The maternal, fetal, and neonatal effects of cocaine exposure in pregnancy

Epigenetic inheritance of phenotypes associated with parental exposure to cocaine

Parental exposure to drugs of abuse induces changes in the germline that can be transmitted across subsequent generations, resulting in enduring effects on gene expression and behavior. This transgenerational inheritance involves a dynamic interplay of environmental, genetic, and epigenetic factors that impact an individual's vulnerability to neuropsychiatric disorders. This chapter aims to summarize recent research into the mechanisms underlying the inheritance of gene expression and phenotypic patterns associated with exposure to drugs of abuse, with an emphasis on cocaine. We will first define the epigenetic modifications such as DNA methylation, histone post-translational modifications, and expression of non-coding RNAs that are impacted by parental cocaine use. We will then explore how parental cocaine use induces heritable epigenetic changes that are linked to alterations in neural circuitry and synaptic plasticity within reward-related circuits, ultimately giving rise to potential behavioral vulnerabilities. This discussion will consider phenotypic differences associated with gestational as well as both maternal and paternal preconception drug exposure and will emphasize differences based on offspring sex. In this context, we explore the complex interactions between genetics, epigenetics, environment, and biological sex. Overall, this chapter consolidates the latest developments in the multigenerational effects and long-term consequences of parental substance abuse.

Perinatal Psychoactive Substances Use: A Rising Perinatal Mental Health Concern

Introduction: A significant increase in psychoactive drugs use was observed in women of childbearing age and during the perinatal period worldwide. Yet, the use of illicit drugs, alcohol and tobacco during pregnancy is a serious health risk for the mother, developing fetus and newborn. Methods: This review of current trends and consequences of psychoactive substance use in the general population and in pregnant women was conducted using the English and French literature published during the years 2000 to 2022, supplemented by guidelines, meta-analyses and reviews. Results: According to current rates of prenatal substances use, it was calculated that 380,000 offspring were exposed to illicit substances, more than 500,000 to alcohol and over one million to tobacco during uterine life. Alarmingly, drug-related pregnancy-associated mortality has shown a staggering 190% rise between 2010 and 2019 in the USA. Different drugs of abuse, when used during pregnancy, increase the risk of stillbirth, neonatal abstinence syndrome and sudden infant death. Adverse effects on pregnancy include premature rupture of membranes, placental abruption, preterm birth, low birth space? weight and small-for-gestational-age infants. There is also an increased risk of morbidity and mortality for the pregnant women. Long-term negative adverse effects of perinatal exposure to substances also include a number of neurocognitive, behavioral and emotional dysfunctions in infants. Each type of substance has its own specificities, which will be briefly summarized. Conclusion: All childbearing age women must be informed about the potential harm of the prenatal use of psychoactive substances and should be encouraged to stop their use when pregnancy is planned and, at least, when pregnancy is known. Questioning women about their alcohol consumption should be systematic at the first prenatal visit and then at every prenatal visit until delivery. Multidisciplinary prevention approaches as well as intervention measures targeted to each type of psychoactive substance can save mothers’ lives and mitigate serious adversities to the offspring.

Increase of cannabis and cocaine use by pregnant women in France from 2005 to 2018: Insights of the annual cross sectional OPPIDUM survey

CONTEXT

Substance use disorders during pregnancy are associated with antenatal, neonatal and long-term adverse drug reactions in children. The aim of this study was to describe, using data from OPPIDUM survey, the evolution of illicit substance use or diverted prescription drug use among pregnant women visiting French addiction care centres from 2005 to 2018.

MATERIAL AND METHOD

The current study focused on women of childbearing age (15-44years old) identified as pregnant, and included in the OPPIDUM survey from 2005 to 2018. OPPIDUM is a French nationwide survey repeated each year since 1995, which anonymously collects information on drug abuse and dependence observed in patients recruited in addiction care centres. Patterns of illicit substance use, psychoactive medications, and opioid maintenance treatment (OMT) were described over time (by period of 2 years) and changes between 2005-2006 and 2017-2018 were investigated.

RESULTS

From 2005 to 2018, 784 pregnant women were included in the OPPIDUM survey (median age 28, interquartile range (IQR): 25-33). The proportion of women using exclusively cannabis (1.2% vs. 17.1%, P=0.0004) and cocaine (including crack) use (4.7% vs. 14.3%, P=0.0384) significantly increased over the period. Considering the first substance reported as leading to dependence, heroin significantly decreased (78.8% vs. 50.0%, P=0.0002) whereas cannabis significantly increased (5.9% vs. 25.7%, P=0.0005).

CONCLUSION

This study highlighted an important change of patterns of drug use by French pregnant women over a 14-year-period. Health professionals must be aware of these changes to adapt prevention and care among women of childbearing age and pregnant women.

Drug use in pregnancy in Ireland's capital city: A decade of trends and outcomes

OBJECTIVE

The aim of this study was to present contemporary trends in opiate use disorder (OUD) and substance use in pregnancy in Ireland, with associated obstetric outcomes, over the last ten years.

STUDY DESIGN

This retrospective observational cohort study was conducted at an Irish tertiary maternity unit. All women with OUD or substance use in pregnancy delivered under this service between 2010 and 2019 were included. Drug-exposure was self-reported. Data was collected by combining electronic and hand-held patient records. Trends and outcomes were analysed by year of delivery. Approval for the study was granted by the institution's clinical governance committee.

