of Audiology and Speech Language Pathology, East Tennessee State University, Johnson City
| | - Jennifer L Lowe
- Department of Audiology and Speech Language Pathology, East Tennessee State University, Johnson City
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Mallinson DC, Kuo HHD, Kirby RS, Wang Y, Berger LM, Ehrenthal DB. Maternal opioid use disorder and infant mortality in Wisconsin, United States, 2010-2018. Prev Med 2024; 181:107914. [PMID: 38408650 PMCID: PMC10947857 DOI: 10.1016/j.ypmed.2024.107914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/21/2024] [Accepted: 02/22/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE The difference in infant health outcomes by maternal opioid use disorder (OUD) status is understudied. We measured the association between maternal OUD during pregnancy and infant mortality and investigated whether this association differs by infant neonatal opioid withdrawal syndrome (NOWS) or maternal receipt of medication for OUD (MOUD) during pregnancy. METHODS We sampled 204,543 Medicaid-paid births from Wisconsin, United States (2010-2018). The primary exposure was any maternal OUD during pregnancy. We also stratified this exposure on NOWS diagnosis (no OUD; OUD without NOWS; OUD with NOWS) and on maternal MOUD receipt (no OUD; OUD without MOUD; OUD with <90 consecutive days of MOUD; OUD with 90+ consecutive days of MOUD). Our outcome was infant mortality (death at age <365 days). Demographic-adjusted logistic regressions measured associations with odds ratios (OR) and 95% confidence intervals (CI). RESULTS Maternal OUD was associated with increased odds of infant mortality (OR 1.43; 95% CI 1.02-2.02). After excluding infants who died <5 days post-birth (i.e., before the clinical presentation of NOWS), regression estimates of infant mortality did not significantly differ by NOWS diagnosis. Likewise, regression estimates did not significantly differ by maternal MOUD receipt in the full sample. CONCLUSIONS Maternal OUD is associated with an elevated risk of infant mortality without evidence of modification by NOWS nor by maternal MOUD treatment. Future research should investigate potential mechanisms linking maternal OUD, NOWS, MOUD treatment, and infant mortality to better inform clinical intervention.
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Affiliation(s)
- David C Mallinson
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States of America.
| | - Hsiang-Hui Daphne Kuo
- Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Russell S Kirby
- The Chiles Center, College of Public Health, University of South Florida, Tampa, FL, United States of America
| | - Yi Wang
- Silberman School of Social Work, Hunter College, New York, NY, United States of America
| | - Lawrence M Berger
- Sandra Rosenbaum School of Social Work, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Deborah B Ehrenthal
- Department of Biobehavioral Health, The Pennsylvania State University, University Park, PA, United States of America; Social Science Research Institute, The Pennsylvania State University, University Park, PA, United States of America
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Tabachnick AR, Eiden RD, Labella MH, Dozier M. Effects of prenatal opioid exposure on infant sympathetic and parasympathetic nervous system activity. Psychophysiology 2024; 61:e14470. [PMID: 37888142 PMCID: PMC10939941 DOI: 10.1111/psyp.14470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/28/2023]
Abstract
Prenatal opioid exposure has been associated with developmental problems, including autonomic nervous system dysregulation. However, little is known about the effects of prenatal opioid exposure on the autonomic nervous system beyond the first days of life, particularly across both the parasympathetic and sympathetic branches, and when accounting for exposure to other substances. The present study examined the effects of prenatal exposure to opioid agonist therapy (OAT, e.g., methadone) and other opioids on infant autonomic nervous system activity at rest and in response to a social stressor (the Still-Face Paradigm) at six months among 86 infants varying in prenatal opioid and other substance exposure. Results indicated that OAT and other opioids have unique effects on the developing autonomic nervous system that may further depend on subtype (i.e., methadone versus buprenorphine) and timing in gestation. Results are discussed in the context of theoretical models of the developing stress response system.
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Affiliation(s)
| | - Rina Das Eiden
- Department of Psychology, Pennsylvania State University, State College, Pennsylvania, USA
| | - Madelyn H Labella
- Department of Psychological Sciences, William & Mary, Williamsburg, Virginia, USA
| | - Mary Dozier
- Department of Psychological and Brain Sciences, University of Delaware, Newark, Delaware, USA
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Louchet M, Tisseyre M, Kaguelidou F, Treluyer JM, Préta LH, Chouchana L. Drug-induced fetal and offspring disorders, beyond birth defects. Therapie 2024; 79:205-219. [PMID: 38008599 DOI: 10.1016/j.therap.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 11/09/2023] [Indexed: 11/28/2023]
Abstract
Studies on drug utilization in western countries disclosed that about nine over ten women use at least one or more drugs during pregnancy. Determining whether a drug is safe or not in pregnant women is a challenge of all times. As a developing organism, the fetus is particularly vulnerable to effects of drugs used by the mother. Historically, research has predominantly focused on birth defects, which represent the most studied adverse pregnancy outcomes. However, drugs can also alter the ongoing process of pregnancy and impede the general growth of the fetus. Finally, adverse drug reactions can theoretically damage all developing systems, organs or tissues, such as the central nervous system or the immune system. This extensive review focuses on different aspects of drug-induced damages affecting the fetus or the newborn/infant, beyond birth defects, which are not addressed here.
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Affiliation(s)
- Margaux Louchet
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Service de gynécologie-obstétrique, Fédération hospitalo-universitaire PREMA, hôpital Louis-Mourier, AP-HP Nord - Université Paris Cité, 75000 Paris, France
| | - Mylène Tisseyre
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre régional de pharmacovigilance, service de pharmacologie périnatale, pédiatrique et adulte, hôpitaux Cochin-Necker, AP-HP Centre - Université Paris Cité, 75000 Paris, France
| | - Florentia Kaguelidou
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre d'investigation clinique pédiatrique, Inserm CIC 1426, hôpital Robert-Debré, AP-HP Nord - Université Paris Cité, 75000 Paris, France
| | - Jean-Marc Treluyer
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre régional de pharmacovigilance, service de pharmacologie périnatale, pédiatrique et adulte, hôpitaux Cochin-Necker, AP-HP Centre - Université Paris Cité, 75000 Paris, France
| | - Laure-Hélène Préta
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France
| | - Laurent Chouchana
- URP 7323 "Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte", Université Paris Cité, 75000 Paris, France; Centre régional de pharmacovigilance, service de pharmacologie périnatale, pédiatrique et adulte, hôpitaux Cochin-Necker, AP-HP Centre - Université Paris Cité, 75000 Paris, France.
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Sadovsky E, Chu T, Barak O, Sadovsky Y, Ouyang Y. The impact of opioids on the transcriptional landscape of human villous trophoblasts. Placenta 2023; 143:54-61. [PMID: 37832183 PMCID: PMC10841529 DOI: 10.1016/j.placenta.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 09/15/2023] [Accepted: 10/05/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION Opioid use disorder (OUD) is implicated in major obstetrical diseases such as fetal growth restriction. Whether or not opioids directly impact placental trophoblast development and function remains unclear. We sought to examine the expression of opioid receptors (OPRs) in villous trophoblasts and the effect of opioids on placental transcriptomics. METHODS Trophoblast stem (TS) cells and primary human trophoblast (PHT) cells from healthy term placentas were used to assess OPR expression in conditions that enhance trophoblast stemness vs differentiation. Placental RNAseq was conducted using our retrospective cohorts of pregnant people with OUD vs controls, both without major obstetrical complications. RT-qPCR was used to determine the effect of fentanyl on the expression of putative opioid targets and stemness or differentiation-associated genes in TS and PHT cells. RESULTS Three main OPRs, including OPRM1, OPRD1, and OPRK1 were expressed in term PHT cells cultured in the stemness medium, whereas only OPRD1 and OPRK1 were expressed in TS cells. Interestingly, upon induction of differentiation, the expressed OPR mRNAs in TS or in PHT cells were downregulated. We found 286 differentially expressed long RNAs in placentas from the OUD participants vs controls. While three putative opioid targets differed their expression in stemness vs differentiation states of trophoblasts, fentanyl had no effect on their expression or the expression of major stemness or differentiation-relevant genes in TS and PHT cells. DISCUSSION Trophoblastic expression of OPRs and opioid RNA targets is impacted by cell differentiation, suggesting differential susceptibility of villous trophoblasts to the effect of opioids.
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Affiliation(s)
- Elena Sadovsky
- Magee-Womens Research Institute, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tianjiao Chu
- Magee-Womens Research Institute, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Oren Barak
- Magee-Womens Research Institute, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yoel Sadovsky
- Magee-Womens Research Institute, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA; Department of Microbiology and Molecular Genetics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yingshi Ouyang
- Magee-Womens Research Institute, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, USA.
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Baldo BA. Neonatal opioid toxicity: opioid withdrawal (abstinence) syndrome with emphasis on pharmacogenomics and respiratory depression. Arch Toxicol 2023; 97:2575-2585. [PMID: 37537419 DOI: 10.1007/s00204-023-03563-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/24/2023] [Indexed: 08/05/2023]
Abstract
The increasing use of opioids in pregnant women has led to an alarming rise in the number of cases of neonates with drug-induced withdrawal symptoms known as neonatal opioid withdrawal syndrome (NOWS). NOWS is a toxic heterogeneous condition with many neurologic, autonomic, and gastrointestinal symptoms including poor feeding, irritability, tachycardia, hypertension, respiratory defects, tremors, hyperthermia, and weight loss. Paradoxically, for the management of NOWS, low doses of morphine, methadone, or buprenorphine are administered. NOWS is a polygenic disorder supported by studies of genomic variation in opioid-related genes. Single-nucleotide polymorphisms (SNPs) in CYP2B6 are associated with variations in NOWS infant responses to methadone and SNPs in the OPRM1, ABCB1, and COMT genes are associated with need for treatment and length of hospital stay. Epigenetic gene changes showing higher methylation levels in infants and mothers have been associated with more pharmacologic treatment in the case of newborns, and for mothers, longer infant hospital stays. Respiratory disturbances associated with NOWS are not well characterized. Little is known about the effects of opioids on developing neonatal respiratory control and respiratory distress (RD), a potential problem for survival of the neonate. In a rat model to test the effect of maternal opioids on the developing respiratory network and neonatal breathing, maternal-derived methadone increased apneas and lessened RD in neonates at postnatal (P) days P0 and P1. From P3, breathing normalized with age suggesting reorganization of respiratory rhythm-generating circuits at a time when the preBötC becomes the dominant inspiratory rhythm generator. In medullary slices containing the preBötC, maternal opioid treatment plus exposure to exogenous opioids showed respiratory activity was maintained in younger but not older neonates. Thus, maternal opioids blunt centrally controlled respiratory frequency responses to exogenous opioids in an age-dependent manner. In the absence of maternal opioid treatment, exogenous opioids abolished burst frequencies at all ages. Prenatal opioid exposure in children stunts growth rate and development while studies of behavior and cognitive ability reveal poor performances. In adults, high rates of attention deficit disorder, hyperactivity, substance abuse, and poor performances in intelligence and memory tests have been reported.
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Affiliation(s)
- Brian A Baldo
- Kolling Institute of Medical Research, Royal North Shore Hospital of Sydney, Sydney, NSW, 2065, Australia.
- Department of Medicine, University of Sydney, Sydney, NSW, 2000, Australia.
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Bishop L, Almquist YB, Pitkänen J, Martikainen P. Offspring hospitalization for substance use and changes in parental mental health: A Finnish register-based study. ADVANCES IN LIFE COURSE RESEARCH 2023; 57:100561. [PMID: 38054862 DOI: 10.1016/j.alcr.2023.100561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 06/20/2023] [Accepted: 06/29/2023] [Indexed: 12/07/2023]
Abstract
Prior research indicates that parental psychiatric disorders increase their offspring's risk of substance use problems. Though the association is likely bidirectional, the effects of an adult child's substance use on parental mental health remain understudied. We examined parents' psychotropic medication use trajectories by parental sex and educational attainment before and after a child's alcohol- or narcotics-attributable hospitalization. We identified Finnish residents, born 1979-1988, with a first hospitalization for substance use during emerging adulthood (ages 18-29, n = 12,851). Their biological mothers (n = 12,283) and/or fathers (n = 10,765) were followed for the two years before and after the hospitalization. Psychotropic medication use was measured in three-month periods centered around the time of child's hospitalization, and the probability of psychotropic medication use at each time point was assessed using generalized estimating equations logit models. Among mothers, the prevalence of psychotropic medication use increased during the year before, peaked during the 0-3 months after hospitalization, and remained at a similarly elevated level until the end of follow-up. The prevalence among fathers increased gradually and linearly across follow-up, with minimal changes evident either directly before or after the hospitalization. Parents' educational attainment did not modify these trajectories. Our results highlight the importance of considering linked lives when quantifying substance use-attributable harms and underscore the need for future research examining the intergenerational spillover effects of substance use in both directions, particularly in mother-child dyads.
