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Iyer NS, Ferguson EB, Yan VZ, Hand DJ, Abatemarco DJ, Boelig RC. Standard Versus Rapid Inpatient Methadone Titration for Pregnant Patients With Opioid Use Disorder: A Retrospective Cohort Study. J Addict Med 2024:01271255-990000000-00337. [PMID: 38912695 DOI: 10.1097/adm.0000000000001339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
ABSTRACT OBJECTIVES Our study evaluated if rapid inpatient titration of methadone for pregnant patients with opioid use disorder (OUD) improved outcomes without increasing the risk for overdose. METHODS This is a retrospective cohort study of pregnant patients admitted for inpatient methadone titration from January 2020 to June 2022. Outcomes were compared between standard versus rapid titration protocols. Standard titration involved an initial methadone dose with additional doses every 6 hours if clinical opiate withdrawal score (COWS) is >9. Rapid titration involved an initial methadone dose with additional doses every 4 hours if COWS is >9. The primary outcome was time required to achieve stable dose. Secondary outcomes included elopement prior to achieving stable dose, methadone-related readmission, opioid overdose, and final dose. RESULTS There were 97 patients in the standard titration (STP) and 97 patients in the rapid titration (RTP) groups. Demographic characteristics and substance use history did not differ between the 2 groups. Time to stable dose did not differ between the 2 groups (RTP, 5.0 days ±4.0; STP, 4.0 days ±3.0; P = 0.08). Patients in the rapid titration group were less likely to elope from the hospital prior to stabilization (RTP 23.0% vs STP 37.9%, P = 0.03) and had fewer methadone-related readmissions (P < 0.001). One patient (1.0%) in the RTP group required naloxone treatment while inpatient for concern for overdose, while none did in the STP group (P = 0.32). There was no difference in median final stable dose between the 2 groups (P = 0.07). CONCLUSIONS Rapid titration of methadone for pregnant patients with OUD was associated with decreased medical elopement and methadone-related readmission, without increasing the risk for overdose.
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Affiliation(s)
- Neel S Iyer
- From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (NSI, RCB); Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (EBF, VZY); and Jefferson College of Nursing and Department of Psychiatry and Human Behavior, Thomas Jefferson University, Philadelphia, PA (DJH, DJA)
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Allen S, Dev A, Canavan C, Goodman D. Intersecting Substance Use Disorder and Unmet Social Needs in Rural Pregnant Women. J Obstet Gynecol Neonatal Nurs 2024:S0884-2175(24)00073-X. [PMID: 38796173 DOI: 10.1016/j.jogn.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/28/2024] Open
Abstract
OBJECTIVE To describe the unique challenges faced by rural pregnant women with intersecting substance use disorder (SUD) and unmet social needs. DESIGN Secondary qualitative data analysis with an analytic expansion approach. SETTING Hospital system in northern New England. PARTICIPANTS Four rural women with food insecurity who were in recovery for SUD. (Three were pregnant and one had given birth in the past 15 weeks.) METHODS: In the primary qualitative descriptive study, we interviewed 14 women about their experience of food insecurity during the perinatal period, including facilitators and barriers to being screened for food insecurity and other social needs during prenatal care and accessing referrals. This secondary analysis centered on the perspectives of four participants who reflected specifically on receiving material and mental health support through the integration of prenatal care and SUD treatment. RESULTS Rural women with SUD who experience social needs during pregnancy have difficulty accessing appropriate prenatal care and maintaining treatment engagement due to intersecting factors (e.g., food and housing insecurity and transportation) and psychological (e.g., mental health challenges, social isolation, and stigma) factors. Participants emphasized the importance of integrating social support within prenatal and substance use care to promote physical and mental health and engagement in SUD treatment. CONCLUSION In line with The Joint Commission's 2022 policy recommendations for universal social determinants of health screening, we support one-stop clinical and social care for pregnant women who face intersecting barriers to health, such as SUD and unmet social needs. Nurses can play an important role in care coordination for people with complex medical and social determinants of health screening needs. This approach is especially relevant to rural areas, where food, housing, and transportation insecurity rates are greater than nonrural areas.