RESULTS

Of the 82,669 women delivered, 525 had OUD or substance use in pregnancy (1 in every 160 women booking). 11.6% were homeless, 20.0% were in full-time employment and 91.0% smoked tobacco in pregnancy. 66.3% had a history of psychiatric disorders. Over the ten years, there was a significant reduction in women delivered with OUD or substance use in pregnancy (0.8 % to 0.4 %, RR 0.55, 95 % CI 0.36-0.85), significant reduction in the proportion of women on Opioid-Substitute-Treatment (OST, RR 0.66 95 % CI 0.51-0.87) and an increase in mean maternal age (30.7to32.0 years). Rates of cocaine and cannabis consumption increased (20.6 %, RR 3.8, 95 % CI 1.57-9.44: 24.0 %, RR 3.7, 95 % CI 1.58-8.86 respectively). The maternal mortality rate was 380.9:100,000 births. The perinatal mortality rate was 15.6:1000 births. The preterm birth rate was 17.9 %, with a mean birth weight of 2832 g. The rate of NICU admission was 52.0 % and the mean length of stay was 22.4 days. Amongst the smaller OUD population, the rate of NICU admission for Neonatal Abstinence Syndrome (NAS) and treatment for NAS increased over the study timeframe (36.0 %, RR 2.97, 95 % CI 1.86-4.75: 28.5 %, RR 2.92, 95 % CI 1.70-5.0 respectively).

CONCLUSIONS

The obstetric population attending an Irish antenatal service with opiate use disorder or substance exposure is reducing in size with older patients, less opioid substitute therapy and increasing cocaine and cannabis use. These women have high rates of maternal and perinatal morbidity and mortality. Specialist antenatal addiction services, coordinated by the drug-liaison midwife, are critical in adapting care to respond to this dynamic and vulnerable patient cohort.

Impact of maternal substance use on offspring's cardiovascular health

Substance use (SU) during pregnancy is on the rise, posing significant risks to the developing fetus. The adverse impact of maternal alcohol and nicotine use during the perinatal period on offspring health has been well established, including their associations with adverse cardiovascular health in offspring. However, limited studies examine the impact of other well-known SU utilized during pregnancy on offspring's cardiovascular health. This review summarizes the proposed mechanism of action of four commonly utilized substances: cocaine, marijuana, methamphetamine, and opioids, and their cardiovascular impact. Furthermore, we will review the current understanding of the adverse impact of substance use during pregnancy on offspring's cardiovascular system based on existing studies. This review will also highlight possible molecular mechanisms underlying the in-utero adverse programming of offspring's cardiovascular system secondary to SU in pregnancy and address the gaps in current understanding of how SU adversely impacts the developing cardiovascular system of offspring in utero.

Metabolic risk factors and fertility disorders: A narrative review of the female perspective

Metabolic risk factors such as obesity are considered major obstacles to female fertility. Chronic infertility imposes psychological and social burdens on women because infertility violates societal gender roles. Although the prevalence of obesity among women is expected to increase in the future, the relevance of metabolic status for fertility is still underestimated. However, the assessment of metabolic risk factors is highly relevant for understanding fertility disorders and improving infertility treatment. This narrative review discusses the associations of metabolic risk factors (e.g. obesity, female athlete triad, oxidative stress) with significant infertility. An electronic search was conducted for studies published between 2006 and 2020 in Cumulative Index to Nursing and Allied Health Literature, ScienceDirect, PubMed, Scopus, Google Scholar and related databases. In total, this search identified 19,309 results for polycystic ovary syndrome, 28,969 results for endometriosis, and only 1611 results for idiopathic and/or unknown infertility. For the present narrative review, 50 relevant studies were included: 19 studies were on obesity, 24 studies investigated the female athlete triad, and seven studies addressed other risk factors, including reactive oxygen species. This narrative review confirms the direct impact of obesity on female infertility, while the effect of other risk factors needs to be confirmed by large-scale population studies.

Trends of Cocaine Use and Manifestations in Hospitalized Patients: A Cross-Sectional Study

Objective

About 41 million people aged ≥18 years reported lifetime use of cocaine, and 5.4 million people reported having used cocaine in 2019. We aim to identify trends of cocaine use, manifestations, concomitant drug use, and financial burden on health care among hospitalized patients.

Methods

We utilized National Inpatient Sample from years 2006-2018. Patients with age ≥18 years, admitted to the hospital with a diagnosis of cocaine abuse, dependence, poisoning, or unspecified cocaine use were included in the study. We used ICD-9 Clinical Modification (CM) and ICD-10-CM codes to retrieve patient samples and comorbid conditions. The primary outcome was the trend in cocaine use among hospitalized patients from the year 2006 to 2018. Cochran-Mantel-Haenszel test was used to assess the significance of trends.

Results

In the year 2006, the prevalence of cocaine abuse among hospitalized patients was 10,751 per million with an initial decline to 7,451 per million in 2012 and a subsequent increase to 11,891 per million hospitalized patients in 2018 with p =0.01. The majority of patients admitted were older than 50 years (43.27%), and a greater percentage of patients were males. All ethnicities showed a rising trend in the use of cocaine except for Native Americans. Cardiovascular effects, neuropsychiatric and infectious manifestations in hospitalized patients with cocaine abuse showed a consistent increase from year 2006 to 2018 with p <0.001.

