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Perez C. Transitioning Care Approach for Neonatal Opioid Withdrawal Syndrome and Neonatal Abstinence Syndrome. Crit Care Nurs Clin North Am 2024; 36:223-233. [PMID: 38705690 DOI: 10.1016/j.cnc.2023.11.005] [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] [Indexed: 05/07/2024]
Abstract
The increase in substance use during pregnancy results in a higher incidence of neonatal abstinence syndrome/neonatal opioid withdrawal syndrome (NAS/NOWS), straining health care and social systems and creating an economic burden. There is a paradigm shift in transitioning the care approach for NAS/NOWS from a medical model of care to a family-centered individualized non-pharmacological care approach with non-pharmacological interventions as the first line of treatment. Supporting families after birth with a nurturing environment and providing them with a toolbox of non-pharmacological interventions prepares them for the transition from hospital to home.
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Affiliation(s)
- Christine Perez
- NICU Thought Leader Philips, Infant Massage USA, 8800 Lombard Place 1507, San Diego, CA 92122, USA.
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2
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Wiese AD, Phillippi JC, Muhar A, Polic A, Liu G, Loch SF, Ong HH, Su WC, Leech AA, Reese T, Wei WQ, Patrick SW. Performance of Phenotype Algorithms for the Identification of Opioid-Exposed Infants. Hosp Pediatr 2024:e2023007546. [PMID: 38804051 DOI: 10.1542/hpeds.2023-007546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
OBJECTIVE Observational studies examining outcomes among opioid-exposed infants are limited by phenotype algorithms that may under identify opioid-exposed infants without neonatal opioid withdrawal syndrome (NOWS). We developed and validated the performance of different phenotype algorithms to identify opioid-exposed infants using electronic health record data. METHODS We developed phenotype algorithms for the identification of opioid-exposed infants among a population of birthing person-infant dyads from an academic health care system (2010-2022). We derived phenotype algorithms from combinations of 6 unique indicators of in utero opioid exposure, including those from the infant record (NOWS or opioid-exposure diagnosis, positive toxicology) and birthing person record (opioid use disorder diagnosis, opioid drug exposure record, opioid listed on medication reconciliation, positive toxicology). We determined the positive predictive value (PPV) and 95% confidence interval for each phenotype algorithm using medical record review as the gold standard. RESULTS Among 41 047 dyads meeting exclusion criteria, we identified 1558 infants (3.80%) with evidence of at least 1 indicator for opioid exposure and 32 (0.08%) meeting all 6 indicators of the phenotype algorithm. Among the sample of dyads randomly selected for review (n = 600), the PPV for the phenotype requiring only a single indicator was 95.4% (confidence interval: 93.3-96.8) with varying PPVs for the other phenotype algorithms derived from a combination of infant and birthing person indicators (PPV range: 95.4-100.0). CONCLUSIONS Opioid-exposed infants can be accurately identified using electronic health record data. Our publicly available phenotype algorithms can be used to conduct research examining outcomes among opioid-exposed infants with and without NOWS.
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Affiliation(s)
- Andrew D Wiese
- Departments of Health Policy
- Vanderbilt Center for Child Health Policy
| | - Julia C Phillippi
- Vanderbilt Center for Child Health Policy
- School of Nursing, Vanderbilt University, Nashville, Tennessee
| | | | | | - Ge Liu
- Center for Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah F Loch
- Pediatrics
- Vanderbilt Center for Child Health Policy
| | - Henry H Ong
- Center for Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Wu-Chen Su
- Center for Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashley A Leech
- Departments of Health Policy
- Vanderbilt Center for Child Health Policy
| | | | - Wei-Qi Wei
- Center for Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen W Patrick
- Departments of Health Policy
- Pediatrics
- Vanderbilt Center for Child Health Policy
- Mildred Stahlman Division of Neonatology
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3
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Pinchman EV, Lende MN, Feustel P, Lynch T. Evaluating the Association between Prenatal Care Visits and Adverse Perinatal Outcome in Pregnancies Complicated by Opioid Use Disorder. Am J Perinatol 2024; 41:e2225-e2229. [PMID: 37286184 DOI: 10.1055/a-2107-1834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE This study aimed to evaluate the association between number of prenatal care visits and adverse perinatal outcome among pregnant individuals with opioid use disorder (OUD). STUDY DESIGN This is a retrospective cohort of singleton, nonanomalous pregnancies complicated by OUD that delivered from January 2015 to July 2020 at our academic medical center. Primary outcome was the presence of composite adverse perinatal outcome, defined as one or more of the following: stillbirth, placental abruption, perinatal death, neonatal respiratory distress syndrome, need for morphine treatment, and hyperbilirubinemia. Logistic and linear regression estimated the association between the number of prenatal care visits and the presence of adverse perinatal outcome. A Mann-Whitney U test evaluated the association between number of prenatal care visits and length of hospital stay for the neonate. RESULTS A total of 185 patients were identified, of which 35 neonates required morphine treatment for neonatal opioid withdrawal syndrome. During pregnancy, most individuals were treated with buprenorphine 107 (57.8%), whereas 64 (34.6%) received methadone, 13 (7.0%) received no treatment, and 1 (0.5%) received naltrexone. The median number of prenatal care visits was 8 (interquartile range: 4-10). With each additional visit per 10 weeks of gestational age, the risk of adverse perinatal outcome decreased by 38% (95% confidence interval [CI]: 0.451-0.854). The need for neonatal intensive care and hyperbilirubinemia also significantly decreased with additional prenatal visits. Neonatal hospital stay decreased by a median of 2 days (95% CI: 1-4) for individuals who received more than the median of eight prenatal care visits. CONCLUSION Pregnant individuals with OUD who attend fewer prenatal care visits experience more adverse perinatal outcome. Future research should focus on barriers to prenatal care and interventions to improve access in this high-risk population. KEY POINTS · Use of prenatal care affects newborn outcomes.. · More prenatal care shortens neonatal hospital stay.. · Prenatal care reduces certain adverse outcomes..
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Affiliation(s)
| | - Michelle N Lende
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Albany Medical Center, Albany, New York
| | - Paul Feustel
- Department of Neuroscience, Albany Medical College, Albany, New York
| | - Tara Lynch
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Albany Medical Center, Albany, New York
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Ferrante JR, Blendy JA. Advances in animal models of prenatal opioid exposure. Trends Neurosci 2024; 47:367-382. [PMID: 38614891 PMCID: PMC11096018 DOI: 10.1016/j.tins.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/20/2024] [Accepted: 03/15/2024] [Indexed: 04/15/2024]
Abstract
Neonatal opioid withdrawal syndrome (NOWS) is a growing public health concern. The complexity of in utero opioid exposure in clinical studies makes it difficult to investigate underlying mechanisms that could ultimately inform early diagnosis and treatments. Clinical studies are unable to dissociate the influence of maternal polypharmacy or the environment from direct effects of in utero opioid exposure, highlighting the need for effective animal models. Early animal models of prenatal opioid exposure primarily used the prototypical opioid, morphine, and opioid exposure that was often limited to a narrow period during gestation. In recent years, the number of preclinical studies has grown rapidly. Newer models utilize both prescription and nonprescription opioids and vary the onset and duration of opioid exposure. In this review, we summarize novel prenatal opioid exposure models developed in recent years and attempt to reconcile results between studies while critically identifying gaps within the current literature.
