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Titus-Glover D, Shaya FT, Welsh C, Roane L. The Lived Experiences of Pregnant and Parenting Women in Recovery Toward Medication Treatment for Opioid Use Disorder. SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:367-377. [PMID: 38254261 DOI: 10.1177/29767342231221055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
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.
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Affiliation(s)
| | - Fadia T Shaya
- Department of Practice, Sciences and Health Outcomes Research, School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Christopher Welsh
- Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, USA
| | - Lynnee Roane
- School of Nursing, University of Maryland, Baltimore, MD, USA
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Curran L, Manuel J. Factors associated with receipt of medication for opioid use disorder among pregnant individuals entering treatment programs in the U.S. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 126:104342. [PMID: 38479161 DOI: 10.1016/j.drugpo.2024.104342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 12/28/2023] [Accepted: 01/30/2024] [Indexed: 04/29/2024]
Abstract
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.
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Affiliation(s)
- Laura Curran
- Tulane University, School of Social Work, United States.
| | - Jennifer Manuel
- University of Connecticut, School of Social Work, United States
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Wouldes TA, Lester BM. Opioid, methamphetamine, and polysubstance use: perinatal outcomes for the mother and infant. Front Pediatr 2023; 11:1305508. [PMID: 38250592 PMCID: PMC10798256 DOI: 10.3389/fped.2023.1305508] [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: 10/01/2023] [Accepted: 11/20/2023] [Indexed: 01/23/2024] Open
Abstract
The escalation in opioid pain relief (OPR) medications, heroin and fentanyl, has led to an increased use during pregnancy and a public health crisis. Methamphetamine use in women of childbearing age has now eclipsed the use of cocaine and other stimulants globally. Recent reports have shown increases in methamphetamine are selective to opioid use, particularly in rural regions in the US. This report compares the extent of our knowledge of the perinatal outcomes of OPRs, heroin, fentanyl, two long-acting substances used in the treatment of opioid use disorders (buprenorphine and methadone), and methamphetamine. The methodological limitations of the current research are examined, and two important initiatives that will address these limitations are reviewed. Current knowledge of the perinatal effects of short-acting opioids, OPRs, heroin, and fentanyl, is scarce. Most of what we know about the perinatal effects of opioids comes from research on the long-acting opioid agonist drugs used in the treatment of OUDs, methadone and buprenorphine. Both have better perinatal outcomes for the mother and newborn than heroin, but the uptake of these opioid substitution programs is poor (<50%). Current research on perinatal outcomes of methamphetamine is limited to retrospective epidemiological studies, chart reviews, one study from a treatment center in Hawaii, and the US and NZ cross-cultural infant Development, Environment And Lifestyle IDEAL studies. Characteristics of pregnant individuals in both opioid and MA studies were associated with poor maternal health, higher rates of mental illness, trauma, and poverty. Infant outcomes that differed between opioid and MA exposure included variations in neurobehavior at birth which could complicate the diagnosis and treatment of neonatal opioid withdrawal (NOWs). Given the complexity of OUDs in pregnant individuals and the increasing co-use of these opioids with MA, large studies are needed. These studies need to address the many confounders to perinatal outcomes and employ neurodevelopmental markers at birth that can help predict long-term neurodevelopmental outcomes. Two US initiatives that can provide critical research and treatment answers to this public health crisis are the US Environmental influences on Child Health Outcomes (ECHO) program and the Medication for Opioid Use Disorder During Pregnancy Network (MAT-LINK).
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Affiliation(s)
- Trecia A. Wouldes
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
| | - Barry M. Lester
- Center for the Study of Children at Risk, Warren Alpert Medical School, Brown University, Providence, RI, United States
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Rodger L, Nader M, Turner S, Lurie E. Initiation and rapid titration of methadone and slow-release oral morphine (SROM) in an acute care, inpatient setting: a case series. Eur J Med Res 2023; 28:573. [PMID: 38066517 PMCID: PMC10704823 DOI: 10.1186/s40001-023-01538-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/02/2022] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Methadone titration in an outpatient setting typically involves initiation with subtherapeutic doses with slow titration to mitigate the risks of respiratory depression and overdose. In pregnancy, and generally, subtherapeutic doses of methadone and slow titrations are associated with poorer outcomes in terms of treatment retention and ongoing illicit opioid use. We aim to describe rapid titration of OAT in an inpatient setting for pregnant injection opioid users with high opioid tolerance secondary to a fentanyl-based illicit drug supply. METHODS Retrospective case series of patients admitted to a tertiary center with a primary indication of opioid withdrawal and treatment for severe opioid use disorder in pregnancy. RESULTS Twelve women received rapid methadone titrations with or without slow-release oral morphine for opioid use disorder during a total of fifteen hospital admissions. All women included in the study were active fentanyl users (12/12). Methadone dosing was increased rapidly with no adverse events with a median dose at day 7 of 65 mg (IQR 60-70 mg) and median discharge dose of 85 mg (IQR 70-92.5 mg) during their admission for titration. Slow-release oral morphine was used in half of the titration admissions (8/15) with a median dose of 340 mg (IQR 187.5-425 mg) at discharge. The median length of admission was 12 days (IQR 9.5-15). CONCLUSIONS A rapid titration of methadone was completed in an inpatient setting with or without slow-release oral morphine, without adverse events showing feasibility of this protocol for a pregnant population in an inpatient setting. Patients achieved therapeutic doses of methadone (and/or SROM) faster than outpatient counterparts with no known adverse events.
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Affiliation(s)
- Laura Rodger
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Maya Nader
- Department of Family & Community Medicine, University of Toronto, Toronto, Canada
| | - Suzanne Turner
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Erin Lurie
- Department of Family & Community Medicine, University of Toronto, Toronto, Canada.
- Wellesley St-James Town Health Centre, 95 Homewood Ave, Toronto, ON, M4Y 1J4, Canada.
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Kushnir A, Bhavsar R, Hanna E, Hegyi T. Neonatal Abstinence Syndrome in Infants with Prenatal Exposure to Methadone versus Buprenorphine. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1030. [PMID: 37371262 DOI: 10.3390/children10061030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/31/2023] [Accepted: 06/04/2023] [Indexed: 06/29/2023]
Abstract
Neonatal abstinence syndrome (NAS) has been of increasing concern. Studies suggest that prenatal exposure to buprenorphine may be preferred to methadone in regard to neonatal withdrawal. Our aim was to determine whether the incidence and severity of NAS are different between babies prenatally exposed to methadone or buprenorphine in pregnancy. This retrospective analysis of infants ≥ 35-weeks-old exposed to methadone/buprenorphine alone or in conjunction with other substances in utero. They were divided into four groups: 1-methadone alone (Met), 2-buprenorphine alone (Bup), 3 and 4-those exposed to methadone and buprenorphine, respectively, in conjunction with other drugs (Met+ and Bup+). The frequency of NAS treatment, duration of treatment (LOT) and length of stay (LOS) were compared between groups. Of the 290 mothers, 59% were in the Met group, 18% in the Bup group, 14% in the Met or Bup and another opiate group, and 9% took methadone or buprenorphine plus various other substances. Infants born to Met/Met+ mothers had a four-times higher likelihood of developing NAS (p < 0.001). There was no difference in the LOS (p = 0.08) or LOT (p = 0.11) between groups. The buprenorphine treatment in pregnancy decreased the risk of babies developing NAS. However, once the NAS required pharmacological treatment, the type of maternal prenatal exposure did not affect the LOS or LOT.
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Affiliation(s)
- Alla Kushnir
- Division of Neonatology, Department of Pediatric, Cooper University Hospital, Camden, NJ 08103, USA
| | - Ravi Bhavsar
- Division of Neonatology, Department of Pediatric, Cooper University Hospital, Camden, NJ 08103, USA
| | - Emad Hanna
- Division of Neonatology, Department of Pediatrics, Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
| | - Thomas Hegyi
- Division of Neonatology, Department of Pediatrics, Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA
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Benck KN, Seide K, Jones AK, Omori M, Rubinstein LB, Beckwith C, Nowotny KM. United States county jail treatment and care of pregnant incarcerated persons with opioid use disorder. Drug Alcohol Depend 2023; 247:109863. [PMID: 37071946 PMCID: PMC10198943 DOI: 10.1016/j.drugalcdep.2023.109863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 02/28/2023] [Accepted: 03/27/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Standards of care for pregnant persons with opioid use disorder (OUD) have been published across multiple institutions specializing in obstetrics and addiction medicine. Yet, this population faces serious barriers in accessing medications for OUD (MOUD) while incarcerated. Therefore, we examined the availability of MOUD in jails. METHODS A Cross-sectional survey of jail administrators (n=371 across 42 states; 2018-2019) was conducted. Key indicators for this analysis include pregnancy testing at intake, number of county jails offering methadone or buprenorphine to pregnant incarcerated persons for detoxification on admission, continuation of pre-incarceration treatment, or linkage to post-incarceration treatment. Analyses were performed using SAS. FINDINGS Pregnant incarcerated persons had greater access to MOUD than non-pregnant persons (χ2=142.10, p<0.0001). Larger jurisdiction size and urban jails were significantly more likely to offer MOUD (χ2=30.12, p<0.0001; χ2=26.46, p<0.0001). Methadone was the most common MOUD offered for continued care for all incarcerated persons. Of the 144 jails within a county with at least one public methadone clinic, 33% did not offer methadone treatment to pregnant persons, and over 80% did not provide linkage after release from jail. CONCLUSION MOUD access was greater for pregnant incarcerated persons compared to non-pregnant persons. Compared to urban jails, rural jails were significantly less likely to offer MOUD, even as the number of opioid deaths in rural counties continues to surpass those in urban counties. The lack of post-incarceration linkage in counties with at least one public methadone clinic could be indicative of broader issues surrounding connections to MOUD resources.
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Affiliation(s)
- Kelley N Benck
- University of Miami Miller School of Medicine, United States
| | | | - Alexis K Jones
- University of Miami Miller School of Medicine, United States
| | - Marisa Omori
- University of Saint Louis Department of Criminology and Criminal Justice, United States
| | | | - Curt Beckwith
- The Miriam Hospital/Alpert Medical School of Brown University, United States
| | - Kathryn M Nowotny
- University of Miami Department of Sociology and Criminology, United States.
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Corbett GA, Carmody D, Rochford M, Cunningham O, Lindow SW, O'Connell MP. Drug use in pregnancy in Ireland's capital city: A decade of trends and outcomes. Eur J Obstet Gynecol Reprod Biol 2023; 282:24-30. [PMID: 36621262 DOI: 10.1016/j.ejogrb.2022.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 11/17/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Gillian A Corbett
- Coombe Women and Infants University Hospital, Dublin, Ireland; University College Dublin, Ireland.
| | - Deirdre Carmody
- Addiction Service, Health Service Executive Dublin South, Kildare and West Wicklow Healthcare, Ireland
| | - Marie Rochford
- Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Orla Cunningham
- Coombe Women and Infants University Hospital, Dublin, Ireland
| | | | - Michael P O'Connell
- Coombe Women and Infants University Hospital, Dublin, Ireland; Royal College of Surgeons in Ireland, University of Medicine and Health Sciences Dublin, Ireland
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Ronan K, Hughes Driscoll C, Decker E, Gopalakrishnan M, El Metwally D. Resource utilization and convalescent care cost in neonatal opioid withdrawal syndrome. J Neonatal Perinatal Med 2022; 16:49-57. [PMID: 36530095 DOI: 10.3233/npm-221060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND: Neonatal opioid withdrawal syndrome (NOWS) is a growing public health problem associated with complex and prolonged medical care and a significant resource utilization burden. The objective of this study was to compare the cost of different convalescent care settings for infants with NOWS. METHODS: Retrospective comparison study of infants with NOWS discharged directly from NICU, transferred to an acute care pediatric floor (PPCU) or rehabilitation hospital (PRH). Primary outcomes were length of stay (LOS) and cost of stay (COS). RESULTS: Infants had 1.3 (95% CI: 1.1,1.6) times and 2.5 (95% CI: 2.1,3.1) times significantly longer mean LOS for PPCU and RH discharges compared to NICU discharges. NICU discharged infants had the lowest mean COS ($25,745.00) and PRH the highest ($60,528.00), despite PRH having a lower cost per day. PRH discharged infants had higher rates of methadone and benzodiazepine and less buprenorphine exposure than NICU/PPCU discharged. Infants born to mothers on marijuana and buprenorphine had a 28% lower mean COS compared to unexposed infants. Median treatment cumulative morphine doses were six-fold higher for PRH than NICU discharge. CONCLUSIONS: Infants transferred to convalescence care facilities had longer and more costly admissions and received more medication. However, there may be a role for earlier transfer of a subset of infants at-risk for longer LOS as those exposed to methadone and/or benzodiazepines. Further studies exploring differences in resource utilization, convalescent care delivery and cost expenditure are recommended.
