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Tabachnick AR, Eiden RD, Labella MH, Dozier M. Effects of prenatal opioid exposure on infant sympathetic and parasympathetic nervous system activity. Psychophysiology 2024; 61:e14470. [PMID: 37888142 PMCID: PMC10939941 DOI: 10.1111/psyp.14470] [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: 03/10/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 10/28/2023]
Abstract
Prenatal opioid exposure has been associated with developmental problems, including autonomic nervous system dysregulation. However, little is known about the effects of prenatal opioid exposure on the autonomic nervous system beyond the first days of life, particularly across both the parasympathetic and sympathetic branches, and when accounting for exposure to other substances. The present study examined the effects of prenatal exposure to opioid agonist therapy (OAT, e.g., methadone) and other opioids on infant autonomic nervous system activity at rest and in response to a social stressor (the Still-Face Paradigm) at six months among 86 infants varying in prenatal opioid and other substance exposure. Results indicated that OAT and other opioids have unique effects on the developing autonomic nervous system that may further depend on subtype (i.e., methadone versus buprenorphine) and timing in gestation. Results are discussed in the context of theoretical models of the developing stress response system.
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Affiliation(s)
| | - Rina Das Eiden
- Department of Psychology, Pennsylvania State University, State College, Pennsylvania, USA
| | - Madelyn H Labella
- Department of Psychological Sciences, William & Mary, Williamsburg, Virginia, USA
| | - Mary Dozier
- Department of Psychological and Brain Sciences, University of Delaware, Newark, Delaware, USA
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2
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Seger C, Tuten M, Storr CL, Majer JM. Delivery Outcomes Among Pregnant Women With Comorbid Psychiatric and Substance Use Disorders Receiving Comprehensive Treatment. J Am Psychiatr Nurses Assoc 2024; 30:121-131. [PMID: 35184607 DOI: 10.1177/10783903221079384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND: Pregnant women with substance use disorders (SUDs) are at risk for adverse delivery outcomes, and some of these women have psychiatric comorbidities that increase this risk. AIMS: Although comprehensive care models offering prenatal care services and substance abuse treatment have been found to positively affect delivery outcomes for pregnant women with SUDs, there is a dearth of research to support such models for women who have psychiatric comorbidities. METHODS: A secondary data analysis was conducted to understand the relationship between pretreatment psychiatric comorbidity and delivery outcomes for pregnant clients with SUDs receiving comprehensive treatment. We analyzed two groups of pregnant women with SUDs and hypothesized that women with psychiatric comorbidities would have worse neonatal and maternal outcomes compared with those who did not have any pretreatment psychiatric comorbidity. Regression models were used to examine changes in delivery outcome criteria (birthweight, neonatal abstinence syndrome, maternal urine toxicology screens at delivery, and hospital length of stay) in relation to psychiatric comorbidity among a sample of 74 mother-baby dyads receiving comprehensive care treatment. RESULTS: Results did not support our hypothesis as delivery outcomes were statistically similar for both groups. CONCLUSION: Findings suggest comprehensive care can reduce the risk of negative delivery outcomes among women with SUDs who have psychiatric comorbidities. Treatment and research implications are provided.
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Affiliation(s)
- Celeste Seger
- Celeste Seger, PhD, RN, University of Maryland, Baltimore, MD, USA
| | - Michelle Tuten
- Michelle Tuten, MSW, LCSW-C, PhD, University of Maryland, Baltimore, MD, USA
| | - Carla L Storr
- Carla L. Storr, ScD, MPH, University of Maryland, Baltimore, MD, USA
| | - John M Majer
- John M. Majer, PhD, Harry S. Truman College, Chicago, IL, USA
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Wouldes TA, Lester BM. Opioid, methamphetamine, and polysubstance use: perinatal outcomes for the mother and infant. Front Pediatr 2023; 11:1305508. [PMID: 38250592 PMCID: PMC10798256 DOI: 10.3389/fped.2023.1305508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 11/20/2023] [Indexed: 01/23/2024] Open
Abstract
The escalation in opioid pain relief (OPR) medications, heroin and fentanyl, has led to an increased use during pregnancy and a public health crisis. Methamphetamine use in women of childbearing age has now eclipsed the use of cocaine and other stimulants globally. Recent reports have shown increases in methamphetamine are selective to opioid use, particularly in rural regions in the US. This report compares the extent of our knowledge of the perinatal outcomes of OPRs, heroin, fentanyl, two long-acting substances used in the treatment of opioid use disorders (buprenorphine and methadone), and methamphetamine. The methodological limitations of the current research are examined, and two important initiatives that will address these limitations are reviewed. Current knowledge of the perinatal effects of short-acting opioids, OPRs, heroin, and fentanyl, is scarce. Most of what we know about the perinatal effects of opioids comes from research on the long-acting opioid agonist drugs used in the treatment of OUDs, methadone and buprenorphine. Both have better perinatal outcomes for the mother and newborn than heroin, but the uptake of these opioid substitution programs is poor (<50%). Current research on perinatal outcomes of methamphetamine is limited to retrospective epidemiological studies, chart reviews, one study from a treatment center in Hawaii, and the US and NZ cross-cultural infant Development, Environment And Lifestyle IDEAL studies. Characteristics of pregnant individuals in both opioid and MA studies were associated with poor maternal health, higher rates of mental illness, trauma, and poverty. Infant outcomes that differed between opioid and MA exposure included variations in neurobehavior at birth which could complicate the diagnosis and treatment of neonatal opioid withdrawal (NOWs). Given the complexity of OUDs in pregnant individuals and the increasing co-use of these opioids with MA, large studies are needed. These studies need to address the many confounders to perinatal outcomes and employ neurodevelopmental markers at birth that can help predict long-term neurodevelopmental outcomes. Two US initiatives that can provide critical research and treatment answers to this public health crisis are the US Environmental influences on Child Health Outcomes (ECHO) program and the Medication for Opioid Use Disorder During Pregnancy Network (MAT-LINK).
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Affiliation(s)
- Trecia A. Wouldes
- Department of Psychological Medicine, The University of Auckland, Auckland, New Zealand
| | - Barry M. Lester
- Center for the Study of Children at Risk, Warren Alpert Medical School, Brown University, Providence, RI, United States
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Turner S, Allen VM, Carson G, Graves L, Tanguay R, Green CR, Cook JL. Guideline No. 443b: Opioid Use Throughout Women's Lifespan: Opioid Use in Pregnancy and Breastfeeding. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102144. [PMID: 37977721 DOI: 10.1016/j.jogc.2023.05.012] [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: 11/19/2023]
Abstract
OBJECTIVE To provide health care providers the best evidence on opioid use and women's health. Areas of focus include pregnancy and postpartum care. TARGET POPULATION The target population includes all women currently using or contemplating using opioids. OUTCOMES Open, evidence-informed dialogue about opioid use will improve patient care. BENEFITS, HARMS, AND COSTS Exploring opioid use through a trauma-informed approach provides the health care provider and patient with an opportunity to build a strong, collaborative, and therapeutic alliance. This alliance empowers women to make informed choices about their own care. It also allows for the diagnosis and possible treatment of opioid use disorders. Opioid use should not be stigmatized, as stigma leads to poor "partnered care" (i.e., the partnership between the patient and care provider). Health care providers need to understand the effect opioids can have on pregnant women and support them to make knowledgeable decisions about their health. EVIDENCE A literature search was designed and carried out in PubMed and the Cochrane Library databases from August 2018 until March 2023 using following MeSH terms and keywords (and variants): opioids, opioid agonist therapy, illicit drugs, fertility, pregnancy, fetal development, neonatal abstinence syndrome, and breastfeeding. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE All health care providers who care for pregnant and/or post-partum women and their newborns. TWEETABLE ABSTRACT Opioid use during pregnancy often co-occurs with mental health issues and is associated with adverse maternal, fetal, and neonatal outcomes; treatment of opioid use disorder with agonist therapy for pregnant women can be safe during pregnancy where the risks outnumber the benefits. SUMMARY STATEMENTS RECOMMENDATIONS.
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Turner S, Allen VM, Carson G, Graves L, Tanguay R, Green CR, Cook JL. Directive clinique n o 443b : Opioïdes aux différentes étapes de la vie des femmes : Grossesse et allaitement. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102146. [PMID: 37977719 DOI: 10.1016/j.jogc.2023.05.014] [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: 11/19/2023]
Abstract
OBJECTIF Présenter aux professionnels de la santé les données probantes concernant l'utilisation des opioïdes et la santé des femmes. Les domaines d'intérêt sont la grossesse et les soins post-partum. POPULATION CIBLE Toutes les femmes qui utilisent des opioïdes. RéSULTATS: Un dialogue ouvert et éclairé sur l'utilisation des opioïdes améliorera les soins aux patientes. BéNéFICES, RISQUES ET COûTS: L'exploration de l'utilisation d'opioïdes par une approche tenant compte des traumatismes antérieurs donne au professionnel de la santé et à la patiente l'occasion de bâtir une alliance solide, collaborative et thérapeutique. Cette alliance permet aux femmes de faire des choix éclairés. Elle favorise le diagnostic et le traitement possible du trouble lié à l'utilisation d'opioïdes. L'utilisation ne doit pas être stigmatisée, puisque la stigmatisation affaiblit le partenariat (le partenariat entre patiente et professionnel de la santé). Les professionnels de la santé ceus-ci doivent comprendre l'effet potentiel des opioïdes sur la santé les femmes enceintes et les aider à prendre des décisions éclairées sur leur santé. DONNéES PROBANTES: Une recherche a été conçue puis effectuée dans les bases de données PubMed et Cochrane Library pour la période d'août 2018 à mars 2023 des termes MeSH et mots clés suivants (et variantes) : opioids, opioid agonist therapy, illicit drugs, fertility, pregnancy, fetal development, neonatal abstinence syndrome et breastfeeding. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Tous les professionnels de la santé qui prodiguent des soins aux femmes et aux nouveaux-nés. RéSUMé POUR TWITTER: La consommation d'opioïdes pendant la grossesse coïncide souvent avec des problèmes de santé mentale et est associée à des conséquences néfastes pour la mère, le fœtus et le nouveau-né ; le traitement des troubles liés à la consommation d'opioïdes par agonistes peut être sûr pendant la grossesse lorsque les risques sont plus nombreux que les avantages. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.