Conclusions

There is a recent uptrend in cocaine use among hospital admissions in the US from 2006 to 2018 with an increased rate of systemic manifestations. This highlights the impact of cocaine use on the health system and the dire need to address this growing problem.

Teratogenic effects of maternal drug abuse on developing brain and underlying neurotransmitter mechanisms

The aim of this review is to highlight our knowledge of the various drugs of abuse that can prove potential teratogens affecting the brain and cognitive development in an individual exposed to maternal consumption of such agents. Among several drugs of abuse in women, we specifically highlighted the commonly used alcohol, nicotine, opioids, cannabis, cocaine and marijuana. These drugs can affect the fetal development and slow the cognitive maturation apart from physical disabilities. However, no known therapy exists to counter the toxic potential of these drugs. Several researchers used animal models of drug abuse to understand the underlying mechanisms affecting brain development and the relevant neurotransmitter system. Identifying such targets can potentially help in drug discovery research. We reported in depth analysis of such mechanisms and discussed the potential targets for drug development research.

The Term Newborn: Prenatal Substance Exposure

Care for pregnant patients with substance use disorder must be provided in a nonjudgmental manner with recognition of addiction as a chronic medical illness in order to establish a therapeutic relationship and improve outcomes. All pregnant patients should be screened for substance use during prenatal care. Screening can be accomplished through several validated screening tools. Patients who screen positive need to be evaluated and referred for treatment as appropriate. This article reviews specific adverse perinatal outcomes associated with the use of a variety of substances and provides guidance on exposure with continued breastfeeding.

Acute psychiatric illness and drug addiction during pregnancy and the puerperium

Pregnancy and the puerperium do not protect against acute psychiatric illness. During puerperium, the chance of acute psychiatric illness, such as a psychotic episode or relapse of bipolar disorder, is greatly increased. Suicide is a leading cause of maternal death. Both psychiatric disease and ongoing drug addiction impact not only the pregnant woman's somatic and mental health but also impact short-term and long-term health of the child. Indeed, prompt recognition and expeditious treatment of acute psychiatric illness during pregnancy and the puerperium optimize health outcomes for two patients. Pregnancy and puerperium represent a stage of life of great physiologic adaptations, as well as emotional and social changes. This conjunction of changes in somatic, emotional health and social health may mitigate the occurrence, clinical presentation, and clinical course of acute psychiatric illness and call for a multidisciplinary approach, taking into account both the medical and social domains. This chapter describes acute psychiatric illnesses during pregnancy and the puerperium and illicit substance abuse, from a clinical perspective, while also describing general principles of diagnosis and clinical management during this stage of life, which is an important window of opportunity for both the pregnant woman and the child.

Society for Maternal-Fetal Medicine Consult Series #54: Assessing the risk of maternal morbidity and mortality

The rates of maternal morbidity and mortality in the United States demand a comprehensive approach to assessing pregnancy-related risks. Numerous medical and nonmedical factors contribute to maternal morbidity and mortality. Reducing the number of women who experience pregnancy morbidity requires identifying which women are at greatest risk and initiating appropriate interventions early in the reproductive life course. The purpose of this Consult is to educate all healthcare practitioners about factors contributing to a high-risk pregnancy, strategies to assess maternal health risks due to pregnancy, and the importance of risk assessment across the reproductive spectrum in reducing maternal morbidity and mortality.

Machine-Learning prediction of comorbid substance use disorders in ADHD youth using Swedish registry data

BACKGROUND

Children with attention-deficit/hyperactivity disorder (ADHD) have a high risk for substance use disorders (SUDs). Early identification of at-risk youth would help allocate scarce resources for prevention programs.

METHODS

Psychiatric and somatic diagnoses, family history of these disorders, measures of socioeconomic distress, and information about birth complications were obtained from the national registers in Sweden for 19,787 children with ADHD born between 1989 and 1993. We trained (a) a cross-sectional random forest (RF) model using data available by age 17 to predict SUD diagnosis between ages 18 and 19; and (b) a longitudinal recurrent neural network (RNN) model with the Long Short-Term Memory (LSTM) architecture to predict new diagnoses at each age.

RESULTS

The area under the receiver operating characteristic curve (AUC) was 0.73(95%CI 0.70-0.76) for the random forest model (RF). Removing prior diagnosis from the predictors, the RF model was still able to achieve significant AUCs when predicting all SUD diagnoses (0.69, 95%CI 0.66-0.72) or new diagnoses (0.67, 95%CI: 0.64, 0.71) during age 18-19. For the model predicting new diagnoses, model calibration was good with a low Brier score of 0.086. Longitudinal LSTM model was able to predict later SUD risks at as early as 2 years age, 10 years before the earliest diagnosis. The average AUC from longitudinal models predicting new diagnoses 1, 2, 5 and 10 years in the future was 0.63.

CONCLUSIONS

Population registry data can be used to predict at-risk comorbid SUDs in individuals with ADHD. Such predictions can be made many years prior to age of the onset, and their SUD risks can be monitored using longitudinal models over years during child development. Nevertheless, more work is needed to create prediction models based on electronic health records or linked population registers that are sufficiently accurate for use in the clinic.