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Affiliation(s)
- K. Ronan
- Department of Pediatrics. University of Maryland School of Medicine, MD, USA
- Women’s and Babies Hospital, Lancaster, PA, USA
| | | | - E. Decker
- Department of Pediatrics. University of Maryland School of Medicine, MD, USA
- The College of Physicians and Surgeons at Columbia University, NY, USA
| | - M. Gopalakrishnan
- Center for Translational Medicine, University of Maryland School of Pharmacy, MD, USA
| | - D. El Metwally
- Department of Pediatrics. University of Maryland School of Medicine, MD, USA
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A review of the safety of buprenorphine in special populations. Am J Med Sci 2022; 364:675-684. [PMID: 35843298 DOI: 10.1016/j.amjms.2022.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/17/2022] [Accepted: 06/29/2022] [Indexed: 01/25/2023]
Abstract
Rates of opioid misuse and opioid use disorder have been increasing in recent years. Buprenorphine has emerged as an appealing medication for its use not only as treatment for opioid use disorder, but also as an opioid for chronic pain that has a ceiling effect on risks associated with opioid therapy. As other opioid prescribing decreases, buprenorphine prescribing continues to increase. As a result, it is imperative to understand the safety and efficacy of its use in special populations. This review article will explore the safety and efficacy of buprenorphine when used in subjects with hepatic and renal impairment, the elderly, and pregnant women. While manufacturer labeling for buprenorphine products may caution against their use in these populations, further examination of available data indicates that buprenorphine can be used safely and effectively for both chronic pain and/or opioid use disorder in all four of these populations.
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Lim G, Soens M, Wanaselja A, Chyan A, Carvalho B, Landau R, George RB, Klem ML, Osmundson SS, Krans EE, Terplan M, Bateman BT. A Systematic Scoping Review of Peridelivery Pain Management for Pregnant People With Opioid Use Disorder: From the Society for Obstetric Anesthesia and Perinatology and Society for Maternal Fetal Medicine. Anesth Analg 2022; 135:912-925. [PMID: 36135926 PMCID: PMC9588509 DOI: 10.1213/ane.0000000000006167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The prevalence of pregnant people with opioid use disorder (OUD), including those receiving medications for opioid use disorder (MOUD), is increasing. Challenges associated with pain management in people with OUD include tolerance, opioid-induced hyperalgesia, and risk for return to use. Yet, there are few evidence-based recommendations for pain management in the setting of pregnancy and the postpartum period, and many peripartum pain management studies exclude people with OUD. This scoping review summarized the available literature on peridelivery pain management in people with OUD, methodologies used, and identified specific areas of knowledge gaps. PubMed and Embase were comprehensively searched for publications in all languages on peripartum pain management among people with OUD, both treated with MOUD and untreated. Potential articles were screened by title, abstract, and full text. Data abstracted were descriptively analyzed to map available evidence and identify areas of limited or no evidence. A total of 994 publications were imported for screening on title, abstracts, and full text, yielding 84 publications identified for full review: 32 (38.1%) review articles, 14 (16.7%) retrospective studies, and 8 (9.5%) case reports. There were 5 randomized controlled trials. Most studies (64%) were published in perinatology (32; 38.1%) journals or anesthesiology (22; 26.2%) journals. Specific areas lacking trial or systematic review evidence include: (1) methods to optimize psychological and psychosocial comorbidities relevant to acute pain management around delivery; (2) alternative nonopioid and nonpharmacologic analgesia methods; (3) whether or not to use opioids for severe breakthrough pain and how best to prescribe and monitor its use after discharge; (4) monitoring for respiratory depression and sedation with coadministration of other analgesics; (5) optimal neuraxial analgesia dosing and adjuncts; and (6) benefits of abdominal wall blocks after cesarean delivery. No publications discussed naloxone coprescribing in the labor and delivery setting. We observed an increasing number of publications on peripartum pain management in pregnant people with OUD. However, existing published works are low on the pyramid of evidence (reviews, opinions, and retrospective studies), with a paucity of original research articles (<6%). Opinions are conflicting on the utility and disutility of various analgesic interventions. Studies generating high-quality evidence on this topic are needed to inform care for pregnant people with OUD. Specific research areas are identified, including utility and disutility of short-term opioid use for postpartum pain management, role of continuous wound infiltration and truncal nerve blocks, nonpharmacologic analgesia options, and the best methods to support psychosocial aspects of pain management.
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Affiliation(s)
- Grace Lim
- University of Pittsburgh Department of Anesthesiology & Perioperative Medicine, Pittsburgh, PA
- University of Pittsburgh Department of Obstetrics & Gynecology, UPMC Magee-Women’s Hospital, Pittsburgh, PA
| | - Mieke Soens
- Brigham & Women’s Hospital, Department of Anesthesiology & Perioperative Medicine, Boston, MA
| | - Anne Wanaselja
- University of Pittsburgh Department of Anesthesiology & Perioperative Medicine, Pittsburgh, PA
| | - Arthur Chyan
- Brigham & Women’s Hospital, Department of Anesthesiology & Perioperative Medicine, Boston, MA
| | - Brendan Carvalho
- Stanford University Department of Anesthesiology, Perioperative & Pain Medicine, Palo Alto, CA
| | - Ruth Landau
- Columbia University Department of Anesthesiology & Perioperative Medicine, New York City, NY
| | - Ronald B. George
- University of California San Francisco Department of Anesthesiology & Perioperative Care, San Francisco, CA
| | - Mary Lou Klem
- University of Pittsburgh Health Sciences Library System, Pittsburgh, PA
| | - Sarah S. Osmundson
- Vanderbilt University, Department of Obstetrics & Gynecology, Nashville, TN
| | - Elizabeth E. Krans
- University of Pittsburgh Department of Obstetrics & Gynecology, UPMC Magee-Women’s Hospital, Pittsburgh, PA
| | | | - Brian T. Bateman
- Stanford University Department of Anesthesiology, Perioperative & Pain Medicine, Palo Alto, CA
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11
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Austin AE, Di Bona V, Cox ME, Proescholdbell SK, Naumann RB. Differences in Mortality Among Infants With Neonatal Opioid Withdrawal Syndrome. Am J Prev Med 2022; 63:619-623. [PMID: 35489960 DOI: 10.1016/j.amepre.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/01/2022] [Accepted: 03/14/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Prior studies are mixed regarding whether infants diagnosed with neonatal opioid withdrawal syndrome have a higher risk of mortality than other infants. However, these studies have not accounted for whether mothers of infants with neonatal opioid withdrawal syndrome received medication for opioid use disorder in pregnancy. METHODS Linked data from 2016‒2018 North Carolina birth certificates, maternal and infant Medicaid claims, and infant death certificates were analyzed in summer 2021 to compare mortality and causes of mortality before age 1 year among infants diagnosed with neonatal opioid withdrawal syndrome whose mothers did and did not have claims for medication for opioid use disorder in pregnancy (N=4,480). RESULTS Compared with mothers with medication for opioid use disorder claims in pregnancy (45.5%), mothers without medication for opioid use disorder claims (55.5%) were younger, more likely to be Black non-Hispanic, less likely to have paternity established, and more likely to have no prenatal care. The proportion (1.3%, n=31 vs 1.0%, n=21) and rate (3.5 vs 2.9 deaths per 100,000 infant days) of mortality was higher among infants of mothers without medication for opioid use disorder claims than infants of mothers with medication for opioid use disorder claims. Sudden unexpected infant death syndrome was the primary cause of death for infants of mothers with (90.5%) and without (58.1%) medication for opioid use disorder claims. CONCLUSIONS Results highlight the importance of assessing for potential differences in outcomes according to whether infants with neonatal opioid withdrawal syndrome were exposed to medication for opioid use disorder. Efforts to ensure equitable access to medication for opioid use disorder and other support services in pregnancy are needed to promote healthy maternal and infant outcomes.
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Affiliation(s)
- Anna E Austin
- Department of Maternal and Child Health, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Injury Prevention Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Vito Di Bona
- North Carolina State Center for Health Statistics, Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, North Carolina
| | - Mary E Cox
- Injury and Violence Prevention Branch, Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, North Carolina
| | - Scott K Proescholdbell
- Injury and Violence Prevention Branch, Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, North Carolina
| | - Rebecca B Naumann
- Injury Prevention Research Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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12
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Camden A, To T, Ray JG, Gomes T, Bai L, Guttmann A. Categorization of Opioid Use Among Pregnant People and Association With Overdose or Death. JAMA Netw Open 2022; 5:e2214688. [PMID: 35622361 PMCID: PMC9142862 DOI: 10.1001/jamanetworkopen.2022.14688] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Early identification of people who use opioids in pregnancy may improve health outcomes for pregnant people and infants. However, characterization of diverse circumstances surrounding type of opioid use and indications for opioid use are lacking. OBJECTIVE To develop clinically distinct groups of people who use opioids in pregnancy and to evaluate their association with drug overdose or death up to 1 year post partum. DESIGN, SETTING, AND PARTICIPANTS This is a population-based, repeated cross-sectional study conducted in Ontario, Canada, with participants who used opioids in pregnancy who had a live birth or stillbirth between January 1, 2014, and December 31, 2019, identified in health administrative databases. Data were analyzed from August 2020 to January 2021. EXPOSURES Prenatal opioid use. MAIN OUTCOMES AND MEASURES Latent class analysis (LCA), based on prenatal opioid use and 19 socioeconomic and medical characteristics, first identified clinically distinct groups of opioid users. Then, within the optimally derived LCA-derived group, adjusted relative risks (aRRs) were generated for the outcome of drug overdose or all-cause death within 1 year post partum, adjusting for birthing parent age and year of delivery. RESULTS The analysis included 31 241 people with prenatal opioid use (mean [SD] age, 30.0 [5.6] years; 86.1% [26 908 individuals] Canadian-born; 30.6% [9574 individuals] lived in low-income neighborhoods). LCA generated a 5-group model that optimally distinguished opioid users in pregnancy as follows: short-term analgesia with low comorbidity (group 1), analgesia in young people (group 2), medication for opioid use disorder or unregulated opioid use (group 3), pain management with comorbidity (group 4), and mixed opioid use plus high social and medical needs (group 5). The overall risk of postpartum drug overdose or death was 1.5%. Using the 5-group model, compared with people in group 1, the aRR of overdose or death was highest among those in group 5 (aRR, 14.0; 95% CI, 10.1-19.5), followed by group 3 (aRR, 4.6; 95% CI, 3.3-6.5), group 2 (aRR, 3.3; 95% CI, 2.2-4.7), and group 4 (aRR, 3.2; 95% CI, 2.3-4.4). CONCLUSIONS AND RELEVANCE In this cross-sectional study, distinct groups of people with opioid use in pregnancy were associated with increasing degrees of risk of postpartum drug overdose or death. Group characteristics can be used to identify people with high risk and inform harm reduction, home visiting programs, and other interventions.