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The Influence of Mediators on the Relationship Between Antenatal Opioid Agonist Exposure and the Severity of Neonatal Opioid Withdrawal Syndrome. Matern Child Health J 2023; 27:1030-1042. [PMID: 36905529 DOI: 10.1007/s10995-022-03521-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2022] [Indexed: 03/12/2023]
Abstract
OBJECTIVES (1) To evaluate the direct (un-mediated) and indirect (mediated) relationship between antenatal exposure to opioid agonist medication as treatment for opioid use disorder (MOUD) and the severity of neonatal opioid withdrawal syndrome (NOWS), and (2) to understand the degree to which mediating factors influence the direct relationship between MOUD exposure and NOWS severity. METHODS This cross-sectional study includes data abstracted from the medical records of 1294 opioid-exposed infants (859 MOUD exposed and 435 non-MOUD exposed) born at or admitted to one of 30 US hospitals from July 1, 2016, to June 30, 2017. Regression models and mediation analyses were used to evaluate the relationship between MOUD exposure and NOWS severity (i.e., infant pharmacologic treatment and length of newborn hospital stay (LOS)) to identify potential mediators of this relationship in analyses adjusted for confounding factors. RESULTS A direct (un-mediated) association was found between antenatal exposure to MOUD and both pharmacologic treatment for NOWS (aOR 2.34; 95%CI 1.74, 3.14) and an increase in LOS (1.73 days; 95%CI 0.49, 2.98). Delivery of adequate prenatal care and a reduction in polysubstance exposure were mediators of the relationship between MOUD and NOWS severity and as thus, were indirectly associated with a decrease in both pharmacologic treatment for NOWS and LOS. CONCLUSIONS FOR PRACTICE MOUD exposure is directly associated with NOWS severity. Prenatal care and polysubstance exposure are potential mediators in this relationship. These mediating factors may be targeted to reduce the severity of NOWS while maintaining the important benefits of MOUD during pregnancy.
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Cutler AJ, Cox DF, Gabrielson SMB, Picarillo AP, Craig AK. Association of medication-assisted treatment and short acting opioids with newborn head circumference and birth weight. J Perinatol 2023; 43:277-282. [PMID: 36509817 DOI: 10.1038/s41372-022-01579-z] [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: 05/17/2022] [Revised: 11/28/2022] [Accepted: 12/01/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We compared the association of methadone, buprenorphine, and short-acting opioid exposure with newborn head circumference (HC) and birth weight (BW), and evaluated gestational age (GA) as a mediator. STUDY DESIGN We included newborns born 2013-2018 identified by neonatal abstinence syndrome diagnosis code (N = 572) and birthday-matched unexposed controls (N = 571). Linear regressions of opioid exposure with HC and BW controlled for tobacco, marijuana, cocaine, gabapentin, cesarean section, Medicaid, and newborn sex, with mediation analysis by GA. RESULT Methadone was associated with 0.81 cm lower HC (95% CI = -1.22, -0.40) and 0.23 kg lower BW (95% CI = -0.35, -0.10) with approximately 24% and 41% mediated by GA, respectively. Buprenorphine and short acting opioids were not associated with HC or BW. CONCLUSION Methadone exposed newborns have smaller HC and lower BW not fully attributable to younger GA, suggesting a direct effect of methadone on intrauterine growth. Exploration of potential developmental consequences of this is urgently needed.
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Affiliation(s)
- Anya J Cutler
- MaineHealth Institute for Research, Portland, ME, USA.
| | - David F Cox
- Barbara Bush Children's Hospital at Maine Medical Center, Department of Pediatrics, Portland, ME, USA
| | - Sarah M B Gabrielson
- Barbara Bush Children's Hospital at Maine Medical Center, Department of Pediatrics, Portland, ME, USA
| | - Alan P Picarillo
- Barbara Bush Children's Hospital at Maine Medical Center, Division of Neonatology, Portland, ME, USA
| | - Alexa K Craig
- Barbara Bush Children's Hospital at Maine Medical Center, Division of Pediatric Neurology, Portland, ME, USA
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Howell MP, Wiseman CA, Rosen MZ, Yeates WM, Wright LA, O'Connell SS, Bhunu B, Intapad S, Kimball TR, Cheang S, Gajewski KK. Impact of prenatal opioids on cardiac and autonomic development: systematic review and meta-analysis. J Perinatol 2023; 43:259-270. [PMID: 35906283 DOI: 10.1038/s41372-022-01466-7] [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: 03/12/2022] [Revised: 06/23/2022] [Accepted: 07/12/2022] [Indexed: 11/09/2022]
Abstract
Prenatal opioid exposure has recently risen four-fold with limited data on the developmental effects on neonatal physiology. The objective of this systematic review is to develop an association between prenatal opioid exposure and fetal and neonatal cardiac and autonomic development and function. The review was conducted in accordance with PRISMA Guidelines, and searches were conducted using PubMed, Embase, CINAHL, and Web of Science between May 25 and October 27, 2020. Twenty studies fit inclusion criteria, in four categories: (1) fetal cardiac outcomes, (2) neonatal cardiac outcomes, (3) noninvasive autonomic outcomes, and (4) clinical and behavioral measures. For the meta-analysis, three studies (total of 210 subjects) were included. Effect sizes were measured as the mean difference in fetal heart rate between opioid-exposed and non-exposed groups. Mothers with prenatal opioid use had a significantly lower fetal heart rate as compared to mothers without prenatal opioid use, requiring further studies to determine clinical significance.
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Affiliation(s)
- Meghan P Howell
- Department of Pediatrics, Tulane University School of Medicine, New Orleans, LA, USA.
| | - Carlie A Wiseman
- School of Science and Engineering, Tulane University, New Orleans, LA, USA
| | - Maya Z Rosen
- School of Public Health, Tulane University, New Orleans, LA, USA
| | | | - Laura A Wright
- Rudolph Matas Library of Health Sciences, Tulane University, New Orleans, LA, USA
| | - Samantha S O'Connell
- Office of Academic Affairs and Provost, Tulane University School of Medicine, New Orleans, LA, USA
| | - Benjamin Bhunu
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Suttira Intapad
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Thomas R Kimball
- Department of Pediatrics, Section of Pediatric Cardiology, Louisiana State University School of Medicine, New Orleans, LA, USA.,Heart Center, Children's Hospital New Orleans, New Orleans, LA, USA
| | - Stefanie Cheang
- Department of Pediatrics, Section of Pediatric Cardiology, Louisiana State University School of Medicine, New Orleans, LA, USA
| | - Kelly K Gajewski
- Department of Pediatrics, Section of Pediatric Cardiology, Louisiana State University School of Medicine, New Orleans, LA, USA.,Heart Center, Children's Hospital New Orleans, New Orleans, LA, USA
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Ronan K, Hughes Driscoll C, Decker E, Gopalakrishnan M, El Metwally D. Resource utilization and convalescent care cost in neonatal opioid withdrawal syndrome. J Neonatal Perinatal Med 2022; 16:49-57. [PMID: 36530095 DOI: 10.3233/npm-221060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND: Neonatal opioid withdrawal syndrome (NOWS) is a growing public health problem associated with complex and prolonged medical care and a significant resource utilization burden. The objective of this study was to compare the cost of different convalescent care settings for infants with NOWS. METHODS: Retrospective comparison study of infants with NOWS discharged directly from NICU, transferred to an acute care pediatric floor (PPCU) or rehabilitation hospital (PRH). Primary outcomes were length of stay (LOS) and cost of stay (COS). RESULTS: Infants had 1.3 (95% CI: 1.1,1.6) times and 2.5 (95% CI: 2.1,3.1) times significantly longer mean LOS for PPCU and RH discharges compared to NICU discharges. NICU discharged infants had the lowest mean COS ($25,745.00) and PRH the highest ($60,528.00), despite PRH having a lower cost per day. PRH discharged infants had higher rates of methadone and benzodiazepine and less buprenorphine exposure than NICU/PPCU discharged. Infants born to mothers on marijuana and buprenorphine had a 28% lower mean COS compared to unexposed infants. Median treatment cumulative morphine doses were six-fold higher for PRH than NICU discharge. CONCLUSIONS: Infants transferred to convalescence care facilities had longer and more costly admissions and received more medication. However, there may be a role for earlier transfer of a subset of infants at-risk for longer LOS as those exposed to methadone and/or benzodiazepines. Further studies exploring differences in resource utilization, convalescent care delivery and cost expenditure are recommended.
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Affiliation(s)
- K. Ronan
- Department of Pediatrics. University of Maryland School of Medicine, MD, USA
- Women’s and Babies Hospital, Lancaster, PA, USA
| | | | - E. Decker
- Department of Pediatrics. University of Maryland School of Medicine, MD, USA
- The College of Physicians and Surgeons at Columbia University, NY, USA
| | - M. Gopalakrishnan
- Center for Translational Medicine, University of Maryland School of Pharmacy, MD, USA
| | - D. El Metwally
- Department of Pediatrics. University of Maryland School of Medicine, MD, USA
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Rates of substance and polysubstance use through universal maternal testing at the time of delivery. J Perinatol 2022; 42:1026-1031. [PMID: 35177791 PMCID: PMC9356969 DOI: 10.1038/s41372-022-01335-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 01/10/2022] [Accepted: 01/27/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To report substance and polysubstance use at the time of delivery. STUDY DESIGN A cross-sectional study was performed on mothers consented for universal drug testing (99%) during hospital admission at six delivery hospitals in Cincinnati, Ohio. Mass spectrometry urinalysis detected positivity rates of 46 substances. Rates of positive drug tests for individual and common co-occurring substances measured were reported. RESULTS 2531 maternal samples were tested (88%) and 33% contained cotinine, 11.3% THC, 7.2% opioids, 3.8% cocaine, and 1.9% methamphetamines. Polysubstance use prevalence was as high as 15%. Among mothers testing positive for methadone or buprenorphine, 93% also tested positive for cotinine and 39% tested positive for a third substance in addition to cotinine. CONCLUSIONS Substance use at delivery is more prevalent than previously reported. Many mothers testing positive for opioids also test positive for other substances, which may increase overdose risk and exacerbate neonatal opioid withdrawal syndrome (NOWS).