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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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Myers AM, Bowen SE, Brummelte S. Maternal care behavior and physiology moderate offspring outcomes following gestational exposure to opioids. Dev Psychobiol 2023; 65:e22433. [PMID: 38010303 DOI: 10.1002/dev.22433] [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: 05/10/2023] [Revised: 08/31/2023] [Accepted: 09/29/2023] [Indexed: 11/29/2023]
Abstract
The opioid epidemic has resulted in a drastic increase in gestational exposure to opioids. Opioid-dependent pregnant women are typically prescribed medications for opioid use disorders ("MOUD"; e.g., buprenorphine [BUP]) to mitigate the harmful effects of abused opioids. However, the consequences of exposure to synthetic opioids, particularly BUP, during gestation on fetal neurodevelopment and long-term outcomes are poorly understood. Further, despite the known adverse effects of opioids on maternal care, many preclinical and clinical studies investigating the effects of gestational opioid exposure on offspring outcomes fail to report on maternal care behaviors. Considering that offspring outcomes are heavily dependent upon the quality of maternal care, it is important to evaluate the effects of gestational opioid exposure in the context of the mother-infant dyad. This review compares offspring outcomes after prenatal opioid exposure and after reduced maternal care and integrates this information to potentially identify common underlying mechanisms. We explore whether adverse outcomes after gestational BUP exposure are due to direct effects of opioids in utero, deficits in maternal care, or a combination of both factors. Finally, suggestions for improving preclinical models of prenatal opioid exposure are provided to promote more translational studies that can help to improve clinical outcomes for opioid-dependent mothers.
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Affiliation(s)
- Abigail M Myers
- Department of Psychology, Wayne State University, Detroit, Michigan, USA
| | - Scott E Bowen
- Department of Psychology, Wayne State University, Detroit, Michigan, USA
- Translational Neuroscience Program, Wayne State University, Detroit, Michigan, USA
| | - Susanne Brummelte
- Department of Psychology, Wayne State University, Detroit, Michigan, USA
- Translational Neuroscience Program, Wayne State University, Detroit, Michigan, USA
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Batista P, Pintado M, Oliveira-Silva P. Overview about Oral Films in Mental Disorders. Pharmaceuticals (Basel) 2023; 16:1063. [PMID: 37630975 PMCID: PMC10458751 DOI: 10.3390/ph16081063] [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: 05/29/2023] [Revised: 07/13/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023] Open
Abstract
Mental disorders are increasing worldwide, and efforts have been developed by multidisciplinary research groups to combine knowledge from different areas such as psychology, neuroscience, medicine, and biotechnology to develop strategies and products to promote the prevention of mental disorders. Excessive antipsychotic consumption is a public health problem, and innovative strategies must be devised. The development of innovative and, if possible, natural products is one of the strategies to combat this public health problem. Oral films are recent delivery systems that have been developed with several advantages that should be applied in this area. This review intends to draw attention to these new dosage forms of drugs and bioactive molecules pertinent to the field of mental health prevention and therapy and to the need for regulatory guidelines to ensure their quality and safety. This is a critical overview about strengths, weaknesses, opportunities, and threats related to oral film implementation in mental disorder treatment.
