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Bell J, Strang J. Medication Treatment of Opioid Use Disorder. Biol Psychiatry 2020; 87:82-88. [PMID: 31420089 DOI: 10.1016/j.biopsych.2019.06.020] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 06/25/2019] [Accepted: 06/25/2019] [Indexed: 12/19/2022]
Abstract
Opioid use disorder (OUD) is a chronic, relapsing condition, often associated with legal, interpersonal, and employment problems. Medications demonstrated to be effective for OUD are methadone (a full opioid agonist), buprenorphine (a partial agonist), and naltrexone (an opioid antagonist). Methadone and buprenorphine act by suppressing opioid withdrawal symptoms and attenuating the effects of other opioids. Naltrexone blocks the effects of opioid agonists. Oral methadone has the strongest evidence for effectiveness. Longer duration of treatment allows restoration of social connections and is associated with better outcomes. Treatments for OUD may be limited by poor adherence to treatment recommendations and by high rates of relapse and increased risk of overdose after leaving treatment. Treatment with methadone and buprenorphine has the additional risk of diversion and misuse of medication. New depot and implant formulations of buprenorphine and naltrexone have been developed to address issues of safety and problems of poor treatment adherence. For people with OUD who do not respond to these treatments, there is accumulating evidence for supervised injectable opioid treatment (prescribing pharmaceutical heroin). Another medication mode of minimizing risk of overdose is take-home naloxone. Naloxone is an opioid antagonist used to reverse opioid overdose, and take-home naloxone programs aim to prevent fatal overdose. All medication-assisted treatment is limited by lack of access and by stigma. In seeking to stem the rising toll from OUD, expanding access to approved treatment such as methadone, for which there remains the best evidence of efficacy, may be the most useful approach.
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Affiliation(s)
- James Bell
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
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Abstract
The number of pregnant people affected by the opioid epidemic in the United States continues to rise. The following key aspects of opioid use disorder in pregnancy are explored through the progression of a pregnancy via a patient case: treatment options, treatment decisions, substance use screening, dosing modifications, and other aspects of peripartum care. Many factors affect opioid use disorder treatment choices during pregnancy; however, when a pregnant person is medically eligible for a therapy and multiple options are available locally, the ultimate decision regarding treatment selection should be left up to the patient and strong support services provided. This approach to treatment results in optimal maternal and neonatal outcomes and long-term maternal engagement and retention in care.
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Abstract
Women with opioid use disorder who become pregnant are a particularly vulnerable population and require a comprehensive treatment approach for mother and fetus. Research is continuing on opioid use disorder, effects of opioid use on the fetus, and best treatment approaches. This article reviews current recommendations and guidelines for treatment.
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Affiliation(s)
- Lillian C Carter
- At the time this article was written, Lillian C. Carter and Molly A. Read were students in the PA program at the University of Lynchburg in Lynchburg, Va. Laura Read is director of didactic education in the PA program at the University of Lynchburg. Joyce S. Nicholas is director of evaluation, assessment, and compliance in the PA program at the University of Lynchburg. Eric Schmidt is an assistant professor at the University of Lynchburg. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Abstract
Pharmacotherapy, or medication-assisted treatment (MAT), is a critical component of a comprehensive treatment plan for the pregnant woman with opioid use disorder (OUD). Methadone and buprenorphine are two types of opioid-agonist therapy which prevent withdrawal symptoms and control opioid cravings. Methadone is a long-acting mu-opioid receptor agonist that has been shown to increase retention in treatment programs and attendance at prenatal care while decreasing pregnancy complications. However methadone can only be administered by treatment facilities when used for OUD. In contrast, buprenorphine is a mixed opioid agonist-antagonist medication that can be prescribed outpatient. The decision to use methadone vs buprenorphine for MAT should be individualized based upon local resources and a patient-specific factors. There are limited data on the use of the opioid antagonist naltrexone in pregnancy. National organizations continue to recommend MAT over opioid detoxification during pregnancy due to higher rates of relapse with detoxification.