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Schiff DM, Work EC, Foley B, Applewhite R, Diop H, Goullaud L, Gupta M, Hoeppner BB, Peacock-Chambers E, Vilsaint CL, Bernstein JA, Bryant AS. Perinatal Opioid Use Disorder Research, Race, and Racism: A Scoping Review. Pediatrics 2022; 149:184771. [PMID: 35156121 PMCID: PMC9044279 DOI: 10.1542/peds.2021-052368] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Racial/ethnic inequities are well documented in both maternal-infant health and substance use disorder treatment outcomes. OBJECTIVE To systematically review research on maternal-infant dyads affected by opioid use disorder (OUD) to evaluate for racial/ethnic disparities in health utilization or outcomes and critically assess the reporting and inclusion of race/ethnicity data. DATA SOURCES Peer-reviewed literature in MEDLINE, Embase, and Web of Science from 2000 to 2020. STUDY SELECTION Research reporting health utilization and outcomes data on dyads affected by OUD during pregnancy through the infant's first birthday. DATA EXTRACTION We extracted data on race/ethnicity, study exposures/outcomes, how race/ethnicity data were analyzed, how authors discussed findings associated with race/ethnicity, and whether racism was mentioned as an explanation for findings. RESULTS Of 2023 articles reviewed, 152 quantitative and 17 qualitative studies were included. Among quantitative studies, 66% examined infant outcomes (n = 101). Three articles explicitly focused on evaluating racial/ethnic differences among dyads. Among quantitative studies, 112 mentioned race/ethnicity, 63 performed analyses assessing for differences between exposure groups, 27 identified racial/ethnic differences, 22 adjusted outcomes for race/ethnicity in multivariable analyses, and 11 presented adjusted models stratified by race/ethnicity. None of the qualitative studies addressed the role that race, ethnicity, or racism may have had on the presented themes. CONCLUSIONS Few studies were designed to evaluate racial/ethnic inequities among maternal-infant dyads affected by OUD. Data on race/ethnicity have been poorly reported in this literature. To achieve health equity across perinatal OUD, researchers should prioritize the inclusion of marginalized groups to better address the role that structural racism plays.
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Affiliation(s)
- Davida M. Schiff
- Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston, Massachusetts,Address correspondence to Davida M. Schiff, MD, MSc, Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston, MA 02114. E-mail:
| | - Erin C. Work
- Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston, Massachusetts
| | - Bridget Foley
- Substance Use Disorder Initiative, Department of Psychiatry
| | | | - Hafsatou Diop
- Massachusetts Department of Public Health, Boston, Massachusetts
| | | | - Munish Gupta
- Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | - Judith A. Bernstein
- Division of Community Health Sciences, Boston University School of Public Health, Boston Massachusetts
| | - Allison S. Bryant
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
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What Obstetrician–Gynecologists Should Know About Substance Use Disorders in the Perinatal Period. Obstet Gynecol 2022; 139:317-337. [DOI: 10.1097/aog.0000000000004657] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/01/2021] [Indexed: 11/26/2022]
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Miller JS, Anderson JG. Factors in children with a history of neonatal abstinence syndrome at 10 years of age: Evidence from the maternal lifestyle study. J SPEC PEDIATR NURS 2022; 27:e12358. [PMID: 34472206 DOI: 10.1111/jspn.12358] [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: 01/27/2021] [Revised: 07/26/2021] [Accepted: 08/23/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Few studies have addressed the impact of prior prenatal substance exposure and current household environment on neurodevelopmental health in children with a history of neonatal abstinence syndrome (NAS). This study aimed to describe the prenatal exposures, household environment, and neurodevelopmental health at 10 years of age among children with a history of NAS. DESIGN AND METHODS This study was a retrospective, descriptive design using data from the Maternal Lifestyle Study. Descriptive analyses were conducted. A total of 234 children with a history of NAS were included in this study. Variables selected based on the socio-ecological model included prenatal exposures, household environment, and neurodevelopmental health outcomes. RESULTS In this sample, most children were male (63%) with prenatal polysubstance exposure (80%). The majority lived in a home where substance use occurred (68%). Children experienced abnormal cognitive development (26%), language disorders (24%), learning disorders (23%), and abnormal behavioral development (16%). IMPLICATIONS This study extends the description of children with a history of NAS beyond 5 years of age. Pediatric nurses can ensure that children with a history of NAS receive neurodevelopmental screening up to and beyond 10 years of age.
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Affiliation(s)
| | - Joel G Anderson
- College of Nursing, University of Tennessee, Knoxville, Tennessee, USA
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Cheng AWF, Chan HB, Ip LS, Wan KKY, Yu ELM, Chiu WK, Chung PH, Yeoh EK. The physical and developmental outcomes of children whose mothers are substance abusers: Analysis of associated factors and the impact of early intervention. Front Pediatr 2022; 10:1004890. [PMID: 36340731 PMCID: PMC9631827 DOI: 10.3389/fped.2022.1004890] [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: 07/27/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND/OBJECTIVES Maternal illicit drug use is associated with negative physical and developmental outcomes for their born children. We aim to find out the incidence of different developmental problems in a cohort of Chinese children born to drug-abusing mothers, compare the physical health and developmental outcomes of the subjects recruited in the Integrated Program to the Comprehensive Child Development Service (CCDS), and to study the potential factors on their associations. METHODS A retrospective longitudinal cohort study with frequent clinical assessments of the children's physical and developmental outcomes in a HKSAR's regional hospital from birth until 5 years old. 123 Children in Integrated Program were compared with 214 children in CCDS between 1 January 2008 and 28 February 2019. Cox regression analysis was performed to determine the possible factors associated with the developmental outcomes. RESULTS Developmental delay was detected in 129 children (38.9%). CCDS group has significantly higher incidence of cognitive delay (p = < 0.001), language delay (p = < 0.001), motor delay (p = < 0.001), social delay (p = 0.002), and global delay (p = 0.002). On Cox multivariable regression analysis, integrated program (HRadj 0.53, 95% C. I. 0.34-0.84), social support (HRadj 0.45, 95% C.I. 0.25-0.80), and maternal abstinence from drug use up to 2-year post-delivery (HRadj 0.62, 95% C.I. 0.40-0.95) were significant protective factors, while male gender (HRadj 1.73, 95% C.I. 1.18-2.54) was a significant risk factor. CONCLUSION CCDS achieves early engagement of drug-abusing expectant mothers during pregnancy, and an early integrated program with multidisciplinary collaboration was an independent factor in improving the developmental outcomes of these vulnerable children.
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Affiliation(s)
- Anna Wai Fun Cheng
- Department of Pediatrics and Adolescent Medicine, United Christian Hospital, Hong Kong, Hong Kong SAR, China
| | - Hin Biu Chan
- Department of Pediatrics and Adolescent Medicine, United Christian Hospital, Hong Kong, Hong Kong SAR, China
| | - Lai Sheung Ip
- Department of Obstetrics and Gynaecology, United Christian Hospital, Hong Kong, Hong Kong SAR, China
| | - Katy Kit Ying Wan
- Rainbow Lutheran Centre, Hong Kong Lutheran Social Service, Hong Kong, Hong Kong SAR, China
| | - Ellen Lok Man Yu
- Clinical Research Centre, Kowloon West Cluster, Hospital Authority, Hong Kong, Hong Kong SAR, China
| | - Wa Keung Chiu
- Department of Pediatrics and Adolescent Medicine, United Christian Hospital, Hong Kong, Hong Kong SAR, China
| | - Pui Hong Chung
- Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Eng Kiong Yeoh
- Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
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15
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Sarfi M, Eikemo M, Konijnenberg C. Children born to women in opioid maintenance treatment: A longitudinal study of child behavioral problems and parenting stress. Front Pediatr 2022; 10:1087956. [PMID: 36619511 PMCID: PMC9816796 DOI: 10.3389/fped.2022.1087956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022] Open
Abstract
In the wake of the "opioid epidemic", there is considerable concern regarding potential harmful long-term effects of prenatal opioid exposure. Opioid misuse and addiction confer increased exposure to lifestyle stressors and health burdens. Accordingly, it is challenging to disentangle effects of prenatal opioid exposure per se from factors related to maternal stress. In this study, we followed 36 women enrolled in comprehensive opioid maintenance treatment (OMT) program and their children alongside 36 age-matched mother-child dyads from a community sample (COMP) from pregnancy until child-age 8 years. Across five sessions, we used a battery of well-established questionnaires to investigate trajectories of parenting stress and mental health symptoms as well as child behavior problems. The 8-year retention was relatively high (OMT: 72%, COMP: 67%), and the OMT sample remarkably stable and well-functioning, with minimal concomitant illicit drug use. Mixed effects regressions showed significantly different trajectories of child behavior problems (F = 3.8, p = 0.024) and parenting stress (F = 3.1, p = 0.016) in the two groups. Differences in experienced stress were largely explained by more distress specifically related to the parenting role in the OMT group (F = 9.7, p = 0.003). The OMT sample also reported higher psychological distress (F = 15.6, p < 0.001) than the comparison group, but notably few participants presented with problems that warranted clinical intervention. The results underscore the benefits of tailored follow-up of children prenatally exposed to opioids and their families beyond infancy and toddlerhood. Long-term direct effects of prenatal opioid exposure on behavior problems are likely modest, given an otherwise stable caregiving environment conducive to healthy development.
