Prenatal drug use in Minneapolis-St Paul, Minn. A 4-year trend

Polydrug Use During Pregnancy and Preterm Birth in a Low-Income, Multiethnic Birth Cohort, Boston, 1998-2018

OBJECTIVE

The opioid epidemic in the United States increasingly affects women of reproductive age and has resulted in a rise in concurrent polydrug use. The objective of this study was to investigate the effect of this polydrug use on preterm birth in a multiethnic birth cohort.

METHODS

We analyzed data from 8261 mothers enrolled in the Boston Birth Cohort from 1998 to 2018 in Boston, Massachusetts. We grouped substances used during pregnancy based on their primary effects (stimulant or depressant) and assessed independent and combined associations with smoking on preterm birth.

RESULTS

Of 8261 mothers, 131 used stimulant drugs and 193 used depressant drugs during pregnancy. The preterm birth rate was 27.5% (2271 of 8261) in the sample. Mothers who smoked had 35% increased odds of preterm birth across adjusted models. Mothers who used stimulant drugs without smoking were not at increased risk of preterm delivery compared with mothers who used neither (odds ratio [OR] = 0.69; 95% confidence interval [CI], 0.19-1.98), whereas mothers who used depressant drugs without smoking had more than twice the odds of having preterm delivery (OR = 2.31; 95% CI, 1.19-4.44), and infants were at risk of a 1-week reduction in gestational age (OR = -1.05; 95% CI, -2.07 to -0.03). Concurrently smoking and using depressant drugs was associated with increased odds of preterm birth (OR = 1.83; 95% CI, 1.28-2.61), as was concurrently smoking and using stimulant drugs (OR = 1.73; 95% CI, 1.14-2.59).

CONCLUSIONS

Using stimulant drugs and depressant drugs during pregnancy is a risk factor for preterm birth. The individual and combined effects of using these drugs with smoking must be considered together to reduce the risk of preterm birth in the United States.

Perinatal Illicit Drug and Marijuana Use

PURPOSE

To assess use, screening, and disclosure of perinatal marijuana and other illicit drugs during first obstetric visits.

DESIGN

Observational study that qualitatively assesses provider screening and patient disclosure of substance use.

SETTING

Study sites were five urban outpatient prenatal clinics and practices located in Pittsburgh, Pennsylvania.

PARTICIPANTS

Pregnant patients and obstetric providers were recruited as participants.

METHODS

We audio recorded patient-provider conversations during first obstetric visits and obtained patient urine samples for drug analyses. Audio recordings were reviewed for provider screening and patient disclosure of illicit drug use. Urine analyses were compared with audio recordings to determine disclosure.

RESULTS

Four hundred and twenty-two pregnant patients provided complete audio recordings and urine samples for analyses. Providers asked about illicit drug use in 81% of the visits. One hundred twenty-three patients (29%) disclosed any current or past illicit drug use; 48 patients (11%) disclosed current use of marijuana while pregnant. One hundred and forty-five samples (34%) tested positive for one or more substances; marijuana was most commonly detected (N = 114, 27%). Of patients who tested positive for any substance, 66 (46%) did not disclose any use; only 36% of patients who tested positive for marijuana disclosed current use.

CONCLUSION

Although marijuana is illegal in Pennsylvania, a high proportion of pregnant patients used marijuana, with many not disclosing use to their obstetric care providers.

Obstetric Health Care Providers' Counseling Responses to Pregnant Patient Disclosures of Marijuana Use

OBJECTIVE

To describe obstetric health care providers' responses and counseling approaches to patients' disclosures of marijuana use during first prenatal visits.

METHODS

We performed a content analysis of audio-recorded patient-health care provider first prenatal visits for obstetrics health care providers' responses to patients' disclosure of marijuana use. The study was conducted at five urban outpatient clinics located in Pittsburgh, Pennsylvania.

RESULTS

Among 468 audio-recorded first obstetric encounters, 90 patients (19%) disclosed marijuana use to 47 health care providers; mean number of recoded encounters containing marijuana disclosures for participating health providers was 1.8±1.4. In 48% of these 90 visits, obstetric health care providers did not respond to marijuana use disclosures or offer counseling. When counseling was offered, it consisted of general statements without specific information on the risks or outcomes related to marijuana use in pregnancy, discussions regarding the need for urine toxicology testing, and warnings that use detected at the time of delivery would initiate child protective services involvement.

CONCLUSION

Obstetric health care provider responses to disclosure of marijuana use occurred in approximately half of patient encounters when marijuana use was disclosed and focused on legal and procedural consequences with less focus on health or medical implications. Our results suggest a need for health care provider training on potential consequences of perinatal marijuana use and communication skills for counseling patients about perinatal marijuana.