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Affiliation(s)
- Julia R Ferrante
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Julie A Blendy
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Lawler K, Dronavalli M, Page A, Lee E, Uebel H, Bajuk B, Burns L, Dickson M, Green C, Dicair L, Eastwood J, Oei JL. 'Joining the Dots: Linking Prenatal Drug Exposure to Childhood and Adolescence' - research protocol of a population cohort study. BMJ Paediatr Open 2024; 8:e002557. [PMID: 38604771 PMCID: PMC11015252 DOI: 10.1136/bmjpo-2024-002557] [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: 02/01/2024] [Accepted: 03/28/2024] [Indexed: 04/13/2024] Open
Abstract
INTRODUCTION Prenatal drug exposure (PDE) is one of the most important causes of child harm, but comprehensive information about the long-term outcomes of the families is difficult to ascertain. The Joining the Dots cohort study uses linked population data to understand the relationship between services, therapeutic interventions and outcomes of children with PDE. METHODS AND ANALYSIS Information from routinely collected administrative databases was linked for all births registered in New South Wales (NSW), Australia between 1 July 2001 and 31 December 2020 (n=1 834 550). Outcomes for seven mutually exclusive groups of children with varying prenatal exposure to maternal substances of addiction, including smoking, alcohol, prescription/illicit drugs and neonatal abstinence syndrome will be assessed. Key exposure measures include maternal drug use type, maternal social demographics or social determinants of health, and maternal physical and mental health comorbidities. Key outcome measures will include child mortality, academic standardised testing results, rehospitalisation and maternal survival. Data analysis will be conducted using Stata V.18.0. ETHICS AND DISSEMINATION Approvals were obtained from the NSW Population and Health Services Research Ethics Committee (29 June 2020; 2019/ETH12716) and the Australian Capital Territory Health Human Research Ethics Committee (11 October 2021; 2021-1231, 2021-1232, 2021-1233); and the Aboriginal Health and Medical Research Council (5 July 2022; 1824/21), and all Australian educational sectors: Board of Studies (government schools), Australian Independent Schools and Catholic Education Commission (D2014/120797). Data were released to researchers in September 2022. Results will be presented in peer-reviewed academic journals and at international conferences. Collaborative efforts from similar datasets in other countries are welcome.
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Affiliation(s)
- Kate Lawler
- School of Women's and Children's Health, Faculty of Medicine and Health, University of New South Wales, Randwick, New South Wales, Australia
| | - Mithilesh Dronavalli
- School of Women's and Children's Health, Faculty of Medicine and Health, University of New South Wales, Randwick, New South Wales, Australia
- Translational Health Research Institute, Western Sydney University, Penrith, New South Wales, Australia
| | - Andrew Page
- Translational Health Research Institute, Western Sydney University, Penrith, New South Wales, Australia
| | - Evelyn Lee
- Centre for Social Research in Health, University of New South Wales, Randwick, New South Wales, Australia
- Centre for Economic Impacts of Genomic Medicine, Macquarie University, North Ryde, New South Wales, Australia
| | - Hannah Uebel
- School of Women's and Children's Health, Faculty of Medicine and Health, University of New South Wales, Randwick, New South Wales, Australia
- Sydney Children's Hospital Randwick, Randwick, New South Wales, Australia
| | - Barbara Bajuk
- Critical Care Program, Sydney Children's Hospitals Network Randwick and Westmead, Westmead, New South Wales, Australia
| | - Lucinda Burns
- National Drug and Alcohol Research Centre, University of New South Wales, Randwick, New South Wales, Australia
| | - Michelle Dickson
- The Poche Centre for Indigenous Health, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | | | | | - John Eastwood
- National Public Health Service, Te Whatu Ora-Health New Zealand, Dunedin, New Zealand
- School of Population Health, University of New South Wales, Randwick, New South Wales, Australia
| | - Ju Lee Oei
- School of Women's and Children's Health, Faculty of Medicine and Health, University of New South Wales, Randwick, New South Wales, Australia
- Department of Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia
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Mallinson DC, Kuo HHD, Kirby RS, Wang Y, Berger LM, Ehrenthal DB. Maternal opioid use disorder and infant mortality in Wisconsin, United States, 2010-2018. Prev Med 2024; 181:107914. [PMID: 38408650 PMCID: PMC10947857 DOI: 10.1016/j.ypmed.2024.107914] [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: 12/13/2023] [Revised: 02/21/2024] [Accepted: 02/22/2024] [Indexed: 02/28/2024]
Abstract
OBJECTIVE The difference in infant health outcomes by maternal opioid use disorder (OUD) status is understudied. We measured the association between maternal OUD during pregnancy and infant mortality and investigated whether this association differs by infant neonatal opioid withdrawal syndrome (NOWS) or maternal receipt of medication for OUD (MOUD) during pregnancy. METHODS We sampled 204,543 Medicaid-paid births from Wisconsin, United States (2010-2018). The primary exposure was any maternal OUD during pregnancy. We also stratified this exposure on NOWS diagnosis (no OUD; OUD without NOWS; OUD with NOWS) and on maternal MOUD receipt (no OUD; OUD without MOUD; OUD with <90 consecutive days of MOUD; OUD with 90+ consecutive days of MOUD). Our outcome was infant mortality (death at age <365 days). Demographic-adjusted logistic regressions measured associations with odds ratios (OR) and 95% confidence intervals (CI). RESULTS Maternal OUD was associated with increased odds of infant mortality (OR 1.43; 95% CI 1.02-2.02). After excluding infants who died <5 days post-birth (i.e., before the clinical presentation of NOWS), regression estimates of infant mortality did not significantly differ by NOWS diagnosis. Likewise, regression estimates did not significantly differ by maternal MOUD receipt in the full sample. CONCLUSIONS Maternal OUD is associated with an elevated risk of infant mortality without evidence of modification by NOWS nor by maternal MOUD treatment. Future research should investigate potential mechanisms linking maternal OUD, NOWS, MOUD treatment, and infant mortality to better inform clinical intervention.
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Affiliation(s)
- David C Mallinson
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States of America.
| | - Hsiang-Hui Daphne Kuo
- Department of Obstetrics and Gynecology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Russell S Kirby
- The Chiles Center, College of Public Health, University of South Florida, Tampa, FL, United States of America
| | - Yi Wang
- Silberman School of Social Work, Hunter College, New York, NY, United States of America
| | - Lawrence M Berger
- Sandra Rosenbaum School of Social Work, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Deborah B Ehrenthal
- Department of Biobehavioral Health, The Pennsylvania State University, University Park, PA, United States of America; Social Science Research Institute, The Pennsylvania State University, University Park, PA, United States of America
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McCreedy K, Chauhan A, Holder G, Kang S, Reinhart E, Beletsky L. Popular media misinformation on neonatal abstinence syndrome, 2015-2021. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 125:104341. [PMID: 38367328 DOI: 10.1016/j.drugpo.2024.104341] [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: 06/21/2023] [Revised: 12/22/2023] [Accepted: 01/28/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND As the overdose crisis unfolded, narratives mischaracterizing neonatal abstinence syndrome (NAS) as "addicted babies" with echoes to the "crack babies" panic proliferated in mainstream media. his study examines NAS misinformation dynamics and characteristics over a seven-year period. METHODS Based on a comprehensive query, Media Cloud was used to compile mainstream media content relating to NAS between 2015 and 2021. Articles were redundantly coded on key parameters such as speakers represented, publication source, and scientific accuracy. RESULTS Of the 348 articles meeting search criteria, 264 (76 %) featured misinformed narratives, 70 (20 %) featured informed narratives, and 14 (4 %) featured both informed and misinformed content. Most frequent misinformation elements related to misrepresentation of babies as "addicted" at birth and exaggeration of NAS symptomatology and long-term harms. Least represented voices were people most affected, with just 11 (2 %) featuring mothers who used opioids prepartum. DISCUSSION Since misinformation contributes to punitive legal responses and harms patient care, efforts to prevent, monitor, and address inaccurate and stigmatizing narratives are essential to improving policy and practice.