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Affiliation(s)
- Monica Sarfi
- Norwegian Centre for Addiction Research (SERAF), Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Marie Eikemo
- Department of Psychology, Faculty of Social Sciences, University of Oslo, Oslo, Norway
| | - Carolien Konijnenberg
- Department of Psychology, Inland Norway University of Applied Sciences, Lillehammer, Norway
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16
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Straub L, Huybrechts KF, Hernández-Díaz S, Zhu Y, Vine S, Desai RJ, Gray KJ, Bateman BT. Trajectories of Prescription Opioid Utilization During Pregnancy Among Prepregnancy Chronic Users and Risk of Neonatal Opioid Withdrawal Syndrome. Am J Epidemiol 2022; 191:208-219. [PMID: 34643225 DOI: 10.1093/aje/kwab249] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 08/24/2021] [Accepted: 10/05/2021] [Indexed: 01/16/2023] Open
Abstract
Little is known about the impact of dose, duration, and timing of prenatal prescription opioid exposure on the risk of neonatal opioid withdrawal syndrome (NOWS). Using a cohort of 18,869 prepregnancy chronic opioid users nested within the 2000-2014 Medicaid Analytic eXtract, we assessed average opioid dosage within biweekly gestational age intervals, created group-based trajectory models, and evaluated the association between trajectory groups and NOWS risk. Women were grouped into 6 distinct opioid use trajectories which, based on observed patterns, were categorized as 1) continuous very low-dose use, 2) continuous low-dose use, 3) initial moderate-dose use with a gradual decrease to very low-dose/no use, 4) initial high-dose use with a gradual decrease to very low-dose use, 5) continuous moderate-dose use, and 6) continuous high-dose use. Absolute risk of NOWS per 1,000 infants was 7.7 for group 1 (reference group), 28.8 for group 2 (relative risk (RR) = 3.7, 95% confidence interval (CI): 2.8, 5.0), 16.5 for group 3 (RR = 2.1, 95% CI: 1.5, 3.1), 64.9 for group 4 (RR = 8.4, 95% CI: 5.6, 12.6), 77.3 for group 5 (RR = 10.0, 95% CI: 7.5, 13.5), and 172.4 for group 6 (RR = 22.4, 95% CI: 16.1, 31.2). Trajectory models-which capture information on dose, duration, and timing of exposure-are useful for gaining insight into clinically relevant groupings to evaluate the risk of prenatal opioid exposure.
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17
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Smith BL. Improving translational relevance: The need for combined exposure models for studying prenatal adversity. Brain Behav Immun Health 2021; 16:100294. [PMID: 34589787 PMCID: PMC8474200 DOI: 10.1016/j.bbih.2021.100294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 12/18/2022] Open
Abstract
Prenatal environmental adversity is a risk factor for neurodevelopmental disorders (NDDs), with the neuroimmune environment proposed to play a role in this risk. Adverse maternal exposures are associated with cognitive consequences in the offspring that are characteristics of NDDs and simultaneous neuroimmune changes that may underlie NDD risk. In both animal models and human studies the association between prenatal environmental exposure and NDD risk has been shown to be complex. Maternal overnutrition/obesity and opioid use are two different examples of complex exposure epidemics, each with their own unique comorbidities. This review will examine maternal obesity and maternal opioid use separately, illustrating the pervasive comorbidities with each exposure to argue a need for animal models of compound prenatal exposures. Many of these comorbidities can impact neuroimmune function, warranting systematic investigation of combined exposures to begin to understand this complexity. While traditional approaches in animal models have focused on modeling a single prenatal exposure or second exposure later in life, a translational approach would begin to incorporate the most prevalent co-occurring prenatal exposures. Long term follow-up in humans is extremely challenging, so animal models can provide timely insight into neurodevelopmental consequences of complex prenatal exposures. Animal models that represent this translational context of comorbid exposures behind maternal obesity or comorbid exposures behind maternal opioid use may reveal potential synergistic neuroimmune interactions that contribute to cognitive consequences and NDD risk. Finally, translational co-exposure models can identify concerning exposure combinations to guide treatment in complex cases, and identify high risk children starting in the prenatal period where early interventions improve prognosis.
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Affiliation(s)
- Brittany L. Smith
- Department of Pharmacology & Systems Physiology, University of Cincinnati, Cincinnati, OH, USA
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18
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Schuetze P, Godleski S, Sassaman J. Prenatal exposure to opioids: Associations between the caregiving environment and externalizing behaviors. Neurotoxicol Teratol 2021; 87:107019. [PMID: 34403741 DOI: 10.1016/j.ntt.2021.107019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 08/02/2021] [Accepted: 08/09/2021] [Indexed: 11/15/2022]
Abstract
Maternal opioid use during pregnancy is a rapidly growing public health crisis and is associated with a range of adverse developmental outcomes including externalizing behaviors among exposed children. Recent work has highlighted the role of indirect pathways from prenatal opioid exposure to behavioral outcomes through aspects of the caregiving environment, including parenting. This review highlights maternal sensitivity and related aspects of the caregiving environment that may impact the development of externalizing behaviors among children with a history of prenatal exposure to opioids. We conclude by providing suggestions for future directions in research examining development among children with prenatal opioid exposure.
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Affiliation(s)
- Pamela Schuetze
- Department of Psychology, Buffalo State College, The State University of New York, USA; The Pennsylvania State University, USA.
| | | | - Jenna Sassaman
- Department of Psychology, College of Liberal Arts, The Pennsylvania State University, USA
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19
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The Term Newborn: Prenatal Substance Exposure. Clin Perinatol 2021; 48:631-646. [PMID: 34353584 DOI: 10.1016/j.clp.2021.05.011] [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: 11/22/2022]
Abstract
Care for pregnant patients with substance use disorder must be provided in a nonjudgmental manner with recognition of addiction as a chronic medical illness in order to establish a therapeutic relationship and improve outcomes. All pregnant patients should be screened for substance use during prenatal care. Screening can be accomplished through several validated screening tools. Patients who screen positive need to be evaluated and referred for treatment as appropriate. This article reviews specific adverse perinatal outcomes associated with the use of a variety of substances and provides guidance on exposure with continued breastfeeding.
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20
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Cleary EM, Smid MC, Charles JE, Jones KM, Costantine MM, Saade G, Rood KM. Buprenorphine X-waiver exemption - beyond the basics for the obstetrical provider. Am J Obstet Gynecol MFM 2021; 3:100451. [PMID: 34320429 DOI: 10.1016/j.ajogmf.2021.100451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 07/20/2021] [Indexed: 11/17/2022]
Abstract
Buprenorphine is 1 of 3 medications approved by the US Food and Drug Administration for the treatment of opioid use disorder, and practitioners must obtain a federal waiver to prescribe buprenorphine. Until recently, physicians and advanced practice clinicians were required to complete 8 and 24 hours of training, respectively, before applying for this waiver and to provide psychosocial services when prescribing buprenorphine to ≤30 patients. The US Department of Health and Human Services announced in April 2021 that eligible providers would be exempt from the educational requirement for certification, making the waiver more accessible for those intending to prescribe to ≤30 patients. Here, we reviewed the historic background to the exemption and provided practical guidelines to practitioners caring for obstetrical patients with opioid use disorder who are considering applying for the waiver for the first time. Because the educational requirements will no longer be required for X-waiver application, we reviewed fundamental topics and challenging scenarios that are often reviewed in certification courses.
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Affiliation(s)
- Erin M Cleary
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH.
| | - Marcela C Smid
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
| | - Jasmin E Charles
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
| | - Kaitlyn M Jones
- College of Nursing, University of Utah Health, Salt Lake City, UT
| | - Maged M Costantine
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH
| | - George Saade
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX
| | - Kara M Rood
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH
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21
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Predictors of pharmacologic therapy for neonatal opioid withdrawal syndrome: a retrospective analysis of a statewide database. J Perinatol 2021; 41:1381-1388. [PMID: 33608626 DOI: 10.1038/s41372-021-00969-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 01/13/2021] [Accepted: 01/27/2021] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Identify factors associated with the need for pharmacologic therapy (PT) among opioid exposed newborn (OENs). STUDY DESIGN Retrospective analysis of a statewide database of OENs from 2017 through 2019. Multivariable mixed-effects logistic regression modeled the association of maternal characteristics, infant characteristics, and family engagement practices on the receipt of PT. RESULTS Of 2098 OENs, 44.8% required PT for NOWS. Higher odds of PT were associated with in-utero exposure to medication treatment for opioid use disorder (MOUD) and non-prescribed opioids in addition to MOUD; nicotine, benzodiazepines, SSRIs; male; out-born infants and mother's ineligibility to provide breast-milk. Lower odds were associated with increasing birth year, skin-to-skin (STS) care, and rooming-in. CONCLUSION Male, out-born infants exposed to MOUD with additional non-prescribed opioids, nicotine, benzodiazepines and SSSRIs with mothers ineligible to provide breast-milk were more likely to require PT, while modifiable care practices including STS care, and rooming-in decreased the likelihood of PT.
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22
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King RS, Peacock-Chambers E, Wilson D, Shimer J, Foss S, Visintainer P, Singh R. Impact of maternal medication for opioid use disorder on neurodevelopmental outcomes of infants treated for neonatal opioid withdrawal syndrome. J Neonatal Perinatal Med 2021; 14:463-473. [PMID: 33843701 DOI: 10.3233/npm-200615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Increasing rates of maternal opioid use disorder has led to greater number of opioid exposed newborns (OENs). Maternal enrollment in medication for opioid use disorder (MOUD) program improves short term neonatal outcomes. This study aimed at assessing neurobehavioral outcomes for OENs. METHODS Retrospective observational cohort study of OENs between Jul 2006 and Dec 2018. Two study groups were identified as initiation of medication for opioid use disorder (MOUD) prior to diagnoses of pregnancy or after. Primary outcome variables were enrollment in and duration of EI services. Secondary outcome variable was diagnoses of a behavioral and/or developmental disorder (BDD) during the study period. RESULTS Of 242 infants, 113 were enrolled in EI and BDD diagnoses data was available for all infants [age range 6 to 12 years], 82% infants had exposure to maternal MOUD, while 18% were exposed to either maternal prescription non-MOUD opioids or illicit opioids. Maternal MOUD initiation prior to pregnancy was associated with improved short term outcomes for OENs. Almost a third of infants were diagnosed with a BDD with no differences between the two study groups. CONCLUSION Early initiation of maternal MOUD improved short term outcomes and discharge disposition for OENs. Prolonged in-utero exposure to opioids presents a potential for negative impact on neurodevelopmental and behavioral outcomes. These risks must be considered to increase access and adherence to EI services, as well as to focus on non-opioid based maternal MOUD. Longitudinal studies assessing the safety of MOUD on short and long-term child health outcomes are needed.