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Affiliation(s)
- Andi Camden
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Teresa To
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joel G. Ray
- ICES, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, St Michaels Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- ICES, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Li Bai
- ICES, Toronto, Ontario, Canada
| | - Astrid Guttmann
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Edwin SH Leong Centre, University of Toronto, Toronto, Ontario, Canada
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13
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Wen H, Chen R, Zhang P, Wei X, Dong Y, Ge S, Luo W, Zhou Y, Xiao S, Lu L. Acupuncture for Opioid Dependence Patients Receiving Methadone Maintenance Treatment: A Network Meta-Analysis. Front Psychiatry 2021; 12:767613. [PMID: 34966304 PMCID: PMC8710762 DOI: 10.3389/fpsyt.2021.767613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/05/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: Opioid dependence has been a threat to public health for hundreds of years. With the increasing number of studies on acupuncture-related therapies for opioid dependence patients receiving methadone maintenance treatment (MMT), its effect of acupuncture therapy in treating MMT patients remains controversial. Therefore, we conducted a multiple-treatments meta-analysis, and incorporated both direct and indirect comparisons, in order to discover the most effective treatment for opioid dependence patients receiving MMT. Methods: Five English databases and three Chinese databases were searched from its inception to August 20, 2020, in order to compare the effects of acupuncture-related therapies and MMT, which was summarized as Western medicine (WM) in the following texts. The quality of studies was assessed according to Cochrane's risk of bias tool 5.1.0, and a pair-wise meta-analysis, cumulative meta-analysis, and the network meta-analysis was performed using the R software (Version 3.6.1) and STATA (Version 14.0). The primary outcome was the effective rate, which was calculated by the ratio of detoxifying patients to the total. The secondary outcome was the Modified Himmelsbach Opiate Withdrawal Scale (MHOWS). Results: A total of 20 trials were included, which consisted of comparisons among WM, traditional Chinese medicine (TCM), and the four types of acupuncture, namely, manual acupuncture (MA), electro-acupuncture (EA), auricular acupuncture (AA), and transcutaneous electrical acupoint stimulation (TEAS). Though none of the trials were at low risk of bias. In the pair-wise meta-analysis, no statistically significant differences were observed in terms of the effective rate. Furthermore, MA was more efficacious than WM, EA, and TEAS in MHOWS, with mean differences (MDs) of (-8.59, 95% CI: -15.96 to -1.23, P < 0.01), (-6.15, 95% CI: -9.45 to -2.85, P < 0.05), and (-10.44, 95% CI: -16.11 to -4.77, P < 0.05), respectively. In the network meta-analysis, MA was more effective than WM (RR: 1.40, 95% CI: 1.05 to 1.99) on the effective rate, and (MD: -5.74, 95% CI: -11.60 to -0.10) on MHOWS. TEAS was more effective than WM (MD: -15.34, 95% CI: -27.34 to -3.46) on MHOWS. Synthetically, MA had the highest probability to rank first in treating opioid dependence. Conclusions: The existing evidence shows that acupuncture related-therapies may effectively be used for treating patients receiving MMT, and that manual acupuncture may be the best choice for opioid dependence among all kinds of acupuncture-related therapies. Nevertheless, reducing the relapse and promoting the recovery of opioid dependence need more efforts from not only the medical industry but also government support, security system, and educational popularization. To strengthen the assurance of acupuncture-related therapies in the treatment of opioid dependence, we expected that clinical trials with high quality would be conducted, to provide more confident evidence.
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Affiliation(s)
- Hao Wen
- Department of Neurology, The Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Rouhao Chen
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Peiming Zhang
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xiaojing Wei
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yu Dong
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shuqi Ge
- Department of Rehabilitation, Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine, Zhuhai, China
| | - Wen Luo
- School of Medical Information Engineering, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yiping Zhou
- Department of Vasculitis, Affiliated Chinese Medicine Hospital of Guangzhou Medical University, Guangzhou, China
| | - Songhua Xiao
- Department of Neurology, The Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China
| | - Liming Lu
- South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine, Guangzhou, China
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14
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Hand DJ, Fischer AC, Gannon ML, McLaughlin KA, Short VL, Abatemarco DJ. Comprehensive and compassionate responses for opioid use disorder among pregnant and parenting women. Int Rev Psychiatry 2021; 33:514-527. [PMID: 34176410 DOI: 10.1080/09540261.2021.1908966] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Pregnant and parenting women with opioid use disorder face multiple challenges to recovery. Trauma histories, poverty, stigma and discrimination, and lack of access to treatment intersect to marginalise this population. It is important that pregnant and parenting women with opioid use disorder receive comprehensive care to improve their health, the health of their child(ren), and prevent the intergenerational transmission of opioid and other substance use disorders. For nearly 50 years the Maternal Addiction Treatment, Education, and Research program has provided an evolving and expanding range of comprehensive services for treating opioid and other substance use disorders in this population. In this review the rationale for, and processes by which, key components of a comprehensive approach are discussed. These components include patient navigation for access to care, low-barrier medications for opioid use disorder, effective trauma-responsive therapy, prenatal and well-child healthcare, and other support services that make it possible for pregnant and parenting women to engage in treatment and improve the health of the entire family. Additionally, a method for supporting staff to build resilience and reduce fatigue and burnout is discussed. These components comprise an effective model of care for pregnant and parenting women with opioid and other substance use disorders.
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Affiliation(s)
- Dennis J Hand
- Department of Obstetrics & Gynecology, Thomas Jefferson University, Philadelphia, PA, USA.,Department of Psychiatry & Human Behavior, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alice C Fischer
- Department of Obstetrics & Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Meghan L Gannon
- Department of Obstetrics & Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kimberly A McLaughlin
- Department of Obstetrics & Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Vanessa L Short
- Department of Obstetrics & Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Diane J Abatemarco
- Department of Obstetrics & Gynecology, Thomas Jefferson University, Philadelphia, PA, USA.,Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA, USA
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15
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Lum JS, Bird KM, Wilkie J, Millard SJ, Pallimulla S, Newell KA, Wright IM. Prenatal methadone exposure impairs adolescent cognition and GABAergic neurodevelopment in a novel rat model of maternal methadone treatment. Prog Neuropsychopharmacol Biol Psychiatry 2021; 110:110281. [PMID: 33571606 DOI: 10.1016/j.pnpbp.2021.110281] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 01/21/2021] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Abstract
Methadone maintenance treatment (MMT) is the most common treatment for opioid-dependent pregnant women worldwide. Despite its widespread use, MMT is associated with a variety of adverse neurodevelopmental outcomes in exposed offspring, particularly cognitive impairments. The neurobiological abnormalities underlying these cognitive impairments are, however, poorly understood. This is, in part, due to a lack of animal models that represents the standard of care that methadone is administered in the clinic, with inconsistencies in the timing, doses and durations of treatment. Here we describe the characterisation of a clinically relevant rat model of MMT in which the long-term behavioural and neurobiological effects of prenatal methadone exposure can be assessed in adolescent offspring. Female Sprague-Dawley rats were treated orally with an ascending methadone dosage schedule (5, 10, 15, 20, 25 and 30 mg/kg/day), self-administered in drinking water prior to conception, throughout gestation and lactation. Pregnancy success, maternal gestational weight gain, litter survival and size were not significantly altered in methadone-exposed animals. Methadone-exposed offspring body and brain weights were significantly lower at birth. Novel object recognition tests performed at adolescence revealed methadone-exposed offspring had impaired recognition memory. Furthermore, the rewarded T-maze alternation task demonstrated that methadone-exposed female, but not male, offspring also exhibit working memory and learning deficits. Immunoblots of the adolescent prefrontal cortex and hippocampus showed methadone-exposed offspring displayed reduced levels of mature BDNF, in addition to the GABAergic proteins, GAD67 and parvalbumin, in a sex- and brain region-specific fashion. This rat model closely emulates the clinical scenario in which methadone is administered to opioid-dependent pregnant woman and provides evidence MMT can cause cognitive impairments in adolescent offspring that may be underlined by perturbed neurodevelopment of the GABAergic system.
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Affiliation(s)
- Jeremy S Lum
- Illawarra Health and Medical Research Institute, Wollongong, NSW 2522, Australia; School of Medicine, University of Wollongong University of Wollongong, Wollongong, NSW 2522, Australia; Molecular Horizons, University of Wollongong, Wollongong, NSW 2522, Australia.
| | - Katrina M Bird
- Illawarra Health and Medical Research Institute, Wollongong, NSW 2522, Australia; School of Medicine, University of Wollongong University of Wollongong, Wollongong, NSW 2522, Australia; Molecular Horizons, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Jennifer Wilkie
- Illawarra Health and Medical Research Institute, Wollongong, NSW 2522, Australia; School of Medicine, University of Wollongong University of Wollongong, Wollongong, NSW 2522, Australia
| | - Samuel J Millard
- Illawarra Health and Medical Research Institute, Wollongong, NSW 2522, Australia; School of Medicine, University of Wollongong University of Wollongong, Wollongong, NSW 2522, Australia
| | - Sachie Pallimulla
- Illawarra Health and Medical Research Institute, Wollongong, NSW 2522, Australia; School of Medicine, University of Wollongong University of Wollongong, Wollongong, NSW 2522, Australia
| | - Kelly A Newell
- Illawarra Health and Medical Research Institute, Wollongong, NSW 2522, Australia; School of Medicine, University of Wollongong University of Wollongong, Wollongong, NSW 2522, Australia; Molecular Horizons, University of Wollongong, Wollongong, NSW 2522, Australia
| | - Ian M Wright
- Illawarra Health and Medical Research Institute, Wollongong, NSW 2522, Australia; School of Medicine, University of Wollongong University of Wollongong, Wollongong, NSW 2522, Australia; University of Queensland Centre for Clinical Research, University of Queensland, Herston, QLD 4029, Australia; College of Medicine and Dentistry, James Cook University, Cairns, QLD 4870, Australia
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16
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A Clinical Trial of a Program for Pain Management and Opioid Reduction During Pregnancy. Reprod Sci 2021; 29:606-613. [PMID: 34403125 DOI: 10.1007/s43032-021-00701-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/16/2021] [Indexed: 12/25/2022]
Abstract
A substantial proportion of pregnant women use prescription opioids. However, the lack of efficacy of chronic prescription opioid use for pain, combined with an increased risk of these medications in general and during pregnancy, suggests that the risks of these medications may outweigh the benefits of continued use. Though research has not evaluated non-pharmacological approaches to treat chronic pain during pregnancy, research conducted with the general population outside of pregnancy suggests that cognitive behavioral therapy (CBT) is an effective, non-pharmacological treatment. Therefore, the purpose of this study was to evaluate the effectiveness of CBT for chronic pain paired with shared decision-making for prescription opioid dose reduction among pregnant women with prescription opioid misuse. The study was an open-label, 8-week clinical trial of CBT for chronic pain and shared decision-making for prescription opioid dose reduction. Participants included a clinical sample of 20 pregnant women between the ages of 18 and 45 years who were misusing opioids but did not meet DSM-IV criteria for an opioid use disorder or other substance use disorder. Compared to baseline, at 8 weeks, participants had significant reductions in average prescription opioid morphine equivalent dose, prescription opioid misuse, worst pain ratings, and pain interference in general activity and at work. They did not report improvement in other pain ratings or areas of functioning. This study provides valuable information regarding the preliminary efficacy of CBT for chronic pain paired with shared decision-making among pregnant women misusing prescription opioids. ClinicalTrials.gov: NCT02804152.
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17
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Hakomäki H, Kokki H, Lehtonen M, Räsänen J, Voipio HM, Ranta VP, Kokki M. MATERNAL AND FETAL BUPRENORPHINE PHARMACOKINETICS IN PREGNANT SHEEP DURING TRANSDERMAL PATCH DOSING: Buprenorphine pharmacokinetics in pregnant sheep. Eur J Pharm Sci 2021; 165:105936. [PMID: 34273481 DOI: 10.1016/j.ejps.2021.105936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/03/2021] [Accepted: 07/04/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Buprenorphine is used in the opioid maintenance treatment for opioid dependent patients, including pregnant women. Despite the wide use, limited data exists on buprenorphine pharmacokinetics and fetal exposure during pregnancy. The aim of our study was to determine the buprenorphine pharmacokinetics during transdermal patch dosing to pregnant sheep and, to determine the extent of transplacental transfer of buprenorphine to the fetus. METHODS Pregnant sheep in late gestation (n=50) received 20, 25 or 40 µg/h of buprenorphine as a 7-day extended-release transdermal patch. Plasma samples were collected from the ewe and the fetus on days 1 - 6, and buprenorphine and norbuprenorphine concentrations were determined. During the exposure period the sheep had a surgical procedure on the second day, a recovery phase, and an experimental procedure on the sixth day. In the experiment, hypoxia was induced under anesthesia for 18 sheep to investigate if decreased fetal pH would cause ion-trapping of buprenorphine in the fetus. The fetal/maternal plasma concentration ratio was determined on the second and on the sixth exposure day at baseline and during hypoxia. Maternal pharmacokinetics were modelled with a population pharmacokinetic method using the data from this study and our previous intravenous administration study. RESULTS The transdermal patch provided an extended release of buprenorphine throughout the exposure period, but the release rate declined approximately 20 h after patch placement. The median fetal/maternal plasma concentration ratio was 13 - 27 % throughout the exposure period at baseline. A ratio over 100 % was observed for four sheep on the sixth exposure day (102 - 269 %). A minor increase was seen in the median fetal/maternal-ratios during maternal hypoxia. Norbuprenorphine was undetected in all plasma samples. CONCLUSIONS The low transplacental passage of less than one fourth of the ewe's exposure supports buprenorphine as an alternative to methadone in opioid maintenance therapy during pregnancy.