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Affiliation(s)
- Katie McCreedy
- Bouve College of Health Sciences, Northeastern University, Boston, MA, United States.
| | - Aanchalika Chauhan
- Bouve College of Health Sciences, Northeastern University, Boston, MA, United States
| | - Gabriel Holder
- Bouve College of Health Sciences, Northeastern University, Boston, MA, United States
| | - Sunyou Kang
- Bouve College of Health Sciences, Northeastern University, Boston, MA, United States
| | - Eric Reinhart
- Bouve College of Health Sciences, Northeastern University, Boston, MA, United States
| | - Leo Beletsky
- Bouve College of Health Sciences, Northeastern University, Boston, MA, United States
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8
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Elmore AL, Boghossian NS, McLain AC, McDermott S, Salemi JL. Trends in maternal opioid use: Statewide differences by sociodemographic characteristics in Florida from 2000 to 2019. J Addict Dis 2024:1-11. [PMID: 38369773 DOI: 10.1080/10550887.2024.2302285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
BACKGROUND Maternal opioid use (MOU) remains a public health concern. Studies have demonstrated significant increases in MOU, but estimates using ICD-10-CM or stratified by sociodemographic variables are limited. OBJECTIVES Using a statewide, population-based dataset of Florida resident deliveries from 2000 to 2019, we examined the trend of MOU by age, race/ethnicity, education level, and insurance. METHODS Florida administrative data was used to conduct a retrospective cohort study. MOU was identified using opioid-related hospital discharge diagnoses documented prenatally or at delivery. Maternal sociodemographic variables were obtained from Florida vital statistics. Joinpoint regression was used to identify statistically significant changes in the trends overall and stratified by sociodemographic variables. Results are presented as annual percentage changes (APC) and 95% confidence intervals. RESULTS Our sample included over 3.6 million Florida resident mothers; of which, MOU was identified in 1% (n = 22,828) of the sample. From 2000 to 2019, MOU increased over ten-fold from 8.7 to 94.7 per 10,000 live birth deliveries. MOU increased significantly from 2000 to 2011 (APC: 32.8; 95% CI: 29.4, 36.2), remained stable from 2011 to 2016, and decreased significantly from 2016 to 2019 (APC: 3.9; 95% CI: -6.6, -1.0). However, from 2016 to 2019, MOU increased among non-Hispanic Black mothers (APC: 9.2; 95% CI: 7.5, 11.0), and those ages 30-34 (APC: 2.9; 95% CI: 1.2, 4.6) and 35-39 (APC: 6.4; 95% CI: 4.3, 8.4). CONCLUSIONS Accurate prevalence estimates of MOU by sociodemographic factors are necessary to fully understand prevalence trends, describe the burden among sub-populations, and develop targeted interventions.
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Affiliation(s)
- Amanda L Elmore
- College of Public Health, University of South Florida, Tampa, FL, USA
- Department of Biostatistics and Epidemiology, University of South Carolina, Columbia, SC, USA
| | - Nansi S Boghossian
- Department of Biostatistics and Epidemiology, University of South Carolina, Columbia, SC, USA
| | - Alexander C McLain
- Department of Biostatistics and Epidemiology, University of South Carolina, Columbia, SC, USA
| | - Suzanne McDermott
- Department of Biostatistics and Epidemiology, University of South Carolina, Columbia, SC, USA
- City University of New York's Graduate School of Public Health and Health Policy, New York, NY, USA
| | - Jason L Salemi
- College of Public Health, University of South Florida, Tampa, FL, USA
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Mascarenhas M, Wachman EM, Chandra I, Xue R, Sarathy L, Schiff DM. Advances in the Care of Infants With Prenatal Opioid Exposure and Neonatal Opioid Withdrawal Syndrome. Pediatrics 2024; 153:e2023062871. [PMID: 38178779 PMCID: PMC10827648 DOI: 10.1542/peds.2023-062871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 01/06/2024] Open
Abstract
A significant number of advances have been made in the last 5 years with respect to the identification, diagnosis, assessment, and management of infants with prenatal opioid exposure and neonatal opioid withdrawal syndrome (NOWS) from birth to early childhood. The primary objective of this review is to summarize major advances that will inform the clinical management of opioid-exposed newborns and provide an overview of NOWS care to promote the implementation of best practices. First, advances with respect to standardizing the clinical diagnosis of NOWS will be reviewed. Second, the most commonly used assessment strategies are discussed, with a focus on presenting new quality improvement and clinical trial data surrounding the use of the new function-based assessment Eat, Sleep, and Console approach. Third, both nonpharmacologic and pharmacologic treatment modalities are reviewed, highlighting clinical trials that have compared the use of higher calorie and low lactose formula, vibrating crib mattresses, morphine compared with methadone, buprenorphine compared with morphine or methadone, the use of ondansetron as a medication to prevent the need for NOWS opioid pharmacologic treatment, and the introduction of symptom-triggered dosing compared with scheduled dosing. Fourth, maternal, infant, environmental, and genetic factors that have been found to be associated with NOWS severity are highlighted. Finally, emerging recommendations on postdelivery hospitalization follow-up and developmental surveillance are presented, along with highlighting ongoing and needed areas of research to promote infant and family well-being for families impacted by opioid use.
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Affiliation(s)
| | - Elisha M. Wachman
- Department of Pediatrics, Boston Medical Center, and Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Iyra Chandra
- Dana Farber Cancer Institute, Boston, Massachusetts
| | - Rachel Xue
- Department of Family Medicine, Boston Medical Center, Boston, Massachusetts
| | - Leela Sarathy
- Newborn Medicine, MassGeneral for Children, Boston, Massachusetts
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Smith BL, Hassler A, Lloyd KR, Reyes TM. Perinatal morphine but not buprenorphine affects gestational and offspring neurobehavioral outcomes in mice. Neurotoxicology 2023; 99:292-304. [PMID: 37981055 PMCID: PMC10842910 DOI: 10.1016/j.neuro.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/06/2023] [Accepted: 11/14/2023] [Indexed: 11/21/2023]
Abstract
Within the national opioid epidemic, there has been an increase in the number of infants exposed to opioids in utero. Additionally, opioid agonist medications are the standard of care for women with opioid use disorder during pregnancy. Buprenorphine (BUP), a partial µ -opioid receptor agonist, has been successful in improving gestational and neonatal outcomes. However, in utero exposure has been linked to childhood cognitive and behavioral problems. Therefore, we sought to compare offspring cognitive and behavioral outcomes after prenatal exposure to a clinically relevant low dose of BUP compared to morphine (MO), a full µ -opioid receptor agonist and immediate metabolite of heroin. We used a mouse model to assess gestational and offspring outcomes. Mouse dams were injected once daily s.c. with saline (SAL, n = 12), MO (10 mg/kg, n = 15), or BUP (0.1 mg/kg, n = 16) throughout pre-gestation, gestation, and lactation until offspring were weaned on postnatal day (P)21. Offspring social interaction and exploratory behavior were assessed, along with executive function via the touchscreen 5 choice serial reaction time task (5CSRTT). We then quantified P1 brain gene expression in the frontal cortex and amygdala (AMG). Perinatal MO but not BUP exposure decreased gestational weight gain and was associated with dystocia. In adolescent offspring, perinatal MO but not BUP exposure increased social exploration in males and grooming behavior in females. In the 5CSRTT, male MO exposed offspring exhibited increased impulsive action errors compared to male BUP offspring. In the AMG of P1 MO exposed offspring, we observed an increase in gene expression of targets related to activity of microglia. Importantly, both MO and BUP caused acute hyperlocomotion in the dams to a similar degree, indicating that the selected doses are comparable, in accordance with previous dose comparisons on analgesic and reward efficacy. These data suggest that compared to MO, low dose BUP improves gestational outcomes and has less of an effect on the neonatal offspring brain and later adolescent and adult behavior.
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Affiliation(s)
- Brittany L Smith
- Department of Pharmacology & Systems Physiology, University of Cincinnati, Cincinnati, OH, USA; Department of Psychological Science, Northern Kentucky University, Highland Heights, KY, USA.
| | - Ally Hassler
- Department of Pharmacology & Systems Physiology, University of Cincinnati, Cincinnati, OH, USA
| | - Kelsey R Lloyd
- Department of Pharmacology & Systems Physiology, University of Cincinnati, Cincinnati, OH, USA
| | - Teresa M Reyes
- Department of Pharmacology & Systems Physiology, University of Cincinnati, Cincinnati, OH, USA
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Ober C, Bloom L, Obiri N. Implementation of the Eat, Sleep, and Console Model of Care: A Quality Improvement Project. Neonatal Netw 2023; 42:320-328. [PMID: 38000800 DOI: 10.1891/nn-2023-0037] [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] [Accepted: 07/22/2023] [Indexed: 11/26/2023]
Abstract
A Southeastern, 741-bed acute care, Magnet designated teaching hospital and level III B NICU identified assessment and treatment concerns for Neonatal Opioid Withdrawal Syndrome (NOWS). In March 2020, a quality improvement project led to a multidisciplinary team formation to determine the effectiveness of the Eat, Sleep, Console (ESC) model of care in reducing the length of treatment (LOT) and length of stay (LOS) for neonates experiencing NOWS rather than use of the Finnegan Neonatal Abstinence Syndrome Scoring tool. The results concluded a decrease in the average LOT from 19.2 to 2.5 days and the average LOS from 23.9 to 9.3 days for those admitted directly into the ESC model of care on postpartum vs previous direct admission to the NICU. A group samples t-test showed there was a statistically significant decrease in LOS for ESC patients (p < .001) and LOT for ESC patients (p <001).