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Affiliation(s)
- Lauren Bishop
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, 00014 Helsinki, Finland; Max Planck-University of Helsinki Center for Social Inequalities in Population Health, 00014 Helsinki, Finland; Department of Public Health Sciences, Stockholm University, 10691 Stockholm, Sweden; International Max Planck Research School for Population, Health and Data Science, Max Planck Institute for Demographic Research, 18057 Rostock, Germany.
| | - Ylva B Almquist
- Department of Public Health Sciences, Stockholm University, 10691 Stockholm, Sweden
| | - Joonas Pitkänen
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, 00014 Helsinki, Finland; Max Planck-University of Helsinki Center for Social Inequalities in Population Health, 00014 Helsinki, Finland; International Max Planck Research School for Population, Health and Data Science, Max Planck Institute for Demographic Research, 18057 Rostock, Germany
| | - Pekka Martikainen
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, 00014 Helsinki, Finland; Max Planck-University of Helsinki Center for Social Inequalities in Population Health, 00014 Helsinki, Finland; Max Planck Institute for Demographic Research, 18057 Rostock, Germany
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Czynski A, Laptook A, Das A, Smith B, Simon A, Greenberg R, Annett R, Lee J, Snowden J, Pedroza C, Lester B, Eggleston B, Bremer D, McGowan E. Pragmatic, randomized, blinded trial to shorten pharmacologic treatment of newborns with neonatal opioid withdrawal syndrome (NOWS). Trials 2023; 24:466. [PMID: 37480087 PMCID: PMC10362592 DOI: 10.1186/s13063-023-07378-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/16/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND The incidence of maternal opioid use in the USA has increased substantially since 2000. As a consequence of opioid use during pregnancy, the incidence of neonatal opioid withdrawal syndrome (NOWS) has increased fivefold between 2002 and 2012. Pharmacological therapy is indicated when signs of NOWS cannot be controlled, and the objective of pharmacological therapy is to control NOWS signs. Once pharmacologic therapy has started, there is great variability in strategies to wean infants. An important rationale for studying weaning of pharmacological treatment for NOWS is that weaning represents the longest time interval of drug treatment. Stopping medications too early may not completely treat NOWS symptoms. METHODS This will be a pragmatic, randomized, blinded trial of opioid weaning to determine whether more rapid weaning, compared to slow wean, will reduce the number of days of opioid treatment in infants receiving morphine or methadone as the primary treatment for NOWS. DISCUSSION The proposed study is a pragmatic trial to determine whether a rapid-weaning intervention reduces the number of days of opioid treatment, compared to a slow-weaning intervention, and we powered the proposed study to detect a 2-day difference in the length of treatment. Hospitals will be able to use either morphine or methadone with the knowledge that we may find a positive treatment effect for both, one, or neither drugs. TRIAL REGISTRATION NCT04214834. Registered January 2, 2020.
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Affiliation(s)
- Adam Czynski
- Connecticut Children's Medical Center, Hartford, USA.
| | - Abbot Laptook
- Brown University/Women & Infants Hospital of Rhode Island, Providence, USA
| | - Abhik Das
- RTI International, Research Triangle Park, USA
| | - Brian Smith
- Duke Clinical Research Institute, Durham, USA
| | - Alan Simon
- National Institutes of Health, Bethesda, USA
| | | | | | | | | | | | - Barry Lester
- Brown University/Women & Infants Hospital of Rhode Island, Providence, USA
| | | | | | - Elisabeth McGowan
- Brown University/Women & Infants Hospital of Rhode Island, Providence, USA
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Heyward A, Minich N, Hoffman AC, Hibbs AM, Zhao L, Crowley M. Characteristics and outcomes of neonatal opioid withdrawal syndrome in preterm infants: a retrospective cohort study in the current era. J Perinatol 2023; 43:909-915. [PMID: 37188773 DOI: 10.1038/s41372-023-01672-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 12/15/2022] [Accepted: 01/05/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE Compare Neonatal Opioid Withdrawal Syndrome (NOWS) in preterm and term infants. STUDY DESIGN Single center, retrospective chart review of all in-utero opioid exposed infants born between 2014 and 2019. Withdrawal symptoms were assessed using Modified Finnegan Assessment Tool. RESULTS Thirteen preterm (PT), 72 late preterm (LPT), and 178 term infants were included. Preterm and LPT compared to term infants had lower peak Finnegan scores (9/9 vs. 12) and received less pharmacologic treatment (23.1/44.4 vs. 66.3%). Similar onset, peak symptoms, and treatment duration was observed in LPT and term infants. CONCLUSIONS Preterm and LPT infants have lower Finnegan scores and require less pharmacologic therapy for NOWS. It is unclear if this is because our current assessment tool does not capture their symptoms or if they truly have less withdrawal. Onset of NOWS is similar in LPT and term infant, thus LPT infants do not require prolonged hospital monitoring for NOWS.
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Affiliation(s)
- Alicia Heyward
- Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH, USA.
- Case Western Reserve University School of Medicine, Cleveland, OH, USA.
| | - Nori Minich
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | - Adriana C Hoffman
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- Department of Pediatrics, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH, USA
| | - Anna Maria Hibbs
- Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Lulu Zhao
- Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Moira Crowley
- Division of Neonatology, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Vella A, Savona-Ventura C, Mahmood T. Harmful effects of opioid use in pregnancy: A scientific review commissioned by the European Board and College of obstetrics and gynaecology (EBCOG). Eur J Obstet Gynecol Reprod Biol 2023; 286:70-75. [PMID: 37216740 DOI: 10.1016/j.ejogrb.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Caring for pregnant women who have a recreational opioid use disorder is a common clinical challenge in modern obstetric care. These are an elusive population who often have multiple social issues that complicate their pregnancy management. Comprehensive and supportive maternal care can motivate these mothers to change her lifestyle. Multidisciplinary non-judgemental approach with appropriate medication and management, can result in good pregnancy outcomes for mother and her baby.
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Affiliation(s)
| | - Charles Savona-Ventura
- Department of Obstetrics and Gynaecology, University of Malta, Member EBCOG Standing Committee on Standards of Care and Position Statements, Malta; Member of the EBCOG Standing Committee on Standards of Care and Position Statements, Malta
| | - Tahir Mahmood
- Victoria Hospital, Kirkcaldy and Spire Murrayfield Hospital, Edinburgh, United Kingdom; Member of the EBCOG Standing Committee on Standards of Care and Position Statements, Malta
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Plouffe R, Grywacheski V, Luo W, Nelson C, Orpana H. Neonatal abstinence syndrome hospitalizations in Canada: a descriptive study. CANADIAN JOURNAL OF PUBLIC HEALTH = REVUE CANADIENNE DE SANTE PUBLIQUE 2023; 114:277-286. [PMID: 36482143 PMCID: PMC9734797 DOI: 10.17269/s41997-022-00726-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 11/14/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The objective of this paper is to describe the trend of newborn hospitalizations with neonatal abstinence syndrome (NAS) in Canada, between 2010 and 2020, and to examine severity indicators for these hospitalizations. METHODS National hospitalization data (excluding Quebec) from the Canadian Institute for Health Information's Discharge Abstract Database, from January 2010 to March 2021, and Statistics Canada's Vital Statistics Birth Database were used. Analyses were performed to examine NAS hospitalizations by year and quarter, and by severity indicators of length of stay, Special Care Unit admission and status upon discharge. Severity indicators were further stratified by gestational age at birth. RESULTS An increasing number and rate of NAS hospitalizations in Canada between 2010 (n = 1013, 3.5 per 1000 live births) and 2020 (n = 1755, 6.3 per 1000 live births) were identified. A seasonal pattern was observed, where rates of NAS were lowest from April to June and highest from October to March. Mean length of stay in acute inpatient care was approximately 15 days and 71% of NAS hospitalizations were admitted to the Special Care Unit. Hospitalizations for pre-term births with NAS had longer durations and greater rates of Special Care Unit admissions compared to term births with NAS. CONCLUSION The number and rate of NAS hospitalizations in Canada increased during the study, and some infants required a significant amount of specialized healthcare. Additional research is required to determine what supports and education for pregnant people can reduce the incidence of NAS hospitalizations.
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Affiliation(s)
- Rebecca Plouffe
- Centre for Surveillance and Applied Research, Health Promotion and Chronic Disease Prevention Branch, Public Health Agency of Canada, Ottawa, Ontario, Canada.
| | - Vera Grywacheski
- Centre for Surveillance and Applied Research, Health Promotion and Chronic Disease Prevention Branch, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Wei Luo
- Centre for Surveillance and Applied Research, Health Promotion and Chronic Disease Prevention Branch, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Chantal Nelson
- Centre for Surveillance and Applied Research, Health Promotion and Chronic Disease Prevention Branch, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Heather Orpana
- Centre for Surveillance and Applied Research, Health Promotion and Chronic Disease Prevention Branch, Public Health Agency of Canada, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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Conradt E, Camerota M, Maylott S, Lester BM. Annual Research Review: Prenatal opioid exposure - a two-generation approach to conceptualizing neurodevelopmental outcomes. J Child Psychol Psychiatry 2023; 64:566-578. [PMID: 36751734 DOI: 10.1111/jcpp.13761] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2023] [Indexed: 02/09/2023]
Abstract
Opioid use during pregnancy impacts the health and well-being of two generations: the pregnant person and the child. The factors that increase risk for opioid use in the adult, as well as those that perpetuate risk for the caregiver and child, oftentimes replicate across generations and may be more likely to affect child neurodevelopment than the opioid exposure itself. In this article, we review the prenatal opioid exposure literature with the perspective that this is not a singular event but an intergenerational cascade of events. We highlight several mechanisms of transmission across generations: biological factors, including genetics and epigenetics and the gut-brain axis; parent-child mechanisms, such as prepregnancy experience of child maltreatment, quality of parenting, infant behaviors, neonatal opioid withdrawal diagnosis, and broader environmental contributors including poverty, violence exposure, stigma, and Child Protective Services involvement. We conclude by describing ways in which intergenerational transmission can be disrupted by early intervention.
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Affiliation(s)
- Elisabeth Conradt
- Department of Psychiatry, Duke University, Durham, NC, USA.,Department of Pediatrics, Duke University, Durham, NC, USA
| | - Marie Camerota
- Brown Center for the Study of Children at Risk, Department of Psychiatry and Pediatrics, Alpert Medical School of Brown University and Women and Infants Hospital of Rhode Island, Providence, RI, USA
| | - Sarah Maylott
- Department of Psychiatry, Duke University, Durham, NC, USA
| | - Barry M Lester
- Brown Center for the Study of Children at Risk, Department of Psychiatry and Pediatrics, Alpert Medical School of Brown University and Women and Infants Hospital of Rhode Island, Providence, RI, USA
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Association between pharmacologic treatment and hospital utilization at birth among neonatal opioid withdrawal syndrome mother-infant dyads. J Perinatol 2023; 43:283-292. [PMID: 36717607 DOI: 10.1038/s41372-023-01623-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/19/2023] [Accepted: 01/23/2023] [Indexed: 01/31/2023]
Abstract
OBJECTIVE We linked mother-baby dyads to explore associations between maternal medication-assisted therapy (MAT) and infants' pharmacologic treatment on birth hospital utilization for infants with NOWS. METHODS We extracted singleton infant and maternal delivery discharges from PHIS hospitals with large volumes of deliveries for 2016-2019. We matched newborns with NOWS to maternal delivery discharges by hospital, day of birth, mode of delivery, and ZIP code. We examined the association between maternal MAT, infants' pharmacologic treatment, and hospital utilization at birth. RESULTS We included N = 146 mother-baby dyads from six hospitals (74% match rate). Among matched dyads, 51% received maternal MAT, 60% pharmacotherapy (37% both). Infants treated non-pharmacologically and born to mothers receiving MAT had the shortest stays vs. infants without pharmacotherapy or MAT (RR = 0.29; 95% CI: 0.25-0.35). CONCLUSIONS These findings underscore the importance of adequate perinatal treatment for opioid use disorder to improve outcomes for mothers and infants with opioid exposure.
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Albano GD, La Spina C, Pitingaro W, Milazzo V, Triolo V, Argo A, Malta G, Zerbo S. Intrauterine and Neonatal Exposure to Opioids: Toxicological, Clinical, and Medico-Legal Issues. TOXICS 2023; 11:toxics11010062. [PMID: 36668788 PMCID: PMC9866828 DOI: 10.3390/toxics11010062] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/27/2022] [Accepted: 01/05/2023] [Indexed: 06/01/2023]
Abstract
Opioids have a rapid transplacental passage (i.e., less than 60 min); furthermore, symptoms characterize the maternal and fetal withdrawal syndrome. Opioid withdrawal significantly impacts the fetus, inducing worse outcomes and a risk of mortality. Moreover, neonatal abstinence syndrome (NAS) follows the delivery, lasts up to 10 weeks, and requires intensive management. Therefore, the prevention and adequate management of NAS are relevant public health issues. This review aims to summarize the most updated evidence in the literature regarding toxicological, clinical, and forensic issues of intrauterine exposure to opioids to provide a multidisciplinary, evidence-based approach for managing such issues. Further research is required to standardize testing and to better understand the distribution of opioid derivatives in each specimen type, as well as the clinically relevant cutoff concentrations in quantitative testing results. A multidisciplinary approach is required, with obstetricians, pediatricians, nurses, forensic doctors and toxicologists, social workers, addiction specialists, and politicians all working together to implement social welfare and social services for the baby when needed. The healthcare system should encourage multidisciplinary activity in this field and direct suspected maternal and neonatal opioid intoxication cases to local referral centers.
