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Wang Y, Berger L, Durrance C, Kirby RS, Kuo D, Pac J, Ehrenthal DB. Duration and Timing of In Utero Opioid Exposure and Incidence of Neonatal Withdrawal Syndrome. Obstet Gynecol 2023; 142:603-611. [PMID: 37548391 PMCID: PMC10526694 DOI: 10.1097/aog.0000000000005289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/25/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE To evaluate the association between prenatal prescription opioid analgesic exposure (duration, timing) and neonatal opioid withdrawal syndrome (NOWS). METHODS We conducted a retrospective cohort study of Wisconsin Medicaid-covered singleton live births from 2011 to 2019. The primary outcome was a NOWS diagnosis in the first 30 days of life. Opioid exposure was identified with any claim for prescription opioid analgesic fills during pregnancy. We measured exposure duration cumulatively in days (1-6, 7-29, 30-89, and 90 or more) and identified timing as early (first two trimesters only) or late (third trimester, regardless of earlier pregnancy use). We used logistic regression modeling to assess NOWS incidence by exposure duration and timing, with and without propensity score matching. RESULTS Overall, 31,456 (14.3%) of 220,570 neonates were exposed to prescription opioid analgesics prenatally. Among exposed neonates, 19,880 (63.2%) had 1-6 days of exposure, 7,694 (24.5%) had 7-29 days, 2,188 (7.0%) had 30-89 days, and 1,694 (5.4%) had 90 or more days of exposure; 15,032 (47.8%) had late exposure. Absolute NOWS incidence among neonates with 1-6 days of exposure was 7.29 per 1,000 neonates (95% CI 6.11-8.48), and incidence increased with longer exposure: 7-29 days (19.63, 95% CI 16.53-22.73); 30-89 days (58.96, 95% CI 49.08-68.84); and 90 or more days (177.10, 95% CI 158.90-195.29). Absolute NOWS incidence for early and late exposures were 11.26 per 1,000 neonates (95% CI 9.65-12.88) and 35.92 per 1,000 neonates (95% CI 32.95-38.90), respectively. When adjusting for confounders including timing of exposure, neonates exposed for 1-6 days had no increased odds of NOWS compared with unexposed neonates, whereas those exposed for 30 or more days had increased odds of NOWS (30-89 days: adjusted odds ratio [aOR] 2.15, 95% CI 1.22-3.79; 90 or more days: 2.80, 95% CI 1.36-5.76). Late exposure was associated with elevated odds of NOWS (aOR 1.57, 95% CI 1.25-1.96) when compared with unexposed after adjustment for exposure duration. CONCLUSION More than 30 days of prenatal prescription opioid exposure was associated with NOWS regardless of exposure timing. Third-trimester opioid exposure, irrespective of exposure duration, was associated with NOWS.
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Affiliation(s)
- Yi Wang
- Social Science Research Institute, The Pennsylvania State University, University Park, PA
- Silberman School of Social Work, Hunter College, City University of New York, New York City, NY
| | - Lawrence Berger
- Sandra Rosenbaum School of Social Work and Institute for Research on Poverty, College of Letters and Sciences, University of Wisconsin-Madison, Madison, WI
| | - Christine Durrance
- La Follette School of Public Affairs, University of Wisconsin-Madison, Madison, WI
| | - Russell S. Kirby
- Chiles Center, College of Public Health, University of South Florida, Tampa, FL
| | - Daphne Kuo
- Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Jessica Pac
- Sandra Rosenbaum School of Social Work and Institute for Research on Poverty, College of Letters and Sciences, University of Wisconsin-Madison, Madison, WI
| | - Deborah B. Ehrenthal
- Social Science Research Institute, The Pennsylvania State University, University Park, PA
- Department of Biobehavioral Health, College of Health and Human Development, The Pennsylvania State University, University Park, PA
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Schreiber K, Frishman M, Russell MD, Dey M, Flint J, Allen A, Crossley A, Gayed M, Hodson K, Khamashta M, Moore L, Panchal S, Piper M, Reid C, Saxby K, Senvar N, Tosounidou S, van de Venne M, Warburton L, Williams D, Yee CS, Gordon C, Giles I, Giles I, Roddy E, Armon K, Astell L, Cotton C, Davidson A, Fordham S, Jones C, Joyce C, Kuttikat A, McLaren Z, Merrison K, Mewar D, Mootoo A, Williams E. British Society for Rheumatology guideline on prescribing drugs in pregnancy and breastfeeding: comorbidity medications used in rheumatology practice. Rheumatology (Oxford) 2022; 62:e89-e104. [PMID: 36318967 PMCID: PMC10070063 DOI: 10.1093/rheumatology/keac552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/14/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Karen Schreiber
- Thrombosis & Haemophilia Centre, Guy's and St Thomas' NHS Foundation Trust , London, UK
- Department of Rheumatology, Danish Hospital for Rheumatic Diseases , Sonderborg, Denmark