Associations of Maternal Prenatal Drug Abuse With Measures of Newborn Brain Structure, Tissue Organization, and Metabolite Concentrations

IMPORTANCE

Increasing rates of illicit drug use during pregnancy may be associated with risk for long-term health problems in prenatally exposed children.

OBJECTIVE

To identify the associations of prenatal exposure to illicit drugs with organization of the newborn brain.

DESIGN, SETTING, AND PARTICIPANTS

For this cohort study, a volunteer sample of 210 illicit drug-using and nonusing mothers and their newborns was enrolled from prenatal clinics and drug abuse treatment programs in New York, New York. Enrollment, scanning, and long-term follow-up occurred from September 2004 through February 2012, and image processing and statistical analyses continued through fall 2018. In addition to 26 participants with incomplete data, a total of 64 mothers were lost to follow-up during pregnancy, and 13 newborns were lost to follow-up at birth because of perinatal complications.

EXPOSURES

Newborns were assigned to 1 of 4 primary exposure groups based on the history of most frequent maternal drug use: marijuana, cocaine, methadone maintenance, and/or heroin. Unexposed newborns were controls.

MAIN OUTCOMES AND MEASURES

Unsedated magnetic resonance imaging (MRI) of newborn brains was performed shortly after birth. Infant neurodevelopmental outcomes were assessed at age 12 months. MRI modalities included anatomical imaging, diffusion tensor imaging, T2 relaxometry, and magnetic resonance spectroscopic imaging. Infant neurodevelopmental outcomes included Bayley scales of infant development-III and Vineland Adaptive Behavior Scales. Statistical analyses were performed with results represented on the brain images.

RESULTS

Of 118 mothers, 42 (35%) were in the control group (mean [SD] age, 25.9 [6.1] years), 29 (25%) were in the cocaine group (mean [SD] age, 29.0 [6.1] years), 29 (25%) were in the marijuana group (mean [SD] age, 24.3 [5.5] years), and 18 (15%) were in the methadone and/or heroin group (mean [SD] age, 30.9 [5.7] years). Not all newborns could be scanned successfully; therefore, usable MRIs were acquired for 118 newborns from predominantly minority groups and with economically disadvantaged mothers. Anatomic abnormalities were detected in similar locations across all 3 drug exposures and included smaller volumes in the dorsal, medial, and ventral surfaces of the frontal lobe and dose-related increases in volumes in the lateral temporal lobe, dorsal parietal lobe, and superior frontal gyrus. Dose-related increases in diffusion tensor measures of tissue organization, decreases in T2 relaxometry times, and increases in spectroscopy metabolite concentrations were similar across exposures. These associations of exposures with brain measures were similar to the associations of newborn age with brain measures. The anatomic and diffusion tensor imaging measures suppressively mediated the associations of prenatal exposure with poorer 12-month infant outcomes.

CONCLUSIONS AND RELEVANCE

The findings suggest that prenatal drug exposure is associated with measures of newborn brain tissue in patterns that may indicate that exposures accelerated normal fetal brain maturation, which in turn mediated the associations with poorer 12-month infant outcomes.

Socioeconomic characteristics of women with substance use disorder during pregnancy and neonatal outcomes in their newborns: A national registry study from the Czech Republic

BACKGROUND

Maternal substance use can pose a risk to the fetal health. We studied the background characteristics of women with substance use disorders (SUDs) and selected neonatal outcomes in their children.

MATERIAL AND METHODS

A database-linkage study was performed. The sample consisted of pregnant women with a SUD during pregnancy (ICD-10 diagnosis F10-F19 except F17, n = 1710), women not diagnosed with a SUD (n = 1,511,310) in Czechia in 2000-2014, and their children. The monitored neonatal outcomes were gestational age, birth weight, preterm birth, and small-for-gestational age (SGA). Binary logistic regression adjusted for age, marital status, education, concurrent substance use, and prenatal care was performed.

RESULTS

Women with illicit SUDs were younger, more often unmarried, with a lower level of education, a higher abortion rate, a higher smoking rate, and lower compliance to prenatal care than women with a SUD related to alcohol, or sedatives and hypnotics (SH). Women with a SUD had worse socioeconomic situations, poorer pregnancy care, and worse neonatal outcomes than women without a SUD. After adjustment, we found no difference in SGA between the illicit SUD groups and the alcohol and the SH groups. The newborns from all SUD groups had a higher risk of SGA when compared to women without a SUD. However after adjustment, the difference remained significant just in the alcohol group (OR = 1.9, 95 % CI = 1.4-2.6).

CONCLUSION

Mother's SUD during pregnancy increased risk of fetal growth restriction as measured by SGA. The role of maternal socioeconomic and lifestyle factors for the risk of SGA was substantial.

Crack cocaine smoke on pregnant rats: Maternal evaluation and teratogenic effect

This study aimed to evaluate maternal toxicity, teratogenic, and placental oxidative effects resulting from the exposure of rats to crack cocaine smoke during pregnancy. Pregnant rats were exposed either to the smoke of crack and ashes (Crack) or to the smoke of ashes alone, nonexposed or pair-fed with the Crack group. Crack group was exposed to the smoke resulting from the burning of 250 mg of crack for 10 min, twice a day, from 7 days prior to mating until cesarian on gestational day 20. Placental oxidative stress and classical parameters of maternal and fetal evaluation were studied, in addition to the morphometric analysis of the fetal metamers. Even in the absence of changes in body weight gain and feed intake, crack altered the reproductive performance of dams. Exposure to the drug promoted late closure of the fetal fontanel. Furthermore, the morphometric study of the brain mass (BM)/skull cap ratio revealed a decrease in the BM of the fetuses exposed to the drug. Exposure to crack has an oxidative potential in fetal development, since exposure to the drug promoted placental lipid peroxidation. Our study showed that daily exposure to crack, even in lower frequency than that performed by users, has a teratogenic potential.