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Affiliation(s)
- Patrícia Batista
- Human Neurobehavioral Laboratory, Research Centre for Human Development, Universidade Católica Portuguesa, Rua Diogo Botelho, 1327, 4169-005 Porto, Portugal
| | - Manuela Pintado
- Laboratório Associado, CBQF—Centro de Biotecnologia e Química Fina, Escola Superior de Biotecnologia, Universidade Católica Portuguesa, Rua Diogo Botelho, 1327, 4169-005 Porto, Portugal
| | - Patrícia Oliveira-Silva
- Human Neurobehavioral Laboratory, Research Centre for Human Development, Universidade Católica Portuguesa, Rua Diogo Botelho, 1327, 4169-005 Porto, Portugal
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Wilson LA, Gandhi P. Opioid Agonist Therapies and Pregnancy Outcomes for Pregnant People With Opioid Use Disorder: Protocol for a Systematic Review. JMIR Res Protoc 2023; 12:e42417. [PMID: 37163329 DOI: 10.2196/42417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 01/27/2023] [Accepted: 01/28/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Opioid use disorder (OUD) during pregnancy presents a significant risk to maternal, fetal, and neonatal health, increasing the likelihood of adverse events, such as maternal overdose, pregnancy loss, stillbirth, preterm birth, low birth weight, and neonatal abstinence syndrome. In order to reduce the risk of these outcomes, the standard of care for OUD during pregnancy in many jurisdictions within the United States and Canada is opioid agonist therapy (OAT). OAT refers to prescription medications that alleviate or eliminate opioid withdrawal symptoms, so that opioid use can be managed more safely. Although OAT has been recognized as a safe option for pregnant people with OUD, many jurisdictions do not have treatment guidelines regarding pharmacological options, dosing recommendations, side effect management, and individual preferences. There is currently a lack of systematic evidence on the impacts of different OAT regimens on pregnancy outcomes. OBJECTIVE We aim to evaluate the impacts of specific OAT agents on pregnancy outcomes and inform recommendations for practitioners treating pregnant people with OUD. METHODS The MEDLINE, Embase, CINAHL, and PsycINFO databases will be searched for published quantitative studies assessing pregnancy outcomes for individuals on OAT. Given the substantially increased risk of preterm birth, low birth weight, small for gestational age, and stillbirth among pregnant people with OUD, these four end points will comprise our primary outcomes. Database searches will not be restricted by date, and conference abstracts will be restricted to the past 2 years. Titles, abstracts, and full-text articles will be independently screened by 2 reviewers. Data will be extracted independently and in duplicate, using a data extraction form to reduce the risk of reviewer bias. The risk of bias within individual studies will be assessed by using the appropriate CASP (Critical Appraisal Skills Programme) checklists. For studies that consider the same research questions, interventions, or outcomes, meta-analyses will be conducted to synthesize the pooled effect size. In the event that studies cannot be compared directly, results will be synthesized in a narrative account. Between-study heterogeneity will be measured by using the τ2 statistic. If more than 10 studies are available for pooling, publication bias will be evaluated by using the Egger regression test. RESULTS As of January 2023, a total of 3266 abstracts have been identified for screening. Data extraction is expected to commence in February 2023. CONCLUSIONS The topic of OAT and its effect on pregnancy is an understudied area that has the potential to improve health outcomes, clinical practice, education, and community advocacy. The results of our review will be used to inform clinical practice guidelines and improve health outcomes for pregnant people. Findings will be disseminated to diverse groups of stakeholders, including policy makers, clinicians, community partners, and individuals with lived experience of drug use. TRIAL REGISTRATION PROSPERO CRD42022332082; https://tinyurl.com/2p94pkx5. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/42417.