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Affiliation(s)
| | - Hannu Kokki
- School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Marko Lehtonen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Juha Räsänen
- Fetal Medicine Center, Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Hanna-Marja Voipio
- Department of Experimental Surgery, Oulu Laboratory Animal Centre, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Veli-Pekka Ranta
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Merja Kokki
- Department of Anesthesia and Intensive Care, Kuopio University Hospital, Kuopio, Finland
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18
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Acute psychiatric illness and drug addiction during pregnancy and the puerperium. HANDBOOK OF CLINICAL NEUROLOGY 2021. [PMID: 32768084 DOI: 10.1016/b978-0-444-64240-0.00007-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
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.
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19
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Precision dosing of methadone during pregnancy: A pharmacokinetics virtual clinical trials study. J Subst Abuse Treat 2021; 130:108521. [PMID: 34118695 DOI: 10.1016/j.jsat.2021.108521] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 04/05/2021] [Accepted: 05/28/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Methadone use for the management of opioid dependency during pregnancy is commonplace. Methadone levels are altered during pregnancy due to changes in maternal physiology. Despite this, a paucity of data exist regarding the most appropriate optimal dosing regimens during pregnancy. METHODS This study applied a pharmacokinetic modeling approach to examine gestational changes in R- and S-methadone concentrations in maternal plasma and fetal (cord) blood. This study did so to derive a theoretical optimal dosing regimen during pregnancy, and to identify the impact of Cytochromes P450 (CYP) 2B6 and 2C19 polymorphisms on methadone maternal and fetal pharmacokinetics. RESULTS The study noted significant decreases in maternal R- and S-methadone plasma concentrations during gestation, with concomitant increases in fetal levels. At a dose of 90 mg once daily, 75% (R-) and 94% (S-) of maternal methadone trough levels were below the lower therapeutic window at term (week 40). The developed optimal dosing regimen escalated doses to 110 mg by week 5, followed by 10 mg increments every 5 weeks up to a maximum of 180 mg once daily near term. This increase resulted in 27% (R-) and 11% (S-) of subjects with trough levels below the lower therapeutic window at term. CYP2B6 poor metabolizers (PM) and either CYP2C19 extensive metabolizers (EM), PM, or ultra-rapid (UM) metabolizer phenotypes demonstrated statistically significant increases in concentrations when compared to their matched CYP2B6 EM counterparts. CONCLUSIONS Specific and gestation-dependent dose titrations are required during pregnancy to reduce the risks associated with illicit drug use and to maintain fetal safety.
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20
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Rosenthal EW, Short VL, Cruz Y, Barber C, Baxter JK, Abatemarco DJ, Roman AR, Hand DJ. Racial inequity in methadone dose at delivery in pregnant women with opioid use disorder. J Subst Abuse Treat 2021; 131:108454. [PMID: 34098304 DOI: 10.1016/j.jsat.2021.108454] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/17/2021] [Accepted: 04/22/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Medications for opioid use disorder, including methadone, combined with comprehensive wraparound services, are the gold standard for treatment in pregnancy. Higher methadone doses are associated with treatment retention in pregnancy and relapse prevention. Given known inequities where individuals of color tend to be prescribed lower doses of opioids for other conditions, the purpose of this study was to determine whether there is racial inequity in methadone dose at delivery in pregnant women with opioid use disorder. METHODS Retrospective review of medical charts identified pregnant women (N = 339) treated with methadone for opioid use disorder during pregnancy at one center from 2012 to 2017. Variables extracted from medical records included race, demographic and relevant clinical information (e.g., methadone dose at delivery, height, weight, etc.). Analyses used simple and multiple linear regressions to determine associations between these characteristics and methadone dose at delivery. RESULTS The mean methadone doses at delivery among women of color and white women were 105.8 mg and 144.9 mg, respectively (p < .0001). After adjusting for maternal age, gestational age at delivery, body mass index, type of opioid used, and parity, race was significantly and independently associated with methadone dose at delivery, with women of color receiving 36.2 mg less than white women (p = .0003). CONCLUSIONS Pregnant women of color with opioid use disorder received 67% of the dose of methadone at delivery that white women received. Antiracist responses to prevent provider bias in evaluating dose needs are needed to correct this inequity and prevent undertreatment of opioid use disorder among women of color.
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Affiliation(s)
- Emily W Rosenthal
- Department of Obstetrics & Gynecology, Boston Medical Center, 85 E. Concord St., Boston, MA 02118, United States of America.
| | - Vanessa L Short
- Department of Obstetrics & Gynecology, Thomas Jefferson University, 833 Chestnut St., Philadelphia, PA 19107, United States of America
| | - Yuri Cruz
- Department of Obstetrics & Gynecology, St. Luke's Hospital, 801 Ostrum St., Bethlehem, PA 18015, United States of America
| | - Cecily Barber
- Department of Obstetrics & Gynecology, Thomas Jefferson University, 833 Chestnut St., Philadelphia, PA 19107, United States of America
| | - Jason K Baxter
- Department of Obstetrics & Gynecology, Thomas Jefferson University, 833 Chestnut St., Philadelphia, PA 19107, United States of America
| | - Diane J Abatemarco
- Department of Obstetrics & Gynecology, Thomas Jefferson University, 833 Chestnut St., Philadelphia, PA 19107, United States of America
| | - Amanda R Roman
- Department of Obstetrics & Gynecology, Thomas Jefferson University, 833 Chestnut St., Philadelphia, PA 19107, United States of America
| | - Dennis J Hand
- Department of Obstetrics & Gynecology, Thomas Jefferson University, 833 Chestnut St., Philadelphia, PA 19107, United States of America; Department of Psychiatry & Human Behavior, Thomas Jefferson University, 1233 Locust St. Suite 401, Philadelphia, PA 19107, United States of America
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21
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Brokatzky S. Patientin mit Schwangerschaft, Borderline-Organisation und schwerer Polytoxikomanie. SUCHTTHERAPIE 2021. [DOI: 10.1055/a-1441-6646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Zusammenfassung
Zielsetzung Ziel dieser Arbeit war es, die Komplexität von Schwangerschaft und Sucht durch ein Fallbeispiel einer Patientin mit schwerer Polytoxikomanie, Borderline-Organisation sowie den Verlauf der Schwangerschaft und die frühe Phase nach der Geburt vorzustellen. Dabei ging es v. a. um die Frage, wie eine langfristige Behandlung mit einem mehrstufigen, multiprofessionellen und multimodalen Setting aussehen könnte. Die Arbeit zeigt zudem Konflikte an Schnittstellen auf und wie wichtig die Kommunikation innerhalb des Teams und fachübergreifend war.
Intervention Qualifizierte stationäre Entgiftungsbehandlung von Benzodiazepinen, Phenothiazin, Lyrica Venlafaxin und Reduktion von Methadon mit anschließender Umstellung auf Buprenorphin sowie ergänzender kombinierter ärztlicher, psychodynamischer Einzel- und Gruppentherapie und einem pflegerischen DBT-S Einzel- und Gruppensetting. Außerdem wurde schon während der Schwangerschaft zusätzlich zum stationären Behandlungsteam ein fächerübergreifendes Behandlungsteam aus Gynäkologen, Kinderärzten, Kinder- und Jugendpsychiatern sowie der Kinder- und Erwachsenenschutzbehörde (KESB, in Deutschland Jugendamt) zusammengestellt und schon zu Beginn wurde eine langfristige Behandlung mit stationärem, teilstationärem und ambulantem Intervall geplant.
Ergebnis Im Laufe der fast 3-jährigen Behandlung und 5 Jahre späteren katamnestischen Nachuntersuchung konnte zunächst unter 8 mg Buprenorphin eine Abstinenz von illegalen Substanzen erzielt werden. Im Verlauf sogar vollständige Abstinenz ohne Substitution. Dies konnte durch ein erneutes Interview und Drogenscreening im Jahr 2020 bestätigt werden. Außerdem konnte im Rahmen der fächerübergreifenden Arbeit ein stabiles soziales Umfeld und ein Wiedereinstieg ins Berufsleben erreicht werden.
Diskussion Trotz der anfänglich häufigen Rückfälle konnte durch den Erhalt der therapeutischen Beziehung (z. B. mittels Time-out auf die Akutstation, Verlängerung einer Wochenendbeurlaubung oder Neuverhandlung der Behandlungsvereinbarung) unter Fortsetzung der Einzelpsychotherapie und Bezugspflege mit Einbezug der Rückfälle, gegenseitiges Vertrauen und Wertschätzung geschaffen werden. Dafür war allerdings viel supervisorische Arbeit innerhalb des Teams, aber auch fächerübergreifend notwendig, da sich die extreme innerer Welt der Patientin häufig in unterschiedlicher Art und Weise im multiprofessionellen Team zeigte und dadurch zu Konflikten führte, die passager das Verlassen der Neutralität verlangten. Ferner waren für diese Art der Behandlung enorme Ressourcen notwendig sowohl zeitlich als auch personell.
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Affiliation(s)
- Stefan Brokatzky
- Klinik für Konsiliarpsychiatrie und Psychosomatik, Kantonsspital St. Gallen, Schweiz
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22
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Titus-Glover D, Shaya FT, Welsh C, Qato DM, Shah S, Gresssler LE, Vivrette R. Opioid use disorder in pregnancy: leveraging provider perceptions to inform comprehensive treatment. BMC Health Serv Res 2021; 21:215. [PMID: 33691677 PMCID: PMC7945667 DOI: 10.1186/s12913-021-06182-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 02/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Medications for opioid use disorder (MOUD) are recommended with adjuvant behavioral therapies, counseling, and other services for comprehensive treatment of maternal opioid use disorder. Inadequate access to treatment, lack of prescribing providers and complex delivery models are among known barriers to care. Multi-disciplinary provider input can be leveraged to comprehend factors that facilitate or inhibit treatment. The objective of this study is to explore provider perceptions of MOUD and factors critical to comprehensive treatment delivery to improve the care of pregnant women with opioid use disorder. METHODS A qualitative research approach was used to gather data from individual provider and group semi-structured interviews. Providers (n = 12) responded to questions in several domains related to perceptions of MOUD, treatment delivery, access to resources, and challenges/barriers. Data were collected, transcribed, coded (by consensus) and emerging themes were analyzed using grounded theory methodology. RESULTS Emerging themes revealed persistent gaps in treatment and challenges in provider, health systems and patient factors. Providers perceived MOUD to be a "lifeline" to women. CONCLUSIONS Inconsistencies in treatment provision, access and uptake can be improved by leveraging provider perceptions, direct experiences and recommendations for an integrated team-based, patient-centered approach to guide the care of pregnant women with opioid use disorder.
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Affiliation(s)
- Doris Titus-Glover
- Department of Pharmaceutical Health Services Research (PHSR), School of Pharmacy, University of Maryland, Baltimore, USA.