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Malthaner LQ, Jetelina KK, Loria H, McLeigh JD. Healthcare utilization among children with a history of neonatal opioid withdrawal syndrome: A matched cohort study. CHILD ABUSE & NEGLECT 2022; 134:105934. [PMID: 36302288 DOI: 10.1016/j.chiabu.2022.105934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/04/2022] [Accepted: 10/13/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Compare longitudinal healthcare utilization patterns in children with and without a history of neonatal opioid withdrawal syndrome (NOWS). STUDY DESIGN A retrospective matched cohort study was conducted using billing data extracted from between 2003 and 2016 in North Texas hospitals. The sample included 595 pediatric patients diagnosed with NOWS (i.e. exposed). The unexposed were patients not diagnosed with NOWS and matched 4:1 on sex, age at first encounter, and ethnicity to the exposed who received care during the same period. Multi-level regression models (accounting for clustered data structure of multiple visits per patient) compared number of hospitalizations, number of outpatient visits, number of emergency department (ED) visits, average length of stay, and healthcare expenditures across patients with and without NOWS. RESULTS Hospitalizations were significantly lower among exposed (Incidence Rate Ratio [IRR] = 0.58, 95 % Confidence Interval [CI] = 0.44-0.77) compared to unexposed. Outpatient visits, ED visits, and average length of stay was significantly higher among exposed compared to unexposed (IRR = 1.19, 95 % CI = 1.04-1.36; IRR = 1.22, 95 % CI = 1.04-1.42; IRR = 2.21, 95 % CI = 2.03-2.42, respectively). Overall healthcare expenditure was greater among exposed, as well as for patients with neurologic, endocrine, cardiac, mental disorders, respiratory, perinatal, infectious disease, eye, ear, digestive, congenital anomaly, and skin diagnoses. CONCLUSIONS Children with a diagnosis of NOWS have significantly higher healthcare expenditures, and with the exception of hospitalizations, higher healthcare utilization beyond the newborn visit. These findings suggest the needs for interventions for children with NOWS beyond the immediate neonatal period.
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Affiliation(s)
- Lauren Q Malthaner
- Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center School of Public Health, Dallas, TX, United States of America; Rees-Jones Center for Foster Care Excellence, Children's Health, Dallas, TX, United States of America.
| | - Katelyn K Jetelina
- Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center School of Public Health, Dallas, TX, United States of America; Center for Pediatric Population Health, University of Texas Health Science Center School of Public Health, Dallas, TX, United States of America
| | - Hilda Loria
- Rees-Jones Center for Foster Care Excellence, Children's Health, Dallas, TX, United States of America; University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Jill D McLeigh
- Rees-Jones Center for Foster Care Excellence, Children's Health, Dallas, TX, United States of America; Center for Pediatric Population Health, University of Texas Health Science Center School of Public Health, Dallas, TX, United States of America
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Manigault AW, Sheinkopf SJ, Silverman HF, Lester BM. Newborn Cry Acoustics in the Assessment of Neonatal Opioid Withdrawal Syndrome Using Machine Learning. JAMA Netw Open 2022; 5:e2238783. [PMID: 36301544 PMCID: PMC9614579 DOI: 10.1001/jamanetworkopen.2022.38783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The assessment of opioid withdrawal in the neonate, or neonatal opioid withdrawal syndrome (NOWS), is problematic because current assessment methods are based on subjective observer ratings. Crying is a distinctive component of NOWS assessment tools and can be measured objectively using acoustic analysis. OBJECTIVE To evaluate the feasibility of using newborn cry acoustics (acoustics referring to the physical properties of sound) as an objective biobehavioral marker of NOWS. DESIGN, SETTING, AND PARTICIPANTS This prospective controlled cohort study assessed whether acoustic analysis of neonate cries could predict which infants would receive pharmacological treatment for NOWS. A total of 177 full-term neonates exposed and not exposed to opioids were recruited from Women & Infants Hospital of Rhode Island between August 8, 2016, and March 18, 2020. Cry recordings were processed for 118 neonates, and 65 neonates were included in the final analyses. Neonates exposed to opioids were monitored for signs of NOWS using the Finnegan Neonatal Abstinence Scoring Tool administered every 3 hours as part of a 5-day observation period during which audio was recorded continuously to capture crying. Crying of healthy neonates was recorded before hospital discharge during routine handling (eg, diaper changes). EXPOSURES The primary exposure was prenatal opioid exposure as determined by maternal receipt of medication-assisted treatment with methadone or buprenorphine. MAIN OUTCOMES AND MEASURES Neonates were stratified by prenatal opioid exposure and receipt of pharmacological treatment for NOWS before discharge from the hospital. In total, 775 hours of audio were collected and trimmed into 2.5 hours of usable cries, then acoustically analyzed (using 2 separate acoustic analyzers). Cross-validated supervised machine learning methods (combining the Boruta algorithm and a random forest classifier) were used to identify relevant acoustic parameters and predict pharmacological treatment for NOWS. RESULTS Final analyses included 65 neonates (mean [SD] gestational age at birth, 36.6 [1.1] weeks; 36 [55.4%] female; 50 [76.9%] White) with usable cry recordings. Of those, 19 neonates received pharmacological treatment for NOWS, 7 neonates were exposed to opioids but did not receive pharmacological treatment for NOWS, and 39 healthy neonates were not exposed to opioids. The mean of the predictions of random forest classifiers predicted receipt of pharmacological treatment for NOWS with high diagnostic accuracy (area under the curve, 0.90 [95% CI, 0.83-0.98]; accuracy, 0.85 [95% CI, 0.74-0.92]; sensitivity, 0.89 [95% CI, 0.67-0.99]; specificity, 0.83 [95% CI, 0.69-0.92]). CONCLUSIONS AND RELEVANCE In this study, newborn acoustic cry analysis had potential as an objective measure of opioid withdrawal. These findings suggest that acoustic cry analysis using machine learning could improve the assessment, diagnosis, and management of NOWS and facilitate standardized care for these infants.
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Affiliation(s)
- Andrew W. Manigault
- Brown Center for the Study of Children at Risk, Women & Infants Hospital of Rhode Island, Providence
| | - Stephen J. Sheinkopf
- Thompson Center for Autism and Neurodevelopmental Disorders, University of Missouri, Columbia
| | | | - Barry M. Lester
- Brown Center for the Study of Children at Risk, Women & Infants Hospital of Rhode Island, Providence
- Department of Psychiatry, Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island
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Neonatal abstinence syndrome and mother's own milk at discharge. J Perinatol 2022; 42:1044-1050. [PMID: 35725804 DOI: 10.1038/s41372-022-01430-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 06/01/2022] [Accepted: 06/08/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To describe factors impacting receipt of mother's own milk (MOM) at discharge among California infants diagnosed with neonatal abstinence syndrome (NAS). STUDY DESIGN Cohort study of the California Perinatal Quality Care Collaborative's Maternal Substance Exposure Database for infants with NAS and gestational age ≥ 34 weeks from 2019 to 2020. RESULT 245 infants with NAS were identified. Variables with an increased likelihood of being discharged on MOM included maternal medication assisted treatment (p = 0.001), use of maternal addiction services (p < 0.001), receiving donor human milk (p = 0.001), being treated in the well baby unit (p < 0.001), rooming-in (p < 0.001), and kangaroo care (p < 0.001). Among infants with NAS for whom MOM was recommended (n = 84), rooming-in was the only factor associated with being discharged on MOM (p = 0.002); receiving formula was the only inversely associated factor (p < 0.001). CONCLUSION Results suggest supporting the mother-infant dyad and using non-pharmacologic treatment methods, such as rooming-in, increase receipt of MOM at discharge.
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Kinsella M, Capel Y, Nelson SM, Kearns RJ. Opioid substitution in pregnancy a narrative review: contemporary evidence for use of methadone and buprenorphine in pregnancy. JOURNAL OF SUBSTANCE USE 2022. [DOI: 10.1080/14659891.2022.2106600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- M. Kinsella
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Y. Capel
- Foundation Programme, NHS Greater Glasgow and Clyde, Glasgow, UK
| | | | - R. J. Kearns
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
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Baldo BA. Current research in pathophysiology of opioid-induced respiratory depression, neonatal opioid withdrawal syndrome, and neonatal antidepressant exposure syndrome. Curr Res Toxicol 2022; 3:100078. [PMID: 35734228 PMCID: PMC9207297 DOI: 10.1016/j.crtox.2022.100078] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/20/2022] [Accepted: 06/01/2022] [Indexed: 01/29/2023] Open
Abstract
Respiratory depression (RD) is the primary cause of death due to opioids. Opioids bind to mu (µ)-opioid receptors (MORs) encoded by the MOR gene Oprm1, widely expressed in the central and peripheral nervous systems including centers that modulate breathing. Respiratory centers are located throughout the brainstem. Experiments with Oprm1-deleted knockout (KO) mice undertaken to determine which sites are necessary for the induction of opioid-induced respiratory depression (OIRD) showed that the pre-Bötzinger complex (preBötC) and the pontine Kölliker-Fuse nucleus (KF) contribute equally to OIRD but RD was not totally eliminated. Morphine showed a differential influence on preBötC and KF neurons - low doses attenuated RD following deletion of MORs from preBötC neurons and an increase in apneas after high doses whereas deletion of MORs from KF neurons but not the preBötC attenuated RD at both high and low doses. In other KO mice studies, morphine administration after deletion of Oprm1 from both the preBötC and the KF/PBN neurons, led to the conclusion that both respiratory centres contribute to OIRD but the preBötC predominates. MOR-mediated post-synaptic activation of GIRK potassium channels has been implicated as a cause of OIRD. A complementary mechanism in the preBötC involving KCNQ potassium channels independent of MOR signaling has been described. Recent experiments in rats showing that morphine depresses normal, but not gasping breathing, cast doubt on the belief that eupnea, sighs, and gasps, are under the control of preBötC neurons. Methadone, administered to alleviate symptoms of neonatal opioid withdrawal syndrome (NOWES), desensitized rats to OIRD. Protection lost between postnatal days 1 and 2 coincides with the preBötC becoming the dominant generator of respiratory rhythm. Neonatal antidepressant exposure syndrome (NADES) and serotonin toxicity (ST) show similarities including RD. Enzyme CYP2D6 involved in opioid detoxification is polymorphic. Individuals of different CYP2D6 genotype may show increased, decreased, or no enzyme activity, contributing to the variability of patient responses to different opioids and OIRD.
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Key Words
- AAV, adeno-associated virus
- CDC, Centers for Disease control and prevention
- CTAP, MOR agonist (D-Phe-Cys-Tyr-D-Trp-Arg-Thr-Pen-Thr-NH2)
- DAMGO, synthetic specific MOR agonist [D-Ala2, N-MePhe4, Gly-ol]-enkephalin
- DRG, dorsal respiratory group
- FDA, Food and Drug Administration
- GIRK, G protein-gated inwardly-rectifying potassium (K+)
- GPCR, G protein-coupled receptor
- KCNQ, voltage-gated potassium (Kv) channels in the KCNQ (Kv7) family
- KF, Kölliker-Fuse nucleus
- Kölliker-Fuse nucleus and opioid-induced respiratory depression
- MOR, mu opioid receptor
- NADES, neonatal antidepressant exposure syndrome
- NAS, neonatal abstinence syndrome
- NIH, National Institutes of Health
- NK-1R, neurokinin-1 receptor
- NOWES, neonatal opioid withdrawal syndrome
- Neonatal opioid withdrawal syndrome
- Neural mediation of opioid-induced respiratory depression
- OAD, opioid analgesic drug
- OIRD, opioid-induced respiratory depression
- PBL, lateral parabrachial
- PBN, parabrachial nucleus
- PRG, pontine respiratory group
- Pathophysiology of opioid-induced respiratory depression
- Pre-Bötzinger complex and opioid-induced respiratory depression
- RD, respiratory depression
- TACR1, tachykinin receptor 1
- VRG, ventral respiratory group
- preBötC, pre-Bötzinger complex
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Affiliation(s)
- Brian A. Baldo
- Kolling Institute of Medical Research, Royal North Shore Hospital of Sydney and Department of Medicine, University of Sydney, Sydney, NSW, Australia
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Incarceration exposure and prescription opioid use during pregnancy. Drug Alcohol Depend 2022; 235:109434. [PMID: 35405460 DOI: 10.1016/j.drugalcdep.2022.109434] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Prior research demonstrates a high prevalence of substance use, including opioid use, among those who have had personal or vicarious contact with the correctional system. Relatedly, alongside patterns of rising opioid use in general, opioid use during pregnancy is becoming a growing public health concern. Still, risk factors for prescription opioid use during pregnancy remain understudied. This study is the first to assess the connection between a women's personal or vicarious exposure to incarceration in the 12 months prior to birth and patterns of prenatal opioid use. METHODS Data are from the Pregnancy Risk Assessment Monitoring System (PRAMS) in 2019 (N = 17,551 mothers). Logistic and multinomial logistic regression are used to assess the association between incarceration exposure and patterns of opioid use during pregnancy. RESULTS Incarceration-exposed women were more likely to use all eight types of prescription opioids assessed in this study (Hydrocodone, Codeine, Oxycodone, Tramadol, Hydromorphone/Meperidine, Oxymorphone, Morphine, and Fentanyl). After adjustment for control variables, incarceration-exposed women were significantly more likely to report any prescription opioid use during pregnancy (OR = 1.745, 95% CI = 1.194, 2.554). Furthermore, relative to no opioid use, incarceration exposure was also associated with illicit prescription opioid use (RRR = 2.979, 1.533, 5.791). CONCLUSIONS Incarceration exposure in the year prior to birth is associated with higher odds of prescription opioid use. These findings add to the burgeoning literature that details a women's exposure to incarceration is a risk marker for substance use and engagement in health risk behaviors that can jeopardize maternal and infant wellbeing.