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Affiliation(s)
- Lindsay A Wilson
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Preet Gandhi
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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Wang S, Meador KJ, Pawasauskas J, Lewkowitz AK, Ward KE, Brothers TN, Hartzema A, Quilliam BJ, Wen X. Comparative Safety Analysis of Opioid Agonist Treatment in Pregnant Women with Opioid Use Disorder: A Population-Based Study. Drug Saf 2023; 46:257-271. [PMID: 36642778 PMCID: PMC10363992 DOI: 10.1007/s40264-022-01267-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2022] [Indexed: 01/17/2023]
Abstract
INTRODUCTION AND OBJECTIVE Receipt of opioid agonist treatment during early and late pregnancy for opioid use disorder may relate to varying perinatal risks. We aimed to assess the effect of time-varying prenatal exposure to opioid agonist treatment using buprenorphine or methadone on adverse neonatal and pregnancy outcomes. METHODS We conducted a retrospective cohort study of pregnant women with opioid use disorder using Rhode Island Medicaid claims data and vital statistics during 2008-16. Time-varying exposure was evaluated in early (0-20 weeks) and late (≥ 21 weeks) pregnancy. Marginal structural models with inverse probability of treatment weighting were applied. RESULTS Of 400 eligible pregnancies, 85 and 137 individuals received buprenorphine and methadone, respectively, during early pregnancy. Compared with 152 untreated pregnancies with opioid use disorders, methadone exposure in both periods was associated with an increased risk of preterm birth (adjusted odds ratio [aOR]: 2.52; 95% confidence interval [CI] 1.07-5.95), low birth weight (aOR: 2.99; 95% CI 1.34-6.66), neonatal intensive care unit admission (aOR, 5.04; 95% CI 2.49-10.21), neonatal abstinence syndrome (aOR: 11.36; 95% CI 5.65-22.82), respiratory symptoms (aOR, 2.71; 95% CI 1.17-6.24), and maternal hospital stay > 7 days (aOR, 14.51; 95% CI 7.23-29.12). Similar patterns emerged for buprenorphine regarding neonatal abstinence syndrome (aOR: 10.27; 95% CI 4.91-21.47) and extended maternal hospital stay (aOR: 3.84; 95% CI 1.83-8.07). However, differences were found favoring the use of buprenorphine for preterm birth versus untreated pregnancies (aOR: 0.17; 95% CI 0.04-0.77), and for several outcomes versus methadone. CONCLUSIONS Methadone and buprenorphine prescribed for the treatment of opioid use disorder during pregnancy are associated with varying perinatal risks. However, buprenorphine may be preferred in the setting of pregnancy opioid agonist treatment. Further research is necessary to confirm our findings and minimize residual confounding.
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Affiliation(s)
- Shuang Wang
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, 02881, USA
| | - Kimford J Meador
- Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Jayne Pawasauskas
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, 02881, USA
| | - Adam K Lewkowitz
- Department of Obstetrics and Gynecology, Women and Infants Hospital of Rhode Island, Alpert Medical School of Brown University, Providence, RI, USA
| | - Kristina E Ward
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, 02881, USA
| | - Todd N Brothers
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, 02881, USA
| | - Abraham Hartzema
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Brian J Quilliam
- College of Health Sciences, University of Rhode Island, Kingston, RI, USA
| | - Xuerong Wen
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, 02881, USA.
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Bukowski HB, Combellick JL. Midwifery Care of Pregnant Individuals Experiencing Opioid use Disorder: Changing Regulations, Complexities, and Call to Action. J Midwifery Womens Health 2022; 67:770-776. [PMID: 36269042 DOI: 10.1111/jmwh.13415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 08/18/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022]
Abstract
Opioid use disorder (OUD), overdose, and death have exploded in the United States in the past 2 decades. The number of pregnant and birthing people reporting opioid use and misuse is also rising. Co-occurring mental illness, multisubstance use, and associated medical comorbidities often complicate care for pregnant individuals with OUD. Neonates who are exposed to opioids in utero are at risk for neonatal opioid withdrawal syndrome and other short- and long-term sequelae. Recent changes to the Department of Health and Human Services Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder have now provided a pathway for midwives to prescribe buprenorphine for opioid use disorder (OUD) for up to 30 individuals at one time without further training or certification of ancillary services. Midwives have a key role to play in expanding the availability and quality of interprofessional care provided to individuals with OUD. The Substance Abuse and Mental Health Services Administration and American Society of Addiction Medicine, along with other professional organizations, provide toolkits and guidelines for the provision of MOUD for pregnant people. Midwives who care for individuals with OUD should be familiar with the unique needs of this population and resources to guide their care. This case study highlights midwives' essential role in treating OUD and co-occurring mental disorders.