- Department of Regional Health Research, University of Southern Denmark , Odense, Denmark
| | - Margreta Frishman
- Obstetrics and Gynaecology, North Middlesex University Hospital NHS Trust , London, UK
| | - Mark D Russell
- Centre for Rheumatic Diseases, King’s College London , London, UK
| | - Mrinalini Dey
- Institute of Life Course and Medical Sciences, University of Liverpool , Liverpool, UK
| | - Julia Flint
- Department of Rheumatology, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust , Shropshire, UK
| | - Alexander Allen
- Clinical Affairs, British Society for Rheumatology , London, UK
| | | | - Mary Gayed
- Rheumatology, University Hospital Birmingham NHS Foundation Trust , Birmingham, UK
| | - Kenneth Hodson
- The UK Teratology Information Service , Newcastle upon Tyne, UK
| | - Munther Khamashta
- Division of Women’s Health, Lupus Research Unit, King's College London , London, UK
| | - Louise Moore
- Rheumatic and Musculoskeletal Disease Unit, Our Lady’s Hospice and Care Service , Dublin, Ireland
| | - Sonia Panchal
- Rheumatology, South Warwickshire NHS Foundation Trust , Warwickshire, UK
| | - Madeleine Piper
- Royal National Hospital for Rheumatic Diseases, Royal United Hospital , Bath, UK
| | | | - Katherine Saxby
- Pharmacology, University College London Hospitals NHS Foundation Trust , London, UK
| | - Naz Senvar
- Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust , London, UK
| | - Sofia Tosounidou
- Lupus UK Centre of Excellence, Sandwell and West Birmingham NHS Trust , Birmingham, UK
| | | | - Louise Warburton
- Shropshire Community NHS Trust , Shropshire, UK
- Primary Care and Health Sciences, Keele University , Keele, UK
| | - David Williams
- Obstetrics, University College London Hospitals NHS Foundation Trust , London, UK
| | - Chee-Seng Yee
- Department of Rheumatology, Doncaster and Bassetlaw, Teaching Hospitals NHS Foundation Trust , Doncaster, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham , Birmingham, UK
| | - Ian Giles
- Centre for Rheumatology, Department of Inflammation, Division of Medicine, University College London , London, UK
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Zhao JP, Berthod C, Sheehy O, Kassaï B, Gorgui J, Bérard A. Prevalence and duration of prescribed opioid use during pregnancy: a cohort study from the Quebec Pregnancy Cohort. BMC Pregnancy Childbirth 2021; 21:800. [PMID: 34847870 PMCID: PMC8638412 DOI: 10.1186/s12884-021-04270-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 11/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background Recent studies show a rapid growth among pregnant women using high potency opioids for common pain management during their pregnancy. No study has examined the duration of treatment among strong opioid users and weak opioid users during pregnancy. We aimed to investigate the prevalence of prescribed opioid use during pregnancy, in Quebec; and to compare the duration of opioid treatment between strong opioid users and weak opioid users. Methods Using the Quebec Pregnancy Cohort (1998–2015), we included all pregnancies covered by the Quebec Public Prescription Drug Insurance Program. Opioid exposure was defined as filled at least one prescription for any opioid during pregnancy or before pregnancy but with a duration that overlapped the beginning of pregnancy. Prevalence of opioids use was calculated for all pregnancies, according to pregnancy outcome, trimester of exposure, and individual opioids. The duration of opioid use during pregnancy was analyzed according to 8 categories based on cumulative duration (< 90 days vs. ≥90 days), duration of action (short-acting vs. long-acting) and strength of the opioid (weak vs. strong). Results Of 442,079 eligible pregnancies, 20,921 (4.7%) were exposed to opioids. Among pregnancies ending with deliveries (n = 249,234), 5.4% were exposed to opioids; the prevalence increased by 40.3% from 3.9% in 1998 to 5.5% in 2015, more specifically a significant increase in the second and third trimesters of pregnancy. Weak opioid, codeine was the most commonly dispensed opioid (70% of all dispensed opioids), followed by strong opioid, hydromorphone (11%), morphine (10%), and oxycodone (5%). The prevalence of codeine use decreased by 47% from 4.3% in 2005 to 2.3% in 2015, accompanied by an increased use of strong opioid, morphine (0.029 to 1.41%), hydromorphone (0.115 to 1.08%) and oxycodone (0.022 to 0.44%), from 1998 to 2015. The average durations of opioid exposure were significantly longer among pregnancies exposed to strong opioid as compared to weak opioid regardless of the cumulative duration or duration of action (P < 0.05). Conclusions Given the differences in the safety profile between strong opioids and the major weak opioid codeine, the increased use of strong opioids during pregnancy with longer treatment duration raises public health concerns. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-04270-x.