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Mahnke AH, Roberts MH, Leeman L, Ma X, Bakhireva LN, Miranda RC. Prenatal opioid-exposed infant extracellular miRNA signature obtained at birth predicts severity of neonatal opioid withdrawal syndrome. Sci Rep 2022; 12:5941. [PMID: 35396369 PMCID: PMC8993911 DOI: 10.1038/s41598-022-09793-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 03/29/2022] [Indexed: 11/09/2022] Open
Abstract
Prenatal opioid exposure (POE) is commonly associated with neonatal opioid withdrawal syndrome (NOWS), which is characterized by a broad variability in symptoms and severity. Currently there are no diagnostic tools to reliably predict which infants will develop severe NOWS, while risk stratification would allow for proactive decisions about appropriate clinical monitoring and interventions. The aim of this prospective cohort study was to assess if extracellular microRNAs (miRNAs) in umbilical cord plasma of infants with POE could predict NOWS severity. Participants (n = 58) consisted of pregnant women receiving medications for opioid use disorder and their infants. NOWS severity was operationalized as the need for pharmacologic treatment and prolonged hospitalization (≥ 14 days). Cord blood miRNAs were assessed using semi-quantitative qRT-PCR arrays. Receiver operating characteristic curves and area under the curve (AUC) were estimated. The expression of three miRNAs (miR-128-3p, miR-30c-5p, miR-421) predicted need for pharmacologic treatment (AUC: 0.85) and prolonged hospitalization (AUC: 0.90). Predictive validity improved after two miRNAs (let-7d-5p, miR-584-5p) were added to the need for pharmacologic treatment model (AUC: 0.94) and another two miRNAs (let-7b-5p, miR-10-5p) to the prolonged hospitalization model (AUC: 0.99). Infant cord blood extracellular miRNAs can proactively identify opioid-exposed neonates at high-risk for developing severe NOWS.
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Affiliation(s)
- Amanda H Mahnke
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, 8447 Riverside Parkway, Bryan, TX, 77807-3260, USA.
| | - Melissa H Roberts
- Department of Pharmacy Practice and Administrative Sciences, Substance Use Research and Education (SURE) Center, University of New Mexico College of Pharmacy, Albuquerque, NM, 87131, USA
| | - Lawrence Leeman
- Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA.,Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA
| | - Xingya Ma
- Department of Pharmacy Practice and Administrative Sciences, Substance Use Research and Education (SURE) Center, University of New Mexico College of Pharmacy, Albuquerque, NM, 87131, USA
| | - Ludmila N Bakhireva
- Department of Pharmacy Practice and Administrative Sciences, Substance Use Research and Education (SURE) Center, University of New Mexico College of Pharmacy, Albuquerque, NM, 87131, USA.,Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA.,Division of Epidemiology, Biostatistics and Preventive Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA
| | - Rajesh C Miranda
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, 8447 Riverside Parkway, Bryan, TX, 77807-3260, USA
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Kinsella M, Halliday LOE, Shaw M, Capel Y, Nelson SM, Kearns RJ. Buprenorphine Compared with Methadone in Pregnancy: A Systematic Review and Meta-Analysis. Subst Use Misuse 2022; 57:1400-1416. [PMID: 35758300 DOI: 10.1080/10826084.2022.2083174] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Illicit opioid use in pregnancy is associated with adverse maternal, neonatal, and childhood outcomes. Opioid substitution is recommended, but whether methadone or buprenorphine is the optimal agent remains unclear. METHODS We searched EMBASE, PubMed, Web of Science, Scopus, Open Gray, CINAHL and the Cochrane Central Registry of Controlled Trials (CENTRAL) from inception to April 2020 for randomized controlled trials (RCTs) and cohort studies comparing methadone and buprenorphine treatment for opioid-using mothers. Included studies assessed maternal and or neonatal outcomes. We used random-effects meta-analyses to estimate summary measures for outcomes and report these separately for RCTs and cohort studies. RESULTS Of 408 abstracts screened, 20 papers were included (4 RCTs, 16 cohort, 223 and 7028 participants respectively). All RCTs (4/4) had a high risk of bias and median (IQR) Newcastle Ottawa Scale for cohort studies was 7.5 (6-9). In both RCTs and cohort studies, buprenorphine was associated with; greater offspring birth weight (weighted mean difference [WMD] 343 g (95% CI: 40-645 g) in RCT and 184 g (95% CI: 121-247 g) in cohort studies); body length at birth (WMD 2.28 cm (95% CI: 1.06-3.49 cm) in RCTs and 0.65 cm (95% CI: 0.31-0.98 cm) in cohort studies); and reduced risk of prematurity (risk ratio [RR] 0.41 (95% CI: 0.18-0.93) in RCTs and 0.63 [95% CI: 0.53-0.75] in cohort studies) when compared to methadone. All other clinical outcomes were comparable. CONCLUSIONS Compared to methadone, buprenorphine was consistently associated with improved birthweight and gestational age, however given potential biases, results should be interpreted with caution.
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Affiliation(s)
- Michael Kinsella
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Lucy O E Halliday
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | | | | | - Scott M Nelson
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - Rachel J Kearns
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
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Sithisarn T, Legan SJ, Westgate PM, Bada HS, Wilson ME. Understanding the effects of opioids vs non-opioids in the treatment of neonatal abstinence syndrome, an in vitro model. Front Pediatr 2022; 10:1068330. [PMID: 36483468 PMCID: PMC9723166 DOI: 10.3389/fped.2022.1068330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 11/04/2022] [Indexed: 11/23/2022] Open
Abstract
Neonatal abstinence syndrome (NAS) refers to cadre of withdrawal manifestations in infants born to mothers who used illicit and licit substances during pregnancy. The increasing prevalence of NAS has been largely due to the maternal use of opioids during pregnancy. NAS contributes to increased morbidity and long-term disability in surviving infants. Clinically, oral opioid therapies for opioid exposure have been a standard treatment with morphine (MO) being the most commonly used medication. Recently, a non-opioid agent, clonidine (CD) has also been used with potentially favorable short- and long-term outcomes in infants. However, data regarding the cellular and molecular effects of these treatments on the developing brain is still lacking due to a lack of a reliable animal model that targets the neonatal brain. To address this gap in knowledge we determined the effects of MO or CD on the cell death of neonatal cortical explant cultures that were exposed to oxycodone (OXY) in utero. Sprague Dawley rats were randomized and implanted with programmable infusion pumps before mating to receive either the OXY (dose increasing from 1.21-1.90 mg/kg/day to a maximum dose of 2.86-3.49 mg/kg/day) or normal saline (NS) throughout pregnancy and until one week after delivery. Male and female rat pups were sacrificed on postnatal day 4, and the prefrontal cortex (PFC) and hippocampus (HC) were dissected and treated with MO (0.10-1.00 µM) or CD (1.20-120.00 µM) in culture media. After 5 days of treatment the explants were labeled with propidium iodide to detect cell death. Dead cells were analyzed and counted under fluorescence microscopy. In explants from the PFC, cell death was greater in those prenatally exposed to OXY and postnatally treated with MO (OXY/MO) (736.8 ± 76.5) compared to OXY/CD (620.9 ± 75.0; p = 0.005). In the HC explants, mean cell death counts were not significantly different between groups regardless of prenatal exposure or postnatal treatment (p = 0.19). The PFC is vital in controlling higher-order executive functions such as behavioral flexibility, learning and working memory. Therefore, our finding is consistent with executive function problems in children with prenatal opioid exposure.
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Affiliation(s)
- Thitinart Sithisarn
- Department of Pediatrics, University of Kentucky, Lexington KY, United States
| | - Sandra J Legan
- Department of Physiology, University of Kentucky, Lexington KY, United States
| | - Philip M Westgate
- Department of Biostatistics, University of Kentucky, Lexington KY, United States
| | - Henrietta S Bada
- Department of Pediatrics, University of Kentucky, Lexington KY, United States
| | - Melinda E Wilson
- Department of Physiology, University of Kentucky, Lexington KY, United States
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Choi S, Stein MD, Raifman J, Rosenbloom D, Clark JA. Estimating the impact on initiating medications for opioid use disorder of state policies expanding Medicaid and prohibiting substance use during pregnancy. Drug Alcohol Depend 2021; 229:109162. [PMID: 34768053 PMCID: PMC8671210 DOI: 10.1016/j.drugalcdep.2021.109162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/15/2021] [Accepted: 10/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Medicaid expansion increased access to addiction treatment services for pregnant women. However, states' imposition of civil or criminal child abuse sanctions for drug use during pregnancy could inhibit access to treatment. We estimated the effects of Medicaid expansion on pregnant women's medications for opioid use disorder (MOUD) use, and its interaction with statutes that prohibit substance use during pregnancy. METHODS Using the Treatment Episode Dataset for Discharge (2010-2018), we identified the initial treatment episode of pregnant women with opioid use disorder (OUD). We described changes in MOUD use and estimated adjusted difference-in-differences and event study models to evaluate differences in changes in MOUD between states that prohibit substance use during pregnancy and states that do not. FINDINGS Among a total of 16,070 treatment episodes for pregnant women with OUD from 2010 to 2018, most (74%) were in states that expanded Medicaid. By one year post-expansion, the proportion of episodes receiving MOUD in states not prohibit substance use during pregnancy increased by 8.7% points (95% CI: 2.7, 14.7) from the pre-expansion period compared to a 5.6% point increase in states prohibiting substance use during pregnancy (95% CI: -3.3, 14.8). In adjusted event study analysis, the expansion was associated with an increase in MOUD use by 15.3% by year 2 in states not prohibiting versus 1.5% percentage points in states prohibiting substance use during pregnancy, respectively. CONCLUSIONS State policies prohibiting substance use during pregnancy may limit the salutary effects of Medicaid expansion for pregnant women who could benefit from MOUD treatment.
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Affiliation(s)
- Sugy Choi
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA 02118, USA; Department of Population Health, New York University Grossman School of Medicine, New York, NY 10016, USA.
| | - Michael D. Stein
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts 02118, USA
| | - Julia Raifman
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts 02118, USA
| | - David Rosenbloom
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts 02118, USA
| | - Jack A Clark
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts 02118, USA
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Abraham EJ, Danis DO, Levi JR. Association Between Neonates With Laryngomalacia and Neonatal Abstinence Syndrome. Ann Otol Rhinol Laryngol 2021; 131:946-953. [PMID: 34595938 DOI: 10.1177/00034894211048278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Laryngomalacia (LM) is the most common congenital anomaly of the larynx. The cause of LM is still largely unknown, but a neurological mechanism has gained the most acceptance. There have not been any studies examining the prevalence of LM in infants with Neonatal Abstinence Syndrome (NAS). The aim of our study is to determine if infants with NAS are more likely to be diagnosed with LM. METHODS This study was a population-based inpatient registry analysis. We examined nationwide neonatal discharges in 2016 using the Kids' Inpatient Database (KID). Only patients listed as neonates were included. The International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) codes for neonatal withdrawal symptoms from maternal use of drugs of addiction (P96.1) and diagnoses denoting LM were used. To quantify associations between the LM and NAS groups, prevalence rates and odds ratios (ORs) were used. RESULTS There were 3 970 065 weighted neonatal discharges in the 2016 KID. Among patients included in our dataset, 0.809% (32 128) had NAS and 0.075% (2974) had LM. There was an increased odds ratio for neonates with NAS and LM (OR of 2.85, 95% CI = 2.24-3.63) compared to infants without NAS. Multiple logistic regression accounting for possible confounders produced an adjusted OR of 1.68 (95% CI = 1.29-2.19). CONCLUSION Our study found an association between NAS and LM. This suggests that prenatal exposure to opioids or possibly the sequelae of withdrawal symptoms may be risk factors for the development of LM.
