Opioid Use Disorder in Pregnancy: Health Policy and Practice in the Midst of an Epidemic

The effects of buprenorphine and morphine during pregnancy: Impact of exposure length on maternal brain, behavior, and offspring neurodevelopment

The escalating incidence of opioid-related issues among pregnant women in the United States underscores the critical necessity to understand the effects of opioid use and Medication for Opioid Use Disorders (MOUDs) during pregnancy. This research employed a translational rodent model to examine the impact of gestational exposure to buprenorphine (BUP) or morphine on maternal behaviors and offspring well-being. Female rats received BUP or morphine before conception, representing established use, with exposure continuing until postnatal day 2 or discontinued on gestational day 19 to mimic treatment cessation before birth. Maternal behaviors - including care, pup retrieval, and preference - as well as hunting behaviors and brain neurotransmitter levels were assessed. Offspring were evaluated for mortality, weight, length, milk bands, surface righting latency, withdrawal symptoms, and brain neurotransmitter levels. Our results reveal that regardless of exposure length (i.e., continued or discontinued), BUP resulted in reduced maternal care in contrast to morphine-exposed and control dams. Opioid exposure altered brain monoamine levels in the dams and offspring, and was associated with increased neonatal mortality, reduced offspring weight, and elevated withdrawal symptoms compared to controls. These findings underscore BUP's potential disruption of maternal care, contributing to increased pup mortality and altered neurodevelopmental outcomes in the offspring. This study calls for more comprehensive research into prenatal BUP exposure effects on the maternal brain and infant development with the aim to mitigate adverse outcomes in humans exposed to opioids during pregnancy.

Trends in prenatal prescription opioid use among Medicaid beneficiaries in Wisconsin, 2010-2019

OBJECTIVE

To examine changes in prenatal opioid prescription exposure following new guidelines and policies.

STUDY DESIGN

Cohort study of all (262,284) Wisconsin Medicaid-insured live births 2010-2019. Prenatal exposures were classified as analgesic, short term, and chronic (90+ days), and medications used to treat opioid use disorder (MOUD). We describe overall and stratified temporal trends and used linear probability models with interaction terms to test their significance.

RESULT

We found 42,437 (16.2%) infants with prenatal exposure; most (90.5%) reflected analgesic opioids. From 2010 to 2019, overall exposure declined 12.8 percentage points (95% CI = 12.1-13.1). Reductions were observed across maternal demographic groups and in both rural and urban settings, though the extent varied. There was a small reduction in chronic analgesic exposure and a concurrent increase in MOUD.

CONCLUSION

Broad and sustained declines in prenatal prescription opioid exposure occurred over the decade, with little change in the percentage of infants chronically exposed.

The Lived Experiences of Pregnant and Parenting Women in Recovery Toward Medication Treatment for Opioid Use Disorder

BACKGROUND

Maternal misuse of prescription opioids and illicit drugs such as, heroin and non-pharmaceutical fentanyl analogs has increased in the last 2 decades and one in 5 women reported misuse of opioids. Medications for opioid use disorder (MOUD) are recommended for treating pregnant women with opioid use disorder (OUD). MOUD is effective in reducing cravings and negative outcomes, yet treatment is underutilized and varies in integration and intensity of resources across health systems. Exploring perceptions of MOUD delivery among pregnant/parenting women promises to uncover and address the underlying challenges to treatment, a perspective that may be different for providers and stakeholders. Therefore, our main purpose is to elicit patients' experiences and perceptions of MOUD, associated access to treatment, and availability of supportive resources during pregnancy/postpartum to inform OUD treatment.

METHODS

Through a qualitative research approach we gathered data from individual interviews/focus group discussions for this pilot study. Pregnant and postpartum parenting women (n = 17) responded to questions related to perceptions of MOUD, access to treatment, and availability of social and psychosocial resources. Data were collected, transcribed, and coded (by consensus) and emerging themes were analyzed using grounded theory methodology.

RESULTS

Emerging themes revealed positive uptake and perceptions of MOUD, continuing gaps in knowledge, negative impact of stigmatization, and limited access to programs and resources. Supportive relationships from family, peers, healthcare providers and child welfare staff, and co-located services were perceived as positive motivators to recovery.

CONCLUSIONS

Through the unique lenses of women with lived experience, this study revealed several themes that can be transformative for women. Overall perceptions of MOUD were positive and likely to facilitate uptake and promote positive recovery outcomes. Bridging knowledge gaps will reduce anxieties, fears about neonatal opioid withdrawal syndrome and adverse maternal outcomes. Additionally, a deeper understanding of stigmatization and relationships can inform an integrated patient-centered approach to OUD treatment.

Informing evidence-based medicine for opioid use disorder using pharmacoeconomic studies

INTRODUCTION

The health and economic consequences of inadequately treated opioid use disorder (OUD) are substantial. Healthcare systems in the United States (US) and other countries are facing a growing healthcare crisis due to opioids. Although effective medications for OUD exist, relying solely on clinical information is insufficient for addressing the opioid crisis.

AREAS COVERED

In this review, the role of pharmacoeconomic studies in informing evidence-based medication treatment for OUD is discussed, with a particular emphasis on the US healthcare system, where the economic burden is significantly higher than the global average. The scope/objective of pharmacoeconomics as a distinct scientific research program is briefly defined, followed by a discussion of existing evidence informed by data from systematic reviews, in addition to a convenience sample of recently published pharmacoeconomic studies and protocols. The review also explores the need for methodological advancements in the field.

EXPERT OPINION

Despite the potential of pharmacoeconomic research in shaping evidence-based medicine for OUD, significant challenges limiting its real-world application remain. How to address these challenges are explored, including how to combine cost-effectiveness and budget impact analyses to address the needs of the healthcare system as a whole and specific stakeholders interested in adopting new OUD treatment strategies.

Investigating the neurobiology of maternal opioid use disorder and prenatal opioid exposure using brain organoid technology

Over the past two decades, Opioid Use Disorder (OUD) among pregnant women has become a major global public health concern. OUD has been characterized as a problematic pattern of opioid use despite adverse physical, psychological, behavioral, and or social consequences. Due to the relapsing-remitting nature of this disorder, pregnant mothers are chronically exposed to exogenous opioids, resulting in adverse neurological and neuropsychiatric outcomes. Collateral fetal exposure to opioids also precipitates severe neurodevelopmental and neurocognitive sequelae. At present, much of what is known regarding the neurobiological consequences of OUD and prenatal opioid exposure (POE) has been derived from preclinical studies in animal models and postnatal or postmortem investigations in humans. However, species-specific differences in brain development, variations in subject age/health/background, and disparities in sample collection or storage have complicated the interpretation of findings produced by these explorations. The ethical or logistical inaccessibility of human fetal brain tissue has also limited direct examinations of prenatal drug effects. To circumvent these confounding factors, recent groups have begun employing induced pluripotent stem cell (iPSC)-derived brain organoid technology, which provides access to key aspects of cellular and molecular brain development, structure, and function in vitro. In this review, we endeavor to encapsulate the advancements in brain organoid culture that have enabled scientists to model and dissect the neural underpinnings and effects of OUD and POE. We hope not only to emphasize the utility of brain organoids for investigating these conditions, but also to highlight opportunities for further technical and conceptual progress. Although the application of brain organoids to this critical field of research is still in its nascent stages, understanding the neurobiology of OUD and POE via this modality will provide critical insights for improving maternal and fetal outcomes.