Assessment of exposure to drugs of abuse during pregnancy by hair analysis in a Mediterranean island

AIMS

  This study aims to estimate the prevalence of drug use by pregnant women living in Ibiza, using structured interviews and biomarkers in maternal hair. In addition, the potentially detrimental effects of maternal drug abuse on their newborns were investigated. Ibiza has a large international night-life resort associated with clubs, music and use of recreational drugs.

DESIGN, SETTING AND PARTICIPANTS

  Hair samples were collected prospectively from January to March 2010 from a cohort of consecutive mothers after giving birth in the Hospital Can Misses in Ibiza.

MEASUREMENTS

  Opiates, cocaine, cannabis, methadone, amphetamines, 3,4-methylenedioxymethamphetamine (MDMA) and their metabolites were detected in a 3-cm-long proximal segment of maternal hair corresponding to the last trimester of pregnancy by gas chromatography coupled to mass spectrometry (n = 107). Data on socio-demographic characteristics and on tobacco, alcohol, drugs of prescription and drugs of abuse consumption during pregnancy were collected using a structured questionnaire.

FINDINGS

  Hair analysis showed an overall 16% positivity for drugs of abuse in the third trimester of pregnancy, with a specific prevalence of cannabis, cocaine, MDMA and opiates use of 10.3, 6.4, 0.9 and 0%, respectively. In the questionnaires, only 1.9% of mothers declared using drugs of abuse during pregnancy. Gestational drug of abuse consumption was associated with active tobacco smoking, a higher number of smoked cigarettes and the mother being Spanish.

CONCLUSIONS

  Illicit drug use is substantially under-reported among pregnant women living in Ibiza, particularly among Spanish nationals. Voluntary, routine objective biological toxicology screening should be considered as part of routine examinations in antenatal clinics on this Mediterranean island.

Universal alcohol/drug screening in prenatal care: a strategy for reducing racial disparities? Questioning the assumptions

Agencies and organizations promoting universal screening for alcohol and drug use in prenatal care argue that universal screening will reduce White versus Black racial disparities in reporting to Child Protective Services (CPS) at delivery. Yet, no published research has assessed the impact of universal screening on reporting disparities or explored plausible mechanisms. This review defines two potential mechanisms: Equitable Surveillance and Effective Treatment and identifies assumptions underlying each mechanism. It reviews published literature relating to each assumption. Research relating to assumptions underlying each mechanism is primarily inconclusive or contradictory. Thus, available research does not support the claim that universal screening for alcohol and drug use in prenatal care reduces racial disparities in CPS reporting at delivery. Reducing these reporting disparities requires more than universal screening.

Opioid detection in maternal and neonatal hair and meconium: characterization of an at-risk population and implications to fetal toxicology

Identification of maternal opioid abuse in pregnancy is often difficult to ascertain in the absence of a reliable self-report. We aimed to characterize an at-risk neonatal population for opioid exposures as well as other drugs of abuse and alcohol. From June 2007 to January 2009, 563 neonatal hair and 1318 meconium specimens were assessed for opioids and were positive in 11.4% and 17.0%, respectively. Neonates testing positive for opioids in hair or meconium analysis were also more likely to test positive for other licit and illicit substances (odds ratiohair, 1.75; 95% confidence interval, 1.03-2.97; odds ratiomeconium, 1.61; 95% confidence interval, 1.16-2.22). Specifically, a positive neonatal hair test for opioids also predicted a positive result for oxycodone. In addition, a positive meconium test result for opioids was associated with positive results for cocaine, oxycodone, methadone, benzodiazepines, and fatty acid ethyl esters (alcohol). Finally, there was a significant correlation between maternal and neonatal hair test results for opioids (Spearman rank rho = 0.657, P = 0.03). Understanding the addiction profiles of these women may lead to better clinical and social management and may largely benefit an at-risk population.