Prenatal Treatment and Outcomes of Women With Opioid Use Disorder

OBJECTIVE

To describe the characteristics, treatment, and outcomes of pregnant women with opioid use disorder.

METHODS

Women attending an obstetric and addiction recovery clinic in Boston from 2015 to 2016 were enrolled in a prospective cohort study and followed through delivery (N=113). Buprenorphine or methadone was initiated clinically. The Addiction Severity Index was administered at enrollment. Prenatal and delivery data were systematically abstracted from medical charts.

RESULTS

Most women in the cohort were non-Hispanic white (80.5%) with a mean age of 28 years. Few women were married (8.9%). More than half of the cohort had been incarcerated, 29.2% had current legal involvement, and 15.0% generally had unstable housing. A majority (70.8%) were infected with hepatitis C and histories of sexual (56.6%) and physical (65.5%) abuse were prevalent. Regular substance used included heroin (92.0%), injection heroin (83.2%), other opioids (69.0%), marijuana (73.5%), alcohol (56.6%), and cocaine (62.8%). Fifty-nine women (52.2%) were treated initially with prenatal buprenorphine and 54 (47.8%) with methadone; 49.6% also were taking concomitant psychotropic medications. Employment (0.766±0.289) and psychologic (0.375±0.187) Addiction Severity Index scores were the highest, indicating the most severe problems in these areas. Opioid use relapse did not differ by treatment (44.7% overall). Thirteen (22.5%) of 59 women treated with buprenorphine transitioned to methadone mainly because of positive opioid screens. Overall, 23.0% (n=26) of the cohort discontinued clinical care. The number of pregnancy losses was small (three therapeutic abortions, four miscarriages, one stillbirth), with an overall live birth rate of 90.8% (95% CI 82.7-95.9).

CONCLUSION

These data on the social circumstances, substance use, treatment, and treatment outcomes of pregnant women with opioid use disorder may help clinicians to understand and treat this clinically complex population.

Noncoding RNAs in development and teratology, with focus on effects of cannabis, cocaine, nicotine, and ethanol

Completion of the Human Genome Project has led to the identification of a large number of transcription start sites that are not paired with protein-coding genes, supporting the growing recognition of the abundance of encoded nonprotein-coding RNAs (ncRNAs) and their importance for speciation and species-specific development. Present in both plants and animals, ncRNAs vary in size, function, primary sequence, and secondary structure. While microRNAs (miRNAs) are the best known, there are a number of other ncRNAs (long[er] nonprotein-coding RNA, pseudogenes, circular RNAs, and so on) that have been shown to play an important role in the development either directly or via networks of proteins and other ncRNAs, including modulating the impact of miRNAs. Furthermore, these ncRNAs and their developmental regulatory networks are sensitive to teratogens such as ethanol, cannabis, cocaine, and nicotine. A better understanding of the developmental role of ncRNAs and their capacity to mediate teratogenesis is a necessary step in efforts to minimize the long-term consequences of developmental exposures to drugs-of-abuse. Moreover, with increasing awareness of the prevalence of polydrug use, experimental models will need to incorporate more complex drug exposure paradigms into meaningful assessments of developmental ncRNA function.

Stimulants: How big is the problem and what are the effects of prenatal exposure?

Globally, cocaine use increased by 7%-18.2 million people in 2016 or 0.4% of the world population aged 15-64. In 2016, over 34 million (0.7%) people aged 15-64 used amphetamines and a further 0.4% used MDMA (Ecstasy). Women of child bearing age worldwide are increasingly using and becoming dependent on stimulants; and are, in turn, more vulnerable to sexually transmitted diseases, sexual violence, unplanned pregnancies and mental health problems. Stimulant use during pregnancy increases obstetric complications for the mother, increases the rate of preterm birth and decreases birth weight, length and head circumference for the exposed infant. No consistent signs of neonatal abstinence syndrome requiring pharmacological treatment have been identified for cocaine or methamphetamine, however, infants exposed to one or both drugs exhibit disorganized neurobehaviour at birth. Increased efforts worldwide are needed to determine the extent of maternal stimulant use and to prevent or identify and treat substance use early during pregnancy.

Substance use in pregnancy: The medical challenge

Substance use contributes significantly to the global burden of disease. Growing numbers of women use nicotine, alcohol, and illicit substances. Women are the most vulnerable to problematic substance use in their reproductive years. The first 1000 days of life, starting at conception, have been established as a critical window of time for long-term health and development. Substance use in pregnancy is associated with negative pregnancy and child health outcomes. The impact of antenatal substance use on these outcomes needs to be considered within a challenging and complex context. This review provides an overview of the current literature on the impact of substances on pregnancy and child outcomes as well as the evidence and guidelines on screening and interventions for women using substances during pregnancy.