Maternal opioid use disorder and infant mortality in Wisconsin, United States, 2010-2018

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Help-Seeking Among Pregnant and Postpartum Women With Lifetime Experiences of Opioid Use Disorder and Intimate Partner Violence

We performed content analysis using a qualitative descriptive approach of 15 semistructured interviews with pregnant and postpartum women who have experienced opioid use disorder (OUD) and intimate partner violence (IPV) regarding their experiences seeking help with both issues. Participants described that their partners impacted their ability to seek OUD care; seeking help for OUD and IPV was siloed; they felt more comfortable disclosing OUD than IPV; they perceived pregnancy as a barrier and facilitator to OUD care; and they wished for integrated services. Pregnant and postpartum women experiencing OUD and IPV acknowledged these phenomena intersect and identified a need for more comprehensive services.

Promoting Innovation in State and Territorial Maternal and Child Health Policymaking

INTRODUCTION

The Association of Maternal & Child Health Programs (AMCHP) and the Association of State and Territorial Health Officials (ASTHO) launched the PRISM (Promoting Innovation in State and Territorial MCH Policymaking) Learning Community, funded by the U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). The goal of PRISM was to build state and territorial health agency program and policy-making capacity to address substance use and mental health in the maternal and child health (MCH) population. Expanding access to care and treatment for perinatal substance use disorders (SUD) emerged as the issue of greatest need for state teams.

METHODS

The PRISM Learning Community consisted of three major components: (1) intensive capacity building for cross-agency state teams, which involved action planning, peer-to-peer learning, and technical assistance; (2) programming to inform the MCH field broadly about innovations in perinatal SUD policy and practice; and (3) a program evaluation involving pre-, mid-, and post-assessments and follow-up key informant interviews with state teams. This manuscript is not based on clinical study or patient data, therefore IRB approval was not required.

RESULTS

States reported that their knowledge of perinatal SUDs increased and their cross-agency partnerships were strengthened as a result of their participation in PRISM. States identified four key priorities for their continued work: to improve multisector collaborations, to institute equitable SUD screening practices for pregnant people, to strengthen the perinatal behavioral health workforce, and to enhance Medicaid coverage for perinatal SUD prevention and treatment services. The need to respond to urgent demands of COVID-19 and the stigma associated with perinatal SUDs were the most significant barriers to advancing state action plan goals.

DISCUSSION

Since 2018, the PRISM project has supported nine jurisdictions across two cohorts. Participation in PRISM advanced state policies and programs to improve perinatal SUD care through capacity building, technical assistance, and virtual programming. Findings and lessons learned from PRISM may inform the activities of other states seeking to address perinatal substance use disorders.

Receipt and duration of buprenorphine treatment during pregnancy and postpartum periods in a national privately-insured cohort

Background

Research gaps exist on the use of medications for opioid use disorder (OUD) among birthing people.

Methods

This retrospective cohort study included people who underwent childbirth deliveries during 2017-2020 and had a diagnosis of OUD identified from a national private insurance claims database. Buprenorphine prescriptions received during the year before childbirth and the year after childbirth were obtained from pharmacy claims. Logistic regressions were used to estimate associations between receipt of buprenorphine and individual and state-level factors.

Results

Among a sample of 1,523 birthing people diagnosed with OUD, 540 (35.5 %) received buprenorphine during the pregnancy or postpartum periods. About half (51.5 %) of new recipients of buprenorphine received treatment for at least six months and, of those, one-third experienced a treatment interruption. The buprenorphine receipt rate differed significantly by race and ethnicity: 28.8 % of non-Hispanic Black birthing people with OUD and 22.8 % of Hispanic birthing people with OUD received buprenorphine treatment in contrast to 37.7 % of non-Hispanic white birthing people (aOR 0.53 [95 % CI 0.35-0.81] and 0.59 [95 % CI 0.37-0.96], respectively). The buprenorphine use rate increased over time from 29.7 % in 2017 to 42.9 % in 2020. Birthing people living in states with punitive policies related to substance use in pregnancy had the lowest buprenorphine use rate of 22.7 % as compared to 43.0 % in states with least restrictive policies.

Conclusion

In this national sample of privately-insured individuals, by 2020, 42.9 % of birthing people with OUD received buprenorphine treatment. Treatment discontinuation and interruptions were common in the period surrounding childbirth.

Substance use during pregnancy and risk of postpartum depression: a systematic review and meta-analysis

Introduction

Postpartum depression (PPD) is a prevalent mental health condition affecting women globally within the first year following childbirth. Substance use during pregnancy has been associated with an increased risk of developing PPD, but the evidence remains inconclusive. This meta-analysis aims to comprehensively assess the effects of different substances on PPD risk, exploring potential modifiers and confounding factors.

Objectives

To examine the proportion of PPD among substance users during pregnancy, compared to non-users, and investigate the specific risk associated with different substances (tobacco, alcohol, and non-specified substance use/multiple substance use).

Methods

A systematic literature search was conducted from inception to November 2022 using the Web of Science database (Clarivate Analytics), incorporating Web of Science Core Collection, the BIOSIS Citation Index, the KCI-Korean Journal Database, MEDLINE®, the Russian Science Citation Index, the SciELO Citation Index, and the Cochrane Central Register of Reviews, and Ovid/PsycINFO databases. Inclusion criteria comprised original studies with pregnant women, using validated depression scales and substance use reporting.

Results

Among the 26 included studies, encompassing 514,441 women, the pooled prevalence of PPD among substance users during pregnancy was 29% (95% CI 25-33). Meta-analyzes revealed an overall odds ratio (OR) of 3.67 (95% CI 2.31-5.85, p < 0.01) indicating a significantly higher risk of PPD among substance users compared to non-users. Subgroup analyzes demonstrated a higher risk for women with non-specified or multiple substance use (OR 4.67, 95% CI 2.59-8.41; p < 0.01) and tobacco use (OR 4.01, 95% CI 2.23-7.20; p < 0.01). Alcohol use showed a trend toward higher risk that did not reach statistical significance (OR 1.88, 95% CI 1.00-3.55; p = 0.051).

