Methadone versus buprenorphine for the treatment of opioid abuse in pregnancy: science and stigma

Therapeutics for Substance-Using Women: The Need to Elucidate Sex-Specific Targets for Better-Tailored Treatments

In the last decade, alcohol consumption in the US has risen by 84% in women compared with 35% in men. Furthermore, research has shown that sex- and gender-related differences may disadvantage women in terms of developing a range of psychological, cognitive, and medical problems considerably earlier in their drinking history than men, and despite consuming a similar quantity of substances. While this "telescoping" process has been acknowledged in the literature, a concomitant understanding of the underlying biobehavioral mechanisms, and an increase in the development of specific treatments tailored to women, has not occurred. In the current chapter we focus on understanding why the need for personalized, sex-specific medications is imperative, and highlight some of the potential sex-specific gonadal and stress-related adaptations underpinning the accelerated progress from controlled to compulsive drug and alcohol seeking in women. We additionally discuss the efficacy of these mechanisms as novel targets for medications development, using exogenous progesterone and guanfacine as examples. Finally, we assess some of the challenges faced and progress made in terms of developing innovative medications in women. We suggest that agents such as exogenous progesterone and adrenergic medications, such as guanfacine, may provide some efficacy in terms of attenuating stress-induced craving for several substances, as well as improving the ability to emotionally regulate in the face of stress, preferentially in women. However, to fully leverage the potential of these therapeutics in substance-using women, greater focus needs to the placed on reducing barriers to treatment and research by encouraging women into clinical trials.

Women-Reported Barriers and Facilitators of Continued Engagement with Medications for Opioid Use Disorder

Opioid-related fatalities increased exponentially during the COVID-19 pandemic and show little sign of abating. Despite decades of scientific evidence that sustained engagement with medications for opioid use disorders (MOUD) yields positive psychosocial outcomes, less than 30% of people with OUD engage in MOUD. Treatment rates are lowest for women. The aim of this project was to identify women-specific barriers and facilitators to treatment engagement, drawing from the lived experience of women in treatment. Data are provided from a parent study that used a community-partnered participatory research approach to adapt an evidence-based digital storytelling intervention for supporting continued MOUD treatment engagement. The parent study collected qualitative data between August and December 2018 from 20 women in Western Massachusetts who had received MOUD for at least 90 days. Using constructivist grounded theory, we identified major themes and selected illustrative quotations. Key barriers identified in this project include: (1) MOUD-specific discrimination encountered via social media, and in workplace and treatment/recovery settings; and (2) fear, perceptions, and experiences with MOUD, including mental health medication synergies, internalization of MOUD-related stigma, expectations of treatment duration, and opioid-specific mistrust of providers. Women identified two key facilitators to MOUD engagement: (1) feeling "safe" within treatment settings and (2) online communities as a source of positive reinforcement. We conclude with women-specific recommendations for research and interventions to improve MOUD engagement and provide human-centered care for this historically marginalized population.

Prevalence and Geographic Distribution of Obstetrician-Gynecologists Who Treat Medicaid Enrollees and Are Trained to Prescribe Buprenorphine

IMPORTANCE

The incidence of opioid use during pregnancy is increasing, and drug overdoses are a leading cause of postpartum mortality. Most women who are pregnant do not receive medications for treatment of opioid use disorder, despite the mortality benefit that these agents confer. Furthermore, buprenorphine is associated with milder symptoms of neonatal abstinence syndrome (NAS) compared with methadone.

OBJECTIVE

To describe the prevalence and geographic distribution across the US of obstetrician-gynecologists who can prescribe buprenorphine (henceforth described as X-waivered) in 2019.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional, nationwide study linking physician-specific data to county- and state-level data was conducted from September 1, 2019, to March 31, 2020. Data were obtained on 31 211 obstetrician-gynecologists who accept Medicaid insurance through the Centers for Medicare & Medicaid Services Physician Compare data set and linked to the Drug Addiction Treatment Act buprenorphine-waived clinician list.

EXPOSURES

State-level NAS incidence and county-level uninsured rates and rurality.

MAIN OUTCOMES AND MEASURES

Prevalence and geographic distribution of obstetrician-gynecologists who are trained to prescribe buprenorphine.

RESULTS

Among the 31 211 identified obstetrician-gynecologists, 18 710 (59.9%) were women. Most had hospital privileges (23 236 [74.4%]) and worked in metropolitan counties (28 613 [91.7%]). Only 560 of the identified obstetrician-gynecologists (1.8%) were X-waivered. Obstetrician-gynecologists in counties with fewer than 5% uninsured residents had nearly twice the odds of being X-waivered (adjusted odds ratio [aOR], 1.59; 95% CI, 1.04-2.44; P = .04) compared with those in counties with greater than 15% uninsured residents. Compared with those located in metropolitan counties, obstetrician-gynecologists in suburban counties (eg, urban population of ≥20 000 and adjacent to a metropolitan area) were more likely to be X-waivered (aOR, 1.85; 95% CI, 1.26-2.71; P = .002). Compared with states with an NAS rate of 5 per 1000 births or less, obstetrician-gynecologists in states with an NAS rate of 15 per 1000 births or greater had nearly 5 times the odds of being X-waivered (aOR, 4.94; 95% CI, 3.60-6.77; P < .001). Obstetrician-gynecologists without hospital privileges were more likely to be X-waivered (aOR, 1.32; 95% CI, 1.08-1.61; P = .007).