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Gomez Pomar E. A mini review of what matters in the management of NAS, is ESC the best care? Front Pediatr 2023; 11:1239107. [PMID: 37520058 PMCID: PMC10376704 DOI: 10.3389/fped.2023.1239107] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
As the use of opioids and polysubstance by pregnant women has increased over the years, there has also been a sharp increase in cases of neonatal abstinence syndrome (NAS). Classically, infants affected by NAS have been cared for in neonatal intensive care units resulting in an increase of healthcare expenditure and resource utilization as well as separation from the families. Consequently, the Eat, Sleep, and Console (ESC) tool was developed and promoted as a novel method that focuses on maternal/infant dyad during hospital stay while decreasing the use of pharmacological interventions and therefore decreasing the length of stay and healthcare expenditure. Thus, it has been implemented in several hospitals in the United States. Although the training of staff has been proposed and the interventions of sleep, eat, and console are defined, there still exists a lack of standardization of this practice specifically in regard to the type of associated non-pharmacological practices as well as the reports of its short- and long-term outcomes.
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Affiliation(s)
- Enrique Gomez Pomar
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, KY, United States
- Department of Pediatrics, St. Bernards Regional Medical Center, Jonesboro, AR, United States
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Grossarth S, Osmundson SS, Wiese AD, Phillips SE, Pham A, Leech AA, Patrick SW, Spieker AJ, Grijalva CG, Adgent MA. Maternal Opioid Use Disorder and the Risk of Postneonatal Infant Mortality. JAMA Pediatr 2023; 177:675-683. [PMID: 37155175 PMCID: PMC10167598 DOI: 10.1001/jamapediatrics.2023.1047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/17/2023] [Indexed: 05/10/2023]
Abstract
Importance The risk of serious long-term outcomes for infants born to individuals with opioid use disorder (OUD) is not fully characterized, nor is it well understood whether risks are modified by infant diagnosis of neonatal opioid withdrawal syndrome (NOWS). Objective To characterize the risk of postneonatal infant mortality among infants with a NOWS diagnosis or born to individuals with OUD. Design, Setting, and Participants The study team conducted a retrospective cohort study of 390 075 infants born from 2007 through 2018 to mothers who were enrolled in Tennessee Medicaid from 183 days prior to delivery through 28 days post partum (baseline). Maternal and infant baseline characteristics were measured using administrative claims and birth certificates, and infants were followed up from day 29 post partum through day 365 or death. Deaths were identified using linked death certificates through 2019. These data were analyzed from February 10, 2022, through March 3, 2023. Exposure Infant exposures included birth to an individual with OUD or postnatal diagnosis of NOWS. The study team defined a pregnant individual's OUD status (maternal OUD) as having OUD diagnosis or a maintenance medication prescription fill during baseline; this study defined NOWS as having NOWS diagnosis up to day 28. Groups were categorized by exposures as maternal OUD with NOWS (OUD positive/NOWS positive), maternal OUD without NOWS (OUD positive/NOWS negative), no documented maternal OUD with NOWS (OUD negative/NOWS positive), and no documented maternal OUD or NOWS (OUD negative/NOWS negative, unexposed). Main Outcome and Measures The outcome was postneonatal infant death, confirmed by death certificates. Cox proportional hazards models were used, adjusting for baseline maternal and infant characteristics, to estimate adjusted hazard ratios (aHRs) and 95% CIs for the association between maternal OUD or NOWS diagnosis with postneonatal death. Results Pregnant individuals in the cohort had a mean (SD) age of 24.5 (5.2) years; 51% of infants were male. The study team observed 1317 postneonatal infant deaths and incidence rates of 3.47 (OUD negative/NOWS negative, 375 718), 8.41 (OUD positive/NOWS positive, 4922); 8.95 (OUD positive/NOWS negative, 7196), and 9.25 (OUD negative/NOWS positive, 2239) per 1000 person-years. After adjustment, the risk of postneonatal death was elevated for all groups, relative to the unexposed: OUD positive/NOWS positive (aHR, 1.54; 95% CI, 1.07-2.21), OUD positive/NOWS negative (aHR, 1.62; 95% CI, 1.21-2.17), and OUD negative/NOWS positive (aHR, 1.64; 95% CI, 1.02-2.65). Conclusions and Relevance Infants born to individuals with OUD or with a NOWS diagnosis had an increased risk of postneonatal infant mortality. Future work is necessary to create and evaluate supportive interventions for individuals with OUD during and after pregnancy to reduce adverse outcomes.
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Affiliation(s)
- Sarah Grossarth
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah S. Osmundson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew D. Wiese
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sharon E. Phillips
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Amelie Pham
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashley A. Leech
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen W. Patrick
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
- Mildred Stahlman Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew J. Spieker
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carlos G. Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
- Veterans’ Health Administration Tennessee Valley Healthcare System, Geriatric Research Education and Clinical Center (GRECC), Nashville
| | - Margaret A. Adgent
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
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Ochoa C, Kilgore PCSR, Korneeva N, Clifford E, Conrad SA, Trutschl M, Bowers JM, Arnold T, Cvek U. Trends in Drug Tests among Children: A 22-Year Retrospective Analysis. PATHOPHYSIOLOGY 2023; 30:219-232. [PMID: 37218917 PMCID: PMC10204533 DOI: 10.3390/pathophysiology30020019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/21/2023] [Accepted: 05/04/2023] [Indexed: 05/24/2023] Open
Abstract
There are several pathophysiological outcomes associated with substance abuse including metabolic disbalance, neurodegeneration, and disordered redox. Drug use in pregnant women is a topic of great concern due to developmental harm which may occur during gestation and the associated complications in the neonate after delivery. We sought to determine what the trajectory of drug use is like in children aged 0-4 years and mothers of neonates. Urine drug screen (UDS) results were obtained of our target demographic during 1998-2011 and 2012-2019 from LSU Health Sciences Center in Shreveport (LSUHSC-S). Statistical analysis was performed using R software. We observed an increase in cannabinoid-positive UDS results in both Caucasian (CC) and African American (AA) groups between 1998-2011 and 2012-2019 periods. Cocaine-positive UDS results decreased in both cohorts. CC children had higher UDS positive results for opiates, benzodiazepines, and amphetamines, while AA children had a higher percentage for illicit drugs such as cannabinoids and cocaine. Neonate's mothers had similar UDS trends to that in children during 2012-2019. Overall, while percentage of positive UDS results for both AA and CC 0-4 year old children started to decline for opiate, benzodiazepine, and cocaine during 2012-2019, cannabinoid- and amphetamine (CC)-positive UDS steadily increased. These results suggest a shift in the type of drug use by mothers from opiates, benzodiazepines, and cocaine to cannabinoids and/or amphetamines. We also observed that 18-year-old females who tested positive for opiates, benzodiazepine, or cocaine had higher than average chances of testing positive for cannabinoids later in life.