Conclusion

This meta-analysis provides evidence of an increased risk of PPD among pregnant substance users, particularly those using multiple substances or tobacco. However, caution is needed in interpreting the association with alcohol use due to its non-significant result.

Systematic review registration

This study protocol was registered at PROSPERO (registration number: CCRD42022375500).

Considerations for the provision of PTSD treatment among pregnant women with substance use histories: A clinical conceptual model based on case consultation field notes

OBJECTIVE

Increasing prevalence of substance use in pregnancy presents a public health crisis that is compounded by posttraumatic stress disorder (PTSD) comorbidity. We aimed to detail the clinical complexities of PTSD treatment provision among pregnant women with substance use histories.

METHODS

We conducted a qualitative study using clinical case consultation field notes (N = 47 meetings) which were gathered during a hybrid effectiveness-implementation pilot study of Written Exposure Therapy (WET) for PTSD among pregnant women seen in an obstetrics-SUD clinic [2019-2021]. Patient baseline survey data (N = 25) were used to characterize the sample and contextualize engagement.

RESULTS

Participants were exposed to a high number of trauma/adversity event types. There was no association between number of trauma/adversity event types and treatment response or dropout. Qualitative findings revealed clinical features relevant to PTSD treatment, including multi-system involvement; parental trauma and substance use; relevance of substance use to trauma context and posttraumatic cognitions, emotions, and behaviors; impact of trauma on experiences of pregnancy, attachment, and child rearing; limited social networks placing women at risk of ongoing violence; and experiences of substance use discrimination.

CONCLUSION

PTSD treatment among pregnant women with substance use histories is highly important to maternal-child health.

Patient and Community Factors Affecting Treatment Access for Opioid Use Disorder

OBJECTIVE

To examine whether access to treatment for women with opioid use disorder (OUD) varied by race and ethnicity, community characteristics, and pregnancy status.

METHODS

We conducted a secondary data analysis of a simulated patient caller study of buprenorphine-waivered prescribers and opioid-treatment programs in 10 U.S. states. We conducted multivariable analyses, accounting for potential confounders, to evaluate factors associated with likelihood of successfully securing an appointment. Descriptive statistics and significance testing examined 1) caller characteristics and call outcome by assigned race and ethnicity and clinic type (combined, opioid-treatment programs, and buprenorphine-waivered prescribers) and 2) clinic and community characteristics and call outcome by community race and ethnicity distribution (majority White vs majority Black, Hispanic, Asian, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander) and clinic type. A multiple logistic regression model was fitted to assess the likelihood of obtaining an appointment by callers' race and ethnicity and pregnancy status with the exposure of interest being majority Black, Hispanic, Asian, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander community distribution.

RESULTS

In total, 3,547 calls reached clinics to schedule appointments. Buprenorphine-waivered prescribers were more likely to be in communities that were more than 50% White (88.9% vs 77.3%, P<.001), and opioid-treatment programs were more likely to be in communities that were less than 50% White (11.1% vs 22.7%, P<.001). Callers were more likely to be granted appointments in majority Black, Hispanic, Asian, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander communities (adjusted odds ratio [aOR] 1.06, 95% CI 1.02-1.10 per 10% Black, Hispanic, Asian, American Indian, Alaska Native, Native Hawaiian, or Pacific Islander community population) and at opioid-treatment programs (aOR 4.94, 95% CI 3.52-6.92) and if they were not pregnant (aOR 1.79, 95% CI 1.53-2.09).

CONCLUSION

Clinic distribution and likelihood of acceptance for treatment varied by community race and ethnicity distribution. Access to treatment for OUD remains challenging for pregnant people and in many historically marginalized U.S. communities.

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

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

Opioid Agonist Therapies and Pregnancy Outcomes for Pregnant People With Opioid Use Disorder: Protocol for a Systematic Review

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.

Methadone alters transcriptional programs associated with synapse formation in human cortical organoids

Opioid use disorder (OUD) among pregnant women has become an epidemic in the United States. Pharmacological interventions for maternal OUD most commonly involve methadone, a synthetic opioid analgesic that attenuates withdrawal symptoms and behaviors linked with drug addiction. However, evidence of methadone's ability to readily accumulate in neural tissue, and cause long-term neurocognitive sequelae, has led to concerns regarding its effect on prenatal brain development. We utilized human cortical organoid (hCO) technology to probe how this drug impacts the earliest mechanisms of cortico-genesis. Bulk mRNA sequencing of 2-month-old hCOs chronically treated with a clinically relevant dose of 1 μM methadone for 50 days revealed a robust transcriptional response to methadone associated with functional components of the synapse, the underlying extracellular matrix (ECM), and cilia. Co-expression network and predictive protein-protein interaction analyses demonstrated that these changes occurred in concert, centered around a regulatory axis of growth factors, developmental signaling pathways, and matricellular proteins (MCPs). TGFβ1 was identified as an upstream regulator of this network and appeared as part of a highly interconnected cluster of MCPs, of which thrombospondin 1 (TSP1) was most prominently downregulated and exhibited dose-dependent reductions in protein levels. These results demonstrate that methadone exposure during early cortical development alters transcriptional programs associated with synaptogenesis, and that these changes arise by functionally modulating extra-synaptic molecular mechanisms in the ECM and cilia. Our findings provide novel insight into the molecular underpinnings of methadone's putative effect on cognitive and behavioral development and a basis for improving interventions for maternal opioid addiction.

An external exposome-wide association study of opioid use disorder diagnosed during pregnancy in Florida

The prevalence of opioid use disorder (OUD) during pregnancy has quadrupled in recent years and widely varies geographically in the US. However, few studies have examined which environmental factors are associated with OUD during pregnancy. We conducted an external exposome-wide association study (ExWAS) to investigate the associations between external environmental factors and OUD diagnosed during pregnancy. Data were obtained from a unique, statewide database in Florida comprising linked individual-level birth and electronic health records. A total of 255,228 pregnancies with conception dates between 2012 and 2016 were included. We examined 82 exposome measures characterizing seven aspects of the built and social environment and spatiotemporally linked them to each individual record. A two-phase procedure was utilized for the external ExWAS. In Phase 1, we randomly divided the data into a discovery set (50 %) and a replication set (50 %). Associations between exposome measures (normalized and standardized) and OUD initially diagnosed during pregnancy were examined using logistic regression. A total of 15 variables were significant in both the discovery and replication sets. In Phase 2, multivariable logistic regression was used to fit all variables selected from Phase 1. Measures of walkability (the national walkability index, OR: 1.23, 95 % CI: 1.17, 1.29), vacant land (the percent vacant land for 36 months or longer, OR: 1.06, 95 % CI: 1.00, 1.12) and food access (the percentage of low food access population that are seniors at 1/2 mile, OR: 1.47, 95 % CI: 1.38, 1.57) were each associated with diagnosis of OUD during pregnancy. This is the first external ExWAS of OUD during pregnancy, and the results suggest that low food access, high walkability, and high vacant land in under-resourced neighborhoods are associated with diagnosis of OUD during pregnancy. These findings could help develop complementary tools for universal screening for substance use and provide direction for future studies.