- Present address: School of Nursing, University of Maryland, Baltimore, Universities at Shady Grove, 9640 Gudelsky Drive, Rockville, MD, 20850, USA.
| | - Fadia T Shaya
- Department of Pharmaceutical Health Services Research (PHSR), School of Pharmacy, University of Maryland, Baltimore, USA
| | - Christopher Welsh
- Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, USA
| | - Danya M Qato
- Department of Pharmaceutical Health Services Research (PHSR), School of Pharmacy, University of Maryland, Baltimore, USA
| | - Savyasachi Shah
- Department of Pharmaceutical Health Services Research (PHSR), School of Pharmacy, University of Maryland, Baltimore, USA
| | - Laura E Gresssler
- Department of Pharmaceutical Health Services Research (PHSR), School of Pharmacy, University of Maryland, Baltimore, USA
| | - Rebecca Vivrette
- Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, USA
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Alemu BT, Beydoun HA, Olayinka O, Young B. Temporal trends in rates of opioid misuse among delivery-related hospitalizations in North Carolina from 2000 to 2014. J Addict Dis 2021; 39:270-282. [PMID: 33416040 DOI: 10.1080/10550887.2020.1859048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Opioid misuse during pregnancy is increasing at an alarming rate across the United States. To determine the prevalence, temporal trends, and resource usage of delivery-related hospitalizations of women who misuse opioids in North Carolina from 2000 to 2014. A retrospective, cross-sectional study was conducted using the State Inpatient Databases. Annual prevalence was calculated, and linear trends were assessed using logistic regression. Temporal trends in hospital charges and length of stay (LOS) were analyzed using ordinary least squares regression with a loge-transformed response. Of 1,937,455 delivery-related hospitalizations in NC, 6,084 were associated with opioid misuse, a prevalence of 3.14 cases per 1,000 delivery-related discharges. During the study period, the prevalence of opioid misuse during pregnancy in NC increased 955%, from 0.9 cases per 1,000 discharges in 2000 to 9.5 cases per 1,000 discharges in 2014, an average annual rate increase of 1.18 cases (95% CI, 1.16-1.21; P < 0.0001). Median LOS for women who misuse opioids remained stable at three days, whereas the median charge per delivery-related hospitalization significantly increased from $6,311 in 2000 to $9,019 in 2010 (annual average change [AAC], 282.2; 95% CI, 182.9-381.5; P < 0.0001) and from $8,908 in 2011 to $10,864 in 2014 (AAC, 667.5; 95% CI, 275.2-1059.9; P < 0.0001). Health care providers and policymakers in NC are advised to introduce system-wide public health responses focused on prevention and increased access to evidence-based treatment that improves the health of the mothers and neonates who are exposed to opioids.
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Affiliation(s)
- Brook T Alemu
- Health Sciences Program, School of Health Sciences, Western Carolina University, Cullowhee, NC, USA
| | - Hind A Beydoun
- Department of Research Programs, Fort Belvoir Community Hospital, Department of Defense, Fort Belvoir, VA, USA
| | - Olaniyi Olayinka
- Department of Psychiatry and Behavioral Sciences, Interfaith Medical Center, Brooklyn, NY, USA
| | - Beth Young
- Department of Social Work, College of Health and Human Sciences, Western Carolina University, Cullowhee, NC, USA
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Coulson CC, Lorencz E, Rittenhouse K, Ramage M, Lorenz K, Galvin SL. Association of Maternal Buprenorphine or Methadone Dose with Fetal Growth Indices and Neonatal Abstinence Syndrome. Am J Perinatol 2021; 38:28-36. [PMID: 31421639 DOI: 10.1055/s-0039-1694729] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Our objective was to compare fetal growth and incidence of neonatal abstinence syndrome requiring treatment across pregnant women with opioid use disorders on two types and two dose categories of medication-assisted treatment. STUDY DESIGN A retrospective cohort study was conducted in a comprehensive, perinatal program in western North Carolina comparing growth percentiles on third-trimester ultrasound and at birth, and diagnosis of neonatal abstinence syndrome requiring treatment. Singletons were exposed in utero to low- to moderate-dose buprenorphine (≤16 mg/day; n = 70), high-dose buprenorphine (≥17 mg/day; n = 36), low- to moderate-dose methadone (≤89 mg/day; n = 41), or high-dose methadone (≥90 mg/day; n = 74). Multivariate analysis of variance with posthoc Bonferroni comparisons (p ≤ 0.01) and multinomial logistic regressions (adjusted odds ratio, 99% confidence interval) were conducted. RESULTS Differences in neonatal outcomes reached statistical significance for larger head circumference for buprenorphine doses (p = 0.01) and for longer length (p < 0.01) and lower odds of neonatal abstinence syndrome requiring treatment (p < 0.01) with low- to moderate-dose buprenorphine versus high-dose methadone. CONCLUSION Among pregnant women using medication-assisted treatment for opioid use disorders, low- to moderate-dose buprenorphine (≤16 mg/day) was associated with the most favorable neonatal outcomes. However, more rigorous control of confounders with a larger sample is necessary to determine if low- to moderate-dose buprenorphine is the better treatment choice.
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Affiliation(s)
- Carol C Coulson
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina.,Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Erin Lorencz
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Katelyn Rittenhouse
- University of North Carolina School of Medicine-Asheville, Asheville, North Carolina
| | - Melinda Ramage
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Kathleen Lorenz
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Shelley L Galvin
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina.,Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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25
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Flannery T, Davis JM, Czynski AJ, Dansereau LM, Oliveira EL, Camardo SA, Lester BM. Neonatal Abstinence Syndrome Severity Index Predicts 18-Month Neurodevelopmental Outcome in Neonates Randomized to Morphine or Methadone. J Pediatr 2020; 227:101-107.e1. [PMID: 32805259 PMCID: PMC7731918 DOI: 10.1016/j.jpeds.2020.08.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/09/2020] [Accepted: 08/12/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To develop an index to determine which opioid-exposed neonates have the most severe neonatal abstinence syndrome (NAS). STUDY DESIGN Full-term neonates with NAS (n = 116) from mothers maintained on methadone or buprenorphine were enrolled from 8 sites into a randomized clinical trial of morphine vs methadone. Ninety-nine (85%) were evaluated at hospital discharge using the NICU Network Neurobehavioral Scale (NNNS). At 18 months, 83 of 99 (83.8%) were evaluated with the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III), and 77 of 99 (77.7%) were evaluated with the Child Behavior Checklist (CBCL). RESULTS Cluster analysis was used to define high (n = 21) and low (n = 77) NAS severity. Compared with infants in the low NAS severity cluster, infants in the high NAS severity cluster had a longer length of stay (P < .001), longer length of stay due to NAS (P < .001), longer duration of treatment due to NAS (P < .001), and higher total dose of the study drug (P < .001) and were more likely to have received phenobarbital (P < .001), to have been treated with morphine (P = .020), and to have an atypical NNNS profile (P = .005). The 2 groups did not differ in terms of maximum Finnegan score. At 18 months, in unadjusted analyses, compared with the high-severity cluster, the low-severity cluster had higher scores on the Bayley-III Cognitive (P = .013), Language (P < .001), and Motor (P = .041) composites and less total behavior problems on the CBCL (P = .028). In adjusted analyses, the difference in the Bayley-III Language composite remained (P = .013). CONCLUSIONS Presumptive measures of NAS severity can be aggregated to develop an index that predicts developmental outcomes at age 18 months.
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Affiliation(s)
- Tess Flannery
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI
| | - Jonathan M Davis
- Department of Pediatrics, The Floating Hospital for Children at Tufts Medical Center, Boston, MA; Tufts Clinical and Translational Science Institute, Boston, MA; Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Adam J Czynski
- Department of Pediatrics, Warren Alpert Medical School of Brown University and Women and Infants Hospital, Providence, RI
| | - Lynne M Dansereau
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI
| | - Erica L Oliveira
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI
| | - Samantha A Camardo
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI
| | - Barry M Lester
- Brown Center for the Study of Children at Risk and Women and Infants Hospital, Providence, RI; Department of Pediatrics, Warren Alpert Medical School of Brown University and Women and Infants Hospital, Providence, RI; Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI.
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van Hoogdalem MW, McPhail BT, Hahn D, Wexelblatt SL, Akinbi HT, Vinks AA, Mizuno T. Pharmacotherapy of neonatal opioid withdrawal syndrome: a review of pharmacokinetics and pharmacodynamics. Expert Opin Drug Metab Toxicol 2020; 17:87-103. [PMID: 33049155 DOI: 10.1080/17425255.2021.1837112] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Neonatal opioid withdrawal syndrome (NOWS) often arises in infants born to mothers who used opioids during pregnancy. Morphine, methadone, and buprenorphine are the most common first-line treatments, whereas clonidine and phenobarbital are generally reserved for adjunctive therapy. These drugs exhibit substantial pharmacokinetic (PK) and pharmacodynamic (PD) variability. Current pharmacological treatments for NOWS are based on institutional protocols and largely rely on empirical treatment of patient symptoms. AREAS COVERED This article reviews the PK/PD of NOWS pharmacotherapies with a focus on the implication of physiological development and maturation. Body size-standardized clearance is consistently low in neonates, except for methadone. This can be ascribed to underdeveloped metabolic and elimination pathways. The effects of pharmacogenetics have been clarified especially for morphine. The PK/PD relationship of medications used in the treatment of NOWS is generally understudied. EXPERT OPINION Providing an appropriate opioid dose in neonates is challenging. Advancements in quantitative pharmacology and PK/PD modeling approaches facilitate identification of key factors driving PK/PD variability and characterization of exposure-response relationships. PK/PD model-informed simulations have been widely employed to define age-appropriate pediatric dosing regimens. The model-informed approach holds promise to aid more rational use of medications in the treatment of NOWS.
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Affiliation(s)
- Matthijs W van Hoogdalem
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,James L. Winkle College of Pharmacy, University of Cincinnati , Cincinnati, OH, USA
| | - Brooks T McPhail
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,School of Medicine Greenville, University of South Carolina , Greenville, SC, USA
| | - David Hahn
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA
| | - Scott L Wexelblatt
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati , Cincinnati, OH, USA.,Center for Addiction Research, College of Medicine, University of Cincinnati , Cincinnati, OH, USA
| | - Henry T Akinbi
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati , Cincinnati, OH, USA
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati , Cincinnati, OH, USA.,Center for Addiction Research, College of Medicine, University of Cincinnati , Cincinnati, OH, USA
| | - Tomoyuki Mizuno
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, College of Medicine, University of Cincinnati , Cincinnati, OH, USA.,Center for Addiction Research, College of Medicine, University of Cincinnati , Cincinnati, OH, USA
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27
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Wouldes TA, Woodward LJ. Neurobehavior of newborn infants exposed prenatally to methadone and identification of a neurobehavioral profile linked to poorer neurodevelopmental outcomes at age 24 months. PLoS One 2020; 15:e0240905. [PMID: 33064777 PMCID: PMC7567379 DOI: 10.1371/journal.pone.0240905] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 10/05/2020] [Indexed: 11/25/2022] Open
Abstract
The abuse of prescription opioids and heroin by women of childbearing age over the past decade has resulted in a five-fold increase in the number of infants born opioid-dependent. Daily opioid substitution treatment with methadone is associated with less maternal illicit opioid use and improved antenatal care. However, research on the neurobehavioral effects of daily prenatal exposure to methadone on the infant is limited. Using the NICU Network Neurobehavioral Scale (NNNS), we compared the neurobehavior at birth of 86 infants born to opioid-dependent mothers receiving methadone treatment (MMT) with 103 infants unexposed to methadone. Generalized linear models, adjusted for covariates, showed methadone exposed infants had significantly poorer attention, regulation, and quality of movement. They were also significantly more excitable, more easily aroused, exhibited more non-optimal reflexes, hypertonicity, and total signs of stress abstinence. Maternal MMT was also associated with more indices of neonatal abstinence, including: CNS, visual, genitourinary (GI), and state. Latent profile analysis of the NNNS summary scores revealed four distinct neurobehavioral profiles with infants characterized by the most disturbed neurobehavior at birth having the poorest clinical outcomes at birth, and poorer cognitive and motor development at 24 months of age.
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Affiliation(s)
- Trecia A. Wouldes
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Lianne J. Woodward
- School of Health Sciences, University of Canterbury, Christchurch, New Zealand
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Wright N, Hard J, Fearns C, Gilman M, Littlewood R, Clegg R, Parimelalagan L, Alam F. OUD Care Service Improvement with Prolonged-release Buprenorphine in Prisons: Cost Estimation Analysis. CLINICOECONOMICS AND OUTCOMES RESEARCH 2020; 12:499-504. [PMID: 32982339 PMCID: PMC7490057 DOI: 10.2147/ceor.s256714] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/31/2020] [Indexed: 11/27/2022] Open
Abstract
Background In prisons in England, integrated treatment for opioid use disorder (OUD) is accessible and effective, commonly based on daily supervised consumption of methadone. Treatment limitations (inadequate dosing, nonengagement with care, stigma, diversion and bullying) are noted. Flexible dose, injectable prolonged-release buprenorphine (PRB) which removes the need for daily dispensing and supervision is suggested for prisoner care. This work aimed to predict the difference in costs of current standard of care vs partial introduction of PRB. Methods A predictive model of compared costs for the provision of OUD care in the prison setting in England evaluated current standard of care (all receive methadone) with a future situation of 30% of prisoners electing to use a monthly dose of PRB. Evidence describing costs to deliver OUD care for 150 prisoners (pharmacotherapy, direct service, indirect health care, indirect security costs) were collected, including assumptions describing how care would be delivered. Evidence sources include national data sources, scientific literature and from experience in the prison health care setting. Results For a representative standard prison population requiring OUD care of 150 prisoners in England PRB introduction is associated with a predicted reduction in direct and indirect costs of OUD care. Annual OUD care costs for current standard of care were £0.6M; with 30% PRB costs reduced by £8665, more than 3000 hours of staff time is saved. Sensitivity analyses showed greater adoption of PRB resulted in further cost reduction. Conclusion PRB can address limitations of OUD care in prisons and improve outcomes. Introduction does not increase cost of care in this predictive analysis. PRB may lead the transformation of prisoner OUD care.