CONCLUSIONS AND RELEVANCE

Fewer than 2% of obstetrician-gynecologists who accept Medicaid are able to prescribe buprenorphine, and their geographic distribution appears to be skewed in favor of suburban counties. This finding suggests that there is an opportunity for health systems and professional societies to incentivize X-waiver trainings among obstetrician-gynecologists to increase patients' access to buprenorphine, especially during pregnancy.

Comparison of buprenorphine and methadone in the management of maternal opioid use disorder in full term pregnancies

Objectives To compare pregnancy outcomes with medication assisted treatment using. methadone or buprenorphine in term mothers with opioid use disorder. Methods A cohort of women receiving medication assisted treatment with either methadone or buprenorphine were identified from delivery records over a 10-year period. Women were excluded with delivery <37 weeks, multiple gestations, or a known anomalous fetus. Maternal demographics, medications, mode of delivery, birthweight, newborn length of stay, and neonatal abstinence syndrome were extracted. The study was IRB approved and a p-value of <0.05 was significant. Results There were 260 women, 140 (53.8%) with methadone use and 120 (46.2%) with buprenorphine use. Groups were similar for maternal age, race, parity, homeless rate, tobacco use, mode of delivery and incidence of neonatal abstinence syndrome. The methadone group had a lower mean newborn birthweight (2874±459 g) and a greater incidence of low birth weight (11.4%) than the buprenorphine group (3282±452 g; p<0.001 and 2.5%; p=0.006). The incidence of neonatal abstinence syndrome was similar between groups (97% methadone vs. 92.5% buprenorphine; p=0.08). The methadone group had a longer newborn length of stay (11.4+7.4 days) and more newborn treatment with morphine (44.6%) than the buprenorphine group (8.2+4.4 days; p<0.001 and 24.2%; p<0.001). Maternal methadone use was an independent predictor for a newborn length of hospital stay >7 days (OR 3.61; 95% confidence interval 1.32-9.86; p=0.01). Conclusions Medication assisted treatment favors buprenorphine use when compared to. methadone with an increased birthweight, reduced need for newborn treatment, and a shorter newborn length of stay in term infants.

A mixed-method comparison of physician-reported beliefs about and barriers to treatment with medications for opioid use disorder

BACKGROUND

Evidence demonstrates that medications for treating opioid use disorder (MOUD) -namely buprenorphine, methadone, and extended-release naltrexone-are effective at treating opioid use disorder (OUD) and reducing associated harms. However, MOUDs are heavily underutilized, largely due to the under-supply of providers trained and willing to prescribe the medications.

METHODS

To understand comparative beliefs about MOUD and barriers to MOUD, we conducted a mixed-methods study that involved focus group interviews and an online survey disseminated to a random group of licensed U.S. physicians, which oversampled physicians with a preexisting waiver to prescribe buprenorphine. Focus group results were analyzed using thematic analysis. Survey results were analyzed using descriptive and inferential statistical methods.

RESULTS

Study findings suggest that physicians have higher perceptions of efficacy for methadone and buprenorphine than for extended-release naltrexone, including for patients with co-occurring mental health disorders. Insurance obstacles, such as prior authorization requirements, were the most commonly cited barrier to prescribing buprenorphine and extended-release naltrexone. Regulatory barriers, such as the training required to obtain a federal waiver to prescribe buprenorphine, were not considered significant barriers by many physicians to prescribing buprenorphine and naltrexone in office-based settings. Nor did physicians perceive diversion to be a prominent barrier to prescribing buprenorphine. In focus groups, physicians identified financial, logistical, and workforce barriers-such as a lack of addiction treatment specialists-as additional barriers to prescribing medications to treat OUD.

CONCLUSIONS

Additional education is needed for physicians regarding the comparative efficacy of different OUD medications. Governmental policies should mandate full insurance coverage of and prohibit prior authorization requirements for OUD medications.

Determinants of selection into buprenorphine/naloxone among people initiating opioid agonist treatment in British Columbia

BACKGROUND

Studies assessing the comparative effectiveness of methadone versus buprenorphine/naloxone for opioid use disorder in real-world settings are rare - challenged by structural differences in delivery across settings and factors influencing treatment selection. We identified determinants of selection into buprenorphine/naloxone and quantified contributions of individual and provider-level covariates in a setting delivering both medications within the same healthcare settings.

METHODS

Utilizing linked health administrative datasets, we conducted a retrospective cohort study of people with opioid use disorder (PWOUD) receiving opioid agonist treatment (OAT) in British Columbia, Canada, from 2008-2017. Determinants of buprenorphine/naloxone selection were identified using a generalized linear mixed model with random intercept terms for providers and individuals. We determined the influence of individual demographics, clinical history, measures of provider experience and preference, and dates of key policy changes.