Utilizing a National Wastewater Monitoring Program to Address the U.S. Opioid Epidemic: A Focus on Metro Atlanta, Georgia

The opioid epidemic has continued to be an ongoing public health crisis within Metro Atlanta for the last three decades. However, estimating opioid use and exposure in a large population is almost impossible, and alternative methods are being explored, including wastewater-based epidemiology. Wastewater contains various contaminants that can be monitored to track pathogens, infectious diseases, viruses, opioids, and more. This commentary is focusing on two issues: use of opioid residue data in wastewater as an alternative method for opioid exposure assessment in the community, and the adoption of a streamlined approach that can be utilized by public health officials. Opioid metabolites travel through the sanitary sewer through urine, fecal matter, and improper disposal of opioids to local wastewater treatment plants. Public health officials and researchers within various entities have utilized numerous approaches to reduce the impacts associated with opioid use. National wastewater monitoring programs and wastewater-based epidemiology are approaches that have been utilized globally by researchers and public health officials to combat the opioid epidemic. Currently, public health officials and policy makers within Metro Atlanta are exploring different solutions to reduce opioid use and opioid-related deaths throughout the community. In this commentary, we are proposing a new innovative approach for monitoring opioid use and analyzing trends by utilizing wastewater-based epidemiologic methods, which may help public health officials worldwide manage the opioid epidemic in a large metro area in the future.

Personas of pregnant and parenting women with substance use and their barriers and pathways to system engagement

BACKGROUND

Women with prenatal substance use have been identified as at-risk for the lack of engagement in perinatal services, such as medical care and home visitation programs. This issue is of particular concern in Florida (United States) where rates of fetal substance exposure have been steadily increasing.

METHODS

To identify pathways of and barriers to perinatal system and service engagement, journey mapping was used to compile various personas of perinatal women with substance use. A structured guide was developed to elicit maternal personas, system and service touchpoints, and system strengths and weaknesses from focus group participants with statewide stakeholders, including perinatal service administrators and community coalition members within three Florida communities. Workshop transcripts, debriefing, and member-checking sessions were transcribed verbatim and analyzed manually.

RESULTS

Six journey-mapping workshops and two member-checking meetings with mothers in-recovery were conducted with a total of 109 participants. Four personas were identified: women who (1) have substance use on a recreational basis, (2) have prescription drug use/misuse, (3) have chronic substance dependence, and (4) are in-recovery from substance dependence. Pathways that promote and barriers that prevent perinatal women with substance use from being identified, referred, or willing to accept and engage in medical care and social services were identified.

CONCLUSIONS

While these personas shed light on differential pathways experienced by women with OUD, they were not intended as fixed-member groups but rather fluid descriptions of circumstances in which individuals could shift over time. These personas are beneficial to understand differences in circumstances, as well as variations in pathways and barriers to service engagement. Additionally, personas may be used to identify approaches to optimize service engagement by perinatal women with substance use and to support system improvements and integrations.

Effects of neonatal fentanyl on late adolescent opioid-mediated behavior

Introduction

Because of the steady increase in the use of synthetic opioids in women of childbearing age, a large number of children are at risk of exposure to these drugs prenatally or postnatally through breast milk. While there is older literature looking at the effects of morphine and heroin, there are relatively few studies looking at the long-term effects of high-potency synthetic opioid compounds like fentanyl. Thus, in the present study, we assessed whether brief exposure to fentanyl in male and female rat pups during a period roughly equivalent to the third trimester of CNS development altered adolescent oral fentanyl self-administration and opioid-mediated thermal antinociception.

Methods

We treated the rats with fentanyl (0, 10, or 100 μg/kg sc) from postnatal day (PD) 4 to PD 9. The fentanyl was administered daily in two injections given 6 h apart. After the last injection on PD 9, the rat pups were left alone until either PD 40 where they began fentanyl self-administration training or PD 60 where they were tested for morphine- (0, 1.25, 2.5, 5, or 10 mg/kg) or U50,488- (0, 2.5, 5, 10, or 20 mg/kg) induced thermal antinociception.

Results

In the self-administration study, we found that female rats had more active nose pokes than male rats when receiving a fentanyl reward but not sucrose alone solution. Early neonatal fentanyl exposure did not significantly alter fentanyl intake or nose-poke response. In contrast, early fentanyl exposure did alter thermal antinociception in both male and female rats. Specifically, fentanyl (10 μg/kg) pre-treatment increased baseline paw-lick latencies, and the higher dose of fentanyl (100 μg/kg) reduced morphine-induced paw-lick latencies. Fentanyl pre-treatment did not alter U50,488-mediated thermal antinociception.

Conclusions

Although our exposure model is not reflective of typical human fentanyl use during pregnancy, our study does illustrate that even brief exposure to fentanyl during early development can have long-lasting effects on mu-opioid-mediated behavior. Moreover, our data suggest that females may be more susceptible to fentanyl abuse than males.

Intrauterine and Neonatal Exposure to Opioids: Toxicological, Clinical, and Medico-Legal Issues

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.

Experiences of Parents with Opioid Use Disorder during Their Attempts to Seek Treatment: A Qualitative Analysis

In the U.S., 12.3% of children live with at least one parent who has a substance use disorder. Prior research has shown that men are more likely to seek treatment than women and that the barriers are different; however, there is limited research focusing specifically on opioid use disorder (OUD). We sought to understand the barriers and motivators for parents with OUD. We conducted a qualitative study by interviewing parents with OUD who were part of an outpatient treatment program. Interviews followed a semi-structured format with questions on access to and motivation for treatment. The interviews were recorded and transcribed using OpenAI software. Transcripts were coded by two separate reviewers and then analyzed for themes using Atlas.ti. We interviewed 14 individuals; 3 were men, and 3 of the women identified as LGBTQ+. The participants ranged in age from 27 to 54 years old. All participants had a least one child. Gender differences existed. Mothers reported experiencing more barriers-notably, a lack of childcare, shame, and guilt-while fathers reported higher levels of support from family. Both mothers and fathers identified their children as a motivation for recovery, albeit in differing ways. Mothers and fathers with OUD experience different barriers to treatment and also rely on different resources. Prior efforts to increase access to treatment for parents have focused on physical barriers; however, our research supports the need for expanded treatment services for families and efforts to address the stigma of substance abuse disorder, but more efforts are also needed to address stigma.