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Affiliation(s)
- Elizabeth J Abraham
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston, MA, USA
| | - David O'Neil Danis
- Department of Otolaryngology-Head and Neck Surgery, Tufts Medical Center, Boston, MA, USA
| | - Jessica R Levi
- Department of Otolaryngology-Head and Neck Surgery, Boston Medical Center, Boston, MA, USA
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Labella MH, Eiden RD, Roben CKP, Dozier M. Adapting an Evidence-Based Home Visiting Intervention for Mothers With Opioid Dependence: Modified Attachment and Biobehavioral Catch-up. Front Psychol 2021; 12:675866. [PMID: 34489793 PMCID: PMC8418066 DOI: 10.3389/fpsyg.2021.675866] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/13/2021] [Indexed: 01/10/2023] Open
Abstract
Infants born to mothers who are dependent on opioids often have difficulty regulating behavior and physiology at birth. Without sensitive maternal care, these infants are at risk for ongoing problems with self-regulation. Mothers who are dependent on opioids may experience challenges related to their substance use (e.g., unsupportive and/or risky environment, impulse control and reward system problems) that increase the likelihood of insensitive parenting in the absence of effective intervention. In this paper, we describe a home-visiting intervention we have adapted to enhance sensitive, responsive caregiving tailored to the specific needs of mothers with opioid dependence. The original intervention, Attachment and Biobehavioral Catch-up (ABC), was designed for mothers of infants aged 6-24 months who were exposed to early adversity. ABC has been shown to enhance sensitive parenting as well as children's behavioral and biological functioning, with positive outcomes extending into at least middle childhood. Mothers who are opioid dependent need earlier support than provided by ABC because opioid-exposed infants are often vulnerable at birth. The adapted intervention (modified ABC or mABC) includes one prenatal session and one early postnatal session, followed by 10 sessions every 2-3 weeks. In the initial two sessions in particular, mothers are helped to anticipate the challenges of caring for a baby who may be difficult to soothe while nonetheless providing sensitive care. mABC is intended to help mothers see the importance of responding sensitively so as to help infants overcome the developmental risks associated with opioid exposure. Additionally, mABC is structured to support mothers with the challenges of early parenting, especially if the mother herself was not parented sensitively. Throughout, the focus is on helping the mother nurture the distressed infant, attend to the infant's signals, and avoid behaving in overstimulating or intrusive ways. Case examples are presented that highlight both the challenges of working with this population as well as the gains made by mothers.
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Affiliation(s)
- Madelyn H. Labella
- Department of Psychological and Brain Sciences, University of Delaware, Newark, DE, United States
| | - Rina D. Eiden
- Department of Psychology, Pennsylvania State University, University Park, PA, United States
| | - Caroline K. P. Roben
- Department of Psychological and Brain Sciences, University of Delaware, Newark, DE, United States
| | - Mary Dozier
- Department of Psychological and Brain Sciences, University of Delaware, Newark, DE, United States
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Abstract
BACKGROUND Neonatal abstinence syndrome (NAS) due to opioid withdrawal may result in disruption of the mother-infant relationship, sleep-wake abnormalities, feeding difficulties, weight loss, seizures and neurodevelopmental problems. OBJECTIVES To assess the effectiveness and safety of using an opioid for treatment of NAS due to withdrawal from opioids in newborn infants. SEARCH METHODS We ran an updated search on 17 September 2020 in CENTRAL via Cochrane Register of Studies Web and MEDLINE via Ovid. We also searched clinical trials databases, conference proceedings and the reference lists of retrieved articles for eligible trials. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi- and cluster-RCTs which enrolled infants born to mothers with opioid dependence and who were experiencing NAS requiring treatment with an opioid. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trial eligibility and risk of bias, and independently extracted data. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included 16 trials (1110 infants) with NAS secondary to maternal opioid use in pregnancy. Seven studies at low risk of bias were included in sensitivity analysis. Opioid versus no treatment / usual care: a single trial (80 infants) of morphine and supportive care versus supportive care alone reported no difference in treatment failure (risk ratio (RR) 1.29, 95% confidence interval (CI) 0.41 to 4.07; very low certainty evidence). No infant had a seizure. The trial did not report mortality, neurodevelopmental disability and adverse events. Morphine increased days hospitalisation (mean difference (MD) 15.00, 95% CI 8.86 to 21.14; very low certainty evidence) and treatment (MD 12.50, 95% CI 7.52 to 17.48; very low certainty evidence), but decreased days to regain birthweight (MD -2.80, 95% CI -5.33 to -0.27) and duration (minutes) of supportive care each day (MD -197.20, 95% CI -274.15 to -120.25). Morphine versus methadone: there was no difference in treatment failure (RR 1.59, 95% CI 0.95 to 2.67; 2 studies, 147 infants; low certainty evidence). Seizures, neonatal or infant mortality and neurodevelopmental disability were not reported. A single study reported no difference in days hospitalisation (MD 1.40, 95% CI -3.08 to 5.88; 116 infants; low certainty evidence), whereas data from two studies found an increase in days treatment (MD 2.71, 95% CI 0.22 to 5.21; 147 infants; low certainty) for infants treated with morphine. A single study reported no difference in breastfeeding, adverse events, or out of home placement. Morphine versus sublingual buprenorphine: there was no difference in treatment failure (RR 0.79, 95% CI 0.36 to 1.74; 3 studies, 113 infants; very low certainty evidence). Neonatal or infant mortality and neurodevelopmental disability were not reported. There was moderate certainty evidence of an increase in days hospitalisation (MD 11.45, 95% CI 5.89 to 17.01; 3 studies, 113 infants), and days treatment (MD 12.79, 95% CI 7.57 to 18.00; 3 studies, 112 infants) for infants treated with morphine. A single adverse event (seizure) was reported in infants exposed to buprenorphine. Morphine versus diluted tincture of opium (DTO): a single study (33 infants) reported no difference in days hospitalisation, days treatment or weight gain (low certainty evidence). Opioid versus clonidine: a single study (31 infants) reported no infant with treatment failure in either group. This study did not report seizures, neonatal or infant mortality and neurodevelopmental disability. There was low certainty evidence for no difference in days hospitalisation or days treatment. This study did not report adverse events. Opioid versus diazepam: there was a reduction in treatment failure from use of an opioid (RR 0.43, 95% CI 0.23 to 0.80; 2 studies, 86 infants; low certainty evidence). Seizures, neonatal or infant mortality and neurodevelopmental disability were not reported. A single study of 34 infants comparing methadone versus diazepam reported no difference in days hospitalisation or days treatment (very low certainty evidence). Adverse events were not reported. Opioid versus phenobarbital: there was a reduction in treatment failure from use of an opioid (RR 0.51, 95% CI 0.35 to 0.74; 6 studies, 458 infants; moderate certainty evidence). Subgroup analysis found a reduction in treatment failure in trials titrating morphine to ≧ 0.5 mg/kg/day (RR 0.21, 95% CI 0.10 to 0.45; 3 studies, 230 infants), whereas a single study using morphine < 0.5 mg/kg/day reported no difference compared to use of phenobarbital (subgroup difference P = 0.05). Neonatal or infant mortality and neurodevelopmental disability were not reported. A single study (111 infants) of paregoric versus phenobarbital reported seven infants with seizures in the phenobarbital group, whereas no seizures were reported in two studies (170 infants) comparing morphine to phenobarbital. There was no difference in days hospitalisation or days treatment. A single study (96 infants) reported no adverse events in either group. Opioid versus chlorpromazine: there was a reduction in treatment failure from use of morphine versus chlorpromazine (RR 0.08, 95% CI 0.01 to 0.62; 1 study, 90 infants; moderate certainty evidence). No seizures were reported in either group. There was low certainty evidence for no difference in days treatment. This trial reported no adverse events in either group. None of the included studies reported time to control of NAS. Data for duration and severity of NAS were limited, and we were unable to use these data in quantitative synthesis. AUTHORS' CONCLUSIONS Compared to supportive care alone, the addition of an opioid may increase duration of hospitalisation and treatment, but may reduce days to regain birthweight and the duration of supportive care each day. Use of an opioid may reduce treatment failure compared to phenobarbital, diazepam or chlorpromazine. Use of an opioid may have little or no effect on duration of hospitalisation or treatment compared to use of phenobarbital, diazepam or chlorpromazine. The type of opioid used may have little or no effect on the treatment failure rate. Use of buprenorphine probably reduces duration of hospitalisation and treatment compared to morphine, but there are no data for time to control NAS with buprenorphine, and insufficient evidence to determine safety. There is insufficient evidence to determine the effectiveness and safety of clonidine.
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Affiliation(s)
- Angelika Zankl
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
| | - Jill Martin
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Jane G Davey
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
| | - David A Osborn
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
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Abstract
BACKGROUND Neonatal abstinence syndrome (NAS) due to opioid withdrawal may result in disruption of the mother-infant relationship, sleep-wake abnormalities, feeding difficulties, weight loss, seizures and neurodevelopmental problems. OBJECTIVES To assess the effectiveness and safety of using a sedative versus control (placebo, usual treatment or non-pharmacological treatment) for NAS due to withdrawal from opioids and determine which type of sedative is most effective and safe for NAS due to withdrawal from opioids. SEARCH METHODS We ran an updated search on 17 September 2020 in CENTRAL via CRS Web and MEDLINE via Ovid. We searched clinical trials databases, conference proceedings and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA We included trials enrolling infants with NAS born to mothers with an opioid dependence with more than 80% follow-up and using randomised, quasi-randomised and cluster-randomised allocation to sedative or control. DATA COLLECTION AND ANALYSIS Three review authors assessed trial eligibility and risk of bias, and independently extracted data. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS We included 10 trials (581 infants) with NAS secondary to maternal opioid use in pregnancy. There were multiple comparisons of different sedatives and regimens. There were limited data available for use in sensitivity analysis of studies at low risk of bias. Phenobarbital versus supportive care: one study reported there may be little or no difference in treatment failure with phenobarbital and supportive care versus supportive care alone (risk ratio (RR) 2.73, 95% confidence interval (CI) 0.94 to 7.94; 62 participants; very low-certainty evidence). No infant had a clinical seizure. The study did not report mortality, neurodevelopmental disability and adverse events. There may be an increase in days' hospitalisation and treatment from use of phenobarbital (hospitalisation: mean difference (MD) 20.80, 95% CI 13.64 to 27.96; treatment: MD 17.90, 95% CI 11.98 to 23.82; both 62 participants; very low-certainty evidence). Phenobarbital versus diazepam: there may be a reduction in treatment failure with phenobarbital versus diazepam (RR 0.39, 95% CI 0.24 to 0.62; 139 participants; 2 studies; low-certainty evidence). The studies did not report mortality, neurodevelopmental disability and adverse events. One study reported there may be little or no difference in days' hospitalisation and treatment (hospitalisation: MD 3.89, 95% CI -1.20 to 8.98; 32 participants; treatment: MD 4.30, 95% CI -0.73 to 9.33; 31 participants; both low-certainty evidence). Phenobarbital versus chlorpromazine: there may be a reduction in treatment failure with phenobarbital versus chlorpromazine (RR 0.55, 95% CI 0.33 to 0.92; 138 participants; 2 studies; very low-certainty evidence), and no infant had a seizure. The studies did not report mortality and neurodevelopmental disability. One study reported there may be little or no difference in days' hospitalisation (MD 7.00, 95% CI -3.51 to 17.51; 87 participants; low-certainty evidence) and 0/100 infants had an adverse event. Phenobarbital and opioid versus opioid alone: one study reported no infants with treatment failure and no clinical seizures in either group (low-certainty evidence). The study did not report mortality, neurodevelopmental disability and adverse events. One study reported there may be a reduction in days' hospitalisation for infants treated with phenobarbital and opioid (MD -43.50, 95% CI -59.18 to -27.82; 20 participants; low-certainty evidence). Clonidine and opioid versus opioid alone: one study reported there may be little or no difference in treatment failure with clonidine and dilute tincture of opium (DTO) versus DTO alone (RR 0.09, 95% CI 0.01 to 1.59; 80 participants; very low-certainty evidence). All five infants with treatment failure were in the DTO group. There may be little or no difference in seizures (RR 0.14, 95% CI 0.01 to 2.68; 80 participants; very low-certainty evidence). All three infants with seizures were in the DTO group. There may be little or no difference in mortality after discharge (RR 7.00, 95% CI 0.37 to 131.28; 80 participants; very low-certainty evidence). All three deaths were in the clonidine and DTO group. The study did not report neurodevelopmental disability. There may be little or no difference in days' treatment (MD -4.00, 95% CI -8.33 to 0.33; 80 participants; very low-certainty evidence). One adverse event occurred in the clonidine and DTO group. There may be little or no difference in rebound NAS after stopping treatment, although all seven cases were in the clonidine and DTO group. Clonidine and opioid versus phenobarbital and opioid: there may be little or no difference in treatment failure (RR 2.27, 95% CI 0.98 to 5.25; 2 studies, 93 participants; very low-certainty evidence). One study reported one infant in the clonidine and morphine group had a seizure, and there were no infant mortalities. The studies did not report neurodevelopmental disability. There may be an increase in days' hospitalisation and days' treatment with clonidine and opioid versus phenobarbital and opioid(hospitalisation: MD 7.13, 95% CI 6.38 to 7.88; treatment: MD 7.57, 95% CI 3.97 to 11.17; both 2 studies, 91 participants; low-certainty evidence). There may be little or no difference in adverse events (RR 1.55, 95% CI 0.44 to 5.40; 2 studies, 93 participants; very low-certainty evidence). However, there was oversedation only in the phenobarbital and morphine group; and hypotension, rebound hypertension and rebound NAS only in the clonidine and morphine group. AUTHORS' CONCLUSIONS There is very low-certainty evidence that phenobarbital increases duration of hospitalisation and treatment, but reduces days to regain birthweight and duration of supportive care each day compared to supportive care alone. There is low-certainty evidence that phenobarbital reduces treatment failure compared to diazepam and very low-certainty evidence that phenobarbital reduces treatment failure compared to chlorpromazine. There is low-certainty evidence of an increase in days' hospitalisation and days' treatment with clonidine and opioid compared to phenobarbital and opioid. There are insufficient data to determine the safety and incidence of adverse events for infants treated with combinations of opioids and sedatives including phenobarbital and clonidine.