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Copeland LA, Kinney RL, Kroll-Desrosiers AR, Shivakumar G, Mattocks KM. Medications with Potential for Fetal Risk Prescribed to Veterans. J Womens Health (Larchmt) 2022; 31:1450-1458. [PMID: 35352967 DOI: 10.1089/jwh.2021.0529] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Women service members of the past 20 years experienced high rates of traumatizing events resulting in pharmacological treatment. Post-military lives may include having children. Typically, Veterans Health Administration (VHA) patients' pregnancies are managed outside the VHA. This study examined medication exposures during pregnancy. Materials and Methods: The Center for Maternal and Infant Outcomes Research in Translation (COMFORT) study collected primary survey data and linked secondary health care data from the VHA from 2015 to 2021. Medication fills and covariates were extracted for three 9-month periods: preconception, pregnancy, and postpartum. Multiple regression assessed factors associated with use during pregnancy of selective serotonin reuptake inhibitor (SSRI)/serotonin norepinephrine reuptake inhibitor (SNRI) or of non-recommended, potentially risky drugs, and of discontinuation of those medications from prepregnancy to pregnancy. Results: The cohort comprised 501 women-29% Black, 65% White, and 6% other races, of whom 63% had 50%-100% service-connected disability. During pregnancy, 36% had a pain-related disorder, 19% major depression, and 18% post-traumatic stress disorder. The median number of drug classes prescribed during pregnancy was 5. The use of SSRI/SNRI antidepressants dropped from 36% preconception to 26% during pregnancy including new starts; 15% discontinued SSRI/SNRI. Comorbidity predicted medication use. Depression predicted discontinuing SSRI/SNRI during pregnancy; no predictors of discontinuing potentially risky drugs were identified. Conclusions: Based on prescriptions filled within the VHA only-ignoring potential community-based fills-women veterans were prescribed numerous medications during pregnancy and discontinued antidepressants alarmingly. Veterans of childbearing potential should receive counseling about medication use before pregnancy occurs. Their non-VHA obstetricians and VHA providers should share information to optimize outcomes, reviewing medications as soon as pregnancy is detected as well as after pregnancy concludes.
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Affiliation(s)
- Laurel A Copeland
- Research Service, VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Rebecca L Kinney
- Research Service, VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Aimee R Kroll-Desrosiers
- Research Service, VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Geetha Shivakumar
- Research Service, VA North Texas Health Care System, Dallas, Texas, USA
- Department of Psychiatry, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Kristin M Mattocks
- Research Service, VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts, USA
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
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Pemathilaka RL, Alimoradi N, Reynolds DE, Hashemi NN. Transport of Maternally Administered Pharmaceutical Agents Across the Placental Barrier In Vitro. ACS APPLIED BIO MATERIALS 2022; 5:2273-2284. [PMID: 35380796 PMCID: PMC9116385 DOI: 10.1021/acsabm.2c00121] [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: 11/28/2022]
Abstract
To understand the transport of pharmaceutical agents and their effects on developing fetus, we have created a placental microsystem that mimics structural phenotypes and physiological characteristic of a placental barrier. We have shown the formation of a continuous network of epithelial adherens junctions and endothelial cell-cell junctions confirming the integrity of the placental barrier. More importantly, the formation of elongated microvilli under dynamic flow condition is demonstrated. Fluid shear stress acts as a mechanical cue triggering the microvilli formation. Pharmaceutical agents were administered to the maternal channel, and the concentration of pharmaceutical agents in fetal channel for coculture and control models were evaluated. In fetal channel, the coculture model exhibited about 2.5 and 2.2% of the maternal initial concentration for naltrexone and 6β-naltrexol, respectively. In acellular model, fetal channel showed about 10.5 and 10.3% of the maternal initial concentration for naltrexone and 6β-naltrexol, respectively. Gene expressions of epithelial cells after direct administration of naltrexone and 6β-naltrexol to the maternal channel and endothelial cells after exposure due to transport through placental barrier are also reported.