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Affiliation(s)
- Carolina Ochoa
- School of Medicine, LSU Health Shreveport, Shreveport, LA 71103, USA
| | | | - Nadejda Korneeva
- Department of Emergency Medicine, LSU Health Shreveport, Shreveport, LA 71103, USA
| | - Eric Clifford
- Department of Computer Science, LSU Shreveport, Shreveport, LA 71115, USA
| | - Steven A. Conrad
- Department of Emergency Medicine, LSU Health Shreveport, Shreveport, LA 71103, USA
| | - Marjan Trutschl
- Department of Computer Science, LSU Shreveport, Shreveport, LA 71115, USA
| | - Jacquelyn M. Bowers
- Department of Emergency Medicine, LSU Health Shreveport, Shreveport, LA 71103, USA
| | - Thomas Arnold
- Department of Emergency Medicine, LSU Health Shreveport, Shreveport, LA 71103, USA
| | - Urska Cvek
- Department of Computer Science, LSU Shreveport, Shreveport, LA 71115, USA
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15
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Standish KR, Morrison TM, Wanar A, Crowell L, Safon CB, Colson E, Drainoni ML, Colvin BN, Friedman H, Schiff DM, Stulac S, Costello E, Parker M. Breastfeeding Decision-Making Among Mothers with Opioid Use Disorder: A Qualitative Study. Breastfeed Med 2023; 18:347-355. [PMID: 37115582 DOI: 10.1089/bfm.2022.0226] [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] [Indexed: 04/29/2023]
Abstract
Background: Factors that contribute to low initiation and continuation of breastfeeding among mothers with opioid use disorder (OUD) are poorly understood. Objective: To understand barriers and facilitators to breastfeeding initiation and continuation beyond the birth hospitalization for mothers with OUD. Materials and Methods: We conducted 23 in-depth, semistructured interviews with mothers with OUD who cared for their infants at home 1-7 months after birth. Our interview guide was informed by the Theory of Planned Behavior (TPB) framework, which has been used to understand decision-making regarding breastfeeding. An iterative approach was used to develop codes and themes. Results: Among 23 participants, 16 initiated breastfeeding, 10 continued after hospital discharge, and 4 continued beyond 8 weeks. We identified factors influencing breastfeeding decisions in the four TPB domains. Regarding attitudes, feeding intentions were based on beliefs of the healthiness of breastfeeding particularly pertaining to infant withdrawal or exposure to mothers' medications. Regarding social norms, breastfeeding was widely recommended, but mothers had varying levels of trust in medical professional advice. Regarding perceived control, infant withdrawal and maternal pain caused breastfeeding to be difficult, with decisions to continue modulated by level of outside support. Regarding self-efficacy, mothers weighed their own recovery and well-being against the constant demands of breastfeeding, impacting decisions to continue. Conclusion: Mothers with OUD face unique barriers to breastfeeding related to their infants' withdrawal as well as their own health, recovery, and social context. Overcoming these barriers may serve as future intervention targets for breastfeeding promotion among this high-risk population.
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Affiliation(s)
- Katherine R Standish
- Department of Family Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Tierney M Morrison
- Department of Newborn Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Amita Wanar
- Department of Obstetrics and Gynecology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Lisa Crowell
- Slone Epidemiology Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Cara B Safon
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Eve Colson
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Mari-Lynn Drainoni
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts, USA
- Section of Infectious Diseases, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Bryanne N Colvin
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Hayley Friedman
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Davida M Schiff
- Division of General Academic Pediatrics, Mass General Hospital for Children, Boston, Massachusetts, USA
| | - Sara Stulac
- Department of Pediatrics, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Eileen Costello
- Department of Pediatrics, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Margaret Parker
- Department of Pediatrics, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
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16
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Conradt E, Camerota M, Maylott S, Lester BM. Annual Research Review: Prenatal opioid exposure - a two-generation approach to conceptualizing neurodevelopmental outcomes. J Child Psychol Psychiatry 2023; 64:566-578. [PMID: 36751734 DOI: 10.1111/jcpp.13761] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2023] [Indexed: 02/09/2023]
Abstract
Opioid use during pregnancy impacts the health and well-being of two generations: the pregnant person and the child. The factors that increase risk for opioid use in the adult, as well as those that perpetuate risk for the caregiver and child, oftentimes replicate across generations and may be more likely to affect child neurodevelopment than the opioid exposure itself. In this article, we review the prenatal opioid exposure literature with the perspective that this is not a singular event but an intergenerational cascade of events. We highlight several mechanisms of transmission across generations: biological factors, including genetics and epigenetics and the gut-brain axis; parent-child mechanisms, such as prepregnancy experience of child maltreatment, quality of parenting, infant behaviors, neonatal opioid withdrawal diagnosis, and broader environmental contributors including poverty, violence exposure, stigma, and Child Protective Services involvement. We conclude by describing ways in which intergenerational transmission can be disrupted by early intervention.
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Affiliation(s)
- Elisabeth Conradt
- Department of Psychiatry, Duke University, Durham, NC, USA.,Department of Pediatrics, Duke University, Durham, NC, USA
| | - Marie Camerota
- Brown Center for the Study of Children at Risk, Department of Psychiatry and Pediatrics, Alpert Medical School of Brown University and Women and Infants Hospital of Rhode Island, Providence, RI, USA
| | - Sarah Maylott
- Department of Psychiatry, Duke University, Durham, NC, USA
| | - Barry M Lester
- Brown Center for the Study of Children at Risk, Department of Psychiatry and Pediatrics, Alpert Medical School of Brown University and Women and Infants Hospital of Rhode Island, Providence, RI, USA
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17
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Bodnar RJ. Endogenous opiates and behavior: 2021. Peptides 2023; 164:171004. [PMID: 36990387 DOI: 10.1016/j.peptides.2023.171004] [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: 02/26/2023] [Revised: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023]
Abstract
This paper is the forty-fourth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2021 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonizts and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, CUNY, 65-30 Kissena Blvd., Flushing, NY 11367, USA.
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18
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Benninger KL, McAllister JM, Merhar SL. Neonatal Opioid Withdrawal Syndrome: An Update on Developmental Outcomes. Clin Perinatol 2023; 50:17-29. [PMID: 36868704 DOI: 10.1016/j.clp.2022.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Infants and children with prenatal opioid exposure generally have development within the normal range; however, they seem to be at risk for behavioral problems and for lower scores on cognitive, language, and motor assessments than children without prenatal opioid exposure. It is as of yet unclear whether prenatal opioid exposure itself causes issues with development and behavior, or whether it is simply correlated, due to other confounding factors.
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Affiliation(s)
- Kristen L Benninger
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children's Hospital, 575 Children's Crossroad, WB 5203, Columbus, OH 43215, USA.
| | - Jennifer M McAllister
- Cincinnati Children's Hospital Perinatal Institute, University of Cincinnati College of Medicine, 3333 Burnet Ave, ML 7009, Cincinnati, OH 45229, USA
| | - Stephanie L Merhar
- Cincinnati Children's Hospital Perinatal Institute, University of Cincinnati College of Medicine, 3333 Burnet Ave, ML 7009, Cincinnati, OH 45229, USA
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19
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Sex-specific inflammatory and white matter effects of prenatal opioid exposure: a pilot study. Pediatr Res 2023; 93:604-611. [PMID: 36280708 PMCID: PMC9998341 DOI: 10.1038/s41390-022-02357-5] [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: 04/14/2022] [Revised: 09/01/2022] [Accepted: 10/11/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Preclinical data demonstrate that opioids modulate brain reward signaling through an inflammatory cascade, but this relationship has yet to be studied in opioid-exposed neonates. METHODS Saliva samples of 54 opioid-exposed and sex- and age-matched non-exposed neonates underwent transcriptomic analysis of inflammatory and reward genes. A subset of 22 neonates underwent brain magnetic resonance imaging (MRI) to evaluate white matter injury commonly associated with inflammatory response. Gene expression and brain MRI were compared between opioid- and non-exposed neonates and further stratified by sex and pharmacotherapy need. RESULTS Opioid-exposed females regardless of pharmacotherapy need had higher expression of inflammatory genes than their male counterparts, with notable differences in the expression of CCL2 and CXCL1 in females requiring pharmacotherapy (p = 0.01 and 0.06, respectively). Opioid-exposed males requiring pharmacotherapy had higher expression of DRD2 than exposed females (p = 0.07), validating our prior research. Higher expression of IL1β, IL6, TNFα, and IL10 was seen in opioid-exposed neonates with T1 white matter hyperintensity (WMH) compared to exposed neonates without WMH (p < 0.05). CONCLUSION Prenatal opioid exposure may promote inflammation resulting in changes in reward signaling and white matter injury in the developing brain, with unique sex-specific effects. The actions of opioids through non-neuronal pathways need further investigation. IMPACT Opioid-exposed neonates are at risk for punctate T1 white matter hyperintensity (WMH). Females carry a greater propensity for WMH. Salivary transcriptomic data showed significantly higher expression of inflammatory genes in opioid-exposed neonates with WMH than those without WMH, irrespective of pharmacotherapy need. Adding to prior studies, our findings suggest that prenatal opioid exposure may modulate white matter injury and reward signaling through a pro-inflammatory process that is sex specific. This novel study highlights the short-term molecular and structural effects of prenatal opioids and the need to elucidate the long-term impact of prenatal opioid exposure.