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Affiliation(s)
| | - Kaylin A Klie
- University of Colorado, Department of Family Medicine, 1693 N Quentin Street, Aurora, CO, USA.
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Cook JL, Green CR, de la Ronde S, Dell CA, Graves L, Morgan L, Ordean A, Ruiter J, Steeves M, Wong S. Screening and Management of Substance Use in Pregnancy: A Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 39:897-905. [PMID: 28935055 DOI: 10.1016/j.jogc.2017.07.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 07/19/2017] [Accepted: 07/19/2017] [Indexed: 11/28/2022]
Abstract
Substance use during pregnancy has important implications for health care providers, policy makers, and can negatively impact a woman's health and the health of her children. Understanding trends, patterns of use and outcomes are critical to prevention campaigns, building awareness, and providing effective care. This review will discuss the current therapeutic approaches and recommendations for screening and patient management for substance use in pregnancy and during the postpartum period, and it is geared towards any care providers who care for patients or those who may care for patients who may be at risk for substance use during pregnancy.
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Affiliation(s)
- Jocelynn L Cook
- The Society for Obstetricians and Gynaecologists of Canada and the Department of Obstetrics and Gynaecology, University of Ottawa, Ottawa, ON.
| | - Courtney R Green
- The Society of Obstetricians and Gynaecologists of Canada, Ottawa, ON
| | | | | | - Lisa Graves
- Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI
| | | | - Alice Ordean
- Department of Family and Community Medicine, University of Toronto and St. Joseph's Health Centre, Toronto, ON
| | | | - Megan Steeves
- School of Public Health, University of Saskatchewan, Saskatoon, SK
| | - Suzanne Wong
- Department of Obstetrics and Gynecology and Department of Family and Community Medicine, University of Toronto, Toronto, ON
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Treadmill exercise alleviated prenatal buprenorphine exposure-induced depression in rats. Neurochem Int 2017; 110:91-100. [DOI: 10.1016/j.neuint.2017.09.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 09/05/2017] [Accepted: 09/24/2017] [Indexed: 01/16/2023]
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Reddy UM, Davis JM, Ren Z, Greene MF. Opioid Use in Pregnancy, Neonatal Abstinence Syndrome, and Childhood Outcomes: Executive Summary of a Joint Workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, American College of Obstetricians and Gynecologists, American Academy of Pediatrics, Society for Maternal-Fetal Medicine, Centers for Disease Control and Prevention, and the March of Dimes Foundation. Obstet Gynecol 2017; 130:10-28. [PMID: 28594753 PMCID: PMC5486414 DOI: 10.1097/aog.0000000000002054] [Citation(s) in RCA: 164] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In April 2016, the Eunice Kennedy Shriver National Institute of Child Health and Human Development invited experts to a workshop to address numerous knowledge gaps and to review the evidence for the screening and management of opioid use in pregnancy and neonatal abstinence syndrome. The rising prevalence of opioid use in pregnancy has led to a concomitant dramatic fivefold increase in neonatal abstinence syndrome over the past decade. Experts from diverse disciplines addressed research gaps in the following areas: 1) optimal screening for opioid use in pregnancy; 2) complications of pregnancy associated with opioid use; 3) appropriate treatments for pregnant women with opioid use disorders; 4) the best approaches for detecting, treating, and managing newborns with neonatal abstinence syndrome; and 5) the long-term effects of prenatal opioid exposure on children. Workshop participants identified key scientific opportunities to advance the understanding of opioid use disorders in pregnancy and to improve outcomes for affected women, their children, and their families. This article provides a summary of the workshop presentations and discussions.
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Affiliation(s)
- Uma M Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland, the Tufts University School of Medicine, Boston, Massachusetts, and the Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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Abstract
Opioid dependence is an epidemic in the United States, and the percentage of pregnant women who are opioid dependent has increased dramatically in the last decade. Pain management, already a concern for intrapartum and postpartum care, is complicated in the context of opioid dependence. This clinical review surveys the literature on pain management in opioid-dependent pregnant women to summarize current consensus and evidence to guide clinical practice. Points of consensus for pain management in opioid-dependent pregnant women include continual opioid maintenance therapy throughout the pregnancy and the postpartum period; adequate management of acute pain; the contraindication of opioid agonist-antagonists for pain management; and the need for interdisciplinary teams using a multimodal approach to provide optimal care to opioid-dependent pregnant women.