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Affiliation(s)
- Rajeendra L Pemathilaka
- Department of Mechanical Engineering, Iowa State University, Ames, Iowa 50011, United States
| | - Nima Alimoradi
- Department of Mechanical Engineering, Iowa State University, Ames, Iowa 50011, United States
| | - David E Reynolds
- Department of Mechanical Engineering, Iowa State University, Ames, Iowa 50011, United States
| | - Nicole N Hashemi
- Department of Mechanical Engineering, Iowa State University, Ames, Iowa 50011, United States.,Department of Mechanical Engineering, Stanford University, Stanford, California 94305, United States
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Laws Forbidding Pregnancy Discrimination in Substance Use Disorder Treatment Are Not Associated With Treatment Access. J Addict Med 2022; 16:364-367. [PMID: 34282081 PMCID: PMC8761200 DOI: 10.1097/adm.0000000000000897] [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: 01/03/2023]
Abstract
OBJECTIVES To determine if state laws that forbid substance use disorder treatment providers from refusing services based on pregnancy are associated with improved ability to secure an initial appointment for opioid use disorder treatment with methadone and buprenorphine. METHODS Ten states in which a "secret shopper" study was conducted were stratified based on whether they have a law that forbids substance use disorder treatment providers from refusing to treat individuals because of pregnancy. We tested for differences in percent of pregnant versus nonpregnant callers offered an initial appointment for medication for opioid use disorder treatment between states with a law and those without. We also tested for differences in acceptance based on caller insurance type. RESULTS Four states with 1461 callers had relevant laws; 6 states with 2495 callers did not. None of the laws apply to all providers. In both groups of states, nonpregnant callers were significantly more likely to obtain a buprenorphine appointment (75.1% vs 60.1% in states with a law, P < 0.01; 73.1% vs 62.3% in states without, P < 0.01). No significant differences were found in methadone appointment access either between pregnant and nonpregnant callers or between pregnant callers in states with a law compared to those without. CONCLUSIONS Laws that forbid providers from refusing to treat potential patients because they are pregnant were not associated with success in obtaining an initial appointment for medication for opioid use disorder treatment. States should consider expanding those laws to apply to all treatment providers and ensure that currently covered providers are in compliance.
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Abstract
PURPOSE Buprenorphine and methadone are international gold standards for managing opioid use disorders. Although they are efficacious in treating opioid dependence, buprenorphine and methadone present risks, especially during pregnancy, causing neonatal abstinence syndrome and adverse obstetrical outcomes. Buprenorphine and methadone are also abused during pregnancy, and identifying their use is important to limit unprescribed prenatal exposure. Previous studies have suggested that concentrations of buprenorphine, but not methadone markers in unconventional matrices may predict child outcomes, although currently only limited data exist. We reviewed the literature on concentrations of buprenorphine, methadone, and their metabolites in unconventional matrices to improve data interpretation. METHODS A literature search was conducted using scientific databases (PubMed, Scopus, Web of Science, and reports from international institutions) to review published articles on buprenorphine and methadone monitoring during pregnancy. RESULTS Buprenorphine and methadone and their metabolites were quantified in the meconium, umbilical cord, placenta, and maternal and neonatal hair. Methadone concentrations in the meconium and hair were typically higher than those in other matrices, although the concentrations in the placenta and umbilical cord were more suitable for predicting neonatal outcomes. Buprenorphine concentrations were lower and required sensitive instrumentation, as measuring buprenorphine glucuronidated metabolites is critical to predict neonatal outcomes. CONCLUSIONS Unconventional matrices are good alternatives to conventional ones for monitoring drug exposure during pregnancy. However, data are currently scarce on buprenorphine and methadone during pregnancy to accurately interpret their concentrations. Clinical studies should be conducted with larger cohorts, considering confounding factors such as illicit drug co-exposure.