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20
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Haggerty DL, Grecco GG, Huang JY, Doud EH, Mosley AL, Lu HC, Atwood BK. Prenatal methadone exposure selectively alters protein expression in primary motor cortex: Implications for synaptic function. Front Pharmacol 2023; 14:1124108. [PMID: 36817148 PMCID: PMC9928955 DOI: 10.3389/fphar.2023.1124108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/16/2023] [Indexed: 02/04/2023] Open
Abstract
As problematic opioid use has reached epidemic levels over the past 2 decades, the annual prevalence of opioid use disorder (OUD) in pregnant women has also increased 333%. Yet, how opioids affect the developing brain of offspring from mothers experiencing OUD remains understudied and not fully understood. Animal models of prenatal opioid exposure have discovered many deficits in the offspring of prenatal opioid exposed mothers, such as delays in the development of sensorimotor function and long-term locomotive hyperactivity. In attempt to further understand these deficits and link them with protein changes driven by prenatal opioid exposure, we used a mouse model of prenatal methadone exposure (PME) and preformed an unbiased multi-omic analysis across many sensoriomotor brain regions known to interact with opioid exposure. The effects of PME exposure on the primary motor cortex (M1), primary somatosensory cortex (S1), the dorsomedial striatum (DMS), and dorsolateral striatum (DLS) were assessed using quantitative proteomics and phosphoproteomics. PME drove many changes in protein and phosphopeptide abundance across all brain regions sampled. Gene and gene ontology enrichments were used to assess how protein and phosphopeptide changes in each brain region were altered. Our findings showed that M1 was uniquely affected by PME in comparison to other brain regions. PME uniquely drove changes in M1 glutamatergic synapses and synaptic function. Immunohistochemical analysis also identified anatomical differences in M1 for upregulating the density of glutamatergic and downregulating the density of GABAergic synapses due to PME. Lastly, comparisons between M1 and non-M1 multi-omics revealed conserved brain wide changes in phosphopeptides associated with synaptic activity and assembly, but only specific protein changes in synapse activity and assembly were represented in M1. Together, our studies show that lasting changes in synaptic function driven by PME are largely represented by protein and anatomical changes in M1, which may serve as a starting point for future experimental and translational interventions that aim to reverse the adverse effects of PME on offspring.
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Affiliation(s)
- David L. Haggerty
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Gregory G. Grecco
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN, United States
- Indiana University School of Medicine, Medical Scientist Training Program, Indianapolis, IN, United States
| | - Jui-Yen Huang
- The Linda and Jack Gill Center for Biomolecular Sciences, Indiana University, Bloomington, IN, United States
- Program in Neuroscience and Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, United States
| | - Emma H. Doud
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Amber L. Mosley
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Hui-Chen Lu
- The Linda and Jack Gill Center for Biomolecular Sciences, Indiana University, Bloomington, IN, United States
- Program in Neuroscience and Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, United States
| | - Brady K. Atwood
- Department of Pharmacology and Toxicology, Indiana University School of Medicine, Indianapolis, IN, United States
- Stark Neurosciences Research Institute, Indiana University School of Medicine, Indianapolis, IN, United States
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21
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Milne BJ, D'Souza S, Andersen SH, Richmond-Rakerd LS. Use of Population-Level Administrative Data in Developmental Science. ANNUAL REVIEW OF DEVELOPMENTAL PSYCHOLOGY 2022; 4:447-468. [PMID: 37284522 PMCID: PMC10241456 DOI: 10.1146/annurev-devpsych-120920-023709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Population-level administrative data-data on individuals' interactions with administrative systems (e.g., health, criminal justice, and education)-have substantially advanced our understanding of life-course development. In this review, we focus on five areas where research using these data has made significant contributions to developmental science: (a) understanding small or difficult-to-study populations, (b) evaluating intergenerational and family influences, (c) enabling estimation of causal effects through natural experiments and regional comparisons, (d) identifying individuals at risk for negative developmental outcomes, and (e) assessing neighborhood and environmental influences. Further advances will be made by linking prospective surveys to administrative data to expand the range of developmental questions that can be tested; supporting efforts to establish new linked administrative data resources, including in developing countries; and conducting cross-national comparisons to test findings' generalizability. New administrative data initiatives should involve consultation with population subgroups including vulnerable groups, efforts to obtain social license, and strong ethical oversight and governance arrangements.
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Affiliation(s)
- Barry J Milne
- School of Social Sciences and Centre of Methods and Policy Application in the Social Sciences (COMPASS), University of Auckland, Auckland, New Zealand
| | - Stephanie D'Souza
- School of Social Sciences and Centre of Methods and Policy Application in the Social Sciences (COMPASS), University of Auckland, Auckland, New Zealand
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22
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Makarious L, Teng A, Oei JL. SIDS is associated with prenatal drug use: a meta-analysis and systematic review of 4 238 685 infants. Arch Dis Child Fetal Neonatal Ed 2022; 107:617-623. [PMID: 35396270 DOI: 10.1136/archdischild-2021-323260] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 03/25/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To conduct a meta-analysis to determine the association between prenatal drug exposure and risk of sudden infant death syndrome (SIDS). DESIGN Studies were searched using PubMed, Medline and Embase and restricted to English, with no publication date limit. Selected studies included published cohort, population or case studies comparing the incidence of SIDS among drug-exposed with drug-free controls. This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analysis of Observational Studies in Epidemiology guidelines. Data were pooled using a random-effects model to evaluate risk ratios (RR). SETTING High-income countries. PATIENTS Children with a history of prenatal drug exposure. INTERVENTIONS None. MAIN OUTCOME MEASURES RR of SIDS between drug-exposed and control infants. RESULTS Sixteen studies (36 730 infants with any prenatal drug exposure, 21 661 exposed to opioids, 21 571 exposed to cocaine, 5031 exposed to methadone compared with 4 201 955 with no exposure). Any prenatal drug exposure was associated with an increased crude risk of SIDS (RR 7.84, 95% CI 5.21 to 11.81). Prenatal opioid exposure had the highest associative crude risk of SIDS (RR 9.76, 95% CI 5.28 to 18.05), followed by methadone (RR 9.52, 95% CI 4.60 to 19.70) and cocaine (RR 4.40, 95% CI 2.52 to 7.67). Increased crude risk persisted after adjusting for socioeconomic factors (RR 4.24, 95% CI 1.39 to 12.88). The incidence of SIDS for this cohort decreased between 1972 and 2020 but remained significantly higher than controls. CONCLUSION Exposure to any drug of dependency during pregnancy is associated with an increased risk of SIDS after controlling for socioeconomic factors. Further study to evaluate mechanisms and contribution of other confounders (eg, smoking) is warranted.
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Affiliation(s)
- Louise Makarious
- School of Women's and Children's Health, University of New South Wales Faculty of Medicine, Sydney, New South Wales, Australia
| | - Arthur Teng
- Sleep Medicine Department, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Ju Lee Oei
- School of Women's and Children's Health, University of New South Wales Faculty of Medicine, Sydney, New South Wales, Australia .,Department of Newborn Care, The Royal Hospital for Women Newborn Intensive Care Unit, Randwick, New South Wales, Australia.,NHMRC Clinical Trial Centre, University of Sydney, Sydney, NSW, Australia
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23
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Perinatal Morphine Exposure Leads to Sex-Dependent Executive Function Deficits and Microglial Changes in Mice. eNeuro 2022; 9:ENEURO.0238-22.2022. [PMID: 36216505 PMCID: PMC9581576 DOI: 10.1523/eneuro.0238-22.2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/19/2022] [Accepted: 08/29/2022] [Indexed: 01/13/2023] Open
Abstract
Children exposed prenatally to opioids are at an increased risk for behavioral problems and executive function deficits. The prefrontal cortex (PFC) and amygdala (AMG) regulate executive function and social behavior and are sensitive to opioids prenatally. Opioids can bind to toll-like receptor 4 (TLR4) to activate microglia, which may be developmentally important for synaptic pruning. Therefore, we tested the effects of perinatal morphine exposure on executive function and social behavior in male and female mouse offspring, along with microglial-related and synaptic-related outcomes. Dams were injected once daily subcutaneously with saline (n = 8) or morphine (MO; 10 mg/kg; n = 12) throughout pregestation, gestation, and lactation until offspring were weaned on postnatal day 21 (P21). Male MO offspring had impairments in attention and accuracy in the five-choice serial reaction time task, while female MO offspring were less affected. Targeted gene expression analysis at P21 in the PFC identified alterations in microglial-related and TLR4-related genes, while immunohistochemical analysis in adult brains indicated decreased microglial Iba1 and phagocytic CD68 proteins in the PFC and AMG in males, but females had an increase. Further, both male and female MO offspring had increased social preference. Overall, these data demonstrate male vulnerability to executive function deficits in response to perinatal opioid exposure and evidence for disruptions in neuron-microglial signaling.