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Affiliation(s)
- R S King
- Department of Pediatrics, University of Massachusetts Medical School-Baystate, Springfield, MA, USA.,Department of Pediatrics, Tufts Medical Center, Boston, MA, USA
| | - E Peacock-Chambers
- Department of Pediatrics, University of Massachusetts Medical School-Baystate, Springfield, MA, USA.,Department of Medicine, Office of Research, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
| | - D Wilson
- Department of Medicine, Office of Research, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
| | - J Shimer
- Massachusetts Department of Public Health, Boston, MA, USA
| | - S Foss
- Department of Pediatrics, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
| | - P Visintainer
- Department of Medicine, Office of Research, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
| | - R Singh
- Department of Pediatrics, University of Massachusetts Medical School-Baystate, Springfield, MA, USA.,Department of Pediatrics, Tufts Medical Center, Boston, MA, USA
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23
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Isaac L, van den Hoogen NJ, Habib S, Trang T. Maternal and iatrogenic neonatal opioid withdrawal syndrome: Differences and similarities in recognition, management, and consequences. J Neurosci Res 2021; 100:373-395. [PMID: 33675100 DOI: 10.1002/jnr.24811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/01/2021] [Indexed: 11/12/2022]
Abstract
Opioids are potent analgesics used to manage pain in both young and old, but the increased use in the pregnant population has significant individual and societal implications. Infants dependent on opioids, either through maternal or iatrogenic exposure, undergo neonatal opioid withdrawal syndrome (NOWS), where they may experience withdrawal symptoms ranging from mild to severe. We present a detailed and original review of NOWS caused by maternal opioid exposure (mNOWS) and iatrogenic opioid intake (iNOWS). While these two entities have been assessed entirely separately, recognition and treatment of the clinical manifestations of NOWS overlap. Neonatal risk factors such as age, genetic predisposition, drug type, and clinical factors like type of opioid, cumulative dose of opioid exposure, and disease status affect the incidence of both mNOWS and iNOWS, as well as their severity. Recognition of withdrawal is dependent on clinical assessment of symptoms, and the use of clinical assessment tools designed to determine the need for pharmacotherapy. Treatment of NOWS relies on a combination of non-pharmacological therapies and pharmacological options. Long-term consequences of opioids and NOWS continue to generate controversy, with some evidence of anatomic brain changes, but conflicting animal and human clinical evidence of significant cognitive or behavioral impacts on school-age children. We highlight the current knowledge on clinically relevant recognition, treatment, and consequences of NOWS, and identify new advances in clinical management of the neonate. This review brings a unique clinical perspective and critically analyzes gaps between the clinical problem and our preclinical understanding of NOWS.
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Affiliation(s)
- Lisa Isaac
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Nynke J van den Hoogen
- Comparative Biology and Experimental Medicine, Physiology and Pharmacology, Hotchkiss Brain Institute, University of Calgary, Toronto, ON, Canada
| | - Sharifa Habib
- Department of Neonatology, Hospital for Sick Children, Toronto, ON, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Tuan Trang
- Comparative Biology and Experimental Medicine, Physiology and Pharmacology, Hotchkiss Brain Institute, University of Calgary, Toronto, ON, Canada
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24
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Kushnir A, Garretson C, Mariappan M, Stahl G. Use of Phenobarbital to Treat Neonatal Abstinence Syndrome From Exposure to Single vs. Multiple Substances. Front Pediatr 2021; 9:752854. [PMID: 35174112 PMCID: PMC8841756 DOI: 10.3389/fped.2021.752854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/21/2021] [Indexed: 11/17/2022] Open
Abstract
Drug use in pregnancy is a major public health issue. Intrauterine exposure to opioids alone or in addition to other substances may lead to neonatal abstinence syndrome (NAS). Little consensus exists on optimal therapy, especially for those exposed to multiple drugs. We aim to determine whether the use of opioids alone vs. in combination with phenobarbital will affect short-term neonatal outcomes. This retrospective review of infants admitted to the neonatal intensive care unit (NICU) included newborns ≥35 weeks of gestation exposed to opioids, or multiple substances including opioids, in utero. Treatment with opioids alone, and addition of phenobarbital as initial therapy vs. rescue, was evaluated. Out of 182 newborns, 54 (30%) were exposed to methadone alone vs. 128 (70%) to multiple drugs. Length of stay (LOS) in the hospital was not significantly affected (p = 0.684) by single vs. multiple drug exposure in utero. Treatment of NAS with opioid alone resulted in significantly shorter LOS (27 days), as compared to those treated with opioid and phenobarbital (45 days, p < 0.001). LOS was further prolonged in those treated with phenobarbital as a "rescue" medication in addition to an opioid (49 days, p < 0.0001). There was a significant increase in LOS and duration of opioid treatment for all infants treated with phenobarbital, both in those exposed to opioids alone, and to multiple substances in utero.
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Affiliation(s)
- Alla Kushnir
- Division of Neonatology, Department of Pediatric, Cooper University Hospital, Camden, NJ, United States.,Department of Pediatric, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Cynthia Garretson
- Ambulatory Clinical Practice, Cooper University Hospital, Cherry Hill, NJ, United States
| | - Maheswari Mariappan
- Division of Neonatology, Department of Pediatric, Cooper University Hospital, Camden, NJ, United States
| | - Gary Stahl
- Department of Pediatric, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, United States
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25
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Roth D, Loudin S, Andrews L, Evans J, Davies TH. Inclusion of Positive Self-reporting by Mothers of Substance Exposed Neonates Increases the Predictability of NAS Severity Over Toxicology Alone. Matern Child Health J 2020; 24:340-350. [PMID: 31916143 DOI: 10.1007/s10995-019-02871-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The rise in opioid use among pregnant women has resulted in an increase in the incidence of neonatal abstinence syndrome (NAS). Despite the focus on opioid use, prenatal polysubstance exposure is often associated with NAS diagnosis and severity. Drug toxicology screens such as urine drug screens and umbilical cord toxicology are dependent upon the substance, timing, frequency, and dose to detect substances present and can underestimate the neonatal exposure. The aim of this study was to identify the predictability of the consequences of prenatal polysubstance exposure versus opioid only exposure based on toxicology and toxicology plus self-report. METHODS Neonates > 35 weeks gestation with prenatal opioid exposure were included in this retrospective data analysis. NAS was identified using maternal urine drug screen (UDS) toxicology, self-reported exposure during pregnancy, and neonatal toxicology. Analysis was conducted using Stata 15.1 utilizing McNemar's test, chi-square for categorical outcomes, and Wilcoxon test for numerical outcomes. RESULTS A statistically significant difference in length of stay and length of treatment with poly-exposed neonates was observed when maternal self-report was considered with toxicology, but not with toxicology alone. This trend was observed for cumulative hospital length of stay as well as length and dose of treatment. CONCLUSIONS FOR PRACTICE The findings in this report demonstrate that self-report is important for identifying substance of exposure. Three substances in particular that often require a change in treatment paradigm went undetected by toxicology were Gabapentin (20.9% of the population), Heroin (20.5% of the population), and Benzodiazepines (8.5% of the population). A healthy rapport with patients is often critical to effective clinical practice. Women with substance use disorder anticipate negative reactions from healthcare providers. Empathetic interview techniques to facilitate accurate disclosure may be more important to the treatment of the exposed neonate.
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Affiliation(s)
- Danielle Roth
- Department of Pediatrics, Joan C Edwards School of Medicine at Marshall University, Huntington, WV, USA
| | - Sean Loudin
- Department of Pediatrics, Joan C Edwards School of Medicine at Marshall University, Huntington, WV, USA
| | - Lacey Andrews
- Division of Addiction Sciences, Family and Community Health, Joan C Edwards School of Medicine of Marshall University, 1600 Medical Center Drive, Huntington, WV, 25701, USA
| | - Joseph Evans
- Department of Pediatrics, Joan C Edwards School of Medicine at Marshall University, Huntington, WV, USA
| | - Todd H Davies
- Division of Addiction Sciences, Family and Community Health, Joan C Edwards School of Medicine of Marshall University, 1600 Medical Center Drive, Huntington, WV, 25701, USA.
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Factors Associated With the Need for Pharmacological Management of Neonatal Opioid Withdrawal Syndrome. Adv Neonatal Care 2020; 20:364-373. [PMID: 32868586 DOI: 10.1097/anc.0000000000000772] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Neonatal opioid withdrawal syndrome (NOWS) is a significant and growing health problem that affects more than 23,000 infants annually, with an estimated hospital cost of more than $720 million. PURPOSE The purpose of this study was to examine factors associated with the need to initiate medication for the treatment of NOWS. METHODS A retrospective review of medical records was conducted of 204 infants born to mothers who used opioids during pregnancy from April 2011 to September 2017. Associations between maternal, infant, and environmental factors and the need for neonatal pharmacological management were examined using χ, t tests, and regression analysis. RESULTS Of 204 neonates exposed to opioids prenatally, 121 (59%) developed symptoms of NOWS, requiring treatment with morphine. Neonates requiring morphine had significantly higher gestational ages (37.7 weeks vs 36.4 weeks; P < .001), and mothers were present at the neonate's bedside for a lower proportion of their total hospital stay (57% vs 74% of days; P < .001). Maternal factors associated with the need for neonatal medication treatment included the mother's reason for opioid use (P = .014), primary type of opioid used (P < .001), tobacco use (P = .023), and use of benzodiazepines (P = .003). IMPLICATIONS FOR PRACTICE This research provides information regarding the proportion of infants exposed to opioids prenatally who develop NOWS that requires treatment, as well as maternal, infant, and environmental factors associated with the need for neonatal medication use. IMPLICATIONS FOR RESEARCH Future research is needed to examine these relationships prospectively in a larger and more diverse sample.