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Affiliation(s)
- Jin-Ping Zhao
- Research Center, CHU Sainte-Justine, 3175, Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada
| | - Christelle Berthod
- Research Center, CHU Sainte-Justine, 3175, Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada.,Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada.,University of Lyon 1, 69008, Lyon, France.,Laboratoire de Biométrie et Biologie Evolutive, University of Lyon 1; CNRS, UMR 5558, 69622, Villeurbanne, France
| | - Odile Sheehy
- Research Center, CHU Sainte-Justine, 3175, Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada
| | - Behrouz Kassaï
- EPICIME-CIC 1407 Lyon, Inserm, Pharmacotoxicology Department, CHU-Lyon, 69677, Bron, France.,University of Lyon 1, 69008, Lyon, France.,Laboratoire de Biométrie et Biologie Evolutive, University of Lyon 1; CNRS, UMR 5558, 69622, Villeurbanne, France
| | - Jessica Gorgui
- Research Center, CHU Sainte-Justine, 3175, Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada.,Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada
| | - Anick Bérard
- Research Center, CHU Sainte-Justine, 3175, Chemin de la Côte-Sainte-Catherine, Montreal, Quebec, H3T 1C5, Canada. .,Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada. .,EPICIME-CIC 1407 Lyon, Inserm, Pharmacotoxicology Department, CHU-Lyon, 69677, Bron, France. .,University of Lyon 1, 69008, Lyon, France. .,Laboratoire de Biométrie et Biologie Evolutive, University of Lyon 1; CNRS, UMR 5558, 69622, Villeurbanne, France.
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Guille C, McCauley JL, Moreland A. Leveraging Telehealth in the United States to Increase Access to Opioid Use Disorder Treatment in Pregnancy and Postpartum During the COVID-19 Pandemic. Am J Psychiatry 2021; 178:290-293. [PMID: 33789451 PMCID: PMC8023749 DOI: 10.1176/appi.ajp.2020.20060949] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Constance Guille
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston
| | - Jenna L. McCauley
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston
| | - Angela Moreland
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston
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Opioid Use During Pregnancy, Observations of Opioid Use, and Secular Trend From 2006 to 2014 at HealthPartners Medical Group. Clin J Pain 2019; 34:707-712. [PMID: 29406367 DOI: 10.1097/ajp.0000000000000592] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the prevalence of opioid use before, during, and after pregnancy and describe its use based on patient-specific characteristics. Determine secular trend of opioid use 2006 to 2014. MATERIALS AND METHODS Retrospective cohort study. A large Upper Midwest integrated health care system and insurer. Female individuals age 10 to 50 years with a delivery diagnosis from July 1, 2006 through June 30, 2014. MAIN OUTCOME MEASURE prevalence of opioid use before, during, and after pregnancy; description of opioid use during these time periods. RESULTS From 11,565 deliveries among 9690 unique women, 862 (7.5%) deliveries were associated with significant opioid use. Significant opioid use was associated with single marital status, Cesarean section, Medicaid coverage, tobacco use, depression, anxiety, bipolar disorder, substance use disorder, nonopioid analgesic use, and referral to physical therapy, psychotherapy, or pain specialists. From 2006 to 2014 opioid use decreased from 9% to 6% before, during, and after pregnancy with a rate of change per year of -0.2%. DISCUSSION Known risk factors including tobacco and alcohol use, mental health diagnoses, substance use disorder, or Medicaid enrollment may enable enhanced assessments and targeted interventions to reduce unnecessary prescribing and use of opioids among pregnant women and those who might become pregnant. Strategies to decrease opioid use during pregnancy should be considered by health care systems and health plans to reduce opioid prescribing in this patient population.