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24
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Manigault AW, Sheinkopf SJ, Silverman HF, Lester BM. Newborn Cry Acoustics in the Assessment of Neonatal Opioid Withdrawal Syndrome Using Machine Learning. JAMA Netw Open 2022; 5:e2238783. [PMID: 36301544 PMCID: PMC9614579 DOI: 10.1001/jamanetworkopen.2022.38783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The assessment of opioid withdrawal in the neonate, or neonatal opioid withdrawal syndrome (NOWS), is problematic because current assessment methods are based on subjective observer ratings. Crying is a distinctive component of NOWS assessment tools and can be measured objectively using acoustic analysis. OBJECTIVE To evaluate the feasibility of using newborn cry acoustics (acoustics referring to the physical properties of sound) as an objective biobehavioral marker of NOWS. DESIGN, SETTING, AND PARTICIPANTS This prospective controlled cohort study assessed whether acoustic analysis of neonate cries could predict which infants would receive pharmacological treatment for NOWS. A total of 177 full-term neonates exposed and not exposed to opioids were recruited from Women & Infants Hospital of Rhode Island between August 8, 2016, and March 18, 2020. Cry recordings were processed for 118 neonates, and 65 neonates were included in the final analyses. Neonates exposed to opioids were monitored for signs of NOWS using the Finnegan Neonatal Abstinence Scoring Tool administered every 3 hours as part of a 5-day observation period during which audio was recorded continuously to capture crying. Crying of healthy neonates was recorded before hospital discharge during routine handling (eg, diaper changes). EXPOSURES The primary exposure was prenatal opioid exposure as determined by maternal receipt of medication-assisted treatment with methadone or buprenorphine. MAIN OUTCOMES AND MEASURES Neonates were stratified by prenatal opioid exposure and receipt of pharmacological treatment for NOWS before discharge from the hospital. In total, 775 hours of audio were collected and trimmed into 2.5 hours of usable cries, then acoustically analyzed (using 2 separate acoustic analyzers). Cross-validated supervised machine learning methods (combining the Boruta algorithm and a random forest classifier) were used to identify relevant acoustic parameters and predict pharmacological treatment for NOWS. RESULTS Final analyses included 65 neonates (mean [SD] gestational age at birth, 36.6 [1.1] weeks; 36 [55.4%] female; 50 [76.9%] White) with usable cry recordings. Of those, 19 neonates received pharmacological treatment for NOWS, 7 neonates were exposed to opioids but did not receive pharmacological treatment for NOWS, and 39 healthy neonates were not exposed to opioids. The mean of the predictions of random forest classifiers predicted receipt of pharmacological treatment for NOWS with high diagnostic accuracy (area under the curve, 0.90 [95% CI, 0.83-0.98]; accuracy, 0.85 [95% CI, 0.74-0.92]; sensitivity, 0.89 [95% CI, 0.67-0.99]; specificity, 0.83 [95% CI, 0.69-0.92]). CONCLUSIONS AND RELEVANCE In this study, newborn acoustic cry analysis had potential as an objective measure of opioid withdrawal. These findings suggest that acoustic cry analysis using machine learning could improve the assessment, diagnosis, and management of NOWS and facilitate standardized care for these infants.
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Affiliation(s)
- Andrew W. Manigault
- Brown Center for the Study of Children at Risk, Women & Infants Hospital of Rhode Island, Providence
| | - Stephen J. Sheinkopf
- Thompson Center for Autism and Neurodevelopmental Disorders, University of Missouri, Columbia
| | | | - Barry M. Lester
- Brown Center for the Study of Children at Risk, Women & Infants Hospital of Rhode Island, Providence
- Department of Psychiatry, Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island
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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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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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Camerota M, Davis JM, Dansereau LM, Oliveira EL, Padbury JF, Lester BM. Effects of Pharmacologic Treatment for Neonatal Abstinence Syndrome on DNA Methylation and Neurobehavior: A Prospective Cohort Study. J Pediatr 2022; 243:21-26. [PMID: 34971656 PMCID: PMC8960328 DOI: 10.1016/j.jpeds.2021.12.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/17/2021] [Accepted: 12/19/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine whether pharmacologic treatment for neonatal abstinence syndrome (NAS) is associated with changes in DNA methylation (DNAm) of the mu-opioid receptor gene (OPRM1) and improvements in neonatal neurobehavior. STUDY DESIGN Buccal swabs were collected from 37 neonates before and after morphine treatment for NAS. Genomic DNA was extracted, and DNAm was examined at 4 cytosine-phosphate-guanine (CpG) sites within the OPRM1 gene. Assessment with the NICU Network Neurobehavioral Scales (NNNS) was also performed before and after NAS treatment. Changes in DNAm (DNAmpost-tx - DNAmpre-tx) and NNNS summary scores (NNNSpost-tx - NNNSpre-tx) were then calculated. Path analysis was used to examine associations among pharmacologic treatment (length of treatment [LOT] and total dose of morphine), changes in DNAm, and changes in NNNS summary scores. RESULTS DNAm was significantly decreased from pretreatment to post-treatment at 1 of 4 CpG sites within the OPRM1 gene. Neonates also demonstrated decreased excitability, hypertonia, lethargy, signs of stress and abstinence, and increased quality of movement and regulation from pretreatment to post-treatment. Longer LOT and higher morphine dose were associated with greater decreases in DNAm; greater decreases in DNAm were associated with greater decreases in excitability and hypertonia on the NNNS. CONCLUSIONS Pharmacologic treatment of NAS is associated with decreased DNAm of the OPRM1 gene and improved neonatal neurobehavior. Epigenetic changes may play a role in these changes in neonatal neurobehavior.
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Affiliation(s)
- Marie Camerota
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI; Department of Pediatrics, Women and Infants Hospital, Providence, RI.
| | - Jonathan M. Davis
- Department of Pediatrics, Tufts Children’s Hospital and the Tufts Clinical and Translational Science Institute, Boston, MA, USA
| | - Lynne M. Dansereau
- Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA
| | - Erica L. Oliveira
- Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA
| | - James F. Padbury
- Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA
| | - Barry M. Lester
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA,Department of Pediatrics, Women and Infants Hospital, Providence, RI, USA
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28
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Jilani SM, Jones HE, Grossman M, Jansson LM, Terplan M, Faherty LJ, Khodyakov D, Patrick SW, Davis JM. Standardizing the Clinical Definition of Opioid Withdrawal in the Neonate. J Pediatr 2022; 243:33-39.e1. [PMID: 34942181 DOI: 10.1016/j.jpeds.2021.12.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/22/2021] [Accepted: 12/05/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To standardize the clinical definition of opioid withdrawal in neonates to address challenges in clinical care, quality improvement, research, and public policy for this patient population. STUDY DESIGN Between October and December 2020, we conducted 2 modified-Delphi panels using ExpertLens, a virtual platform for performing iterative expert engagement panels. Twenty clinical experts specializing in care for the substance-exposed mother-neonate dyad explored the necessity of key evidence-based clinical elements in defining opioid withdrawal in the neonate leading to a diagnosis of neonatal abstinence syndrome (NAS)/neonatal opioid withdrawal syndrome (NOWS). Expert consensus was assessed using descriptive statistics, the RAND/UCLA Appropriateness Method, and thematic analysis of participants' comments. RESULTS Expert panels concluded the following were required for diagnosis: in utero exposure (known by history, not necessarily by toxicology testing) to opioids with or without the presence of other psychotropic substances, and the presence of at least two of the most common clinical signs characteristic of withdrawal (excessive crying, fragmented sleep, tremors, increased muscle tone, gastrointestinal dysfunction). CONCLUSIONS Results indicate that both a known history of in utero opioid exposure and a distinct set of withdrawal signs are necessary to standardize a definition of neonatal withdrawal. Implementation of a standardized definition requires both patient engagement and a mother-neonate dyadic approach mindful of program and policy implications.