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Affiliation(s)
- Nat Wright
- Spectrum Community Health CIC, Wakefield, UK
| | - Jake Hard
- Royal College of General Practitioners, London, UK
| | | | | | | | | | | | - Farrukh Alam
- Central & North West London NHS Foundation Trust, London, UK
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Dopp A, Zabel Thornton M, Kozhimannil K, Jones CW, Greenfield B. Hospital care for opioid use disorder in pregnancy: Challenges and opportunities identified from a Minnesota survey. ACTA ACUST UNITED AC 2020; 16:1745506520952006. [PMID: 32833589 PMCID: PMC7448132 DOI: 10.1177/1745506520952006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: The prevalence of opioid use disorder continues to rise in the United States, with a simultaneous increase in the diagnosis of both opioid use disorder during pregnancy and neonatal opioid withdrawal syndrome. Despite these increases in pregnancy-related care, little is known about hospital policy and policy implementation related to opioid use disorder in pregnancy. In addition, it is unknown whether policies might differ in rural or urban hospitals. To better examine these issues, Minnesota hospitals were surveyed regarding the existence and implementation of policies related to opioid use disorder in pregnancy and whether any policy implementation challenges had been identified. Methods: From August to December 2017, the research team contacted all Minnesota hospitals that offered obstetric services (n = 82) to survey challenges to implementing policies for opioid use disorder during pregnancy, among other questions. Fifty-nine hospitals had respondents (primarily obstetric department supervisors) who provided information about policy implementation challenges for a 72% response rate. Qualitative responses were analyzed using qualitative description and according to hospital location: metropolitan (urban), micropolitan (rural), or non-core (rural). Results: Ninety-one percent of respondents said that they had pregnancies affected by opioid use disorder at their hospital within the last year. Four major challenges to policy implementation were identified in qualitative responses: (1) provider consensus, (2) patient response to policy, (3) lack of resources, and (4) low frequency of occurrence. All four challenges were more frequently identified by respondents at rural hospitals compared to urban hospitals. Conclusion: This study identified challenges in standardizing hospital care for pregnancies affected by opioid use disorder, and these challenges were identified more frequently in rural locations. These non-urban hospitals may require increased state and federal support and funding.
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Affiliation(s)
- Alana Dopp
- Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School, Duluth, MN, USA
| | - Morgan Zabel Thornton
- Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School, Duluth, MN, USA
| | - Katy Kozhimannil
- Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Cresta W Jones
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Brenna Greenfield
- Department of Family Medicine and Biobehavioral Health, University of Minnesota Medical School, Duluth, MN, USA
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30
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Prenatal exposure to methadone or buprenorphine and long-term outcomes: A meta-analysis. Early Hum Dev 2020; 143:104997. [PMID: 32146140 DOI: 10.1016/j.earlhumdev.2020.104997] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 02/18/2020] [Accepted: 02/18/2020] [Indexed: 01/13/2023]
Abstract
AIM To combine meta-analyses of multiple long-term outcomes in children prenatally exposed to methadone or buprenorphine through their mothers' Opioid maintenance therapy (OMT) with a systematic review of similar outcomes in experimental animals. METHOD The Medline, Embase, Web of Science, CINAHL, Cochrane and Epistemonikos databases were searched through August 30, 2018. Clinical studies measuring effects on cognitive, behavioral or visual outcomes in 3 months or older children prenatally exposed to OMT and control group(s) were included for meta-analyses. Experimental animal studies with similar exposures and outcomes were included in a systematic review. The three authors independently performed abstract screenings and full-text reviews, and extracted the data. One author performed the meta-analyses. RESULTS The pooled results of the meta-analyses showed worse cognitive, psychomotor, behavioral, attentional and executive functioning, and affected vision in children born to mothers who were in OMT during pregnancy compared to children without prenatal drug exposure (overall effect size = 0.49, 95% confidence interval = 0.38, 0.59, p < 0.00001). Many of the experimental animal studies showed impaired outcomes after prenatal exposure to methadone or buprenorphine. The clinical results may be biased, e.g., with the OMT group having more concurrent risk factors than the unexposed comparison group. There are few studies of older children. CONCLUSION Children born to mothers in OMT show worse outcomes for a number of different behaviors and impaired vision compared to children born to nonusers. Experimental animal studies indicate that there might be a causal relationship between prenatal methadone or buprenorphine exposure and subsequent negative outcomes.
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31
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Howard HG, Freeman K. U.S. Survey of factors associated with adherence to standard of care in treating pregnant women with opioid use disorder. J Psychosom Obstet Gynaecol 2020; 41:74-81. [PMID: 31244358 DOI: 10.1080/0167482x.2019.1634048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Objective: To identify, factors associated with obstetricians' treatment recommendations for pregnant women with an opioid use disorder (PWOUD), and to determine the prevalence of physicians waivered for buprenorphine as a medication-assisted treatment (MAT).Methods: We conducted a structured online survey of a nationally representative sample of 565 obstetrical physicians, with a response rate of 38%. Logistic regression models were derived to identify factors that influence treatment recommendations for PWOUD. The Clopper-Pearson method was used to derive the confidence interval (CI) for the number of physicians waivered for buprenorphine.Results: Approximately 77% of respondents had provided care for a PWOUD within the last year. Physicians reported that at least 75% of their PWOUD received Medicaid for prenatal care. The most common opioids used at patient presentation were prescription opioids, with the second most common being methadone. A total of 14.0% had buprenorphine waivers (95% CI: 11.6-16.7%), and among those waivered, 47% prescribed buprenorphine to PWOUD. Factors associated with buprenorphine waiver encompass referrals to community support services. The three most prominent factors associated with adherence to standard of care were: type of opioid at presentation, patient's choice, and physician's experience. Type of opioid was associated with methadone presentation, socioeconomic status, shared decision making and practice setting. Patient's choice was associated with physician preparedness and practice duration. Physician's experience was associated with referral to recovery-oriented services.Conclusions: Novel interventions are needed to (1) promote office-based treatment for opioid use disorder through continuing medical education, (2) provide physicians with access to recovery-oriented resources and (3) increase patient autonomy in healthcare decision making. These proposed evidence-based interventions will promote best practices for women and their infants and greater accessibility to standard of care.
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Affiliation(s)
- Heather Grimshaw Howard
- Phyllis and Harvey Sandler School of Social Work, Florida Atlantic University, Boca Raton, FL, USA
| | - Katherine Freeman
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
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Meinhofer A, Hinde JM, Ali MM. Substance use disorder treatment services for pregnant and postpartum women in residential and outpatient settings. J Subst Abuse Treat 2019; 110:9-17. [PMID: 31952630 DOI: 10.1016/j.jsat.2019.12.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 10/28/2019] [Accepted: 12/05/2019] [Indexed: 12/22/2022]
Abstract
The increasing prevalence of opioid use disorders among pregnant and postpartum women (PPW) has generated a need for greater availability of specialized programs offering evidence-based and comprehensive substance use disorder treatment services tailored to this population. In this study, we used data from the 2007 to 2018 National Survey of Substance Abuse Treatment Services to describe recent time trends and the geographic distribution of treatment facilities with specialized programs for PPW. We also compared differences in the availability of opioid agonist medication treatments (MT), key ancillary services, and health insurance acceptance between PPW Programs and Other Programs, overall and by residential and outpatient settings. We found that the prevalence of PPW Programs increased from 17% in 2007 to 23% in 2018, for a total of 3,429 PPW Programs and 11,230 Other Programs in 2018. The prevalence of PPW Programs was lowest in some states in the South and Midwest. Compared to Other Programs, PPW Programs were more likely to accept Medicaid (75% vs. 64%) and offer opioid agonist MTs methadone (24% vs. 6%), buprenorphine (44% vs. 30%), or both (18% vs. 4%). PPW Programs were also more likely to offer other key ancillary services such as childcare (16% vs. 3%), transportation (50% vs. 42%), and domestic violence assistance (51% vs. 35%). Compared to PPW Programs in outpatient settings, PPW Programs in residential settings were more likely to offer these key ancillary services but less likely to offer methadone or accept Medicaid. Our findings reflect considerable variation in the availability of PPW Programs over time and across states, as well as substantial gaps in key services offered in PPW Programs, let alone in Other Programs.
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Affiliation(s)
- Angélica Meinhofer
- Weill Cornell Medicine, Department of Healthcare Policy & Research, New York, NY, United States of America.
| | - Jesse M Hinde
- RTI International, Behavioral Health Research Division, Research Triangle Park, NC, United States of America
| | - Mir M Ali
- Office of the Assistant Secretary for Planning and Evaluation, US Department of Health & Human Services, Washington, DC, United States of America
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Abstract
Women with opioid use disorder who become pregnant are a particularly vulnerable population and require a comprehensive treatment approach for mother and fetus. Research is continuing on opioid use disorder, effects of opioid use on the fetus, and best treatment approaches. This article reviews current recommendations and guidelines for treatment.
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Affiliation(s)
- Lillian C Carter
- At the time this article was written, Lillian C. Carter and Molly A. Read were students in the PA program at the University of Lynchburg in Lynchburg, Va. Laura Read is director of didactic education in the PA program at the University of Lynchburg. Joyce S. Nicholas is director of evaluation, assessment, and compliance in the PA program at the University of Lynchburg. Eric Schmidt is an assistant professor at the University of Lynchburg. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Handal M, Nechanská B, Skurtveit S, Lund IO, Gabrhelík R, Engeland A, Mravčík V. Prenatal exposure to opioid maintenance treatment and neonatal outcomes: Nationwide registry studies from the Czech Republic and Norway. Pharmacol Res Perspect 2019; 7:e00501. [PMID: 31428431 PMCID: PMC6694203 DOI: 10.1002/prp2.501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 06/14/2019] [Accepted: 06/16/2019] [Indexed: 12/03/2022] Open
Abstract
There is lack of knowledge about the safety of treatment with methadone and buprenorphine as part of opioid maintenance treatment (OMT) during pregnancy. The purpose of this study was to examine neonatal outcomes concerning the use of OMT during pregnancy. We used nationwide registry linkages from the Czech Republic (2000-2014) and Norway (2004-2013). We compared prenatally OMT-exposed newborns with (a) newborns of women hospitalized with opioid use disorder during pregnancy in the Czech sample and (b) newborns with neonatal abstinence syndrome (NAS) in Norway. We performed multivariate linear and binary logistic regression exploring the associations between OMT and neonatal outcomes (growth parameters, gestational age, fetal death, small for gestational age, Apgar score, and NAS). Regression coefficients (b) and odds ratios (ORs) were estimated. The cohorts consisted of 333 Czech, and 235 Norwegian OMT-exposed newborns, and 106 and 294 newborns in the comparison groups, respectively. In both countries, the neonatal growth parameters were similar in the OMT and the comparison groups. In Norway, OMT exposure prolonged gestational age (adjusted b = 0.96 weeks, 95% confidence interval [CI] =0.39-1.53) while the odds of preterm birth and Apgar score at 5 minutes were lower than in the comparison group (adjusted OR = 0.35, 0.16-0.75 and aOR = 0.21, 0.06-0.78, respectively). Newborns of women in OMT had similar growth parameters as newborns of women with opioid use disorders who were not in OMT during pregnancy. Overall, our findings do not suggest that OMT results in worse neonatal outcomes.