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Affiliation(s)
- Angelika Zankl
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
| | - Jill Martin
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Jane G Davey
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
| | - David A Osborn
- Department of Neonatal Medicine, RPA Women and Babies, Royal Prince Alfred Hospital, Camperdown, Australia
- Central Clinical School, School of Medicine, The University of Sydney, Sydney, Australia
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Abu Y, Roy S. Prenatal opioid exposure and vulnerability to future substance use disorders in offspring. Exp Neurol 2021; 339:113621. [PMID: 33516730 PMCID: PMC8012222 DOI: 10.1016/j.expneurol.2021.113621] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 01/06/2023]
Abstract
The heightened incidence of opioid use during pregnancy has resulted in unprecedented rates of neonates prenatally exposed to opioids. Prenatal opioid exposure (POE) results in significantly adverse medical, developmental, and behavioral outcomes in offspring. Of growing interest is whether POE contributes to future vulnerability to substance use disorders. The effects of POE on brain development is difficult to assess in humans, as the timing, dose, and route of drug exposure together with complex genetic and environmental factors affect susceptibility to addiction. Preclinical models of POE have allowed us to avoid methodological difficulties and confounding factors of POE in humans. Here, we review the effects of maternal opioid exposure on the developing brain with an emphasis on the neurobiological basis of drug addiction and on preclinical models of POE and their limitations. These studies have indicated that POE increases self-administration of drugs, reward-driven behaviors in the conditioned place paradigm, and locomotor sensitization. While addiction is multifaceted and vulnerability to drug addiction is still inconclusive in human studies of prenatally exposed infants, animal studies do provide a noteworthy corroboration of negative behavioral outcomes.
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Affiliation(s)
- Yaa Abu
- Medical Scientist Training Program, University of Miami Miller School of Medicine, Miami, FL 33136, USA; Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33136, USA
| | - Sabita Roy
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL 33136, USA; Department of Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA.
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Denisova K. Genetic vulnerability of exposures to antenatal maternal treatments in 1- to 2-month-old infants. INFANCY 2021; 26:515-532. [PMID: 33877744 DOI: 10.1111/infa.12398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 12/24/2020] [Accepted: 01/08/2021] [Indexed: 11/30/2022]
Abstract
The growth and maturation of the nervous system are vulnerable during pregnancy. The impact of antenatal exposures to maternal treatments, in the context of genetic vulnerability of the fetus, on sensorimotor functioning in early infancy remains unexplored. Statistical features of head movements obtained from resting-state sleep fMRI scans are examined in 1- to 2-month-old infants, both those at high risk (HR) for autism spectrum disorder (ASD) due to a biological sibling with ASD and at low risk (LR) (N = 56). In utero exposures include maternal prescription medications (psychotropic Rx: N = 3HR ; N = 5LR vs. non-psychotropic Rx: N = 11HR ; N = 9LR vs. none: N = 11HR ; N = 16LR ), psychiatric diagnoses (two or more Dx2 : N = 5HR ; N = 1LR ; one Dx1 : N = 4HR ; N = 5LR ; no Dx: N = 12HR ; N = 19LR ), infections requiring antibiotics (infection: N = 5HR ; N = 8LR ; no infection: N = 20HR ; N = 22LR ), or high fever (fever: N = 2HR ; N = 2LR ; no fever: N = 23HR ; N = 27LR ). Movements with significantly higher variability are detected in infants exposed to psychotropics (e.g., opioid analgesics) and those whose mothers had fever, and this effect is significantly worse for infants at HR for ASD. Movements are significantly less variable in HR infants with non-psychotropic exposures (e.g., antibiotics). Heightened number of psychiatric or mental health conditions is associated with noisier movements in both risk groups. Genetic vulnerability due to in utero exposure to maternal treatments is an important future approach to be advanced in the field of early mind and brain development.
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Affiliation(s)
- Kristina Denisova
- Sackler Institute for Developmental Psychobiology, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Division of Developmental Neuroscience, New York State Psychiatric Institute, New York, NY, USA.,Biobehavioral Sciences Department, Teachers College Columbia University, New York, NY, USA
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Lake ET, French R, Clark RRS, O'Rourke K, Lorch S. Newborns With Neonatal Abstinence Syndrome Are Concentrated in Poorer-Quality Hospitals. Hosp Pediatr 2021; 11:342-349. [PMID: 33737332 PMCID: PMC8120655 DOI: 10.1542/hpeds.2020-003145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To determine the extent to which newborns with neonatal abstinence syndrome (NAS) are concentrated in some hospitals as compared with newborns without NAS and whether care quality and safety differed among these hospitals. We hypothesized that newborns with NAS would be cared for in poorer-quality hospitals. METHODS Secondary analysis of 3 2016 data sets: (1) the panel study of effects of changes in nursing on patient outcomes-US survey of hospital registered nurses regarding work conditions and safety, (2) inpatient discharge abstracts, and (3) the American Hospital Association annual survey. Newborns in 266 hospitals from the 4 states where the panel study of effects of changes in nursing on patient outcomes was conducted were included. We used Lorenz curves to determine if newborns with NAS were concentrated in different hospitals than newborns without NAS and whether care quality and safety differed among those hospitals. Quality and safety were assessed by staff nurses by using standard survey questions. RESULTS Of the 659 403 newborns in this study, 3130 were diagnosed with noniatrogenic NAS. We found that newborns with NAS were cared for in different hospitals compared with newborns without NAS (Gini coefficient 0.62, 95% confidence interval, 0.56-0.68) and that the hospitals in which they received care were rated as having poorer quality and safety (Gini coefficient 0.12, 95% confidence interval, 0.01-0.23). CONCLUSIONS Newborns with NAS are cared for in poorer-quality hospitals than other newborns. Our findings are of concern because poorer-quality care is linked to patient outcomes. As stakeholders seek to address the opioid epidemic and improve outcomes of newborns with NAS, our findings suggest the importance of examining hospital factors.
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Affiliation(s)
- Eileen T Lake
- Center for Health Outcomes and Policy Research, School of Nursing and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel French
- Center for Health Outcomes and Policy Research, School of Nursing and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rebecca R S Clark
- Center for Health Outcomes and Policy Research, School of Nursing and
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathleen O'Rourke
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Scott Lorch
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Radhakrishna U, Vishweswaraiah S, Uppala LV, Szymanska M, Macknis J, Kumar S, Saleem-Rasheed F, Aydas B, Forray A, Muvvala SB, Mishra NK, Guda C, Carey DJ, Metpally RP, Crist RC, Berrettini WH, Bahado-Singh RO. Placental DNA methylation profiles in opioid-exposed pregnancies and associations with the neonatal opioid withdrawal syndrome. Genomics 2021; 113:1127-1135. [PMID: 33711455 DOI: 10.1016/j.ygeno.2021.03.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 12/29/2020] [Accepted: 03/02/2021] [Indexed: 12/11/2022]
Abstract
Opioid abuse during pregnancy can result in Neonatal Opioid Withdrawal Syndrome (NOWS). We investigated genome-wide methylation analyses of 96 placental tissue samples, including 32 prenatally opioid-exposed infants with NOWS who needed therapy (+Opioids/+NOWS), 32 prenatally opioid-exposed infants with NOWS who did not require treatment (+Opioids/-NOWS), and 32 prenatally unexposed controls (-Opioids/-NOWS, control). Statistics, bioinformatics, Artificial Intelligence (AI), including Deep Learning (DL), and Ingenuity Pathway Analyses (IPA) were performed. We identified 17 dysregulated pathways thought to be important in the pathophysiology of NOWS and reported accurate AI prediction of NOWS diagnoses. The DL had an AUC (95% CI) =0.98 (0.95-1.0) with a sensitivity and specificity of 100% for distinguishing NOWS from the +Opioids/-NOWS group and AUCs (95% CI) =1.00 (1.0-1.0) with a sensitivity and specificity of 100% for distinguishing NOWS versus control and + Opioids/-NOWS group versus controls. This study provides strong evidence of methylation dysregulation of placental tissue in NOWS development.
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Affiliation(s)
- Uppala Radhakrishna
- Department of Obstetrics and Gynecology, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA.
| | - Sangeetha Vishweswaraiah
- Department of Obstetrics and Gynecology, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Lavanya V Uppala
- College of Information Science & Technology, University of Nebraska at Omaha, Peter Kiewit Institute, Omaha, NE, USA
| | - Marta Szymanska
- Department of Obstetrics and Gynecology, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | | | - Sandeep Kumar
- Department of Pathology, Beaumont Health System, Royal Oak, MI, USA
| | - Fozia Saleem-Rasheed
- Department of Newborn Medicine, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
| | - Buket Aydas
- Department of Healthcare Analytics, Meridian Health Plans, Detroit, MI, USA
| | - Ariadna Forray
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | | | - Nitish K Mishra
- Department of Genetics, Cell Biology & Anatomy College of Medicine, University of Nebraska Medical Center Omaha, NE, USA
| | - Chittibabu Guda
- Department of Genetics, Cell Biology & Anatomy College of Medicine, University of Nebraska Medical Center Omaha, NE, USA
| | - David J Carey
- Department of Molecular and Functional Genomics, Geisinger, Danville, PA, USA
| | - Raghu P Metpally
- Department of Molecular and Functional Genomics, Geisinger, Danville, PA, USA
| | - Richard C Crist
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Wade H Berrettini
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Geisinger Clinic, Danville, PA, USA
| | - Ray O Bahado-Singh
- Department of Obstetrics and Gynecology, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
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Hocker AD, Morrison NR, Selby ML, Huxtable AG. Maternal Methadone Destabilizes Neonatal Breathing and Desensitizes Neonates to Opioid-Induced Respiratory Frequency Depression. Front Physiol 2021; 12:604593. [PMID: 33716765 PMCID: PMC7946987 DOI: 10.3389/fphys.2021.604593] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 02/08/2021] [Indexed: 11/28/2022] Open
Abstract
Pregnant women and developing infants are understudied populations in the opioid crisis, despite the rise in opioid use during pregnancy. Maternal opioid use results in diverse negative outcomes for the fetus/newborn, including death; however, the effects of perinatal (maternal and neonatal) opioids on developing respiratory circuitry are not well understood. Given the profound depressive effects of opioids on central respiratory networks controlling breathing, we tested the hypothesis that perinatal opioid exposure impairs respiratory neural circuitry, creating breathing instability. Our data demonstrate maternal opioids increase apneas and destabilize neonatal breathing. Maternal opioids also blunted opioid-induced respiratory frequency depression acutely in neonates; a unique finding since adult respiratory circuity does not desensitize to opioids. This desensitization normalized rapidly between postnatal days 1 and 2 (P1 and P2), the same age quantal slowing emerged in respiratory rhythm. These data suggest significant reorganization of respiratory rhythm generating circuits at P1-2, the same time as the preBötzinger Complex (key site of respiratory rhythm generation) becomes the dominant respiratory rhythm generator. Thus, these studies provide critical insight relevant to the normal developmental trajectory of respiratory circuits and suggest changes to mutual coupling between respiratory oscillators, while also highlighting how maternal opioids alter these developing circuits. In conclusion, the results presented demonstrate neurorespiratory disruption by maternal opioids and blunted opioid-induced respiratory frequency depression with neonatal opioids, which will be important for understanding and treating the increasing population of neonates exposed to gestational opioids.