Associations of Mental Health Measures and Retention in a Community-Based Perinatal Care Recovery Support Program for Women of Childbearing Age With Substance Use Disorder

Objective: This research was undertaken to evaluate factors related to program retention among participants in a community-based peer recovery program for women of childbearing age with a history of substance use disorder. Methods: In all, 184 women of childbearing age with a history of substance use disorder were enrolled in a community-based peer recovery program. Half of the participants were pregnant or postpartum. The outcome of interest was retention in the program as measured at 2 and 6 months. Participants were paired with a peer recovery coach (PRC). PRCs were women with a personal history of substance use disorder who assisted with healthcare system navigation, facilitated access to local resources, and provided advice and emotional support. All PRCs were also licensed perinatal community health workers. Independent variables included gestational status, depression, anxiety, type and frequency of substance use, childhood trauma, abuse, readiness for treatment, and attachment patterns. Results: Anxiety was found to be a key factor associated with retention. Moderate anxiety was associated with higher rates of retention compared to normal to mild anxiety. Severe anxiety was associated with lower rates of retention compared to normal to mild anxiety. Attrition was highest in the first 2 months. Conclusions: Early integration with mental health services to address severe anxiety symptoms could potentially improve retention in substance use disorder recovery programs, thereby improving outcomes. More research is needed regarding severe anxiety and care-avoidant behaviors, particularly among women of childbearing age.

Identifying family-child activities among children with prenatal drug exposure in a Tribal Nation: Caregiver perspectives on barriers, facilitators and positive outcomes

BACKGROUND

Native American newborns experience high rates of prenatal drug exposure leading to devastating outcomes within Indigenous communities. Such children are at heightened risk of maladaptive outcomes if early intervention does not occur. A need exists to identify strategies that promote resilience.

OBJECTIVES

Identify barriers and facilitators that families experience in family-child engagement activities across the community, culture, outdoors, and home settings to inform a cultural-sensitive and community-relevant study aimed at quantifying positive family-child engagement activities as a resilience factor in this population.

METHODS

Biological parents and caregivers to children, ages 0-3 years old with or without prenatal drug exposure (N = 15) were recruited from the Confederated Salish and Kootenai Tribes to participate in an in-person semi-structured interview. Data analysis consisted of research yarning and directed content analysis to collect unique stories and to identify common activities, barriers, supports and positive outcomes to families, respectively.

RESULTS

Attending multiple powwows/celebrations, swimming, and reading were the most mentioned activities. Cost and transportation were common barriers. The most common support mechanism provided was having family or friends present to participate in activities. Cultural knowledge and bonding were common positive outcomes for a child engaging in activities. A collection of stories identified both familial barriers to traditional ways of knowing and participation in community, and community-implemented efforts to bridge that gap among families with a history of drug and alcohol use.

CONCLUSIONS

This study identifies potential resilience factors specific to families to children with prenatal drug exposure that reside in Indigenous communities.

Optimizing Outcomes: A Systematic Review of Psychosocial Risk Factors Affecting Perinatal Black/African-American Women with Substance Use Disorder in the United States

INTRODUCTION

Despite studies having examined and discussed the various multifaceted risk factors affecting perinatal women with substance use disorder (SUD), the limited amount of research on Black/African-American (B/AA) women allows health disparities in this population to widen. Segmenting the needs of the low-income B/AA female population with SUD is crucial when creating multi-layered and multi-faceted innovative upstream evidence-based interventions. This review assesses and examines studies that investigate psychosocial, environmental, and systemic level risk factors related to implicit bias, trauma, toxic stress, food issues, and SUD.

METHODS

The principal investigator (PI) utilized PubMed, Google Scholar, ProQuest Dissertations and Theses Global to perform a systematic scoping review of the published literature. Research focused on risks factors affecting low-income perinatal B/AA women. The literature review examined articles published January 2010 through December 2020. Inclusion criteria incorporated risk factors, health disparities, and SUD. Studies selected for this review have been published in English and conducted in the USA.

RESULTS

Our research identified 509 articles, of which we chose to include 75. The literature highlights health disparities influenced by risks factors of implicit biases, trauma, and toxic stress, which construct physical and emotional barriers to healthy food and food resources in B/AA women with SUD.

CONCLUSION

The PI found limited or non-existent research on innovative interventions targeting perinatal B/AA women with SUD. This review recommends deconstructing hidden psychosocial, environmental, and systematic risk factors to assist in developing novel comprehensive strategies and wraparound support services.

Emergency Department Utilization for Substance Use Disorder During Pregnancy and Postpartum in the United States (2006-2016)

OBJECTIVES

We aimed to better understand emergency department (ED) use, admission patterns, and demographics for substance use disorder in pregnancy and postpartum (SUDPP).

METHODS

In this longitudinal study, the United States Nationwide Emergency Department Sample was queried for all ED visits by 15- to 50-year-old women with a primary diagnosis defined by International Classification of Diseases, 9th or 10th edition Clinical Modification, codes of SUDPP between 2006 and 2016. Patterns of ED visit counts, rates, admissions, and ED charges were analyzed.

RESULTS

Annual national estimated ED visits for SUDPP increased from 2,919 to 9,497 between 2006 and 2016 (a 12.4% annual average percentage change), whereas admission rates decreased (from 41.9% to 32.0%). ED visits were more frequent among women who were 20-29 years old, using Medicaid insurance, in the lowest income quartile, living in the South, and in metropolitan areas. Compared with the proportion of ED visits, 15- to 19-year-olds had significantly lower admission rates, whereas women with Medicaid and in the lowest income quartile had higher admission rates (p < .001). Opioid use, tobacco use, and mental health disorders were most commonly associated with SUDPP. The ED average inflation-adjusted charges for SUDPP increased from $1,486 to $3,085 between 2006 and 2016 (7.1% annual average percentage change; p < .001), yielding total annual charges of $4.02 million and $28.53 million.

CONCLUSIONS

Despite the decrease in admissions, the number and charges for ED visits for SUDPP increased substantially between 2006 and 2016. These increasing numbers suggest a continuous need to implement preventive public health measures and provide adequate outpatient care for this condition in this population specifically.

Child Abuse Prevention and Treatment Act, family care plans and infants with prenatal substance exposure: Theoretical framework and directions for future research

In May 2021, a reauthorization of the Child Abuse Prevention and Treatment Act (CAPTA) was introduced in the U.S. Senate. This reauthorization substantially amends provisions concerning infants affected by prenatal substance exposure and decidedly shifts the policy from a child safety- to a public health-focused approach to achieve the larger goals of healthy and safe child development and caregiver recovery from substance use disorder. Despite its honorable aspirations, no research has tested whether CAPTA "works". To advance scholarship on this policy, we summarize the service needs for this population and clarify how the CAPTA reauthorization aims to address these needs. We then apply a health utilization theory to understanding the mechanisms of effect on maternal-child outcomes. Based on this theoretical analysis, we discuss directions for future research.