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27
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Jantzie LL, Maxwell JR, Newville JC, Yellowhair TR, Kitase Y, Madurai N, Ramachandra S, Bakhireva LN, Northington FJ, Gerner G, Tekes A, Milio LA, Brigman JL, Robinson S, Allan A. Prenatal opioid exposure: The next neonatal neuroinflammatory disease. Brain Behav Immun 2020; 84:45-58. [PMID: 31765790 PMCID: PMC7010550 DOI: 10.1016/j.bbi.2019.11.007] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/29/2019] [Accepted: 11/17/2019] [Indexed: 01/19/2023] Open
Abstract
The rates of opioid use disorder during pregnancy have more than quadrupled in the last decade, resulting in numerous infants suffering exposure to opioids during the perinatal period, a critical period of central nervous system (CNS) development. Despite increasing use, the characterization and definition of the molecular and cellular mechanisms of the long-term neurodevelopmental impacts of opioid exposure commencing in utero remains incomplete. Thus, in consideration of the looming public health crisis stemming from the multitude of infants with prenatal opioid exposure entering school age, we undertook an investigation of the effects of perinatal methadone exposure in a novel preclinical model. Specifically, we examined the effects of opioids on the developing brain to elucidate mechanisms of putative neural cell injury, to identify diagnostic biomarkers and to guide clinical studies of outcome and follow-up. We hypothesized that methadone would induce a pronounced inflammatory profile in both dams and their pups, and be associated with immune system dysfunction, sustained CNS injury, and altered cognition and executive function into adulthood. This investigation was conducted using a combination of cellular, molecular, biochemical, and clinically translatable biomarker, imaging and cognitive assessment platforms. Data reveal that perinatal methadone exposure increases inflammatory cytokines in the neonatal peripheral circulation, and reprograms and primes the immune system through sustained peripheral immune hyperreactivity. In the brain, perinatal methadone exposure not only increases chemokines and cytokines throughout a crucial developmental period, but also alters microglia morphology consistent with activation, and upregulates TLR4 and MyD88 mRNA. This increase in neuroinflammation coincides with reduced myelin basic protein and altered neurofilament expression, as well as reduced structural coherence and significantly decreased fractional anisotropy on diffusion tensor imaging. In addition to this microstructural brain injury, adult rats exposed to methadone in the perinatal period have significant impairment in associative learning and executive control as assessed using touchscreen technology. Collectively, these data reveal a distinct systemic and neuroinflammatory signature associated with prenatal methadone exposure, suggestive of an altered CNS microenvironment, dysregulated developmental homeostasis, complex concurrent neural injury, and imaging and cognitive findings consistent with clinical literature. Further investigation is required to define appropriate therapies targeted at the neural injury and improve the long-term outcomes for this exceedingly vulnerable patient population.
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Affiliation(s)
- Lauren L. Jantzie
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Neurology, Kennedy Krieger Institute, Baltimore, MD.,Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM.,Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM.,Correspondence: Lauren L. Jantzie, PhD, Johns Hopkins University, Department of Pediatrics, Division of Neonatal-Perinatal Medicine, 600 N. Wolfe Street, CMSC Building Room 6-104A, Baltimore, MD 21287,
| | - Jessie R. Maxwell
- Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM.,Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM
| | - Jessie C. Newville
- Department of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM.,Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM
| | - Tracylyn R. Yellowhair
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yuma Kitase
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nethra Madurai
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sindhu Ramachandra
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ludmila N. Bakhireva
- Substance Use Research and Education (SURE) Center, University of New Mexico College of Pharmacy, Albuquerque, NM
| | | | - Gwendolyn Gerner
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aylin Tekes
- Division of Pediatric Radiology and Pediatric Neuroradiology, Russell Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lorraine A. Milio
- Department of Obstetrics & Gynecology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan L. Brigman
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM
| | - Shenandoah Robinson
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrea Allan
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM
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Newville J, Maxwell JR, Kitase Y, Robinson S, Jantzie LL. Perinatal Opioid Exposure Primes the Peripheral Immune System Toward Hyperreactivity. Front Pediatr 2020; 8:272. [PMID: 32670993 PMCID: PMC7332770 DOI: 10.3389/fped.2020.00272] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/29/2020] [Indexed: 11/29/2022] Open
Abstract
The increased incidence of opioid use during pregnancy warrants investigation to reveal the impact of opioid exposure on the developing fetus. Exposure during critical periods of development could have enduring consequences for affected individuals. Particularly, evidence is mounting that developmental injury can result in immune priming, whereby subsequent immune activation elicits an exaggerated immune response. This maladaptive hypersensitivity to immune challenge perpetuates dysregulated inflammatory signaling and poor health outcomes. Utilizing an established preclinical rat model of perinatal methadone exposure, we sought to investigate the consequences of developmental opioid exposure on in vitro activation of peripheral blood mononuclear cells (PBMCs). We hypothesize that PBMCs from methadone-exposed rats would exhibit abnormal chemokine and cytokine expression at baseline, with exaggerated chemokine and cytokine production following immune stimulation compared to saline-exposed controls. On postnatal day (P) 7, pup PMBCs were isolated and cultured, pooling three pups per n. Following 3 and 24 h, the supernatant from cultured PMBCs was collected and assessed for inflammatory cytokine and chemokine expression at baseline or lipopolysaccharide (LPS) stimulation using multiplex electrochemiluminescence. Following 3 and 24 h, baseline production of proinflammatory chemokine and cytokine levels were significantly increased in methadone PBMCs (p < 0.0001). Stimulation with LPS for 3 h resulted in increased tumor necrosis factor (TNF-α) and C-X-C motif chemokine ligand 1 (CXCL1) expression by 3.5-fold in PBMCs from methadone-exposed PBMCs compared to PBMCs from saline-exposed controls (p < 0.0001). Peripheral blood mononuclear cell hyperreactivity was still apparent at 24 h of LPS stimulation, evidenced by significantly increased TNF-α, CXCL1, interleukin 6 (IL-6), and IL-10 production by methadone PMBCs compared to saline control PBMCs (p < 0.0001). Together, we provide evidence of increased production of proinflammatory molecules from methadone PBMCs at baseline, in addition to sustained hyperreactivity relative to saline-exposed controls. Exaggerated peripheral immune responses exacerbate inflammatory signaling, with subsequent consequences on many organ systems throughout the body, such as the developing nervous system. Enhanced understanding of these inflammatory mechanisms will allow for appropriate therapeutic development for infants who were exposed to opioids during development. Furthermore, these data highlight the utility of this in vitro PBMC assay technique for future biomarker development to guide specific treatment for patients exposed to opioids during gestation.
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Affiliation(s)
- Jessie Newville
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Jessie R Maxwell
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM, United States.,Departments of Pediatrics, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Yuma Kitase
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Shenandoah Robinson
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Lauren L Jantzie
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,Department of Neurology, Kennedy Krieger Institute, Baltimore, MD, United States
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Feizi M, Gholami M, Poosti A, Mayvan FA, Kamali Z, Toghraee M. Comparison of attachment styles of addicted parents and non-addicted parents in health-care referents. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2019; 8:182. [PMID: 31867367 PMCID: PMC6796296 DOI: 10.4103/jehp.jehp_397_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 01/09/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Growing interest in issues of attachment, sociocultural, psychological, and above all clinical perspectives is also reflected in the emergence of research on "attachment style and parental parenting style in referrals to addiction treatment centers." METHODS This was a cross-sectional study. Three health centers were selected randomly from among the health centers of Neyshabur city in 2015-2016 year. The sampling was done so that all individuals who had the characteristics of the research unit and had the consent to participate in the study were justified by the researcher and completed questionnaire form. We used Chi-square, one-way analysis of variance, Mann-Whitney, and Kruskal-Wallis tests. RESULTS In the present study, safe attachment scores in children with healthy parents were significantly more than children with addicted parents. CONCLUSION Addiction has an important role in reducing attachment to children, and because this decrease in attachment has dangerous consequences in child's life.
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Affiliation(s)
- Marzeiyeh Feizi
- Department of Psychology, Neyshabur University of Medical Sciences, Neyshabur, Iran
| | - Mahboobe Gholami
- Department of Midwifery, School of Nursing and Midwifery, Neyshabur University of Medical Sciences, Neyshabur, Iran
| | - Akram Poosti
- Department of Midwifery, Student Research Committee, Neyshabur University Medical Science, Neyshabur, Iran
| | - Fatemeh Azizi Mayvan
- Department of Biostatistics, Neyshabur University of Medical Science, Neyshabur, Iran
| | - Zahra Kamali
- Department of Midwifery, School of Nursing and Midwifery, Neyshabur University of Medical Sciences, Neyshabur, Iran
| | - Minoo Toghraee
- Department of Midwifery, Student Research Committee, Neyshabur University Medical Science, Neyshabur, Iran
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Abstract
OBJECTIVE To describe the characteristics, treatment, and outcomes of pregnant women with opioid use disorder. METHODS Women attending an obstetric and addiction recovery clinic in Boston from 2015 to 2016 were enrolled in a prospective cohort study and followed through delivery (N=113). Buprenorphine or methadone was initiated clinically. The Addiction Severity Index was administered at enrollment. Prenatal and delivery data were systematically abstracted from medical charts. RESULTS Most women in the cohort were non-Hispanic white (80.5%) with a mean age of 28 years. Few women were married (8.9%). More than half of the cohort had been incarcerated, 29.2% had current legal involvement, and 15.0% generally had unstable housing. A majority (70.8%) were infected with hepatitis C and histories of sexual (56.6%) and physical (65.5%) abuse were prevalent. Regular substance used included heroin (92.0%), injection heroin (83.2%), other opioids (69.0%), marijuana (73.5%), alcohol (56.6%), and cocaine (62.8%). Fifty-nine women (52.2%) were treated initially with prenatal buprenorphine and 54 (47.8%) with methadone; 49.6% also were taking concomitant psychotropic medications. Employment (0.766±0.289) and psychologic (0.375±0.187) Addiction Severity Index scores were the highest, indicating the most severe problems in these areas. Opioid use relapse did not differ by treatment (44.7% overall). Thirteen (22.5%) of 59 women treated with buprenorphine transitioned to methadone mainly because of positive opioid screens. Overall, 23.0% (n=26) of the cohort discontinued clinical care. The number of pregnancy losses was small (three therapeutic abortions, four miscarriages, one stillbirth), with an overall live birth rate of 90.8% (95% CI 82.7-95.9). CONCLUSION These data on the social circumstances, substance use, treatment, and treatment outcomes of pregnant women with opioid use disorder may help clinicians to understand and treat this clinically complex population.