Alcohol, drugs, caffeine, tobacco, and environmental contaminant exposure: reproductive health consequences and clinical implications

Reproductive function and fertility are thought to be compromised by behaviors such as cigarette smoking, substance abuse, and alcohol consumption; however, the strength of these associations are uncertain. Furthermore, the reproductive system is thought to be under attack from exposure to environmental contaminants, particularly those chemicals shown to affect endocrine homeostasis. The relationship between exposure to environmental contaminants and adverse effects on human reproductive health are frequently debated in the scientific literature and these controversies have spread into the lay press drawing increased public and regulatory attention. Therefore, the objective of the present review was to critically evaluate the literature concerning the relationship between lifestyle exposures and adverse effects on fertility as well as examining the evidence for a role of environmental contaminants in the purported decline of semen quality and the pathophysiology of subfertility, polycystic ovarian syndrome, and endometriosis. The authors conclude that whereas cigarette smoking is strongly associated with adverse reproductive outcomes, high-level exposures to other lifestyle factors are only weakly linked with negative fertility impacts. Finally, there is no compelling evidence that environmental contaminants, at concentrations representative of the levels measured in contemporary biomonitoring studies, have any effect, positive or negative, on reproductive health in the general population. Further research using prospective study designs with robust sample sizes are needed to evaluate testable hypotheses that address the relationship between exposure and adverse reproductive health effects.

Cigarette smoking knowledge, attitudes, and practices of patients and staff at a perinatal substance abuse treatment center

This study compares cigarette smoking knowledge, attitudes, and practices (S-KAP) of opioid- and other substance-dependent patients and their multidisciplinary staff at an outpatient perinatal substance abuse treatment center. Consenting patients (n = 95) and staff (n = 41) concurrently completed a modified form of the S-KAP survey instrument. Ninety-five percent of patients reported currently smoking, and half endorsed wanting "to quit smoking now." This patient desire to quit smoking was significantly underrated by staff compared to the patients themselves (p = .028). Both patients and staff demonstrated suboptimal knowledge of smoking health risks, but 73% of patients reported trying to quit with past pregnancies to avoid harm to the fetus/baby. Although results show that patients could benefit from smoking cessation strategies centered on smoking's fetal/neonatal health risks, organizational interventions that focus on changing staff attitudes about patient desire to quit smoking may first need to be implemented.

Relationship between cigarette use and mood/anxiety disorders among pregnant methadone-maintained patients

This study investigates the association between cigarette use and current mood/anxiety disorders among pregnant opioid-dependent patients. Pregnant methadone-maintained women (N = 122) completed the Addiction Severity Index and Structured Clinical Interview for DSM-IV. Participants were categorized based on past 30 days cigarette use: no (n = 15) and any smoking (n = 107); this latter group was then subdivided into light (one to ten cigarettes/day; n = 55), and heavy smokers (11+ cigarettes/day; n = 52). Any smoking was significantly associated with any current mood/anxiety disorder (p < 0.001), any current mood disorder (p = 0.007), and any current anxiety disorder (p < 0.001). No significant association was found between specific level of cigarette use and mood/anxiety disorders. This association between smoking and psychiatric disorders has implications for the mental and physical health of methadone-maintained women and their children, and may contribute to the understanding of the physiological mechanisms underlying smoking and nicotine dependence.

Development of an Instrument to Assess Problem Behavior in First Grade Students Prenatally Exposed to Cocaine. Part II: Validation

In Part I, the initial development of a preliminary tool, the PROBS-14, was reported. The tool was developed and initially tested through a consensus process that tapped the perceptions of early education teachers. Concurrent validity between the PROBS-14 and the Conners' Teacher Rating Scale (CTRS) was established with factor analysis, yielding a hyperactivity-conduct factor, composed of PROBS items and all but two of the CTRS subscales, and a central processing factor, composed of PROBS items and the remaining CTRS scales. The purpose of Part II was to further establish concurrent validity of the PROBS-14 with known pediatric behavior measures (TRF, CTRS) and to ascertain if the PROBS-14 better predicts a cocaine behavioral effect. A sample of 468 African American children with known cocaine exposure (n = 200) and control status (n = 268) were evaluated. Factor analyses produced results similar to those reported in Part I, with PROBS items accounting for problem behavior variance beyond that accounted for by the TRF, and more specific than that accounted for by the CTRS. Additionally, children prenatally exposed to cocaine, particularly those exposed late in pregnancy, differed significantly from controls on the PROBS total, central processing scale, and several PROBS items. The PROBS instrument offers a promising brief measure of child problem behaviors with adequate concurrent and predictive validity, and which outperforms the TRF and CTRS in discriminating prenatal cocaine exposure status.

Fetal effects of cocaine: an updated meta-analysis

BACKGROUND

A very large number of women in the reproductive age group consume cocaine, leading to grave concerns regarding the long term health of millions of children after in utero exposure. The results of controlled studies have been contradictory, leading to confusion, and, possible, misinformation and misperception of teratogenic risk.

OBJECTIVE

To systematically review available data on pregnancy outcome when the mother consumed cocaine.