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Irwin M, Petersen KS, Smith MA. Rapid Buprenorphine Induction for Cancer Pain in Pregnancy. J Palliat Med 2020; 24:1257-1262. [PMID: 33275857 DOI: 10.1089/jpm.2020.0524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Most patients with cancer-related pain are managed using opioids; cancer-related pain in the setting of pregnancy can be challenging to address owing to risk to the fetus associated with in utero opioid exposure. Buprenorphine is a unique opioid with potential benefits over other opioids for use in pregnancy and is often used for management of cancer-related pain in nonpregnant adults. There are limited data on cancer-related pain management in pregnant patients and no data supporting the use of buprenorphine for cancer-related pain in pregnant patients. This case describes a rapid buprenorphine induction using a microdosing regimen in a pregnant patient and highlights the potential of buprenorphine for cancer-related pain in this population.
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Affiliation(s)
- Madison Irwin
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA.,University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Ketti S Petersen
- Department of Family Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Michael A Smith
- Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA.,University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
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MacMillan KDL. Neonatal Abstinence Syndrome: Review of Epidemiology, Care Models, and Current Understanding of Outcomes. Clin Perinatol 2019; 46:817-832. [PMID: 31653310 DOI: 10.1016/j.clp.2019.08.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The incidence of neonatal abstinence syndrome owing to prenatal opioid exposure has grown rapidly in recent decades and it disproportionately affects rural, non-white, and public insurance-dependent populations. Treatment consists of pharmacologic and nonpharmacologic interventions with wide variability in approaches across the United States. Standardizing clinical assessment, minimizing unnecessary interruptions, and prioritizing nonpharmacologic and family-centered care seems to improve hospital outcomes. Neonatal abstinence syndrome may have long-term developmental and biological effects, but understanding is limited owing in part confounding biosocial factors. Early intervention and longitudinal support of the infant and family promote better outcomes.
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Affiliation(s)
- Kathryn Dee Lizcano MacMillan
- Division of Neonatology and Newborn Medicine, Massachusetts General Hospital for Children, Good Samaritan Medical Center, 55 Fruit Street, Founders 5-530, Boston, MA 02114, USA; Division of Pediatric Hospital Medicine, Massachusetts General Hospital for Children, Good Samaritan Medical Center, 55 Fruit Street, Founders 5-530, Boston, MA 02114, USA.
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Abstract
PURPOSE OF REVIEW Perinatal opioid use is a major public health problem and is associated with a number of deleterious maternal and fetal effects. We review recent evidence of perinatal outcomes and treatment of opioid use disorder (OUD) during pregnancy. RECENT FINDINGS Opioid exposure in pregnancy is associated with multiple obstetric and neonatal adverse outcomes, with the most common being neonatal opioid withdrawal syndrome (NOWS). Treatment with buprenorphine or methadone is associated with NOWS, but neither medication appears to have significant adverse effects on early childhood development. Buprenorphine appears to be superior to methadone in terms of incidence and severity of NOWS in exposed infants. The long-term effects of opioid exposure in utero have been inconclusive, but recent longitudinal studies point to potential differences in brain morphology that may increase vulnerability to future stressors. Maintenance therapy with methadone or buprenorphine remains the standard of care for pregnant women with OUD given its consistent superiority to placebo in terms of rates of illicit drug use and pregnancy outcomes. New non-pharmacologic management options for NOWS appear promising. Future research is needed to further evaluate the effects of opioid exposure in utero and determine the optimal delivery model for maintenance therapy.
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Affiliation(s)
- Amalia Londono Tobon
- Department of Psychiatry, Yale School of Medicine, 40 Temple Street, Suite 6B, New Haven, CT, 06510, USA
| | - Erin Habecker
- Department of Psychiatry, Yale School of Medicine, 40 Temple Street, Suite 6B, New Haven, CT, 06510, USA
| | - Ariadna Forray
- Department of Psychiatry, Yale School of Medicine, 40 Temple Street, Suite 6B, New Haven, CT, 06510, USA.
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