Identification of biochemical and cytotoxic markers in cocaine treated PC12 cells

Cocaine is one of the powerful addictive drugs, widely abused in most Western countries. Because of high lipophilic nature, cocaine easily reaches various domains of the central nervous system (CNS) and triggers different levels of cellular toxicity. The aim of this investigation was to reproduce cocaine toxicity in differentiated PC12 cells through quantitative knowledge on biochemical and cytotoxicity markers. We differentiated the cells with 0.1 μg/ml nerve growth factor (NGF) for 5 days, followed by treatment with cocaine for 48 h at in vivo and in vitro concentrations. Results indicated that cocaine at in vivo concentrations neither killed the cells nor altered the morphology, but decreased the mitochondrial membrane potential that paralleled with increased lactate and glutathione (GSH) levels. On the other hand, cocaine at in vitro concentrations damaged the neurites and caused cell death, which corresponded with increased reactive oxygen species (ROS) generation, plasma membrane damage, and GSH depletion with no detectable nitric oxide (NO) level. While direct understanding of cocaine and cell interaction under in vivo animal models is impeded due to high complexity, our present in vitro results assisted in understanding the onset of some key events of neurodegenerative diseases in cocaine treated neuronal cells.

Use of fast-scan cyclic voltammetry to assess phasic dopamine release in rat models of early postpartum maternal behavior and neglect

Maternal behavior (MB) is a complex response to infant cues, orchestrated by postpartum neurophysiology. Although mesolimbic dopamine contributes toward MB, little is known about real-time dopamine fluctuations during the postpartum period. Thus, we used fast-scan cyclic voltammetry to measure individual dopamine transients in the nucleus accumbens of early postpartum rats and compared them with dopamine transients in virgins and in postpartum females exposed to cocaine during pregnancy, which is known to disrupt MB. We hypothesized that dopamine transients are normally enhanced postpartum and support MB. In anesthetized rats, electrically evoked dopamine release was larger and clearance was faster in postpartum females than in virgins and gestational cocaine exposure blocked the change in clearance. In awake rats, control mothers showed more dopamine transients than cocaine-exposed mothers during MB. Salient pup-produced stimuli may contribute toward differences in maternal phasic dopamine by evoking dopamine transients; supporting the feasibility of this hypothesis, urine composition (glucose, ketones, and leukocytes) differed between unexposed and cocaine-exposed infants. These data, resulting from the novel application of fast-scan cyclic voltammetry to models of MB, support the hypothesis that phasic dopamine signaling is enhanced postpartum. Future studies with additional controls can delineate which aspects of gestational cocaine reduce dopamine clearance and transient frequency.

Use of crack in pregnancy: repercussions for the newborn

OBJECTIVES

To know the effects for the newborn of the use of crack in pregnancy.

METHODS

This is a qualitative study conducted in a university hospital in southern Brazil, in the first half of 2014. Fifteen mothers crack users and five grandparents participated. The data were produced through semi-structured interviews and later submitted to content analysis.

RESULTS

It was found that the use of crack in pregnancy leads to repercussions related to the health of the newborn and repercussions related to family restructuring. In relation to the newborn, prematurity, congenital malformation, hospitalization in an intensive care unit, use of care and feeding technologies through artificial milk formulas were mentioned. In the family context, it was evidenced the occurrence of abandonment of the child by the mother, causing the adoption of the newborn by relatives of the family nucleus or their institutionalization due to lack of family structure.

CONCLUSIONS

It was found that the use of crack in pregnancy leads to repercussions related to the health of the newborn and repercussions related to family restructuring. In this sense, the recruitment of pregnant users of crack by health/nursing professionals and referral for high-risk prenatal care, as well as early identification of the peculiarities of the newborns of these women, and the development of actions that minimize the repercussions of crack are imperative.

The Protective Effect of Pregnancy on Risk for Drug Abuse: A Population, Co-Relative, Co-Spouse, and Within-Individual Analysis

OBJECTIVE

The authors sought to determine whether pregnancy is an intrinsic motivator for cessation of drug abuse.

METHOD

The authors conducted prospective cohort, co-relative, co-spouse, and within-person analyses of registration for drug abuse during pregnancy among Swedish women born between 1980 and 1990 who gave birth between ages 20 and 35 (N=149,512). Drug abuse was assessed from medical, criminal, and pharmacy registries.

RESULTS

In the population, rates of drug abuse were lower during pregnancy (unadjusted odds ratio=0.67, 95% CI=0.60, 0.74). Compared with population results, the negative association between pregnancy and drug abuse was moderately stronger in cousins (odds ratio=0.49, 95% CI=0.39, 0.62) and substantially stronger in siblings (odds ratio=0.35, 95% CI=0.24, 0.51) discordant for pregnancy. The estimated odds ratio for drug abuse in pregnancy-discordant monozygotic twins was even stronger, at 0.17 (95% CI=0.10, 0.31). Within individuals, the odds ratio for drug abuse while pregnant compared with an equivalent prepregnancy interval was similar to that seen in pregnancy-discordant monozygotic twins, at 0.22 (95% CI=0.19, 0.26). Compared with cohabiting fathers, mothers had a greater reduction in risk for drug abuse during pregnancy (odds ratio=0.40, 95% CI=0.34, 0.47). Pregnancy was more protective in women with low parental education and without a cohabiting, actively drug-abusing father. Compared with prepregnancy baseline, within-individual analyses indicate that risk for drug abuse is also substantially reduced in the postpartum period, for example, the odds ratio for postpartum days 0-242 was 0.13 (95% CI=0.11, 0.16).

