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Barber CM, Terplan M. Principles of care for pregnant and parenting people with substance use disorder: the obstetrician gynecologist perspective. Front Pediatr 2023; 11:1045745. [PMID: 37292372 PMCID: PMC10246753 DOI: 10.3389/fped.2023.1045745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 04/17/2023] [Indexed: 06/10/2023] Open
Abstract
Substance use in pregnant and parenting persons is common, yet still underdiagnosed. Substance use disorder (SUD) is one of the most stigmatized and undertreated chronic medical conditions, and this is exacerbated in the perinatal period. Many providers are not sufficiently trained in screening or treatment for substance use, so gaps in care for this population persist. Punitive policies towards substance use in pregnancy have proliferated, lead to decreased prenatal care, do not improve birth outcomes, and disproportionately impact Black, Indigenous, and other families of color. We discuss the importance of understanding the unique barriers of pregnancy-capable persons and drug overdose as one of the leading causes of maternal death in the United States. We highlight the principles of care from the obstetrician-gynecologist perspective including care for the dyad, person-centered language, and current medical terminology. We then review treatment of the most common substances, discuss SUD during the birthing hospitalization, and highlight the high risk of mortality in the postpartum period.
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Affiliation(s)
- Cecily May Barber
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, United States
- Department of Obstetrics and Gynecology, Boston University School of Medicine and Boston Medical Center, Boston, MA, United States
| | - Mishka Terplan
- Friends Research Institute, Baltimore, MD, United States
- Department of Family and Community Medicine, University of California, San Francisco, CA, United States
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Suarez EA, Huybrechts KF, Straub L, Hernández-Díaz S, Creanga AA, Connery HS, Gray KJ, Vine SM, Jones HE, Bateman BT. Postpartum Opioid-Related Mortality in Patients With Public Insurance. Obstet Gynecol 2023; 141:657-665. [PMID: 36897177 PMCID: PMC10125002 DOI: 10.1097/aog.0000000000005115] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 12/15/2022] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To assess the incidence and risk factors for postpartum opioid overdose death and describe other causes of postpartum death in individuals with opioid use disorder (OUD). METHODS We conducted a cohort study that used health care utilization data from the Medicaid Analytic eXtract linked to the National Death Index in the United States from 2006 to 2013. All pregnant individuals with live births or stillbirths and continuous enrollment for 3 months before delivery were eligible, including 4,972,061 deliveries. A subcohort of individuals with a documented history of OUD in the 3 months before delivery was identified. We estimated the cumulative incidence of death as occurring between delivery and 1 year postpartum among all individuals and individuals with OUD. Risk factors for opioid overdose death were assessed using odds ratios (ORs) and descriptive statistics, including demographics, health care utilization, obstetric conditions, comorbidities, and medications. RESULTS The incidence of postpartum opioid overdose death per 100,000 deliveries was 5.4 (95% CI 4.5-6.4) among all individuals and 118 (95% CI 84-163) among individuals with OUD. Individuals with OUD had a sixfold higher incidence of all-cause postpartum death than all individuals. Common causes of death in individuals with OUD were other drug- and alcohol-related deaths (47/100,000), suicide (26/100,000), and other injuries, including accidents and falls (33/100,000). Risk factors strongly associated with postpartum opioid overdose death included mental health and other substance use disorders. Among patients with OUD, postpartum use of medication to treat OUD was associated with 60% lower odds of opioid overdose death (OR 0.4, 95% CI 0.1-0.9). CONCLUSION Postpartum individuals with OUD have a high incidence of postpartum opioid overdose death and other preventable deaths, including nonopioid substance-related injuries, accidents, and suicide. Use of medications for OUD is strongly associated with lower opioid-related mortality.