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Affiliation(s)
- Marte Handal
- Department of Mental DisordersNorwegian Institute of Public HealthOsloNorway
| | - Blanka Nechanská
- Department of Addictology, First Faculty of MedicineCharles UniversityPragueCzech Republic
- Institute of Health Information and Statistics of the Czech RepublicPragueCzech Republic
| | - Svetlana Skurtveit
- Department of Mental DisordersNorwegian Institute of Public HealthOsloNorway
- Norwegian Centre for Addiction Research at the University of OsloOsloNorway
| | - Ingunn Olea Lund
- Department of Mental DisordersNorwegian Institute of Public HealthOsloNorway
| | - Roman Gabrhelík
- Department of Addictology, First Faculty of MedicineCharles UniversityPragueCzech Republic
| | - Anders Engeland
- Department of Chronic Diseases and AgeingNorwegian Institute of Public HealthOsloNorway
- Department of Global Public Health and Primary CareUniversity of BergenBergenNorway
| | - Viktor Mravčík
- Department of Addictology, First Faculty of MedicineCharles UniversityPragueCzech Republic
- National Monitoring Centre for Drugs and AddictionOffice of the Government of the Czech RepublicPragueCzech Republic
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Oni HT, Khan MN, Abdel-Latif M, Buultjens M, Islam MM. Short-term health outcomes of newborn infants of substance-using mothers in Australia and New Zealand: A systematic review. J Obstet Gynaecol Res 2019; 45:1783-1795. [PMID: 31313404 DOI: 10.1111/jog.14051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 06/22/2019] [Indexed: 12/22/2022]
Abstract
AIM Substance use is not unusual among women of childbearing age. Pregnant women who use a substance and the consequent impacts on a newborn vary across studies and settings. We reviewed New Zealand and Australian literature to examine the short-term health outcomes of newborn of substance-using mothers and their demographic characteristics. METHODS Five medical/nursing databases and google scholar were searched in April 2017. Studies were considered eligible if they described outcomes of newborn of substance-using mothers. Mixed Methods Appraisal Tool was used for quality assessment of candidate studies. Relevant data were extracted and analyzed using narrative synthesis. Based on data availability, a subset of studies was included in meta-analysis. RESULTS Although findings of individual studies vary, there are some evidence that the infants born to substance-using mothers were likely to have preterm birth, low birthweight, small-for-gestational age, low Apgar score, and admission to neo-natal intensive care unit. The likelihood of adverse health outcomes was much higher for newborns of polysubstance-using mothers, than newborns of mothers using a single substance. Pregnant women who use illicit substance are predominantly socially disadvantaged, in their twenties and or of Aboriginal descent. CONCLUSION Infants of substance-using mothers suffer a range of adverse health outcomes. Multidisciplinary and integrated approach of services that ensure supportive social determinants of health may result in a better outcome for newborn and positive behavioral change among mothers.
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Affiliation(s)
- Helen T Oni
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Md Nuruzzaman Khan
- Research Centre for Generational Health and Ageing, School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Mohamed Abdel-Latif
- Department of Neonatology, Centenary Hospital for Women and Children, Canberra Hospital, Canberra, Australia
| | - Melissa Buultjens
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - M Mofizul Islam
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia
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Ecker J, Abuhamad A, Hill W, Bailit J, Bateman BT, Berghella V, Blake-Lamb T, Guille C, Landau R, Minkoff H, Prabhu M, Rosenthal E, Terplan M, Wright TE, Yonkers KA. Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine. Am J Obstet Gynecol 2019; 221:B5-B28. [PMID: 30928567 DOI: 10.1016/j.ajog.2019.03.022] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Goetzl L, Thompson-Felix T, Darbinian N, Merabova N, Merali S, Merali C, Sanserino K, Tatevosian T, Fant B, Wimmer ME. Novel biomarkers to assess in utero effects of maternal opioid use: First steps toward understanding short- and long-term neurodevelopmental sequelae. GENES BRAIN AND BEHAVIOR 2019; 18:e12583. [PMID: 31119847 DOI: 10.1111/gbb.12583] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/17/2019] [Accepted: 05/21/2019] [Indexed: 12/24/2022]
Abstract
Maternal opioid use disorder is common, resulting in significant neonatal morbidity and cost. Currently, it is not possible to predict which opioid-exposed newborns will require pharmacotherapy for neonatal abstinence syndrome. Further, little is known regarding the effects of maternal opioid use disorder on the developing human brain. We hypothesized that novel methodologies utilizing fetal central nervous system-derived extracellular vesicles isolated from maternal blood can address these gaps in knowledge. Plasma from opioid users and controls between 9 and 21 weeks was precipitated and extracellular vesicles were isolated. Mu opioid and cannabinoid receptor levels were quantified. Label-free proteomics studies and unbiased small RNA next generation sequencing was performed in paired fetal brain tissue. Maternal opioid use disorder increased mu opioid receptor protein levels in extracellular vesicles independent of opioid equivalent dose. Moreover, cannabinoid receptor levels in extracellular vesicles were upregulated with opioid exposure indicating cross talk with endocannabinoids. Maternal opioid use disorder was associated with significant changes in extracellular vesicle protein cargo and fetal brain micro RNA expression, especially in male fetuses. Many of the altered cargo molecules and micro RNAs identified are associated with adverse clinical neurodevelopmental outcomes. Our data suggest that assays relying on extracellular vesicles isolated from maternal blood extracellular vesicles may provide information regarding fetal response to opioids in the setting of maternal opioid use disorder. Prospective clinical studies are needed to evaluate the association between extracellular vesicle biomarkers, risk of neonatal abstinence syndrome and neurodevelopmental outcomes.
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Affiliation(s)
- Laura Goetzl
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Sciences Center, Houston, Texas
| | - Tara Thompson-Felix
- Department of Psychiatry and Behavioral Science, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Nune Darbinian
- Shriners Pediatric Research Center, Center for Neural Repair and Rehabilitation, Temple University, Philadelphia, Pennsylvania
| | - Nana Merabova
- Shriners Pediatric Research Center, Center for Neural Repair and Rehabilitation, Temple University, Philadelphia, Pennsylvania
| | - Salim Merali
- School of Pharmacy, Temple University, Philadelphia, Pennsylvania
| | - Carmen Merali
- School of Pharmacy, Temple University, Philadelphia, Pennsylvania
| | - Kathryne Sanserino
- Department of Obstetrics & Gynecology, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Tamara Tatevosian
- Shriners Pediatric Research Center, Center for Neural Repair and Rehabilitation, Temple University, Philadelphia, Pennsylvania
| | - Bruno Fant
- Department of Psychiatry, Center for Neurobiology and Behavior, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mathieu E Wimmer
- Department of Psychology, Temple University, Philadelphia, Pennsylvania
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Zakerabasali S, Safdari R, Kadivar M, Rostam Niakan Kalhori S, Mokhtaran M, Karbasi Z, Sayarifard A, Abhari S. Neonatal abstinence syndrome: a systematic review of current databases and registries. J Matern Fetal Neonatal Med 2019; 34:979-992. [PMID: 31092074 DOI: 10.1080/14767058.2019.1618827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Registries are considered as rich sources of data for determination of infants with neonatal abstinence syndrome (NAS), the improvement of provided care and research. The aims of this study were: (1) to investigate the existing studies including NAS registries, (2) to identify and extract the required data elements. METHODS The following electronic databases were searched: PubMed, Scopus, Web of Science, ProQuest, Embase/Medline, and Psych Info. In addition, a review of gray literature was undertaken to identify relevant studies in English covering the period from 1 January 2009 to 1 November 2018 including registries and databases. Screening of titles, abstracts, and full-texts were conducted independently by two researchers based on PRISMA guidelines. The basic registry information, scope, registry type, data source, the purpose of registry, important variables were extracted and analyzed. RESULTS Twenty-five articles were eligible and included in the review; they reported 37 registries and databases related to NAS at the national and state levels in 11 countries from 1876 to 2013. We proposed a NAS registry design framework based on well-known data-information-knowledge (DIK) structure due to Ackoff's DIK hierarchy has a defined role as a central model of information systems, information management, and knowledge management. CONCLUSIONS To the best of our knowledge, this is the first study which has systematically reviewed NAS-related registries. Since there are no international standards to develop new NAS registries, the proposed framework in this article can be beneficial. This framework is essential not only to facilitate the NAS registry design but also to help the collection of high-value clinical data necessary for the acquisition of better clinical knowledge.
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Affiliation(s)
- Somayyeh Zakerabasali
- Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Safdari
- Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Maliheh Kadivar
- Department of Pediatrics, Division of Neonatology, Tehran University of Medical Sciences, Tehran, Iran.,Community Based Participatory Research Center, Iranian Institute for Reduction of High-Risk Behaviors, Tehran, Iran
| | - Sharareh Rostam Niakan Kalhori
- Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Zahra Karbasi
- Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Azadeh Sayarifard
- Community Based Participatory Research Center, Iranian Institute for Reduction of High-Risk Behaviors, Tehran, Iran
| | - Shahabeddin Abhari
- Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
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Crane D, Marcotte M, Applegate M, Massatti R, Hurst M, Menegay M, Mauk R, Williams S. A statewide quality improvement (QI) initiative for better health outcomes and family stability among pregnant women with opioid use disorder (OUD) and their infants. J Subst Abuse Treat 2019; 102:53-59. [PMID: 31202289 DOI: 10.1016/j.jsat.2019.04.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/12/2019] [Accepted: 04/25/2019] [Indexed: 12/12/2022]
Abstract
A collaborative led by state health and human service agencies, academic leaders, and stakeholders tested interventions to expand use of medication assisted treatment (MAT) through a maternal medical home (MMH) model that coordinated behavioral health and prenatal care with social supports for pregnant women with opioid use disorder (OUD) enrolled in Medicaid. The program was anchored in four clinical organizations with distinct models of care: community behavioral health, residential behavioral health, hospital-based obstetrical practice, and co-located obstetrical and behavioral health. A modified version of the Institute for Healthcare Improvement Breakthrough Series Model for Improvement was implemented using monthly performance data feedback to conduct small tests of change and improve care. Administrative data from the state's Medicaid, vital statistics, and child welfare systems were linked to evaluate the impact of MOMS on 252 mother-infant dyads compared to a sample of 846 Medicaid beneficiaries with OUD in the third trimester of pregnancy. MOMS participation was associated with increased likelihood of MAT in trimesters one, two and three (AOR = 2.30, 4.40, 2.75, respectively), behavioral health counseling during trimesters two and three (AOR = 3.75 and 2.07, respectively), retention in MAT during postpartum months one through three and four through six (AOR = 2.86, 2.40, respectively), and marginally lower out-of-home placement of infants born to mothers with OUD (AOR = 0.66). Within the MOMS program, greater participation in behavioral health treatment and MAT (χ2(3) ≥ 12.09) was observed in the co-located behavioral health/obstetrical care practice site compared to behavioral health-led and obstetrical provider-led sites.
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Affiliation(s)
- Dushka Crane
- Ohio Colleges of Medicine Government Resource Center, Ohio State University Medical Center, United States of America.
| | - Michael Marcotte
- Tri-State Maternal-Fetal Medicine Associates, United States of America.
| | - Mary Applegate
- FACP - NASHP, Ohio Department of Medicaid, United States of America.
| | - Richard Massatti
- Ohio Department of Mental Health and Addiction Services, United States of America.
| | - Mark Hurst
- Ohio Department of Mental Health and Addiction Services, United States of America.
| | - Michelle Menegay
- Ohio Colleges of Medicine Government Resource Center, Ohio State University Medical Center, United States of America.
| | - Rachel Mauk
- Ohio Colleges of Medicine Government Resource Center, Ohio State University Medical Center, United States of America.
| | - Susan Williams
- Ohio Department of Job and Family Services, United States of America.
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40
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Martins F, Oppolzer D, Santos C, Barroso M, Gallardo E. Opioid Use in Pregnant Women and Neonatal Abstinence Syndrome-A Review of the Literature. TOXICS 2019; 7:E9. [PMID: 30781484 PMCID: PMC6468487 DOI: 10.3390/toxics7010009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/10/2019] [Accepted: 02/13/2019] [Indexed: 02/07/2023]
Abstract
Opiate use during pregnancy has been an increasing problem over the last two decades, making it an important social and health concern. The use of such substances may have serious negative outcomes in the newborn, and clinical and cognitive conditions have been reported, including neonatal abstinence syndrome, developmental problems, and lower cognitive performance. These conditions are common when opiates are used during pregnancy, making the prescription of these kinds of drugs problematic. Moreover, the mother may develop opiate addiction, thus, increasing the likelihood of the infant being born with any of those conditions. This paper reviews the use of opiates during pregnancy and focuses mainly on the neonatal abstinence syndrome. First, the commonly prescribed opiates will be identified, namely those usually involved in cases of addiction and/or neonatal abstinence syndrome. Second, published approaches to deal with those problems will be presented and discussed, including the treatment of both the mother and the infant. Finally, we will outline the treatments that are safest and most efficient, and will define future goals, approaches, and research directions for the scientific community regarding this problem.