METHODS

A meta-analysis of all epidemiologic studies based on a priori criteria was conducted. Comparisons of adverse events in subgroups of exposed vs. unexposed children were performed. Analyses were based on several exposure groups: mainly cocaine, cocaine plus polydrug, polydrug but no cocaine, and drug free.

RESULTS

Thirty three studies met our inclusion criteria. For all end points of interest (rates of major malformations, low birth weight, prematurity, placental abruption, premature rupture of membrane [PROM], and mean birth weight, length and head circumference), cocaine-exposed infants had higher risks than children of women not exposed to any drug. However, most of these adverse effects were nullified when cocaine exposed children were compared to children exposed to polydrug but no cocaine. Only the risk of placental abruption and premature rupture of membranes were statistically associated with cocaine use itself.

CONCLUSIONS

Many of the perinatal adverse effects commonly attributed to cocaine may be caused by the multiple confounders that can occur in a cocaine using mother. Only the risk for placental abruption and PROM could be statistically related to cocaine. For other adverse effects, additional studies will be needed to ensure adequate statistical power.

Understanding drug testing in the neonate and the role of meconium analysis

The use of illicit drugs during pregnancy is a problem that affects a significant number of pregnant women or women of childbearing age. For many reasons, the identification of the drug exposed mother and her infant is a necessary, albeit difficult, task. This article will discuss drug testing to detect the antenatal exposure of the newborn infant to illicit drugs and review the different laboratory methods that are used and the role of meconium analysis in neonatal drug testing.

Cost-effectiveness of treatment for drug-abusing pregnant women

Neonatal intensive care unit (NICU) and drug treatment costs were compared in two groups of pregnant drug abusing women: 100 admissions to a multidisciplinary treatment program and active in care at the time of delivery and 46 controls not entering drug treatment. Clinical measures included urine toxicology at delivery, infant birthweight. Apgar scores and need for and duration of NICU services. Cost measures included drug treatment and NICU costs. Treatment patients showed better clinical outcome at delivery, with less drug use and higher infant estimated gestational age, birthweight and Apgar scores. Infants of treatment patients were also less likely to require NICU services and, for those that did, had a shorter stay. When total cost was examined (including drug treatment), mean net savings for treatment subjects was $4644 per mother/infant pair. The study demonstrates the cost-effectiveness of treatment for pregnant drug abusing women, with savings in NICU costs exceeding costs of drug treatment.

Prevalence of human immunodeficiency virus infection and drug use in pregnant women: a critical review of the literature

Many studies have been undertaken in the last 10 years to determine the prevalence of both human immunodeficiency virus (HIV) infection and drug use in pregnant women. These studies could have a serious impact on the delivery of health care as well as the development of health policy. We provide an overview of the key findings from these studies and a critical review of their strengths and weaknesses. For example, although many prevalence studies were conducted with enough participants to reach statistical significance, flaws in study design limit the generalizability of the findings. In addition, the development of profiles, risk groups, or characteristics was an unsuccessful method of identifying pregnant women at risk for drug use or HIV infection. These findings have implications for the type of screening procedures that are undertaken in the clinical setting and the development of health policy at various levels of government. We also conclude that the issue of stigma and discrimination in relation to drug and HIV testing, as well as race, gender, and socioeconomic status, must be addressed. Finally, we outline how these studies could have a significant effect on the health of pregnant women.

Gender differences in crack users who are research volunteers

This study compared gender differences in a non-treatment sample of crack cocaine users interested in participating in a research study on addiction. Data was collected from initial telephone screening interviews of women and men responding to cocaine research recruitment in a midwest urban environment over a two-year period. Female respondents (n = 88) were age- and race-matched with men interviewed over the same time period, for a total sample size of 176. Mean age of the female sample was 33 years and the majority were African-American. Basic demographics were similar for both genders. Respondents had first used cocaine at 24 years of age and currently smoked 2 g cocaine/day for 5 days/week, a rate higher than that found in many treatment samples. Women were found to have significantly higher rates of cigarette smoking, headaches and history of suicidal ideation, and significantly more women reported emergency room visits following crack use than did men. Equal numbers of men and women had been convicted of a crime (56%), with significantly fewer women reporting having committed a crime involving violence. Nearly all respondents (94%) reported that crack use had negative effects on their value systems, and significant numbers of both genders reported involvement with bartering crack and sex. Two-thirds of women able to become pregnant used no method of birth control and the use of barrier methods was infrequent. Forty-two percent admitted to using cocaine during pregnancy. These data indicate that while patterns of crack use per se do not differ between women and men in this sample, community outreach programs may benefit from focusing on other associated behaviors that do show differences between genders.