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Affiliation(s)
- Shahla M Jilani
- Office of the Assistant Secretary for Health, US Department of Health and Human Services, Washington, DC
| | - Hendrée E Jones
- Department of Obstetrics and Gynecology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew Grossman
- Department of Pediatrics, Yale School of Medicine, New Haven, CT
| | - Lauren M Jansson
- Department of Pediatrics, Center for Addiction and Pregnancy, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Laura J Faherty
- Pardee RAND Graduate School, Santa Monica, CA; Department of Pediatrics, Boston University School of Medicine, Boston, MA
| | | | - Stephen W Patrick
- Division of Neonatology, Department of Pediatrics and Department of Health Policy, Vanderbilt Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN
| | - Jonathan M Davis
- Division of Newborn Medicine, Tufts Children's Hospital and the Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
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29
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BENNINGER KRISTENL, PURNELL JESSICA, CONROY SARA, JACKSON KENNETH, BATTERSON NANCY, NEEL MARYLAUREN, HESTER MARKE, MAITRE NATHALIEL. Intrauterine drug exposure as a risk factor for cerebral palsy. Dev Med Child Neurol 2022; 64:453-461. [PMID: 34528707 PMCID: PMC8897226 DOI: 10.1111/dmcn.15050] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 07/28/2021] [Accepted: 08/02/2021] [Indexed: 11/30/2022]
Abstract
AIM To determine whether infants with intrauterine drug exposure (IUDE) are similarly at risk for cerebral palsy (CP) as other high-risk populations, whether CP classification differs based on IUDE status, and describe the association of CP with specific substances among exposed infants. METHOD This was a retrospective analysis of infants in a high-risk follow-up program (n=5578) between January 2014 and February 2018 with a history of IUDE or who received a CP diagnosis. CP rates were compared using two-sample z-tests. CP classification was assessed using Fisher's exact, Cochran-Armitage, and Wilcoxon rank-sum tests. Models for CP risk were assessed using multivariable logistic regression. RESULTS Among all infants with IUDE (n=1086), 53.8% were male with a mean (SD) birth gestational age of 36.8 (3.6) weeks. Among unexposed infants with CP (n=259), 54.4% were male with a mean (SD) birth gestational age of 29.9 (5.7) weeks. Opioids were the most common exposure (93.7%) of all infants with IUDE. The CP rate in the IUDE (5.2%) and unexposed (5.7%) high-risk populations were not significantly different (p=0.168), nor were there differences in CP typology, topography, or severity between exposed (n=57) and unexposed (n=259) infants (all p>0.05). In patients with IUDE and after controlling for established CP risk factors, the observed odds of CP varied among substances. INTERPRETATION We suggest that IUDE should be considered a 'newborn-detectable risk' in the guidelines for the early detection of CP.
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Affiliation(s)
- KRISTEN L BENNINGER
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH,Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University Wexner Medical Center, Columbus, OH
| | - JESSICA PURNELL
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH
| | - SARA CONROY
- Biostatistics Core, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH,Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - KENNETH JACKSON
- Biostatistics Core, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH,Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - NANCY BATTERSON
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH,Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University Wexner Medical Center, Columbus, OH
| | - MARY LAUREN NEEL
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH,Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University Wexner Medical Center, Columbus, OH
| | - MARK E HESTER
- Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University Wexner Medical Center, Columbus, OH,The Steve and Cindy Rasmussen Institute for Genomic Medicine, The Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus, OH
| | - NATHALIE L MAITRE
- Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, Atlanta, GA, USA
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30
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Yen E, Davis JM. The immediate and long-term effects of prenatal opioid exposure. Front Pediatr 2022; 10:1039055. [PMID: 36419918 PMCID: PMC9676971 DOI: 10.3389/fped.2022.1039055] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/18/2022] [Indexed: 11/09/2022] Open
Abstract
The opioid epidemic has adversely affected neonates and children, yet the mechanisms by which it impacts this population are not well understood. Not only does prenatal opioid exposure result in short-term consequences shortly after birth, it also creates long-term sequelae that may predispose these children to physical, emotional, psychiatric, cognitive, and socioeconomic problems in the future. This article provides a scoping overview of the long-term effects of antenatal opioid exposure on neonates and children as well as quality improvement and research efforts to understand and mitigate this major public health concern.
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Affiliation(s)
- Elizabeth Yen
- Department of Pediatrics, Tufts Medical Center, Boston, MA, United States.,Mother Infant Research Institute, Tufts Medical Center, Boston, MA, United States
| | - Jonathan M Davis
- Department of Pediatrics, Tufts Medical Center, Boston, MA, United States.,Tufts Clinical and Translational Science Institute, Boston, MA, United States
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31
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Krans EE, Kim JY, Chen Q, Rothenberger SD, James AE, Kelley D, Jarlenski MP. Outcomes associated with the use of medications for opioid use disorder during pregnancy. Addiction 2021; 116:3504-3514. [PMID: 34033170 PMCID: PMC8578145 DOI: 10.1111/add.15582] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/28/2021] [Accepted: 05/12/2021] [Indexed: 12/18/2022]
Abstract
AIM To test the effect of the duration of medication for opioid use disorder (MOUD) use during pregnancy on maternal, perinatal and neonatal outcomes. DESIGN Retrospective cohort analysis of claims, encounter and pharmacy data. SETTING Pennsylvania, USA. PARTICIPANTS We analyzed 13 320 pregnancies among 10 741 women with opioid use disorder aged 15-44 years enrolled in Pennsylvania Medicaid between 2009 and 2017. MEASUREMENTS We examined five outcomes during pregnancy and for 12 weeks postpartum: (1) overdose, (2) postpartum MOUD continuation, (3) preterm birth (< 37 weeks gestation), (4) term low birth weight (< 2500 g at ≥ 37 weeks) and (5) neonatal abstinence syndrome (NAS). Our primary exposure was the duration (count of weeks) of any MOUD use, including methadone or buprenorphine, during pregnancy. FINDINGS Among 13 320 pregnancies, 306 (2.3%) were complicated by an overdose, 1753 (13.2%) resulted in a preterm birth and 6787 (50.9%) continued MOUD postpartum. Among infants, 874 (7.6%) were low birth weight at term and 7706 (57.9%) were diagnosed with NAS. As the duration of MOUD use increased, we found a statistically significant decrease in the rate of overdose and preterm birth, a statistically significant increase in the rate of postpartum MOUD continuation and NAS and a decline in term low birth weight. Specifically, for each additional week of MOUD, the adjusted odds of overdose decreased by 2% [adjusted odds ratio (aOR) = 0.98; 95% confidence interval (CI) = 0.97, 0.99], preterm birth decreased by 1% (aOR = 0.99; 95% CI = 0.99, 1.00), postpartum MOUD continuation increased by 95% (aOR = 1.95; 95% CI = 1.87, 2.04) and NAS increased by 41% (aOR = 1.41; 95% CI = 1.35, 1.47). The odds of term low birth weight did not change (aOR = 1.00; 95% CI = 0.99, 1.00), although the rate declined with a longer duration of MOUD use during pregnancy. CONCLUSIONS Longer duration of medication for opioid use disorder use during pregnancy appears to be associated with improved maternal and perinatal outcomes.
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Affiliation(s)
- Elizabeth E. Krans
- Department of Obstetrics, Gynecology & Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joo Yeon Kim
- Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Qingwen Chen
- Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Scott D. Rothenberger
- Center for Research on Health Care Data Center, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alton Everette James
- Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David Kelley
- Pennsylvania Department of Human Services, Harrisburg, Pennsylvania
| | - Marian P. Jarlenski
- Department of Health Policy and Management, University of Pittsburgh, Pittsburgh, Pennsylvania
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