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Lisonkova S, Richter LL, Ting J, Muraca GM, Wen Q, Mehrabadi A, Mitchell-Foster S, Oviedo-Joekes E, Lyons J. Neonatal Abstinence Syndrome and Associated Neonatal and Maternal Mortality and Morbidity. Pediatrics 2019; 144:peds.2018-3664. [PMID: 31300529 DOI: 10.1542/peds.2018-3664] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/15/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We examined demographic characteristics and birth outcomes of infants with neonatal abstinence syndrome (NAS) and their mothers in Canada. METHODS This retrospective, population-based, descriptive cross-sectional study of mother-infant dyads included all singleton live births in Canada (excluding Quebec), from 2005-2006 to 2015-2016 (N = 2 881 789). Demographic characteristics, NAS, and neonatal and maternal morbidities were identified from delivery hospitalization data (including diagnostic codes). The main composite outcomes were maternal and neonatal mortality and/or severe morbidity, including death and potentially life-threatening conditions in the mother and the infant, respectively. Logistic regression yielded adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS The study included 10 027 mother-infant dyads with NAS. The incidence of NAS increased from 0.20% to 0.51%. Maternal mortality was 1.99 vs 0.31 per 10 000 women in the NAS group versus the comparison group (aOR = 6.53; 95% CI: 1.59 to 26.74), and maternal mortality and/or severe morbidity rates were 3.10% vs 1.35% (aOR = 2.21; 95% CI: 1.97 to 2.49). Neonatal mortality was 0.12% vs 0.19% (aOR = 0.28; 95% CI: 0.15 to 0.53), and neonatal mortality and/or severe morbidity rates were 6.36% vs 1.73% (aOR = 2.27; 95% CI: 2.06 to 2.50) among infants with NAS versus without NAS. CONCLUSIONS NAS incidence increased notably in Canada between 2005-2006 and 2015-2016. Infants with NAS had elevated severe morbidity, and their mothers had elevated mortality and severe morbidity. These results highlight the importance of implementing integrated care services to support the mother-infant dyad during childbirth and in the postpartum period.
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Affiliation(s)
- Sarka Lisonkova
- Departments of Obstetrics and Gynecology and .,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Joseph Ting
- Pediatrics, University of British Columbia and the British Columbia Women's Hospital and Health Center, Vancouver, British Columbia, Canada
| | | | - Qi Wen
- Department of Statistics and Actuarial Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Azar Mehrabadi
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Sheona Mitchell-Foster
- Departments of Obstetrics and Gynecology and.,Northern Medical Program, University of British Columbia, Prince George, British Columbia, Canada; and
| | - Eugenia Oviedo-Joekes
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Health Evaluation and Outcome Sciences, Providence Health Care, St Paul's Hospital, Vancouver, Canada
| | - Janet Lyons
- Departments of Obstetrics and Gynecology and
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Rana D, Pollard L, Rowland J, Dhanireddy R, Pourcyrous M. Amplitude-integrated EEG in infants with neonatal abstinence syndrome. J Neonatal Perinatal Med 2019; 12:391-397. [PMID: 31356218 DOI: 10.3233/npm-1834] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND To describe amplitude-integrated encephalogram (aEEG) characteristics of neonates with neonatal abstinence syndrome (NAS). METHODS This is a prospective observational study. Newborns exposed to prenatal opioids and their gestational matched controls were included. A single-channel aEEG was obtained using Olympic 6000 CFM monitor. The background activity (continuous/discontinuous), the amplitudes (μV) and the presence of sleep-wake cycle (SWC) were documented. RESULTS A total of 59 infants, 23 with NAS and 36 controls were enrolled. All aEEG were completed within 48 hours of life prior to initiation of treatment. Birth weight and gestational age were similar in both groups. An aEEG was abnormal (discontinuous pattern and/or absent SWC) in 78 % (18/23) of infants with NAS versus only 25% in control group (9/36), [OR 10.8, CI (2.7-46.5) P < 0.001]. 61% of infants with NAS had discontinuous pattern [OR 7.8, CI (2-32) P = 0.001] and 39% had absence of sleep-wake cycle [OR 7.1, CI (1.4-39.4) P = 0.007]. CONCLUSIONS A majority of infants with NAS have abnormal aEEG activity.
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Affiliation(s)
- Divya Rana
- Department of Pediatrics, Division of Neonatology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Leann Pollard
- Department of Pediatrics, Division of Neonatology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jonathan Rowland
- Department of Pediatrics, Division of Neonatology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ramasubbareddy Dhanireddy
- Department of Pediatrics, Division of Neonatology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Massroor Pourcyrous
- Department of Pediatrics, Division of Neonatology, University of Tennessee Health Science Center, Memphis, TN, USA
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Whalen BL, Holmes AV, Blythe S. Models of care for neonatal abstinence syndrome: What works? Semin Fetal Neonatal Med 2019; 24:121-132. [PMID: 30926259 DOI: 10.1016/j.siny.2019.01.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Opioid use disorders and the prescription of long-acting medications for their treatment have increased dramatically over the last decade among pregnant women. Newborns who experience prolonged in utero opioid exposure may develop neonatal abstinence syndrome (NAS). Until recently, much of the focus on improving care for NAS has been on pharmacologically-based care models. Recent studies have illustrated the benefits of rooming-in and parental presence on NAS outcomes. Single center Quality Improvement (QI) initiatives demonstrate the benefits of non-pharmacologic care bundles and symptom prioritization in decreasing the proportion of infants pharmacologically treated and length of hospital stay. Little remains known about the impact of these varied cared models on maternal-infant attachment and mental health. In this review article, we will propose an optimal model of care to improve short- and long-term outcomes for newborns, their mothers and families, and perinatal care systems.
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Affiliation(s)
- Bonny L Whalen
- Geisel School of Medicine at Dartmouth, Children's Hospital at Dartmouth-Hitchcock, Dartmouth-Hitchcock Medical Center, DHMC Pediatrics, One Medical Center Dr., Lebanon, NH, 03756, USA.
| | - Alison V Holmes
- Geisel School of Medicine at Dartmouth, Children's Hospital at Dartmouth-Hitchcock, Dartmouth-Hitchcock Medical Center, The Dartmouth Institute, DHMC Pediatrics, One Medical Center Dr, Lebanon, NH, 03756, USA.
| | - Stacy Blythe
- School of Nursing and Midwifery, Western Sydney University, Translational Health Research Institute (THRI), Locked Bag 1797, Western Sydney University, Penrith, NSW, 2751, Australia.
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Klaman SL, Isaacs K, Leopold A, Perpich J, Hayashi S, Vender J, Campopiano M, Jones HE. Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance. J Addict Med 2018; 11:178-190. [PMID: 28406856 PMCID: PMC5457836 DOI: 10.1097/adm.0000000000000308] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 02/12/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The prevalence of opioid use disorder (OUD) during pregnancy is increasing. Practical recommendations will help providers treat pregnant women with OUD and reduce potentially negative health consequences for mother, fetus, and child. This article summarizes the literature review conducted using the RAND/University of California, Los Angeles Appropriateness Method project completed by the US Department of Health and Human Services Substance Abuse and Mental Health Services Administration to obtain current evidence on treatment approaches for pregnant and parenting women with OUD and their infants and children. METHODS Three separate search methods were employed to identify peer-reviewed journal articles providing evidence on treatment methods for women with OUD who are pregnant or parenting, and for their children. Identified articles were reviewed for inclusion per study guidelines and relevant information was abstracted and summarized. RESULTS Of the 1697 articles identified, 75 were included in the literature review. The perinatal use of medication for addiction treatment (MAT, also known as medication-assisted treatment), either methadone or buprenorphine, within comprehensive treatment is the most accepted clinical practice, as withdrawal or detoxification risks relapse and treatment dropout. Medication increases may be needed with advancing pregnancy, and are not associated with more severe neonatal abstinence syndrome (NAS). Switching medication prenatally is usually not recommended as it can destabilize opioid abstinence. Postnatally, breastfeeding is seen as beneficial for the infant for women who are maintained on a stable dose of opioid agonist medication. Less is known about ideal pain management and postpartum dosing regimens. NAS appears generally less severe following prenatal exposure to buprenorphine versus methadone. Frontline NAS medication treatments include protocol-driven methadone and morphine dosing in the context of nonpharmacological supports. CONCLUSIONS Women with OUD can be treated with methadone or buprenorphine during pregnancy. NAS is an expected and manageable condition. Although research has substantially advanced, opportunities to guide future research to improve maternal and infant outcomes are provided.