CONCLUSIONS

Risk for drug abuse in women is substantially reduced during pregnancy. Multiple analyses suggest that this association is largely causal, suggesting that pregnancy is indeed a strong intrinsic motivator for drug abuse cessation. Similar strong protective effects may be present in the immediate postpartum period. Our results have implications for our etiologic models of drug abuse and especially for contingency management programs seeking to reduce drug abuse risk.

Global cocaine intoxication research trends during 1975-2015: a bibliometric analysis of Web of Science publications

BACKGROUND

Cocaine is subject to recreational abuse as a stimulant and psychoactive agent, which poses a major worldwide health problem. The aim of the present study was to perform a bibliometric analysis of publication related to cocaine intoxication an insight of the research trends at a global level to enable recommendations for future research strategies in this field.

METHODS

Publications about cocaine intoxication were retrieved from the Web of Science (WoS) Core Collection database on December 28, 2016, and analysed regarding the following bibliometric indicators: research trends, document types, languages, countries/territories with their h-index, collaboration patterns, journals with their impact factors (IF), and institutions.

RESULTS

In total, 2,902 scientific publications from 1975 to 2015 were retrieved from the WoS database. The annual number of publications related to cocaine toxicity increased slightly after 1990 and reached a peak of 148 in 1992, with an average of 103 publications per year. The USA outranked other countries/territories with 2,089 publications, of which 1,927 arose exclusively from the USA and 162 involved international collaborations. The h-index for all publications related to cocaine was 212, and the h-index for all publications related to cocaine intoxication was 99. Moreover, the USA had the highest h-index of 95, followed by Spain with h-index of 24, and Canada with h-index of 24. The main research topics were consistently reproductive toxicity, clinical management of acute cocaine exposure, laboratory methods for detection of exposure to cocaine, cocaine metabolism, and cocaine toxicity in animals.

CONCLUSIONS

This is the first bibliometric approach to examining research related to cocaine toxicity and shows that research activity has become more global and extensive since 1990. The USA remains the leading country regarding published literature, the highest h-index, and greatest role in international collaborations.

β-Blockers, Cocaine, and the Unopposed α-Stimulation Phenomenon

Cocaine abuse remains a significant worldwide health problem. Patients with cardiovascular toxicity from cocaine abuse frequently present to the emergency department for treatment. These patients may be tachycardic, hypertensive, agitated, and have chest pain. Several pharmacological options exist for treatment of cocaine-induced cardiovascular toxicity. For the past 3 decades, the phenomenon of unopposed α-stimulation after β-blocker use in cocaine-positive patients has been cited as an absolute contraindication, despite limited and inconsistent clinical evidence. In this review, the authors of the original studies, case reports, and systematic review in which unopposed α-stimulation was believed to be a factor investigate the pathophysiology, pharmacology, and published evidence behind the unopposed α-stimulation phenomenon. We also investigate other potential explanations for unopposed α-stimulation, including the unique and deleterious pharmacologic properties of cocaine in the absence of β-blockers. The safety and efficacy of the mixed β-/α-blockers labetalol and carvedilol are also discussed in relation to unopposed α-stimulation.

Treatment of opioid use disorder in an innovative community-based setting after multiple treatment attempts in a woman with untreated HIV

Opioid use disorder is associated with significant health and social harms. Various evidence-based interventions have proven successful in mitigating these harms, including harm reduction strategies and pharmacological treatment such as methadone. We present a case of a 35-year-old HIV-positive woman who was off antiretroviral therapy due to untreated opioid use disorder, and had a history of frequently self-discharging from hospital against medical advice. During the most recent hospital admission, the patient was transferred to an innovative community-based clinical support residence that supported harm reduction. Initially, she received methadone to only manage the withdrawal symptoms rather than for long-term maintenance therapy. However, with gradual dose increases to treat cravings and withdrawal, she ultimately discontinued all drug use and reinitiated antiretroviral therapy. This case highlights that patients whose goal is not abstinence can be successfully treated for acute medical illnesses and comorbid substance use disorders using harm reduction approaches, including appropriate dosing of pharmacotherapy.

Treatment of cocaine cardiovascular toxicity: a systematic review

INTRODUCTION

Cocaine abuse is a major worldwide health problem. Patients with acute cocaine toxicity presenting to the emergency department may require urgent treatment for tachycardia, dysrhythmia, hypertension, and coronary vasospasm, leading to pathological sequelae such as acute coronary syndrome, stroke, and death.

OBJECTIVE

The objective of this study is to review the current evidence for pharmacological treatment of cardiovascular toxicity resulting from cocaine abuse.