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Currie CL, Tough SC. Adverse childhood experiences are associated with illicit drug use among pregnant women with middle to high socioeconomic status: findings from the All Our Families Cohort. BMC Pregnancy Childbirth 2021; 21:133. [PMID: 33583407 PMCID: PMC7882074 DOI: 10.1186/s12884-021-03591-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 01/26/2021] [Indexed: 11/10/2022] Open
Abstract
Background Adverse childhood experiences (ACEs) are associated with illicit drug use among pregnant women who are socioeconomically vulnerable. While it is assumed that the impact of ACEs on illicit drug use in pregnancy is reduced among women with higher socioeconomic status (SES), this assumption is not well tested in the literature. The objective of this study was to examine the impact of maternal ACEs on illicit drug use in a community-based sample of pregnant women with middle to high SES. Methods This study is a secondary analysis of a prospective cohort study that collected data from 1660 women during and after pregnancy in Calgary, Canada between 2008 and 2011 using mailed surveys. Illicit drug use in pregnancy was self-reported by women at 34–36 weeks gestation. An established scale examined maternal ACEs before 18 years. Logistic regression models and 95% confidence intervals tested associations between maternal ACE scores and illicit drug use in pregnancy. Results Overall, 3.1% of women in this predominantly married, well-educated, middle and upper middle income sample reported illicit drug use in pregnancy. Women with 2–3 ACEs had more than a two-fold increase, and women with 4 or more ACEs had almost a four-fold increase in illicit drug use in pregnancy, relative to women with 0–1 ACEs after adjustment for confounders. Exposure to child abuse was more consistently associated with illicit drug use in pregnancy than exposure to household dysfunction in childhood. Conclusions Maternal ACEs were common and associated with a moderate increase in the odds of illicit drug use in pregnancy among Canadian women with middle to high SES.
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Affiliation(s)
- Cheryl L Currie
- Faculty of Health Sciences, University of Lethbridge, M3083 Markin Hall, 4401 University Drive, Lethbridge, Alberta, T1K 3M4, Canada.
| | - Suzanne C Tough
- Cummings School of Medicine, University of Calgary, Calgary, Canada
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Liang OS, Chen Y, Bennett DS, Yang CC. Identifying Self-Management Support Needs for Pregnant Women With Opioid Misuse in Online Health Communities: Mixed Methods Analysis of Web Posts. J Med Internet Res 2021; 23:e18296. [PMID: 33538695 PMCID: PMC7892281 DOI: 10.2196/18296] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 12/11/2020] [Accepted: 12/20/2020] [Indexed: 12/18/2022] Open
Abstract
Background The current opioid crisis in the United States impacts broad population groups, including pregnant women. Opioid use during pregnancy can affect the health and wellness of both mothers and their infants. Understanding women’s efforts to self-manage opioid use or misuse in pregnancy is needed to identify intervention points for improving maternal outcomes. Objective This study aims to identify the characteristics of women in an online health community (OHC) with opioid use or misuse during pregnancy and the self-management support needs of these mothers. Methods A total of 200 web posts by pregnant women with opioid use participating in an OHC were double coded. Concepts and their thematic connections were identified through an inductive process until theoretical saturation was reached. Statistical tests were performed to identify patterns. Results The majority of pregnant women (150/200, 75.0%) in the OHC exhibited signs of misuse, and 62.5% (125/200) of the participants were either contemplating or pursuing dosage reduction. Self-managed withdrawal was more common (P<.001) than professional treatment among the population. A total of 5 themes of self-management support needs were identified as women sought information about the potential adverse effects of gestational opioid use, protocols for self-managed withdrawal, pain management safety during pregnancy, hospital policies and legal procedures related to child protection, and strategies for navigating offline support systems. In addition, 58.5% (117/200) of the pregnant women expressed negative emotions, of whom only 10.2% (12/117) sought to address their emotional needs with the help of the OHC. Conclusions OHCs provide vital self-management support for pregnant women with opioid use or misuse. Women pursuing self-managed dosage reduction are prone to misinformation and repeated relapses, which can result in extreme measures to avoid testing positive for drug use at labor. The study findings provide evidence for public policy considerations, including universal screening of substance use for pregnant women, emphasis on treatment rather than legal punishment, and further expansion of the Drug Addiction Treatment Act waiver training program. The improvement of web-based platforms that can organize geo-relevant information, dispense clinically validated withdrawal schedules, and offer structured peer support is envisioned for harm reduction among pregnant women who opt for self-management of opioid misuse.
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Affiliation(s)
- Ou Stella Liang
- College of Computing and Informatics, Drexel University, Philadelphia, PA, United States
| | - Yunan Chen
- Donald Bren School of Information and Computer Sciences, University of California, Irvine, Irvine, CA, United States
| | - David S Bennett
- Department of Psychiatry, College of Medicine, Drexel University, Philadelphia, PA, United States
| | - Christopher C Yang
- College of Computing and Informatics, Drexel University, Philadelphia, PA, United States
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40
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Schwartz AN, Reyes LM, Meschke LL, Kintziger KW. Prenatal Opioid Exposure and ADHD Childhood Symptoms: A Meta-Analysis. CHILDREN-BASEL 2021; 8:children8020106. [PMID: 33557208 PMCID: PMC7913969 DOI: 10.3390/children8020106] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/28/2021] [Accepted: 01/31/2021] [Indexed: 11/16/2022]
Abstract
To systematically investigate the association between prenatal opioid exposure (POE) and attention-deficit hyperactivity disorder (ADHD) symptoms in children 2-18 years old, studies were searched using PubMed, CINAHL, PsycINFO, and Web of Science from January of 1950 to October of 2019. Inclusion criteria were observational studies reporting ADHD symptoms of children with POE compared with non-exposed children or normative data. The study protocol was registered with PROSPERO: CRD42018115967. Two independent reviewers extracted data on hyperactivity/impulsivity, inattention symptoms, ADHD combined subscale symptoms, and sample characteristics. Of 223 articles screened, seven met the inclusion criteria. Data represent 319 children with POE and 1308 non-exposed children from 4.3 to 11.2 mean years from five countries. POE was positively associated with childhood hyperactivity/impulsivity (d = 1.40; 95% CI, 0.49-2.31; p = 0.003), inattention (d = 1.35; 95% CI, 0.69-2.01; p < 0.0001), and combined ADHD symptoms scores (d = 1.27; 95% CI = 0.79-1.75; p < 0.0001). POE was positively associated with ADHD combined symptom scores at preschool (d = 0.83, 95% CI, 0.57, 1.09; p < 0.0001) and school age (d = 1.45, 95% CI, 0.85 to 2.04; p < 0.0001). Results suggest increased risk of ADHD symptoms during school age. Future research is needed to clarify the relationship between biological, social, and environmental risk and ADHD symptoms for children who experienced POE.
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Affiliation(s)
- Ashlyn N. Schwartz
- The Department of Public Health, The University of Tennessee, Knoxville, TN 37996, USA; (L.L.M.); (K.W.K.)
- Correspondence: ; Tel.: +1-678-447-3930
| | - Lucia M. Reyes
- The Department of Child and Family Studies, The University of Tennessee, Knoxville, TN 37996, USA;
| | - Laurie L. Meschke
- The Department of Public Health, The University of Tennessee, Knoxville, TN 37996, USA; (L.L.M.); (K.W.K.)
| | - Kristina W. Kintziger
- The Department of Public Health, The University of Tennessee, Knoxville, TN 37996, USA; (L.L.M.); (K.W.K.)
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McPhail BT, Emoto C, Butler D, Fukuda T, Akinbi H, Vinks AA. Opioid Treatment for Neonatal Opioid Withdrawal Syndrome: Current Challenges and Future Approaches. J Clin Pharmacol 2021; 61:857-870. [PMID: 33382111 DOI: 10.1002/jcph.1811] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/26/2020] [Indexed: 02/06/2023]
Abstract
Chronic intrauterine exposure to psychoactive drugs often results in neonatal opioid withdrawal syndrome (NOWS). When nonpharmacologic measures are insufficient in controlling NOWS, morphine, methadone, and buprenorphine are first-line medications commonly used to treat infants with NOWS because of in utero exposure to opioids. Research suggests that buprenorphine may be the leading drug therapy used to treat NOWS when compared with morphine and methadone. Currently, there are no consensus or standardized treatment guidelines for medications prescribed for NOWS. Opioids used to treat NOWS exhibit large interpatient variability in pharmacokinetics (PK) and pharmacodynamic (PD) response in neonates. Organ systems undergo rapid maturation after birth that may alter drug disposition and exposure for any given dose during development. Data regarding the PK and PD of opioids in neonates are sparse. Pharmacometric methods such as physiologically based pharmacokinetic and population pharmacokinetic modeling can be used to explore factors predictive of some of the variability associated with the PK/PD of opioids in newborns. This review discusses the utility of pharmacometric techniques for enhancing precision dosing in infants requiring opioid treatment for NOWS. Applying these approaches may contribute to optimizing the outcome by reducing cumulative drug exposure, mitigating adverse drug effects, and reducing the burden of NOWS in neonates.
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Affiliation(s)
- Brooks T McPhail
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Biomedical Sciences, University of South Carolina School of Medicine Greenville, Greenville, South Carolina, USA
| | - Chie Emoto
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dawn Butler
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Tsuyoshi Fukuda
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Henry Akinbi
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Perinatal Institute, Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Dale RC, Ford LT, Street C. Are point-of-care urine drug testing devices suitable for antenatal drug screening? A study verifying the Alere® Drug Screen Test Cup for the detection of six classes of drug in a pregnant population. Ann Clin Biochem 2021; 58:166-173. [PMID: 33435699 DOI: 10.1177/0004563221990699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Currently, there are no national guidelines for antenatal drug testing. At Colchester Hospital, we use a strategy of screen-only using point-of-care testing to detect illicit drug use in pregnancy. To determine the suitability of this approach, we have compared the results of urine analysis by point-of-care testing with another NHS specialist clinical toxicology service that uses confirmation mass spectrometry. METHODS A total of 482 anonymized random urine specimens from antenatal clinics were tested for six drug classes: amphetamine, benzodiazepines, buprenorphine, cocaine, methadone and opiates using the Alere™ Drug Screen Urine Test Cup. The manufacturer's claims for positive cut-off and result stability were verified using spiked blank urine. Confirmatory testing was performed using ultra-performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS) for detection of 26 individual drugs. RESULTS Of 473 urine samples with adequate volume for point-of-care screening, 4.4% tested positive: 19 opiate and 2 cocaine. Concordance between point-of-care screening and UPLC-MS/MS confirmation was 97.9% for all drugs and 78.9% for opiates. Using spiked urine, only positive results for opiates were stable when read up to the manufacturer's recommended time of 60 min. CONCLUSIONS The key advantages of using point-of-care devices to detect drug use in pregnancy are that is convenient and cheap. However, the clinical utility of point-of-care testing is limited by its poor sensitivity. Best practice is to confirm results using a more specific and sensitive method. As a result of this study, we are now reviewing our own procedures to consider introducing routine confirmation by mass spectrometry.
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Affiliation(s)
- Rachel C Dale
- Blood Sciences Department, North East Essex and Suffolk Pathology Services, Colchester, UK
| | - Loretta T Ford
- West Midlands Toxicology Laboratory, Birmingham City Hospital, Birmingham, UK
| | - Catherine Street
- Blood Sciences Department, North East Essex and Suffolk Pathology Services, Colchester, UK
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Hussaini KS, Drummond D, Bartoshesky LE, Acheson A, Stomieroski K, Paul DA, Kirby RS. Assessing the relationship between neonatal abstinence syndrome and birth defects in Delaware. Birth Defects Res 2021; 113:144-151. [PMID: 32996723 PMCID: PMC10947796 DOI: 10.1002/bdr2.1811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/14/2020] [Accepted: 09/17/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Neonatal abstinence syndrome (NAS) is a withdrawal syndrome in newborns and is frequently caused by maternal opioid use during pregnancy. Our study examines whether NAS is associated with birth defects in Delaware. METHODS We conducted a retrospective analysis of linked Delaware birth certificate data (BCD), hospital discharge data (HDD), and birth defects registry (BDR) data to examine the association between NAS and birth defects for all hospital births to Delaware residents from 2010 to 2017. Birth defects data were abstracted from medical records from Delaware's BDR. We used International Classification of Diseases Ninth and Tenth Revision Clinical Modification (ICD-9-CM/ICD-10-CM) 779.5 and P96.1 codes to determine NAS using HDD and excluded iatrogenic cases of NAS. We estimated crude and adjusted odds ratio with 95% confidence intervals (CIs). RESULTS During 2010-2017, there were 2,784 cases of birth defects and 1,651 cases of NAS in Delaware. Among infants with a diagnosis of NAS, 56 also had a birth defect (3.4%), similar to 2,728 birth defects among 79,636 infants without a diagnosis of NAS (3.4%). We found no statistically significant association between an NAS diagnosis and birth defects (adjusted odds ratios = 1.0; 95% CI: 0.8-1.3). CONCLUSIONS Our multiyear state-wide study using linked BCD, HDD, and BDR data for Delaware did not show a statistically significant association between infants diagnosed with NAS and birth defects, overall.