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McKeever AE, Spaeth-Brayton S, Sheerin S. The role of nurses in comprehensive care management of pregnant women with drug addiction. Nurs Womens Health 2016; 18:284-93. [PMID: 25145717 DOI: 10.1111/1751-486x.12134] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Drug addiction during pregnancy is a complex health and social issue that requires an interdisciplinary health care team providing nonjudgmental, comprehensive care. Critical challenges include onset of and attendance at prenatal care, potential obstetric complications, transition to extrauterine life and potential neonatal abstinence syndrome for the neonate, newborn feeding issues, postpartum depression and risk of relapse for women.
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Samarghandian S, Azimi-Nezhad M, Afshari R, Farkhondeh T, Karimnezhad F. Effects of Buprenorphine on Balance of Oxidant/Antioxidant System in the Different Ages of Male Rat Liver. J Biochem Mol Toxicol 2015; 29:249-53. [DOI: 10.1002/jbt.21691] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 12/23/2014] [Accepted: 01/06/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Saeed Samarghandian
- Department of Basic Medical Sciences; Neyshabur University of Medical Sciences; Neyshabur Iran
| | - Mohsen Azimi-Nezhad
- Department of Genetics, Faculty of Medicine; Mashhad University of Medical Sciences; Mashhad Iran
| | - Reza Afshari
- Addiction Research Center; Mashhad University of Medical Sciences; Mashhad Iran
| | - Tahereh Farkhondeh
- Addiction Research Center; Mashhad University of Medical Sciences; Mashhad Iran
| | - Fatemeh Karimnezhad
- Department of Food Hygiene, Science and Research Branch; Islamic Azad University; Tehran Iran
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Gawronski KM, Prasad MR, Backes CR, Lehman KJ, Gardner DK, Cordero L. Neonatal outcomes following in utero exposure to buprenorphine/naloxone or methadone. SAGE Open Med 2014; 2:2050312114530282. [PMID: 26770721 PMCID: PMC4607220 DOI: 10.1177/2050312114530282] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 03/12/2014] [Indexed: 01/06/2023] Open
Abstract
Objectives: To study neonatal outcomes following buprenorphine/naloxone and methadone exposure during pregnancy. Methods: This study is a retrospective review of clinical and demographic information of 58 infants whose mothers were treated with buprenorphine/naloxone and 92 infants whose mothers were treated with methadone for opioid dependence during pregnancy. Results: Gestational age, birth weight, prematurity, admission to neonatal intensive care unit, and length of stay were similar between both groups of infants. Neonatal abstinence syndrome occurred less frequently among infants of mothers treated with buprenorphine/naloxone than those treated with methadone (64% and 80%, respectively, p = 0.03). All infants with neonatal abstinence syndrome were treated postnatally with methadone. There was a trend toward shorter duration of treatment and lower cumulative dosages of methadone among the buprenorphine/naloxone–exposed infants. Conclusions: No apparent significant adverse neonatal outcomes were detected following treatment with either maintenance medication; however, further prospective research is necessary to examine the safety and efficacy of buprenorphine/naloxone in pregnancy and its effects on the neonate.
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Affiliation(s)
| | - Mona R Prasad
- Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Carl R Backes
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - K Joy Lehman
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Debra K Gardner
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Leandro Cordero
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Mozurkewich EL, Rayburn WF. Buprenorphine and methadone for opioid addiction during pregnancy. Obstet Gynecol Clin North Am 2014; 41:241-53. [PMID: 24845488 DOI: 10.1016/j.ogc.2014.02.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Buprenorphine and methadone are opioid-receptor agonists used as opioid substitution therapy during pregnancy to limit exposure of the fetus to cycles of opioid withdrawal and reduce the risk of infectious comorbidities of illicit opioid use. As part of a comprehensive care plan, such therapy may result in improved access to prenatal care, reduced illicit drug use, reduced exposure to infections associated with intravenous drug use, and improved maternal nutrition and infant birth weight. This article describes differences in patient selection between the two drugs, their relative safety during pregnancy, and changes in daily doses as a guide for prescribing clinicians.