Risk Factors Associated with Perinatal Relapse to Opioid Use Disorder

The recent opioid epidemic in the United States has led to rising prevalence of maternal opioid use disorder (OUD). First-line treatment for maternal OUD involves the use of opioid agonist pharmacotherapy, such as methadone or buprenorphine, in addition to cognitive behavioral therapy and counseling. The management of maternal OUD can become overwhelming for both patients and clinicians, especially during the early postpartum period. Therefore, it is imperative that clinicians understand the impact of additional stressors in caring for these patients. Maternal chronic opioid dependence can lead to neonatal opioid withdrawal syndrome after birth. This multisystem condition affects neonatal neurobehavioral functioning and has significant human and socioeconomic consequences. First-line treatment for this syndrome involves intensive nonpharmacologic comforting measures, with maternal presence and involvement being central to ensuring the success of such measures. In this review, we describe the factors that place pregnant and postpartum women with OUD at risk of returning to illicit opioid use. We evaluate these multifaceted personal, social, societal, and systemic factors to inform the development of future clinical care initiatives.

Postpartum Follow-up Care for Pregnant Persons With Opioid Use Disorder and Hepatitis C Virus Infection

Among Medicaid-enrolled pregnant persons with opioid use disorder, one third are diagnosed with hepatitis C virus, but only 6% receive postpartum follow-up or medication treatment.

Barriers to care for perinatal patients with opioid use disorder: family physician perspectives

BACKGROUND

While barriers to care for pregnant patients with opioid use disorder (OUD) have been described, the experiences and challenges of the physicians providing care to these patients are poorly understood.

OBJECTIVES

To describe the experiences of family physicians providing comprehensive care to pregnant people with OUD and the challenges they face in providing such care.

METHODS

Qualitative thematic analysis of 17 semistructured interviews conducted from July 2019 to September 2020 with family physicians who possess a Drug Enforcement Administration "X" waiver and provide care to pregnant patients.

RESULTS

Seventeen family physicians practicing in the United States who care for pregnant people with OUD were interviewed. They described physician-, patient-, and systems-level barriers to providing and accessing care for this patient population. Of the 12 interrelated themes regarding challenges to delivering and accessing this care, 3 were particularly salient: the pervasive effects of social determinants of health, a lack of adequately trained providers, and social stigma associated with pregnant people with OUD.

CONCLUSION

A comprehensive, multilevel, and multidisciplinary approach is necessary to address these barriers and move towards health equity for this vulnerable patient population.

Medications for opioid use disorder during pregnancy: Access and continuity in a state women's prison facility, 2016-2019

BACKGROUND

Although medications to treat opioid use disorder (MOUD) are the standard of care during pregnancy, there are many potential gaps in the cascade of care for pregnant people experiencing incarceration.

METHODS

We conducted a retrospective cohort study of pregnant people with opioid use disorder incarcerated in a Southeastern women's prison from 2016 to 2019. The primary outcomes were access to MOUD during incarceration and continuity in the community. We used descriptive statistics to summarize aspects of our sample and logistic regression to identify predictors of MOUD receipt during incarceration.

RESULTS

Of the 279 pregnant people with OUD included in the analysis, only 40.1% (n = 112) received MOUD during incarceration, including 67 (59.8%) who received methadone and 45 (40.1%) who received buprenorphine. Less than one-third of the participants were referred to a community MOUD provider (n = 83, 30%) on return to the community. Significant predictors of MOUD receipt included medium/close custody level during incarceration, incarceration during the latter portion of the study period, pre-incarceration heroin use, and receipt of pre-incarceration MOUD.

CONCLUSIONS

Although prisons can serve as an important site of retention in MOUD for some pregnant people, there were substantial gaps in initiation of MOUD and retention in MOUD among pregnant people with OUD imprisoned in the Southeast during the study period.

Reduced Child-Oriented Face Mirroring Brain Responses in Mothers With Opioid Use Disorder: An Exploratory Study

While the prevalence of opioid use disorder (OUD) among pregnant women has multiplied in the United States in the last decade, buprenorphine treatment (BT) for peripartum women with OUD has been administered to reduce risks of repeated cycles of craving and withdrawal. However, the maternal behavior and bonding in mothers with OUD may be altered as the underlying maternal behavior neurocircuit (MBN) is opioid sensitive. In the regulation of rodent maternal behaviors such as licking and grooming, a series of opioid-sensitive brain regions are functionally connected, including the ventral pallidum (VP). In humans, these brain regions, interact with the supplementary motor area (SMA) to regulate maternal behaviors and are functionally dysregulated by opioids. It is unclear how these brain regions respond to the emotions of their child for mothers receiving BT. In this functional magnetic resonance imaging (fMRI) pilot study in 22 mothers within the first postpartum year, including six mothers receiving BT and 16 non-OUD mothers as a comparison group (CG), we devised a child face mirroring task in fMRI settings to assess maternal responses to pictures of facial expressions of own child and an unknown child in an empathic mirroring condition (Join) and a non-mirroring observation condition (Observe). In each condition, faces of neutral, ambiguous, distressed, and joyful expressions of each child were repeatedly displayed in a random order. The response of SMA during empathic mirroring (Join) vs. non-mirroring (Observe) of own child was reduced among BT/OUD vs. CG. Within MBN, the left VP, critical for parental sensitivity, had a similar deficit. This study outlines potential mechanisms for investigating the risks of deficits in the neural responses to actual maternal sensitivity and parenting behavior in mothers with OUD, and potential targets for interventions that reduce stress and augment maternal behavior and child outcome.

Ethical Issues in Providing and Promoting Contraception to Women with Opioid Use Disorder

Women with opioid use disorder (OUD) face unique challenges meeting their reproductive goals. Because the rate of unintended pregnancy in this population is almost 80 percent, there has been a push to increase the use of contraceptives among reproductive-aged women with OUD.1 The patient-level ethical issues of such initiatives, however, are often overlooked. This review discusses the ethical issues in two realms: obtaining contraception when it is desired and avoiding contraceptive coercion when contraception is not desired. It is important that access to reproductive education and care be improved to ensure autonomous decision making by women with OUD. It is also necessary to be mindful of the history of oppressive and coercive contraception and sterilization policies in the United States. These policies have left a legacy of mistrust and continue to be manifested in the form of more subtly oppressive policies in contemporary medical practice. Such policies point to the ongoing stigmatization of, and implicit biases held against, women with OUD. Based on these ethical issues, solutions are suggested at the clinical, systemic, and societal levels.

Association between punitive policies and neonatal abstinence syndrome among Medicaid-insured infants in complex policy environments

AIMS

To estimate the association between punitive policies for women with substance use during pregnancy and odds of neonatal abstinence syndrome (NAS) diagnosis among Medicaid-insured infants, and to estimate this association controlling for the presence of four other policies related to substance use in pregnancy.