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Affiliation(s)
- Khaleel S. Hussaini
- Field Support Branch, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
- Division of Public Health, Delaware Department of Health and Social Services, Dover, Delaware
| | - Dana Drummond
- Drug Overdose Surveillance Epidemiologist, Division of Prevention and Community Health, Washington State Department of Health, Tumwater, Washington
| | - Louis E. Bartoshesky
- Pediatrics, ChristianaCare, Newark, Delaware
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Amy Acheson
- Center for Women’s, Infants’ and Children’s Health Research, ChristianaCare, Newark, Delaware
| | - Kathleen Stomieroski
- Center for Women’s, Infants’ and Children’s Health Research, ChristianaCare, Newark, Delaware
| | - David A. Paul
- Pediatrics, ChristianaCare, Newark, Delaware
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Russell S. Kirby
- Distinguished Professor and Marrell Endowed Chair, Birth Defects Surveillance ProgramCollege of Public Health, University of South Florida, Tampa, Florida
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Kushnir A, Garretson C, Mariappan M, Stahl G. Use of Phenobarbital to Treat Neonatal Abstinence Syndrome From Exposure to Single vs. Multiple Substances. Front Pediatr 2021; 9:752854. [PMID: 35174112 PMCID: PMC8841756 DOI: 10.3389/fped.2021.752854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/21/2021] [Indexed: 11/17/2022] Open
Abstract
Drug use in pregnancy is a major public health issue. Intrauterine exposure to opioids alone or in addition to other substances may lead to neonatal abstinence syndrome (NAS). Little consensus exists on optimal therapy, especially for those exposed to multiple drugs. We aim to determine whether the use of opioids alone vs. in combination with phenobarbital will affect short-term neonatal outcomes. This retrospective review of infants admitted to the neonatal intensive care unit (NICU) included newborns ≥35 weeks of gestation exposed to opioids, or multiple substances including opioids, in utero. Treatment with opioids alone, and addition of phenobarbital as initial therapy vs. rescue, was evaluated. Out of 182 newborns, 54 (30%) were exposed to methadone alone vs. 128 (70%) to multiple drugs. Length of stay (LOS) in the hospital was not significantly affected (p = 0.684) by single vs. multiple drug exposure in utero. Treatment of NAS with opioid alone resulted in significantly shorter LOS (27 days), as compared to those treated with opioid and phenobarbital (45 days, p < 0.001). LOS was further prolonged in those treated with phenobarbital as a "rescue" medication in addition to an opioid (49 days, p < 0.0001). There was a significant increase in LOS and duration of opioid treatment for all infants treated with phenobarbital, both in those exposed to opioids alone, and to multiple substances in utero.
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Affiliation(s)
- Alla Kushnir
- Division of Neonatology, Department of Pediatric, Cooper University Hospital, Camden, NJ, United States.,Department of Pediatric, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Cynthia Garretson
- Ambulatory Clinical Practice, Cooper University Hospital, Cherry Hill, NJ, United States
| | - Maheswari Mariappan
- Division of Neonatology, Department of Pediatric, Cooper University Hospital, Camden, NJ, United States
| | - Gary Stahl
- Department of Pediatric, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States
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Wijekoon N, Aduroja O, Biggs JM, El-Metwally D, Gopalakrishnan M. Model-Based Approach to Improve Clinical Outcomes in Neonates With Opioid Withdrawal Syndrome Using Real-World Data. Clin Pharmacol Ther 2020; 109:243-252. [PMID: 33119888 DOI: 10.1002/cpt.2093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/11/2020] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Nadeesri Wijekoon
- Department of Mathematics and Statistics, University of Maryland, Baltimore County, Baltimore, Maryland, USA
| | - Oluwatobi Aduroja
- Department of Pediatrics, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Jessica M Biggs
- University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Dina El-Metwally
- Department of Pediatrics, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
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Prenatal Opioid Exposure Enhances Responsiveness to Future Drug Reward and Alters Sensitivity to Pain: A Review of Preclinical Models and Contributing Mechanisms. eNeuro 2020; 7:ENEURO.0393-20.2020. [PMID: 33060181 PMCID: PMC7768284 DOI: 10.1523/eneuro.0393-20.2020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/01/2020] [Accepted: 10/05/2020] [Indexed: 12/21/2022] Open
Abstract
The opioid crisis has resulted in an unprecedented number of neonates born with prenatal opioid exposure (POE); however, the long-term effects of POE on offspring behavior and neurodevelopment remain relatively unknown. The advantages and disadvantages of the various preclinical POE models developed over the last several decades are discussed in the context of clinical and translational relevance. Although considerable and important variability exists among preclinical models of POE, the examination of these preclinical models has revealed that opioid exposure during the prenatal period contributes to maladaptive behavioral development as offspring mature including an altered responsiveness to rewarding drugs and increased pain response. The present review summarizes key findings demonstrating the impact of POE on offspring drug self-administration (SA), drug consumption, the reinforcing properties of drugs, drug tolerance, and other reward-related behaviors such as hypersensitivity to pain. Potential underlying molecular mechanisms which may contribute to this enhanced addictive phenotype in POE offspring are further discussed with special attention given to key brain regions associated with reward including the striatum, prefrontal cortex (PFC), ventral tegmental area (VTA), hippocampus, and amygdala. Improvements in preclinical models and further areas of study are also identified which may advance the translational value of findings and help address the growing problem of POE in clinical populations.
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Clennon EK, Garg B, Duty BD, Caughey AB. Obstetric outcomes of pregnancy complicated by urolithiasis: a retrospective cohort study. J Perinat Med 2020; 49:54-59. [PMID: 32809965 DOI: 10.1515/jpm-2020-0199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/30/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Evaluate the association between urolithiasis during pregnancy and obstetric outcomes outside the context of urological intervention. METHODS We conducted a retrospective cohort study of singleton, non-anomalous gestations delivered at 23-42 weeks in California from 2007 to 2011. Maternal outcomes (preterm delivery [early (<32 weeks) and late (<37 weeks)], preeclampsia, gestational diabetes, cesarean deliveries, urinary tract infection [UTI] at delivery, chorioamnionitis, endomyometritis, and maternal sepsis) and newborn outcomes (seizure, respiratory distress syndrome, hypoglycemia, jaundice, and neonatal abstinence syndrome [NAS]) were compared using χ2-tests and multivariable logistic regression. RESULTS A total of 2,013,767 pregnancies met inclusion criteria, of which 5,734 (0.28%) were complicated by urolithiasis. Stone disease during pregnancy was associated with 30% greater odds of each early (aOR 1.30; 95% CI 1.19-1.43) and late (aOR 1.29; 95% CI 1.18-1.41) preterm delivery. Cesarean delivery, UTI at delivery, gestational hypertension, gestational diabetes, preeclampsia, and sepsis were all significantly positively associated with urolithiasis. Odds of NAS (aOR 2.11; 95% CI 1.27-3.51) and jaundice were significantly greater in the neonates of stone-forming patients (aOR 1.08; 95% CI 1.01-1.16). CONCLUSIONS Urolithiasis during pregnancy was associated with 30% greater odds of preterm delivery and increased risk of myriad metabolic, hypertensive, and infectious disorders of gestation. Neonates born to stone-forming patients were more than twice as likely to develop neonatal abstinence syndrome but did not have significantly greater odds of complications of prematurity.
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Affiliation(s)
- Emily K Clennon
- Oregon Health & Science University, Departments of Obstetrics and Gynecology and Urology, Portland, OR, USA
| | - Bharti Garg
- Oregon Health & Science University, Departments of Obstetrics and Gynecology and Urology, Portland, OR, USA
| | - Brian D Duty
- Oregon Health & Science University, Departments of Obstetrics and Gynecology and Urology, Portland, OR, USA
| | - Aaron B Caughey
- Oregon Health & Science University, Departments of Obstetrics and Gynecology and Urology, Portland, OR, USA
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Mohamed E, Paisley CE, Meyer LC, Bigbee JW, Sato-Bigbee C. Endogenous opioid peptides and brain development: Endomorphin-1 and Nociceptin play a sex-specific role in the control of oligodendrocyte maturation and brain myelination. Glia 2020; 68:1513-1530. [PMID: 32065429 PMCID: PMC11006003 DOI: 10.1002/glia.23799] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 01/30/2020] [Accepted: 02/03/2020] [Indexed: 12/26/2022]
Abstract
The generation of fully functional oligodendrocytes, the myelinating cells of the central nervous system, is preceded by a complex maturational process. We previously showed that the timing of oligodendrocyte differentiation and rat brain myelination were altered by perinatal exposure to buprenorphine and methadone, opioid analogs used for the management of pregnant addicts. Those observations suggested the involvement of the μ-opioid receptor (MOR) and the nociceptin/orphanin FQ receptor (NOR). However, it remained to be determined if these receptors and their endogenous ligands could indeed control the timing of myelination under normal physiological conditions of brain development. We now found that the endogenous MOR ligand endomorphin-1 (EM-1) exerts a striking stimulatory action on cellular and morphological maturation of rat pre-oligodendrocytes, but unexpectedly, these effects appear to be restricted to the cells from the female pups. Critically, this stimulation is abolished by coincubation with the endogenous NOR ligand nociceptin. Furthermore, NOR antagonist treatment of 9-day-old female pups results in accelerated brain myelination. Interestingly, the lack of sex-dependent differences in developmental brain levels of EM-1 and nociceptin, or oligodendroglial expression of MOR and NOR, suggests that the observed sex-specific responses may be highly dependent on important intrinsic differences between the male and female oligodendrocytes. The discovery of a significant effect of EM-1 and nociceptin in the developing female oligodendrocytes and brain myelination, underscores the need for further studies investigating brain sex-related differences and their implications in opioid use and abuse, pain control, and susceptibility and remyelinating capacity in demyelinating disease as multiple sclerosis.
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Affiliation(s)
- Esraa Mohamed
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Caitlin E Paisley
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Logan C Meyer
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - John W Bigbee
- Department of Anatomy and Neurobiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Carmen Sato-Bigbee
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
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Special High-Risk Populations in Dentistry: The Adolescent Patient, the Elderly Patient, and the Woman of Childbearing Age. Dent Clin North Am 2020; 64:585-595. [PMID: 32448461 DOI: 10.1016/j.cden.2020.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Comprehensive and compassionate treatment of vulnerable patients is an important service to the community, although dental treatment of special populations can represent a challenge. The dental provider must be able to recognize the issues surrounding substance use and abuse, coordinate care with medical providers, and build a trusting provider-patient relationship to achieve success. Open conversations regarding expectations of pain, and the risks, benefits, and alternatives to opioids are important aspects of the best care of these patients.
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Mravčík V, Nechanská B, Gabrhelík R, Handal M, Mahic M, Skurtveit S. Socioeconomic characteristics of women with substance use disorder during pregnancy and neonatal outcomes in their newborns: A national registry study from the Czech Republic. Drug Alcohol Depend 2020; 209:107933. [PMID: 32109712 DOI: 10.1016/j.drugalcdep.2020.107933] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 02/17/2020] [Accepted: 02/18/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Maternal substance use can pose a risk to the fetal health. We studied the background characteristics of women with substance use disorders (SUDs) and selected neonatal outcomes in their children. MATERIAL AND METHODS A database-linkage study was performed. The sample consisted of pregnant women with a SUD during pregnancy (ICD-10 diagnosis F10-F19 except F17, n = 1710), women not diagnosed with a SUD (n = 1,511,310) in Czechia in 2000-2014, and their children. The monitored neonatal outcomes were gestational age, birth weight, preterm birth, and small-for-gestational age (SGA). Binary logistic regression adjusted for age, marital status, education, concurrent substance use, and prenatal care was performed. RESULTS Women with illicit SUDs were younger, more often unmarried, with a lower level of education, a higher abortion rate, a higher smoking rate, and lower compliance to prenatal care than women with a SUD related to alcohol, or sedatives and hypnotics (SH). Women with a SUD had worse socioeconomic situations, poorer pregnancy care, and worse neonatal outcomes than women without a SUD. After adjustment, we found no difference in SGA between the illicit SUD groups and the alcohol and the SH groups. The newborns from all SUD groups had a higher risk of SGA when compared to women without a SUD. However after adjustment, the difference remained significant just in the alcohol group (OR = 1.9, 95 % CI = 1.4-2.6). CONCLUSION Mother's SUD during pregnancy increased risk of fetal growth restriction as measured by SGA. The role of maternal socioeconomic and lifestyle factors for the risk of SGA was substantial.
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Affiliation(s)
- Viktor Mravčík
- Department of Addictology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic; National Monitoring Centre for Drugs and Addiction, Office of the Government, Prague, Czech Republic.
| | - Blanka Nechanská
- Department of Addictology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic; Institute of Health Information and Statistics of the Czech Republic, Prague, Czech Republic
| | - Roman Gabrhelík
- Department of Addictology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Marte Handal
- Norwegian Institute of Public Health, Oslo, Norway
| | - Milada Mahic
- Norwegian Institute of Public Health, Oslo, Norway
| | - Svetlana Skurtveit
- Norwegian Institute of Public Health, Oslo, Norway; Norwegian Centre for Addiction Research at the University of Oslo, Norway
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