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Affiliation(s)
- Ellen L Mozurkewich
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, MSC 10 5580, 1 University of New Mexico, Albuquerque, NM 87131, USA.
| | - William F Rayburn
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, MSC 10 5580, 1 University of New Mexico, Albuquerque, NM 87131, USA
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O'Connor AB, Collett A, Alto WA, O'Brien LM. Breastfeeding rates and the relationship between breastfeeding and neonatal abstinence syndrome in women maintained on buprenorphine during pregnancy. J Midwifery Womens Health 2014; 58:383-8. [PMID: 23931660 DOI: 10.1111/jmwh.12009] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Although a growing body of evidence suggests that buprenorphine is a safe alternative to methadone in the treatment of opioid-dependent pregnant women, little is known about breastfeeding in this population. The first objective of this study was to describe breastfeeding rates among opioid-dependent pregnant women maintained on buprenorphine in an integrated medical and behavioral health program. The second objective was to determine whether breastfeeding is related to the duration, severity, and frequency of pharmacologic treatment for neonatal abstinence syndrome (NAS). METHODS A retrospective chart review was conducted for all infants born to opioid-dependent pregnant women treated in the integrated buprenorphine program between December 2007 and August 2012. RESULTS Eighty-five maternal-infant pairs were identified. Sixty-five women (76%) chose to breastfeed their infants after birth; of the women who initiated breastfeeding in the hospital, 66% were still breastfeeding 6 to 8 weeks postpartum. Although the data suggest that infants who were breastfed had less severe NAS (mean peak NAS, 8.83 vs 9.65 on a modified Finnegan Scoring System) and were less likely to require pharmacologic treatment (23.1% vs 30.0%) than infants who were not breastfed, these results were not statistically significant. DISCUSSION More than three-quarters of the opioid-dependent pregnant women in this case series chose to breastfeed after birth. Although a direct comparison of care models is not possible, the integrated model of care potentially reduced some of the barriers to breastfeeding as the women accessed all their care in a single, infant-friendly setting. Further work is needed to definitively determine whether breastfeeding mitigates NAS.
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Affiliation(s)
- Alane B O'Connor
- Maine Dartmouth Family Medicine Residency, 4 Sheridan Drive, Fairfield, ME 04937, USA.
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Hung CJ, Wu CC, Chen WY, Chang CY, Kuan YH, Pan HC, Liao SL, Chen CJ. Depression-like effect of prenatal buprenorphine exposure in rats. PLoS One 2013; 8:e82262. [PMID: 24367510 PMCID: PMC3867331 DOI: 10.1371/journal.pone.0082262] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 11/01/2013] [Indexed: 12/20/2022] Open
Abstract
Studies indicate that perinatal opioid exposure produces a variety of short- and long-term neurobehavioral consequences. However, the precise modes of action are incompletely understood. Buprenorphine, a mixed agonist/antagonist at the opioid receptors, is currently being used in clinical trials for managing pregnant opioid addicts. This study provides evidence of depression-like consequence following prenatal exposure to supra-therapeutic dose of buprenorphine and sheds light on potential mechanisms of action in a rat model involving administration of intraperitoneal injection to pregnant Sprague-Dawley rats starting from gestation day 7 and lasting for 14 days. Results showed that pups at postnatal day 21 but not the dams had worse parameters of depression-like neurobehaviors using a forced swimming test and tail suspension test, independent of gender. Neurobehavioral changes were accompanied by elevation of oxidative stress, reduction of plasma levels of brain-derived neurotrophic factor (BDNF) and serotonin, and attenuation of tropomyosin-related kinase receptor type B (TrkB) phosphorylation, extracellular signal-regulated kinase (ERK) phosphorylation, protein kinase A activity, cAMP response element-binding protein (CREB) phosphorylation, and CREB DNA-binding activity. Since BDNF/serotonin and CREB signaling could orchestrate a positive feedback loop, our findings suggest that the induction of oxidative stress, reduction of BDNF and serotonin expression, and attenuation of CREB signaling induced by prenatal exposure to supra-therapeutic dose of buprenorphine provide evidence of potential mechanism for the development of depression-like neurobehavior.