DESIGN, SETTING AND PARTICIPANTS

Analysis of live births in Medicaid claims data from 39 US states in varying years between 2006 and 2014 using weighted generalized linear models with clustered standard errors and state and year fixed-effects.

MEASUREMENTS

NAS rates in states without punitive policies were compared with rates in states with policies before and after policy enactment using logistic regression models adjusted for individual and county-level factors and including state and year fixed-effects. We estimated odds of NAS controlling for the presence of a potentially treatment-deterring policy requiring reporting of suspected prenatal substance use, and three treatment-supportive policies that create targeted programs for pregnant and postpartum women, prioritize pregnant women's access to substance use disorder treatment programs and prohibit discrimination towards pregnant women in treatment programs.

FINDINGS

Among 9 714 798 weighted live births (1 896 082 unweighted), 49 670 (0.51%) had an NAS diagnosis. The findings were inconclusive as to whether or not punitive policies were associated with odds of NAS either in the short or long term. Odds of NAS among infants born in states with reporting policies were lower than those born in states without such policies [adjusted odds ratio (aOR) = 0.77, 95% confidence interval (CI) = 0.61-0.98].

CONCLUSIONS

In the United States, punitive policies for women with substance use during pregnancy do not appear to be associated with lower odds of neonatal abstinence syndrome (NAS). Reporting policies, which are heterogenous in their components and implementation, appear to be associated with lower odds of NAS when controlling for other relevant policies.

Co-occurrence of preconception maternal childhood adversity and opioid use during pregnancy: Implications for offspring brain development

Understanding of the effects of in utero opioid exposure on neurodevelopment is a priority given the recent dramatic increase in opioid use among pregnant individuals. However, opioid abuse does not occur in isolation-pregnant individuals abusing opioids often have a significant history of adverse experiences in childhood, among other co-occurring factors. Understanding the specific pathways in which these frequently co-occurring factors may interact and cumulatively influence offspring brain development in utero represents a priority for future research in this area. We highlight maternal history of childhood adversity (CA) as one such co-occurring factor that is more prevalent among individuals using opioids during pregnancy and which is increasingly shown to affect offspring neurodevelopment through mechanisms beginning in utero. Despite the high incidence of CA history in pregnant individuals using opioids, we understand very little about the effects of comorbid prenatal opioid exposure and maternal CA history on fetal brain development. Here, we first provide an overview of current knowledge regarding effects of opioid exposure and maternal CA on offspring neurodevelopment that may occur during gestation. We then outline potential mechanistic pathways through which these factors might have interactive and cumulative influences on offspring neurodevelopment as a foundation for future research in this area.

Knowledge of community pharmacists in the Kathmandu Valley, Nepal about the risks associated with medication use during pregnancy

BACKGROUND

Community pharmacists are among the most accessible health care providers.

OBJECTIVE

This study evaluates the knowledge of community pharmacists about the risks associated with medication use during pregnancy.

METHODS

A cross-sectional study was carried out in March 2021 among the 344 community pharmacies in the Kathmandu Valley, Nepal. Convenience sampling was used for data collection using a structured and validated questionnaire.

RESULTS

The majority of participants were male: 264 (76.7%), 94.2% were between the age of 21 to 30 years, and 53.1% had work experience of less than one year. Over half had completed diploma in pharmacy. Less than 10 medicines were dispensed to pregnant women daily in 61.6% of the pharmacies. Only 28.8% of the community pharmacists always inquired about pregnancy status from women in the reproductive age group. The mean knowledge score was significantly different among individuals with different work experience and qualifications (p < 0.001). There was also difference in mean scores according to average number of medicines dispensed daily (p = 0.006). The knowledge score also differed according to average number of medicines dispensed to pregnant woman and inquiry by the pharmacist about pregnancy status (p < 0.001).

CONCLUSION

Our study revealed that the mean knowledge scores need improvement.

Care Experiences of Persons With Perinatal Opioid Use: A Qualitative Study

Opioid use in the perinatal period has escalated rapidly, with potentially devastating outcomes for perinatal persons and infants. Substance use treatment is effective and has the potential to greatly improve clinical outcomes; however, characteristics of care received from providers including nurses have been described as a barrier to treatment. Our purpose was to describe supportive perinatal care experiences of persons with opioid use disorder. A qualitative descriptive study design was used to examine experiences of 11 postpartum persons (ages 22-36 years) in medication-assisted treatment for opioid use disorder at an academic medical center in the southern region of the United States. Participants were interviewed about experiences with perinatal and neonatal care during the child's hospitalization for neonatal abstinence syndrome surveillance and/or treatment. Four themes of supportive care experiences emerged: informing, relating, accepting, and holistic supporting. Participants reported a range of positive and negative perinatal care experiences, with examples and counterexamples provided. This fuller understanding of perceptions and lived experiences of care can inform practice changes and educational/training priorities. Future research is needed to facilitate development of comprehensive care models geared to address perinatal care needs of persons with opioid use disorder.

Nurses' Priorities for Improving Pregnancy and Birth Care for Individuals with Opioid use Disorder

INTRODUCTION

The motivation to seek treatment for opioid use disorder (OUD) can increase during the perinatal period. However, several identified barriers, such as poor access to services, lack of trained providers, stigma, and legal ramifications of OUD, limit the ability for individuals with OUD to receive safe and supportive care during pregnancy and birth. During the birth hospital stay in particular, nurses provide the majority of care for pregnant and birthing families. We aimed to engage nurses, with experience caring for pregnant and postpartum individuals with OUD, in priority setting as a way to identify areas of need in the current health care systems.

METHODS

Using community-engaged priority setting methods, we recruited a sample of 47 nurses (phase 1) and 20 nurses (phase 2), including nurse-midwives and other advanced practice nurses, at a statewide nursing conference, who reported regularly providing care for pregnant and postpartum individuals with OUD. We invited participants to submit questions and concerns regarding the provision of care for individuals with OUD (phase 1). A selection of those who submitted questions attended a focus group to rank and prioritize submitted questions into a set of priorities for research, policy, and care improvement (phase 2).

RESULTS

In phase 1, participants submitted a total of 165 questions and concerns. In phase 2, participants prioritized the following: funding to support improvements in OUD care in the perinatal period, increased access to services, supportive housing for individuals in recovery, standardization of care for individuals with OUD, and efforts to destigmatize care.

DISCUSSION

Nurses who work with pregnant and postpartum individuals with OUD have a unique insight as to how health care providers, including midwives, can better support this community and should be engaged setting priorities for research, changes to policy, and improvement in care.