RESULTS

A total of 39,605 individuals experienced 178,976 OAT episodes (methadone:139,439(77.9 %);buprenorphine/naloxone:39,537(22.1 %)). Male sex, less OAT experience, younger age, mental health conditions and chronic pain were associated with higher odds of buprenorphine/naloxone prescription. For providers, higher client-attachment, more complex OAT case-mixes, and higher buprenorphine/naloxone prescribing-preference were also associated with higher odds of buprenorphine/naloxone prescription. Observed individual-level covariates explained 9.7 % of variance in odds of buprenorphine/naloxone selection, while observed provider-level covariates explained 20.0 %. Controlling for covariates, residual unmeasured between-individual variance accounted for 18.5 % of the explained variation in the odds of buprenorphine/naloxone selection, while unmeasured between-provider variance accounted for 28.4 %.

CONCLUSION

Provider characteristics were more influential in selection of buprenorphine/naloxone over methadone informing subsequent analyses of comparative effectiveness of these regimens.

Factors associated with treatment retention in pregnant women with opioid use disorders prescribed methadone or electing non-pharmacological treatment

Opioid use during pregnancy is rising, with an estimated 14-22% of women obtaining an opioid prescription during pregnancy. Methadone maintenance therapy (MMT) has been the gold standard for treatment of opioid use disorders during pregnancy; however, its use is limited in clinical practice due to availability, stigma, and reluctance on the part of clinicians. The present study compared against medical advice (AMA) treatment dropout from seven days of residential care between pregnant women diagnosed with opioid dependence who elected either MMT (n = 119) or non-pharmacological treatment (NPT) (n = 91) within the same treatment program in Baltimore, Maryland from 1996 to 1998. Multiple logistic regression analysis was conducted to compare the rate of AMA drop out between the two modalities. Patients who elected NPT were 2.77 times as likely to leave residential treatment as patients who elected MMT (adjusted odds ratio [OR = 2.77, 95% confidence interval [CI]: 1.23-6.17]. AMA was associated with interviewer-assessed drug severity and patient's rating of the importance of psychiatric treatment. The present findings further support the clinical utility of MMT and suggest that policies that facilitate the implementation of MMT in clinical practice would be beneficial to the engagement and retention of pregnant women with opioid use disorders.

Psychoeducational Strategies During Outpatient Transition to Extended-Release Naltrexone for Patients With Opioid Use Disorder

BACKGROUND: The United States is experiencing an opioid epidemic. Better approaches to encourage outpatient utilization of Food and Drug Administration-approved medications for the treatment of opioid use disorder, including extended-release naltrexone (XR-NTX), are needed. Withdrawal management before initiation of XR-NTX is challenging for clinicians and patients and represents a major barrier to treatment. AIMS: To review psychoeducational strategies that support patients during outpatient withdrawal management and transition to XR-NTX. METHOD: We reviewed the literature on psychoeducational strategies used during opioid withdrawal management and described the role that nurses can play in facilitating transition to XR-NTX in a Phase 3, placebo-controlled, outpatient trial comparing induction regimens. RESULTS: Supportive interventions include general psychoeducation on addiction, overcoming ambivalence, treatment adherence, anticipating XR-NTX induction, managing psychological and physiological aspects of opioid withdrawal, risks of opioid use, and sources of support during recovery. CONCLUSIONS: Psychoeducational strategies led by nurses can promote treatment adherence during withdrawal management and induction onto XR-NTX.

Moms Supporting Moms: Digital Storytelling With Peer Mentors in Recovery From Substance Use

Substance use disorder (SUD) is a growing issue nationally, and SUD in pregnancy has significant consequences for mothers and their children. This article describes findings from a pilot project that used digital storytelling as a mechanism for understanding substance use and recovery from the perspective of women in recovery from SUD in pregnancy who worked as peer mentors with pregnant women currently experiencing SUD. Research on peer mentorship has primarily focused on outcomes for mentees but not the experience of the peer mentors themselves. In this qualitative study, a 3-day digital storytelling workshop was conducted with five women in recovery serving as peer mentors in their community. Each mentor also participated in an individual, in-depth interview. The digital storytelling workshop process helped peer mentors make linkages between their past substance use experiences to their present work of recovery, and fostered deep social connections between mentors through the shared experience. The workshop process also elicited a sense of hope among participants, which served as groundwork for developing advocacy-based efforts. Digital storytelling may be therapeutic for women in recovery and has the potential to be integrated into recovery programs to bolster hope and social support among participants.

Pharmacologic Treatment of Opioid Addiction During Pregnancy

Opioid addiction during pregnancy presents a treatment challenge to clinicians and women alike. Untreated addiction can lead to poor maternal and fetal health outcomes. Medication-assisted treatment is the standard of care, and methadone is the current drug of choice for treatment. Emerging evidence also supports the use of buprenorphine during pregnancy. Both methadone and buprenorphine have risks and benefits that should be explored before initiating treatment. Clinicians who work in obstetrics and in addiction treatment can collaborate and coordinate treatment to ensure optimal maternal and fetal outcomes. Women undergoing treatment will require frequent monitoring, particularly in the third trimester. Neonates born to women receiving treatment may have withdrawal symptoms and require additional treatment.