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Affiliation(s)
- Chih-Jen Hung
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Graduate School of Nursing, HungKuang University, Taichung, Taiwan, ROC
| | - Chih-Cheng Wu
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Department of Financial and Computational Mathematics, Providence University, Taichung, Taiwan, ROC
| | - Wen-Ying Chen
- Department of Veterinary Medicine, National Chung Hsing University, Taichung, Taiwan, ROC
| | - Cheng-Yi Chang
- Department of Surgery, Fong Yuan Hospital, Taichung, Taiwan, ROC
| | - Yu-Hsiang Kuan
- Department of Pharmacology, Chung Shan Medical University, Taichung, Taiwan, ROC
| | - Hung-Chuan Pan
- Department of Neurosurgery, Research, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Su-Lan Liao
- Department of Education and Research, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Chun-Jung Chen
- Graduate School of Nursing, HungKuang University, Taichung, Taiwan, ROC
- Department of Education and Research, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
- Institute of Biomedical Sciences, National Chung Hsing University, Taichung, Taiwan, ROC
- Center for General Education, Tunghai University, Taichung, Taiwan, ROC
- * E-mail:
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Wu CC, Hung CJ, Shen CH, Chen WY, Chang CY, Pan HC, Liao SL, Chen CJ. Prenatal buprenorphine exposure decreases neurogenesis in rats. Toxicol Lett 2013; 225:92-101. [PMID: 24321744 DOI: 10.1016/j.toxlet.2013.12.001] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 11/05/2013] [Accepted: 12/02/2013] [Indexed: 10/25/2022]
Abstract
Perinatal opioid exposure has a negative effect on neurogenesis and produces neurological consequences. However, its mechanisms of action are incompletely understood. Buprenorphine, a mixed opioid agonist/antagonist, is an alternative medication for managing pregnant opioid addicts. This study provides evidence of decreased neurogenesis and depression-like consequences following prenatal exposure to buprenorphine and sheds light on mechanisms of action in a rat model involving administration of intraperitoneal injection to pregnant rats starting from gestation day 7 and lasting for 14 days and a cultured neurosphere model. Results of forced swimming test and tail suspension test showed that pups at postnatal day 21 had worse parameters of depression-like neurobehaviors, independent of gender. Neurobehavioral changes were accompanied by reduction of neuronal composition, biochemical parameters of neural stem/progenitor cells, brain-derived neurotrophic factor (BDNF) expression, tropomyosin-related kinase receptor type B phosphorylation, protein kinase A (PKA) activity, and cAMP response element-binding protein phosphorylation. Results of parallel cell studies further demonstrated a negative impact of buprenorphine on cultured neurospheres, including proliferation, differentiation, BDNF expression and signaling, and PKA activity. Taken together, our results suggest that prenatal exposure to buprenorphine might result in depression-like phenotypes associated with impaired BDNF action and decreased neurogenesis in the developing brain of weanlings.