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Affiliation(s)
- Fábio Martins
- Centro de Investigação em Ciências da Saúde, Faculdade de Ciências da Saúde da Universidade da Beira Interior (CICS-UBI), 6200-506 Covilhã, Portugal.
| | - David Oppolzer
- Centro de Investigação em Ciências da Saúde, Faculdade de Ciências da Saúde da Universidade da Beira Interior (CICS-UBI), 6200-506 Covilhã, Portugal.
| | - Catarina Santos
- Centro de Investigação em Ciências da Saúde, Faculdade de Ciências da Saúde da Universidade da Beira Interior (CICS-UBI), 6200-506 Covilhã, Portugal.
| | - Mário Barroso
- Serviço de Química e Toxicologia Forenses, Instituto de Medicina Legal e Ciências Forenses-Delegação do Sul, 1150-334 Lisboa, Portugal.
| | - Eugenia Gallardo
- Centro de Investigação em Ciências da Saúde, Faculdade de Ciências da Saúde da Universidade da Beira Interior (CICS-UBI), 6200-506 Covilhã, Portugal.
- Laboratório de Fármaco-Toxicologia-UBIMedical, Universidade da Beira Interior, 6200-284 Covilhã, Portugal.
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Williams JB. Do Pregnant Inmates have a Constitutional Right to Opioid Replacement Therapy? Am J Obstet Gynecol 2018; 219:455.e1-455.e4. [PMID: 30017681 DOI: 10.1016/j.ajog.2018.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/08/2018] [Accepted: 07/02/2018] [Indexed: 11/24/2022]
Abstract
Changes in the national drug laws have resulted in a marked increase in the number of individuals who have been incarcerated in the United States over the past several decades; women have not been exempt from this trend. Incarcerated women who are pregnant and at risk of experiencing opioid withdrawal often lack access to opioid replacement therapy while in jails and prisons, although this treatment is necessary to prevent significant acute withdrawal that can be detrimental to maternal-fetal health. I contend that pregnant inmates who are at risk of experiencing opioid withdrawal possess a constitutional right to receive opioid replacement therapy while incarcerated and that failure to provide this treatment represents a violation of the Eighth Amendment's protection against cruel and unusual punishment.
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Lacaze-Masmonteil T, O’Flaherty P. La prise en charge des nouveau-nés dont la mère a pris des opioïdes pendant la grossesse. Paediatr Child Health 2018. [DOI: 10.1093/pch/pxx200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Pat O’Flaherty
- Société canadienne de pédiatrie, comité d’étude du fœtus et du nouveau-né, Ottawa (Ontario)
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43
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Lacaze-Masmonteil T, O'Flaherty P. Managing infants born to mothers who have used opioids during pregnancy. Paediatr Child Health 2018; 23:220-226. [PMID: 29769809 DOI: 10.1093/pch/pxx199] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The incidence of infant opioid withdrawal has grown rapidly in many countries, including Canada, in the last decade, presenting significant health and early brain development concerns. Increased prenatal exposure to opioids reflects rising prescription opioid use as well as the presence of both illegal opiates and opioid-substitution therapies. Infants are at high risk for experiencing symptoms of abstinence or withdrawal that may require assessment and treatment. This practice point focuses specifically on the effect(s) of opioid withdrawal and current management strategies in the care of infants born to mothers with opioid dependency.
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Affiliation(s)
| | - Pat O'Flaherty
- Canadian Paediatric Society, Fetus and Newborn Committee, Ottawa, Ontario
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Kelty E, Hulse G. A retrospective cohort study of the health of children prenatally exposed to methadone, buprenorphine or naltrexone compared with non-exposed control children. Am J Addict 2017; 26:845-851. [PMID: 29143398 DOI: 10.1111/ajad.12642] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/24/2017] [Accepted: 10/22/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Little is known about the health of children exposed to opioid pharmacotherapies in utero. This study aims to examine the health of children from birth to 5 years of age, who were exposed to methadone, buprenorphine, or naltrexone with non-exposed children. METHODS Children were identified by linking the treatment records of women treated with one of the three opioid pharmacotherapies with midwife notifications. Live-born children exposed to methadone (n = 198), buprenorphine (n = 122), naltrexone (n = 67) in utero, and neonates not prenatally exposed to opioids (n = 387) born between 2001 and 2011 in Western Australia were included in the study. The children were then linked to state mortality, hospital, emergency department (ED), mental health, cancer, and reportable diseases from birth up to their 5th birthday. RESULTS Overall rates of hospital admission were elevated in all three treatments as compared with the control children, while rates of ED attendances were only significantly elevated in the methadone (p = .002) and naltrexone (p = .044) exposed children. In terms of both hospital and ED attendances, the differences between the exposed and control children was most apparent in the neonatal period. Rates of mental health out-patient attendances were elevated in buprenorphine-exposed children as compared with the control (p = .005). DISCUSSION AND CONCLUSIONS The study provides evidence to suggest a disparity in the health of children exposed to opioid pharmacotherapies in utero compared with non-exposed control children. SCIENTIFIC SIGNIFICANCE Exposure to opioid pharmacotherapies in utero may influence the health of children beyond the neonatal period. (Am J Addict 2017;26:845-851).
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Affiliation(s)
- Erin Kelty
- Discipline of Psychiatry, University of Western Australia, Sir Charles Gairdner Hospital, Nedlands, Western Australian.,School of Population and Global Health, University of Western Australia, Crawley, Western Australian
| | - Gary Hulse
- Discipline of Psychiatry, University of Western Australia, Sir Charles Gairdner Hospital, Nedlands, Western Australian.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia
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45
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Chavan NR, Ashford KB, Wiggins AT, Lofwall MR, Critchfield AS. Buprenorphine for Medication-Assisted Treatment of Opioid Use Disorder in Pregnancy: Relationship to Neonatal Opioid Withdrawal Syndrome. AJP Rep 2017; 7:e215-e222. [PMID: 29226017 PMCID: PMC5720890 DOI: 10.1055/s-0037-1608783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 10/09/2017] [Indexed: 11/17/2022] Open
Abstract
Objective To examine the relationship between antepartum buprenorphine dose for medication-assisted treatment (MAT) of opioid use disorder (OUD) and incident neonatal opioid withdrawal syndrome (NOWS). Study Design We performed a prospective cohort study of pregnant women with a singleton gestation diagnosed with OUD and receiving buprenorphine for MAT at a tertiary care academic institution from July 2015 to January 2017. We divided the study cohort into two groups-pregnancies with versus without NOWS. Substance abuse patterns in pregnancy, maternal, and neonatal clinical outcomes were compared. Results The incidence of NOWS was 31.11% ( n = 28/90) in our study cohort. Pregnancies with NOWS had a significantly higher rate of benzodiazepine positive urine tests and number of positive urine drug screen (UDS) results for illicit opioids. The group without NOWS had significantly higher number of patients with an appropriate UDS result at delivery through postpartum. Rates of neonatal intensive care unit (NICU) admission, length of NICU stay, and maximum Finnegan score were significantly higher in the group with NOWS. Neither the initial (10.6 ± 5.2 versus 10.3 ± 4.8 mg, p = 0.80) nor the final buprenorphine doses (13.3 ± 5.1 versus 13.0 ± 4.6 mg, p = 0.81) were significantly different between study groups. Conclusion The occurrence of NOWS was not related to buprenorphine dose used for MAT.
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Affiliation(s)
- Niraj R Chavan
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Kentucky College of Medicine, Lexington, Kentucky
| | | | | | - Michelle R Lofwall
- Department of Behavioral Science and Psychiatry, Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Agatha S Critchfield
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Kentucky College of Medicine, Lexington, Kentucky
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Kahn LS, Mendel WE, Fallin KL, Borngraber EA, Nochajski TH, Rea WE, Blondell RD. A parenting education program for women in treatment for opioid-use disorder at an outpatient medical practice. SOCIAL WORK IN HEALTH CARE 2017; 56:649-665. [PMID: 28594601 DOI: 10.1080/00981389.2017.1327470] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Opioid use during pregnancy poses serious risks for the mother and the unborn child. Opioid-use disorder may be managed with medication-assisted treatment (MAT) in an outpatient setting, but few MAT practices specifically address the challenges faced by pregnant women. This article describes a medical office-based educational support group for women in MAT for opioid-use disorder who were pregnant and/or parenting young children. Focus groups were conducted to elicit patient feedback. Women indicated that they found the educational support groups beneficial and offered suggestions. In-office educational support groups for pregnant women in treatment for opioid-use disorder are feasible and well received.
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Affiliation(s)
- Linda S Kahn
- a Department of Family Medicine , Primary Care Research Institute, University at Buffalo , Buffalo , NY , USA
| | - Whitney E Mendel
- b Master of Public Health Program, Daemen College , Amherst , NY , USA
| | - Kyla L Fallin
- c School of Social Work , University at Buffalo , Amherst , NY , USA
| | | | | | - William E Rea
- d Center for Development of Human Services , Institute for Community Health Promotion , Rochester , NY , USA
| | - Richard D Blondell
- a Department of Family Medicine , Primary Care Research Institute, University at Buffalo , Buffalo , NY , USA
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Treating Neonatal Abstinence Syndrome from Clinical Perspectives. IRANIAN JOURNAL OF PEDIATRICS 2017. [DOI: 10.5812/ijp.6266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Chen CY, Li X, Ma LY, Wu PH, Zhou Y, Feng Q, Cui YM. In Utero Oxcarbazepine Exposure and Neonatal Abstinence Syndrome: Case Report and Brief Review of the Literature. Pharmacotherapy 2017; 37:e71-e75. [PMID: 28543284 PMCID: PMC5575550 DOI: 10.1002/phar.1955] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Oxcarbazepine is a second‐generation antiepileptic drug that is used to treat partial seizures. Although it has been increasingly used in pregnant women, its fetal safety has not been fully validated. We describe a 12‐hour‐old neonate who developed neonatal abstinence syndrome (NAS) after intrauterine exposure to oxcarbazepine. The neonate was born via cesarean section to a mother who took oxcarbazepine 300 mg/day for treatment of seizures throughout her pregnancy. Approximately 12 hours after birth, the infant developed paroxysmal jitter, which mainly presented as increased excitability, irritability, limb shaking, and increased muscle tone. These symptoms resolved by day 9 of life. Although NAS occurs most often after in utero exposure to opioids, exposure to other drugs during pregnancy may contribute to a small proportion of NAS cases. To our knowledge, this is the second case report of oxcarbazepine‐induced NAS. Pregnant women with epilepsy should weigh the pros and cons of continuing oxcarbazepine during their pregnancy when they are prescribed this drug. For infants with in utero oxcarbazepine exposure, comprehensive assessments and examinations are necessary for screening oxcarbazepine‐induced NAS.
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Affiliation(s)
- Chao-Yang Chen
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Xing Li
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Ling-Yue Ma
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Peng-Hui Wu
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Ying Zhou
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Qi Feng
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Yi-Min Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China
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Abstract
Opioid abuse among pregnant women has reached epidemic proportions and has influenced maternal and child health policy at the federal, state, and local levels. As a result, we review the current state of opioid use in pregnancy and evaluate recent legislative and health policy initiatives designed to combat opioid addiction in pregnancy. We emphasize the importance of safe and responsible opioid-prescribing practices, expanding the availability and accessibility of medication-assisted treatment and standardizing care for neonates at risk of neonatal abstinence syndrome. Efforts to penalize pregnant women and negative consequences for disclosing substance use to health care providers are harmful and may prevent women from seeking prenatal care and other beneficial health care services during pregnancy. Instead, health care providers should advocate for health policy informed by scientific research and evidence-based practice to reduce the burden of prenatal opioid abuse and optimize outcomes for mothers and their neonates.
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