METHODS

MEDLINE, PsycINFO, Database of Abstracts of Reviews of Effects (DARE), OpenGrey, Google Scholar, and the Cochrane Library were searched from inception to November 2015. Articles on pharmacological treatment involving human subjects and cocaine were selected and reviewed. Evidence was graded using Oxford Centre for Evidence-Based Medicine guidelines. Treatment recommendations were compared to current American College of Cardiology/American Heart Association guidelines. Special attention was given to adverse drug events or treatment failure. The search resulted in 2376 articles with 120 eligible involving 2358 human subjects. Benzodiazepines and other GABA-active agents: There were five high-quality (CEBM Level I/II) studies, three retrospective (Level III), and 25 case series/reports (Level IV/V) supporting the use of benzodiazepines and other GABA-active agents in 234 subjects with eight treatment failures. Benzodiazepines may not always effectively mitigate tachycardia, hypertension, and vasospasm from cocaine toxicity. Calcium channel blockers: There were seven Level I/II, one Level III, and seven Level IV/V studies involving 107 subjects and one treatment failure. Calcium channel blockers may decrease hypertension and coronary vasospasm, but not necessarily tachycardia. Nitric oxide-mediated vasodilators: There were six Level I/II, one Level III, and 25 Level IV/V studies conducted in 246 subjects with 11 treatment failures and two adverse drug events. Nitroglycerin may lead to severe hypotension and reflex tachycardia. Alpha-adrenoceptor blocking drugs: There were two Level I studies and three case reports. Alpha-1 blockers may improve hypertension and vasospasm, but not tachycardia, although evidence is limited. Alpha-2-adrenoceptor agonists: There were two high-quality studies and one case report detailing the successful use of dexmedetomidine. Beta-blockers and β/α-blockers: There were nine Level I/II, seven Level III, and 34 Level IV/V studies of β-blockers, with 1744 subjects, seven adverse drug events, and three treatment failures. No adverse events were reported for use of combined β/α-blockers such as labetalol and carvedilol, which were effective in attenuating both hypertension and tachycardia. Antipsychotics: Seven Level I/II studies, three Level III studies, and seven Level IV/V case series and reports involving 168 subjects have been published. Antipsychotics may improve agitation and psychosis, but with inconsistent reduction in tachycardia and hypertension and risk of extrapyramidal adverse effects. Other agents: There was only one high level study of morphine, which reversed cocaine-induced coronary vasoconstriction but increased heart rate. Other agents reviewed included lidocaine, sodium bicarbonate, amiodarone, procainamide, propofol, intravenous lipid emulsion, propofol, and ketamine.

CONCLUSIONS

High-quality evidence for pharmacological treatment of cocaine cardiovascular toxicity is limited but can guide acute management of associated tachycardia, dysrhythmia, hypertension, and coronary vasospasm. Future randomized prospective trials are needed to evaluate new agents and further define optimal treatment of cocaine-toxic patients.

Translational analysis of effects of prenatal cocaine exposure on human infant cries and rat pup ultrasonic vocalizations

Spectral and temporal features of human infant crying may detect neurobehavioral effects of prenatal cocaine exposure (PCE). Finding comparable measures of rodent ultrasonic vocalizations (USVs) would promote translational analyses by controlling the effects of correlated variables that confound human studies. To this end, two studies examined the sensitivity of similar acoustic structures in human infant and rat pup vocalizations to effects of PCE. In Study 1, cry sounds of 107 one month-old infants were spectrum analyzed to create a novel set of measures and to detect the presence of hyperphonation - a qualitative shift to an atypically high fundamental frequency (basic pitch) associated with neurobehavioral insult. Infants with PCE were compared to infants with prenatal polydrug-exposure (PPE) without cocaine and with infants in a standard comparison (SC) group with no prenatal drug exposure. In Study 2, USVs of 118 five day-old rat pups with either PCE, prenatal saline exposure or no prenatal exposures were spectrum analyzed to detect the presence of frequency shifts - acoustic features that have a frequency waveform similar to that of hyperphonation. Results of study 1 showed PCE had two sets of sex-dependent effects on human infants: PCE males had higher pitched cries with more dysphonation (turbulence); PCE females had longer pauses between fewer cry sounds that were of lower amplitude than comparison groups. PCE and PPE infants had more cries with hyperphonation than SC infants. In study 2, PCE pups had a greater percentage of USVs with shift in the acoustic structure than pups in the two control groups. As such, the novel measures of human infant crying and rat pup USVs were sensitive to effects of PCE. These studies provide the first known translational analysis of similar acoustic structures of vocalizations in two species to detect adverse effects of prenatal drug exposure.

Fetal surveillance in late pregnancy and during labor

During early gestation, drugs have teratogenic effects and can be associated with structural anomalies in the fetus. Substance abuse can also have physiologic effects on the mother and fetus, including decreased uterine blood flow, increased vascular resistance, and an increase in fetal blood pressure. Women at increased risk for stillbirth should undergo antepartum fetal surveillance initiated at 32 weeks of gestation. Because of the high incidence of low birth weight, fetal anomalies, preterm delivery, and growth restriction in these patients, ultrasonography for appropriate pregnancy dating, a detailed anatomic survey, and cervical length should be performed at 20 weeks' gestation.

Care of Drug-Addicted Pregnant Women: Current Concepts and Future Strategies – an Overview

This review focuses on drug use during pregnancy and the perinatal period, a constellation that is seen more often. Drug use in pregnant women poses an increased risk for adverse health outcomes both for the mother and child. Care is often complicated by social and environmental factors, as well as psychiatric comorbidities. It is, therefore, very important to provide drug-using pregnant women with optimal ante-, peri- and post-natal care. Health professionals should approach them in a nonjudgmental and supportive way, and provide them with the same care and attention as nondrug-using women. Adequate care requires interdisciplinary teams. Ideally, healthcare providers should be specialized in the care of drug-using pregnant women.