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Black E, Khor KE, Kennedy D, Chutatape A, Sharma S, Vancaillie T, Demirkol A. Medication Use and Pain Management in Pregnancy: A Critical Review. Pain Pract 2019; 19:875-899. [PMID: 31242344 DOI: 10.1111/papr.12814] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/20/2019] [Accepted: 06/21/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pain during pregnancy is common, and its management is complex. Certain analgesics may increase the risk for adverse fetal and pregnancy outcomes, while poorly managed pain can result in adverse maternal outcomes such as depression and hypertension. Guidelines to assist clinicians in assessing risks and benefits of exposure to analgesics for the mother and unborn infant are lacking, necessitating evidence-based recommendations for managing pain in pregnancy. METHODS A comprehensive literature search was conducted to assess pregnancy safety data for pharmacological and nonpharmacological pain management methods. Relevant clinical trials and observational studies were identified using multiple medical databases, and included studies were evaluated for quality and possible biases. RESULTS Paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) are appropriate for mild to moderate pain, but NSAIDs should be avoided in the third trimester due to established risks. Short courses of weaker opioids are generally safe in pregnancy, although neonatal abstinence syndrome must be monitored following third trimester exposure. Limited safety data for pregabalin and gabapentin indicate that these are unlikely to be major teratogens, and tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors have limited but overall reassuring safety data. Many of the included studies were limited by methodological issues. CONCLUSIONS Findings from this review can guide clinicians in their decision to prescribe analgesics for pregnant women. Treatment should be tailored to the lowest therapeutic dose and shortest possible duration, and management should involve a discussion of risks and benefits and monitoring for response. Further research is required to better understand the safety profile of various analgesics in pregnancy.
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Affiliation(s)
- Eleanor Black
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, NSW, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Kok Eng Khor
- Pain Management Centre, Prince of Wales Hospital, Randwick, NSW, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Debra Kennedy
- MotherSafe, The Royal Hospital for Women, Randwick, NSW, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - Anuntapon Chutatape
- Department of Pain Medicine, Singapore General Hospital, Singapore, Singapore
| | - Swapnil Sharma
- Pain Management Centre, Prince of Wales Hospital, Randwick, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia
| | - Thierry Vancaillie
- School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia.,Women's Health and Research Institute of Australia, Sydney, NSW, Australia
| | - Apo Demirkol
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, NSW, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia.,Pain Management Centre, Prince of Wales Hospital, Randwick, NSW, Australia
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Desai RJ, Huybrechts KF, Hernandez-Diaz S, Mogun H, Patorno E, Kaltenbach K, Kerzner LS, Bateman BT. Exposure to prescription opioid analgesics in utero and risk of neonatal abstinence syndrome: population based cohort study. BMJ 2015; 350:h2102. [PMID: 25975601 PMCID: PMC4431352 DOI: 10.1136/bmj.h2102] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2015] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To provide absolute and relative risk estimates of neonatal abstinence syndrome (NAS) based on duration and timing of prescription opioid use during pregnancy in the presence or absence of additional NAS risk factors of history of opioid misuse or dependence, misuse of other substances, non-opioid psychotropic drug use, and smoking. DESIGN Observational cohort study. SETTING Medicaid data from 46 US states. PARTICIPANTS Pregnant women filling at least one prescription for an opioid analgesic at any time during pregnancy for whom opioid exposure characteristics including duration of therapy: short term (<30 days) or long term (≥ 30 days); timing of use: early use (only in the first two trimesters) or late use (extending into the third trimester); and cumulative dose (in morphine equivalent milligrams) were assessed. MAIN OUTCOME MEASURE Diagnosis of NAS in liveborn infants. RESULTS 1705 cases of NAS were identified among 290,605 pregnant women filling opioid prescriptions, corresponding to an absolute risk of 5.9 per 1000 deliveries (95% confidence interval 5.6 to 6.2). Long term opioid use during pregnancy resulted in higher absolute risk of NAS per 1000 deliveries in the presence of additional risk factors of known opioid misuse (220.2 (200.8 to 241.0)), alcohol or other drug misuse (30.8 (26.1 to 36.0)), exposure to other psychotropic medications (13.1 (10.6 to 16.1)), and smoking (6.6 (4.3 to 9.6)) than in the absence of any of these risk factors (4.2 (3.3 to 5.4)). The corresponding risk estimates for short term use were 192.0 (175.8 to 209.3), 7.0 (6.0 to 8.2), 2.0 (1.5 to 2.6), 1.5 (1.0 to 2.0), and 0.7 (0.6 to 0.8) per 1000 deliveries, respectively. In propensity score matched analyses, long term prescription opioid use compared with short term use and late use compared with early use in pregnancy demonstrated greater risk of NAS (risk ratios 2.05 (95% confidence interval 1.81 to 2.33) and 1.24 (1.12 to 1.38), respectively). CONCLUSIONS Use of prescription opioids during pregnancy is associated with a low absolute risk of NAS in the absence of additional risk factors. Long term use compared with short term use and late use compared with early use of prescription opioids are associated with increased NAS risk independent of additional risk factors.
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Affiliation(s)
- Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA
| | | | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA
| | - Karol Kaltenbach
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Leslie S Kerzner
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
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