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Affiliation(s)
- Elizabeth A Suarez
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, and the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, the Department of Epidemiology, Harvard T.H. Chan School of Public Health, and the Department of Psychiatry, Harvard Medical School, Boston, and the Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, Massachusetts; the Departments of International Health and Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland; UNC Horizons and the Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and the Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California
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Sajwani HS, Williams AV. A systematic review of the distribution of take-home naloxone in low- and middle-income countries and barriers to the implementation of take-home naloxone programs. Harm Reduct J 2022; 19:117. [PMID: 36266701 PMCID: PMC9585764 DOI: 10.1186/s12954-022-00700-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 10/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Opioid overdose epidemic is hitting record highs worldwide, accounting for 76% of mortality related to substance use. Take-home naloxone (THN) strategies are being implemented in many developed countries that suffer from high opioid overdose death rates. They aim to provide overdose identification and naloxone administration training, along with THN delivery to opioid users and others likely to witness an overdose incident such as family members and peers. However, little is known about such measures in low- and middle-income countries (LMIC), where opioid use and opioid-related deaths are reportedly high. This systematic literature review aims to examine the distribution of THN in LMIC, review studies identifying barriers to the implementation of THN programs worldwide, and assess their applicability to LMIC. METHODS The literature was searched and analyzed for eligible studies with quality assessment. RESULTS Two studies were found from LMIC on THN programs with promising results, and 13 studies were found on the barriers identified in implementing THN programs worldwide. The main barriers to THN strategies were the lack of training of healthcare providers, lack of privileges, time constraints, cost, legislative/policy restrictions, stigma, fear of litigation, and some misperceptions around THN. CONCLUSIONS The barriers outlined in this paper are probably applicable to LMIC, but more difficult to overcome considering the differences in their response to opioid overdose, their cultural attitudes and norms, the high cost, the waivers required, the legislative differences and the severe penalties for drug-related offenses in some of these countries. The solutions suggested to counter-act these obstacles can also be more difficult to achieve in LMIC. Further research is required in this area with larger sample sizes to provide a better understanding of the obstacles to the implementation, feasibility, accessibility, and utilization of THN programs in LMIC.
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Affiliation(s)
- Hawraa Sameer Sajwani
- Department of Addictions, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- University of Adelaide, Adelaide, Australia
- Virginia Commonwealth University, Richmond, VA US
- University of California, Los Angeles, Los Angeles, CA US
- Sheikh Khalifa Medical City, Abu Dhabi, UAE
| | - Anna V Williams
- Department of Addictions, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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Kelty E, Pyle A, Preen DB. Opioid poisoning during pregnancy: prevalence, characteristics, and neonatal outcomes. Arch Womens Ment Health 2022; 25:957-963. [PMID: 35984500 PMCID: PMC9492584 DOI: 10.1007/s00737-022-01260-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/12/2022] [Indexed: 11/25/2022]
Abstract
While it has been postulated that opioid poisoning during pregnancy may cause adverse maternal and neonatal outcomes, the harm associated with opioid poisoning during pregnancy has not been robustly examined. Pregnant women admitted to hospital or presenting to the emergency department (ED) in Western Australia (WA) with a diagnosis of opioid poisoning were identified by linking state midwifery records with hospital and ED administrative data. Maternal and neonatal outcomes were compared with opioid poisoning that occurred in the 12 months prior to conception or the 12 months following birth. Between 2003 and 2018, 57 neonates were born to women who had experienced opioid poisoning during pregnancy (14.1 per 100,000 births) in WA. The incidence of opioid poisoning in the year prior to pregnancy (IRR: 3.04, 95%CI: 2.30, 4.02) and the year following pregnancy (IRR: 1.96, 95%CI: 1.46, 2.64) was significantly higher than during pregnancy. Opioid poisoning during pregnancy was less likely to involve multiple substances and be intentional (rather than accidental). Neonatal conditions associated with in utero hypoxia were significantly less common in neonates born to women who experience opioid poisoning prior to pregnancy compared with during pregnancy (OR: 0.17, 95%CI: 0.04, 0.80). Opioid poisoning in pregnancy was not associated with an increased risk of other serious adverse neonatal outcomes. Opioid poisoning during pregnancy is uncommon and less likely to be intentional and involve multiple substances. Opioid poisoning during pregnancy is likely associated with an increased risk of conditions associated with in utero hypoxia.