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Affiliation(s)
- Chih-Cheng Wu
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung 407, Taiwan; Department of Financial and Computational Mathematics, Providence University, Taichung 433, Taiwan
| | - Chih-Jen Hung
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung 407, Taiwan; Graduate School of Nursing, HungKuang University, Taichung 433, Taiwan
| | - Ching-Hui Shen
- Department of Anesthesiology, Taichung Veterans General Hospital, Taichung 407, Taiwan
| | - Wen-Ying Chen
- Department of Veterinary Medicine, National Chung Hsing University, Taichung 402, Taiwan
| | - Cheng-Yi Chang
- Department of Surgery, Feng Yuan Hospital, Taichung 420, Taiwan
| | - Hung-Chuan Pan
- Department of Neurosurgery, Taichung Veterans General Hospital, Taichung 407, Taiwan; Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei 112, Taiwan
| | - Su-Lan Liao
- Department of Education and Research, Taichung Veterans General Hospital, Taichung 407, Taiwan
| | - Chun-Jung Chen
- Graduate School of Nursing, HungKuang University, Taichung 433, Taiwan; Department of Education and Research, Taichung Veterans General Hospital, Taichung 407, Taiwan; Institute of Biomedical Sciences, National Chung Hsing University, Taichung 402, Taiwan; Center for General Education, Tunghai University, Taichung 407, Taiwan.
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Stanhope TJ, Gill LA, Rose C. Chronic opioid use during pregnancy: maternal and fetal implications. Clin Perinatol 2013; 40:337-50. [PMID: 23972743 DOI: 10.1016/j.clp.2013.05.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Current trends in the United States suggest that chronic narcotic use has increased in reproductive aged women over the past 10 years. Regular exposure to such substances during pregnancy has maternal and fetal implications. Appropriate prenatal care is critical to optimizing outcomes. Management options for narcotic dependence should be patient-specific and may include discontinuation of narcotics with careful observation, limitation of prescription dispensing, or substitution therapy with methadone or buprenorphine. A multidisciplinary, collaborative approach is highly recommended. This review discusses usage of narcotic medications, associated maternal and fetal risks, and management strategies for the antepartum, intrapartum, and postpartum periods.
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Affiliation(s)
- Todd J Stanhope
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, 200 First Street SW, Rochester, MN 55902, USA
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Abstract
UNLABELLED The purpose of this review is to discuss the incidence, risks, pregnancy complications, and maintenance options for treatment of opioid addiction in pregnancy. SUMMARY Opioid dependence in pregnancy carries clear identifiable maternal and fetal risk. Providing care for patients with dependence is best done in a multidisciplinary care model addressing the particular needs of this population. There are limited data on maternal detoxification, with data still emerging surrounding the safety profile of this practice. Historically, methadone has been the recommended maintenance treatment; however, recent data on buprenorphine identify this as a safe and effective option. The majority of births from women with opioid dependence result in neonatal abstinence syndrome requiring prolonged neonatal hospitalization. Intrapartum pain management should not differ from the general obstetric population. Postpartum pain is magnified in this population, and particular attention should be focused on this issue. Breast-feeding is recommended regardless of maintenance dose, unless other conditions restricting breast-feeding are present. Comprehensive postpartum care and transition of care to addiction specialists are highly recommended. TARGET AUDIENCE Obstetricians and gynecologists, family physicians, addiction specialists. LEARNING OBJECTIVES After completing this CME activity, physicians should be better able to assess the treatment options available to patients with opioid addiction during pregnancy, compare the risk/safety profiles of methadone and buprenorphine, and evaluate the recommendations and current data surrounding breast-feeding while on opioid maintenance treatment.
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Abstract
Opioid dependence in the setting of pregnancy provides a distinct set of challenges for providers. Treatment plans must take into consideration psychiatric and medical comorbidities while balancing risks and benefits for the maternal-fetal dyad. Treatment is best offered through a comprehensive treatment program designed to effectively deliver opioid agonist maintenance treatment along with psychosocial and obstetric care. As misuse of prescription analgesics increases in the United States, identification of the problem in pregnancy will become more important because this misuse is expected to lead to an increased prevalence of opioid dependence in pregnancy. Buprenorphine as maintenance treatment of opioid dependence during pregnancy has promise and may offer some benefits, but more research is needed, especially regarding induction of actively addicted women during pregnancy. For the present, methadone maintenance remains the standard of care for agonist treatment of opioid dependence in pregnancy against which other treatments must be compared.
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Affiliation(s)
- Jessica L Young
- Vanderbilt University Medical Center, Nashville, TN 37232, USA.
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