Prenatal exposure to opioids: Associations between the caregiving environment and externalizing behaviors

Maternal opioid use during pregnancy is a rapidly growing public health crisis and is associated with a range of adverse developmental outcomes including externalizing behaviors among exposed children. Recent work has highlighted the role of indirect pathways from prenatal opioid exposure to behavioral outcomes through aspects of the caregiving environment, including parenting. This review highlights maternal sensitivity and related aspects of the caregiving environment that may impact the development of externalizing behaviors among children with a history of prenatal exposure to opioids. We conclude by providing suggestions for future directions in research examining development among children with prenatal opioid exposure.

Can buprenorphine be used for opioid use disorder during pregnancy?

ABSTRACT

New clinical studies indicate that buprenorphine can be a promising alternative to methadone for treating opioid use disorder (OUD) in pregnant women. Various benefits for the mother have been identified with buprenorphine's unique pharmacokinetics, effect on clinical outcomes, and convenience for the patient. With the growing problem of OUD in pregnant women, clinicians must be aware of treatment options and their associated advantages and disadvantages.

Stakeholder Perspectives on Advancing Understanding of Prenatal Opioid Exposure and Brain Development From the iOPEN Consortium of the Healthy Brain and Child Development Study

Introduction: There is a dire need for research regarding the implications of opioid use during pregnancy on fetal and childhood development to better inform both medical practice and policy. The Healthy Brain and Child Development Study will examine brain and behavioral development from birth through the first decade of life. Due to large scope and anticipated complexity of this initiative, an 18-month planning phase was implemented across 28 sites across the nation. A core element of the Phase I initiative involved the development of Stakeholder Advisory Committees to inform the next phase of the initiative. Methods: Phase I stakeholder meetings were conducted at Oregon Health and Science University, New York University Langone Medical Center, the University of Pittsburgh, and the University of Vermont to better understand perspectives and inform upcoming research. Despite differences in the structure of the stakeholder meetings by site, the overarching goals for the meetings included establishing relationships, gathering input, and learning about research engagement. Documents from each meeting were reviewed for location, duration, attendees, common research themes, and pertinent suggestions for improving research approaches. Results: All stakeholders had high levels of interest in research for pregnant people with substance use disorders and agreed on research priorities including collaboration, connection, communication, and support. Different stakeholders offered unique perspectives on various aspects of study design and themes that emerged through meetings. Discussion: Overall, there was excitement about the research, especially the opportunity to include the voices of people with lived experience; collaboration between providers, peer support specialists, patients, and others; and excitement around contributing to research that could elucidate new and pertinent findings in the realm of addiction medicine and child development. Sites also found that there is mistrust between people with substance use disorder and the medical system, and this could be addressed by including people with lived experience on the research team, forming connections, communicating clearly, training the research team in implicit bias, and practicing trauma-informed care. In conclusion, these stakeholder meetings provided valuable information for structuring upcoming studies; however, researchers would have benefitted from more time and more opportunities for in-person connection.

Buprenorphine X-waiver exemption - beyond the basics for the obstetrical provider

Buprenorphine is 1 of 3 medications approved by the US Food and Drug Administration for the treatment of opioid use disorder, and practitioners must obtain a federal waiver to prescribe buprenorphine. Until recently, physicians and advanced practice clinicians were required to complete 8 and 24 hours of training, respectively, before applying for this waiver and to provide psychosocial services when prescribing buprenorphine to ≤30 patients. The US Department of Health and Human Services announced in April 2021 that eligible providers would be exempt from the educational requirement for certification, making the waiver more accessible for those intending to prescribe to ≤30 patients. Here, we reviewed the historic background to the exemption and provided practical guidelines to practitioners caring for obstetrical patients with opioid use disorder who are considering applying for the waiver for the first time. Because the educational requirements will no longer be required for X-waiver application, we reviewed fundamental topics and challenging scenarios that are often reviewed in certification courses.

Pregnancy and the Opioid Crisis: Heightened Effects of COVID-19

The opioid epidemic continues to affect pregnant women with opioid use disorder adversely in unique and enduring ways. The onset of the coronavirus disease 2019 (COVID-19) pandemic and the necessary public health measures implemented to slow the transmission have increased barriers to care for these same women. This commentary explores the implications of these measures and discusses strategies we have developed to manage these challenges based on our work in a clinical trial providing patient navigation to pregnant mothers with OUD. We believe these solutions can be applied in medical, behavioral health, and research settings through the pandemic and beyond to increase the quality of care and resources to this vulnerable population.

Unmet Mental Health Care Needs and Illicit Drug Use During Pregnancy

OBJECTIVES

The prevalence of drug use is at alarmingly high levels in the United States. Of particular concern is prenatal drug use, which exposes the underdeveloped organ systems of the fetus to harsh chemicals. Identifying factors associated with illicit drug use during pregnancy is critical to identify and treat at-risk pregnant women and improve maternal and infant health outcomes. The goal of this study was to examine the association between unmet mental health care needs and substance use during pregnancy.

METHODS

The present cross-sectional study analyzed secondary data from the 2002 to 2014 National Survey on Drug Use and Health (n = 10,516). The main outcome of interest was self-reported illicit drug use in the last 30 days. The independent variable was unmet mental health care needs in the last 12 months.

RESULTS

Overall, 6.4% of the participants reported a history of unmet mental health care needs and 4.5% used a substance during pregnancy. The odds of illicit drug use during pregnancy were higher among women who had an unmet mental health care needs compared to women without a history of unmet mental health care needs, multivariable-adjusted odds ratio (95% CI) 4.06 (3.01 to 5.48; P < 0.001). The observed association between unmet mental health care needs and illicit drug use persisted in subgroup analyses by age, race/ethnicity and education.

CONCLUSION

In a nationally representative cross-sectional sample of pregnant women, having unmet mental health care needs was positively associated with illicit drug use during pregnancy after adjusting for potential confounders.

Five-Year Outcomes Among Medicaid-Enrolled Children With In Utero Opioid Exposure

The health of women and children affected by opioid use disorder is a priority for state Medicaid programs. Little is known about longer-term outcomes among Medicaid-enrolled children exposed to opioids in utero. We examined well-child visit use and diagnoses of pediatric complex chronic conditions in the first five years of life among children with opioid exposure, tobacco exposure, or neither exposure in utero. The sample consisted of 82,329 maternal-child dyads in the Pennsylvania Medicaid program in which the children were born in the period 2008-11 and followed up for five years. Children with in utero opioid exposure had a lower predicted probability of recommended well-child visit use at age fifteen months (42.1 percent) compared to those with tobacco exposure (54.1 percent) and those with neither exposure (55.7 percent). Children with in utero opioid exposure had a predicted probability of being diagnosed with a pediatric complex chronic condition similar to that among children with tobacco exposure and those with neither exposure (20.4 percent, 18.7 percent, and 20.2 percent, respectively). Our findings were consistent when we examined a subgroup of opioid-exposed children identified as having neonatal opioid withdrawal symptoms.