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Affiliation(s)
- Erin Kelty
- The School of Population and Global Health, the University of Western Australia, 35 Stirling Highway, Crawley, WA, Australia.
| | - Anwyn Pyle
- The Department of Health, Government of Western Australia, East Perth, WA, Australia
| | - David B Preen
- The School of Population and Global Health, the University of Western Australia, 35 Stirling Highway, Crawley, WA, Australia
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What Obstetrician–Gynecologists Should Know About Substance Use Disorders in the Perinatal Period. Obstet Gynecol 2022; 139:317-337. [DOI: 10.1097/aog.0000000000004657] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/01/2021] [Indexed: 11/26/2022]
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Campbell J, Matoff-Stepp S, Velez ML, Cox HH, Laughon K. Pregnancy-Associated Deaths from Homicide, Suicide, and Drug Overdose: Review of Research and the Intersection with Intimate Partner Violence. J Womens Health (Larchmt) 2021; 30:236-244. [PMID: 33295844 PMCID: PMC8020563 DOI: 10.1089/jwh.2020.8875] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The leading causes of pregnancy-associated deaths, as defined by the Centers for Disease Control and Prevention, are homicide, suicide, and drug overdose. Intimate partner violence during pregnancy has been shown to contribute to maternal mortality from pregnancy-associated deaths. In this article, we discuss these leading causes of pregnancy-associated deaths. We review the prevalence, demographic characteristics, and possible factors leading to each cause of death, as well as evidence-based methods of identification, prevention, and intervention. The review also will include data showing racial and ethnic inequities. In addition, we identify gaps and guiding questions for further research, as well as suggestions for immediate changes in practice and policy.
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Affiliation(s)
| | - Sabrina Matoff-Stepp
- Office of Planning, Analysis, and Evaluation, Health Resources and Services Administration, Rockville, Maryland, USA
| | - Martha L. Velez
- Center for Addiction and Pregnancy, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Helen Hunter Cox
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Kathryn Laughon
- Department of Family, Community & Mental Health Systems, University of Virginia School of Nursing, Charlottesville, Virginia, USA
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Bonomo Y, Pastor A, Leung L, Blandthorn J, Dietze P. Managing opioid overdose in pregnancy with nasal naloxone. Aust N Z J Obstet Gynaecol 2020; 60:E11-E12. [PMID: 33043439 DOI: 10.1111/ajo.13216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 06/20/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Yvonne Bonomo
- Department of Addiction Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia.,Women's Alcohol and Drug Service, Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Adam Pastor
- Department of Addiction Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Laura Leung
- Pharmacy Department, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Julie Blandthorn
- Women's Alcohol and Drug Service, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Paul Dietze
- Alcohol and Drugs Research Group, Centre for Population Health, Behaviours and Health Risks Program, Burnet Institute, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Abstract
Women with opioid use disorder are at increased risk of other medical complications of pregnancy. Providing care for such complex patients requires the ability to 1) acknowledge addiction as a chronic disease, 2) incorporate the altered physiology of pregnancy, and 3) devise a treatment plan that can effectively manage acute conditions. A basic tenet of care is rooted in experience, rather than evidence, but includes stabilization of opiate use disorder (OUD) as a primary goal of management of other medical complications of pregnancy. Proceeding with treatment for other medical conditions will be suboptimal without stabilization of the underlying chronic disease process. This chapter outlines some associated medical complications of OUD both in general and some of which are unique to pregnancy: infectious diseases, soft tissue infections, endocarditis, cholestasis of pregnancy, and overdose.
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Affiliation(s)
- Mona Prasad
- Maternal-Fetal Medicine and Addiction Medicine, OhioHealth, 285 E State St, Suite 620, Columbus, OH 43215, United States.
| | - Megan Jones
- UNLV School of Medicine, Las Vegas, NV, United States
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