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Affiliation(s)
- Stacey L Klaman
- Department of Maternal and Child Health, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC (SLK); JBS International, Inc., North Bethesda, MD (KI, AL, JP, SH, JV); Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services, Rockville, MD (MC); UNC Horizons, Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC (HEJ); Departments of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, School of Medicine, Johns Hopkins University, Baltimore, MD (HEJ)
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Jansson LM, Velez ML, McConnell K, Spencer N, Tuten M, Jones H, Rios R, King VL, Gandotra N, Millio L, DiPietro JA. Maternal buprenorphine treatment and infant outcome. Drug Alcohol Depend 2017; 180:56-61. [PMID: 28869859 PMCID: PMC5788458 DOI: 10.1016/j.drugalcdep.2017.08.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/19/2017] [Accepted: 08/01/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND OBJECTIVES Maternal buprenorphine maintenance predisposes the infant to exhibit neonatal abstinence syndrome (NAS), but there is insufficient published information regarding the nature of NAS and factors that contribute to its severity in buprenorphine-exposed infants. METHODS The present study evaluated forty-one infants of buprenorphine-maintained women in comprehensive substance use disorder treatment who participated in an open-label study examining the effects of maternal buprenorphine maintenance on infant outcomes. Modifiers of the infant outcomes, including maternal treatment and substance use disorder parameters, were also evaluated. RESULTS Fifty-nine percent of offspring exhibited NAS that required pharmacologic management. Both maternal buprenorphine dose as well as prenatal polysubstance exposure to illicit substance use/licit substance misuse were independently associated with NAS expression. Polysubstance exposure was associated with more severe NAS expression after controlling for the effects of buprenorphine dose. Other exposures, including cigarette smoking and SRI use, were not related to outcomes. Maternal buprenorphine dose was positively associated with lower birth weight and length. CONCLUSIONS Polysubstance exposure was the most potent predictor of NAS severity in this sample of buprenorphine-exposed neonates. This finding suggests the need for interventions that reduce maternal polysubstance use during medication assisted treatment for opioid use disorder, and highlights the necessity of a comprehensive approach, beyond buprenorphine treatment alone, for the optimal care for pregnant women with opioid use disorders.
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Affiliation(s)
| | | | | | | | | | - Hendree Jones
- University of North Carolina Chapel Hill, Chapel Hill, NC
| | - Rebeca Rios
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Van L. King
- Johns Hopkins University School of Medicine, Baltimore, MD
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Huybrechts KF, Bateman BT, Desai RJ, Hernandez-Diaz S, Rough K, Mogun H, Kerzner LS, Davis JM, Stover M, Bartels D, Cottral J, Patorno E. Risk of neonatal drug withdrawal after intrauterine co-exposure to opioids and psychotropic medications: cohort study. BMJ 2017; 358:j3326. [PMID: 28768628 PMCID: PMC5538591 DOI: 10.1136/bmj.j3326] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objectives To assess the impact of in utero co-exposure to psychotropic medications and opioids on the incidence and severity of neonatal drug withdrawal.Design Observational cohort study.Setting Nationwide sample of pregnancies in publicly insured women in the US, nested in the Medicaid Analytic eXtract (2000-10).Participants 201 275 pregnant women with public insurance who were exposed to opioids around the time of delivery and their liveborn infants.Interventions In utero exposure to psychotropic medications, in particular antidepressants, atypical antipsychotics, benzodiazepines, gabapentin, and non-benzodiazepine hypnotics (Z drugs), with prescriptions filled within the same time window as prescriptions for opioids.Main outcome measure Diagnosis of neonatal drug withdrawal in infants exposed in utero to opioids and psychotropic medications compared with opioids alone.Results The absolute risk for neonatal drug withdrawal ranged from 1.0% in infants exposed in utero to prescription opioids alone to 11.4% for those exposed to opioids co-prescribed with gabapentin. Among neonates exposed in utero to prescription opioids, the relative risk adjusted for propensity score was 1.34 (95% confidence interval 1.22 to 1.47) with concomitant exposure to antidepressants, 1.49 (1.35 to 1.63) with benzodiazepines, 1.61 (1.26 to 2.06) with gabapentin, 1.20 (0.95 to 1.51) with antipsychotics, and 1.01 (0.88 to 1.15) with Z drugs. In utero exposure to two or more psychotropic medications along with opioids was associated with a twofold increased risk of withdrawal (2.05, 1.77 to 2.37). The severity of the withdrawal seemed increased in neonates exposed to both opioids and psychotropic medications compared with opioids alone.Conclusions During pregnancy, the use of psychotropic medications in addition to prescription opioids is common, despite a lack of safety data. The current findings suggest that these drugs could further increase the risk and severity of neonatal drug withdrawal.
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Affiliation(s)
- Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sonia Hernandez-Diaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Kathryn Rough
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Leslie S Kerzner
- Department of Pediatrics, Massachusetts General Hospital for Children and Harvard Medical School, Boston, MA, USA
| | - Jonathan M Davis
- Department of Pediatrics, The Floating Hospital at Tufts Medical Center and the Tufts Clinical and Translational Science Institute, Tufts University , Boston, MA, USA
| | - Megan Stover
- Department of Obstetrics and Gynecology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA, USA
| | - Devan Bartels
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jennifer Cottral
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Abstract
PURPOSE OF REVIEW Over the last 15 years the prevalence of neonatal abstinence syndrome (NAS) increased almost five-fold. A considerable diversity seems to prevail in the management of NAS. This review provides an overview of factors affecting the expression and course of NAS, and recent developments in NAS assessment and treatment. RECENT FINDINGS Apart from different pharmacological and nonpharmacological treatment modalities, maturity of the infant and genetic variations likely are (co)responsible for interpatient variability in NAS severity, despite similar maternal exposure. Recent efforts concerning the further development of NAS severity scoring systems focus on the development of brief screening measures; in addition, pupil diameter and skin conductance have been proposed as complements to observer-rated scales. The decrease in incidence of NAS begins in the appropriate management of medication assisted treatment of the mother. SUMMARY Mitigating the negative outcomes for infants affected by NAS, their mothers and the healthcare system implies, first and foremost, developing and implementing an organized protocol for the management of NAS, and the homogenous use of a standardized scoring system utilizing interobserver reliability and a guide for medication initiation, maintenance, and weaning which is consistent with traditional methods of treatment for neonates.
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Wang X, Zhu Y, Dave CV, Alrwisan AA, Voils SA, Winterstein AG. Trends of Neonatal Abstinence Syndrome Epidemic and Maternal Risk Factors in Florida. Pharmacotherapy 2017; 37:806-813. [PMID: 28500694 DOI: 10.1002/phar.1947] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE This study aimed to examine secular trends of (i) maternal prescription opioid use in late pregnancy, (ii) neonatal abstinence syndrome (NAS) stratified by late maternal prescription opioid use, and (iii) maternal risk factors among NAS deliveries. METHODS Women with a live birth who were enrolled 90 days before and 30 days after delivery in Florida Medicaid Analytic Extract billing records linked to birth certificates from 2000 to 2010 were identified for the study. Changes in the annual prevalence of prescription opioid use during pregnancy were tested with use of the Cochran-Armitage trend test. Temporal trends of NAS deliveries were estimated with the use of Poisson regression and stratified by prescription opioid exposure in the last 90 days of pregnancy in the study period. To identify contributors to the increase in NAS cases, variations in prevalence of opioid dispensing, tobacco use, antidepressant use, and substance use disorder among NAS and non-NAS deliveries were examined. RESULTS There were 41,968 (9.4%) deliveries exposed to at least one opioid prescription in late pregnancy, and this rate remained stable from 2000 to 2010. Among prescription opioid-exposed deliveries, frequency of NAS increased from 1.6 to 25.2 per 1000 live births during the study period (p<0.05). Although the prevalence of maternal use of prescription opioid, tobacco, and antidepressants remained stable among NAS deliveries from 2000 to 2010, the prevalence of substance use disorder diagnoses increased substantially from 38.9% in 2000 to 67.9% in 2006 (p<0.05). CONCLUSIONS The prevalence of NAS increased dramatically whereas the prevalence of major risk factors, including maternal prescription opioid use, remained stable in Florida between 2000 and 2010. The increase in substance use disorder may be responsible for the sharp increase in NAS deliveries.
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Affiliation(s)
- Xi Wang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Yanmin Zhu
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Chintan V Dave
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Adel A Alrwisan
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida.,National Pharmacovigilance Center, Saudi Food and Drug Authority, Riyadh, Saudi Arabia
| | - Stacy A Voils
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida.,Department of Epidemiology, College of Public Health and Health Professions, University of Florida, Gainesville, Florida
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Ryan G, Dooley J, Windrim R, Bollinger M, Gerber Finn L, Kelly L. Maternal-Fetal Monitoring of Opioid-Exposed Pregnancies: Analysis of a Pilot Community-Based Protocol and Review of the Literature. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:443-452. [PMID: 28363609 DOI: 10.1016/j.jogc.2017.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 12/19/2016] [Accepted: 01/18/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES To describe/analyse a novel, community-based prenatal monitoring protocol for opioid-exposed pregnancies developed by our centre in 2014 to optimize prenatal care for this population. A literature review of published monitoring protocols for this population is also presented. METHODS Retrospective comparison of pre-protocol (n = 215) and post-protocol (n = 251) cohorts. Medline and Embase were searched between 2000-2016 using MeSH terms: [fetal monitoring OR prenatal care] AND [opioid-related disorders OR substance-related disorders] in Medline and [fetal monitoring OR prenatal care] AND [opiate addiction OR substance abuse] in Embase, producing 518 results. Thirteen studies included protocols for monitoring opioid-exposed pregnancies. No comprehensive monitoring protocols with high-quality supporting evidence were found. RESULTS We evaluated 466 opioid-exposed pregnancies, 215 before and 251 after introduction of the protocol. Since implementation, there was a significant increase in the number of opioid-exposed patients who have underwent urine drug screening (72.6% to 89.2%, P < 0.0001); a significant reduction in the number of urine drug screenings positive for illicit opioids (50.2% to 29.1%, P < 0.0001); and a significant increase in the number of patients who discontinued illicit opioid use by the time of delivery (24.7% to 39.4%, P < 0.01). There was no difference in the CS rate (27.4% vs. 26.3%, P > 0.05). There were no observed differences in the rate of preterm birth, birth weight <2500 g, or Apgar score <7 (P > 0.05). CONCLUSIONS Care of women with increased opioid use during pregnancy is an important but under-studied health issue. A novel protocol for focused antenatal care provision for women with opioid-exposed pregnancies improves standard of care and maternal/fetal outcomes.
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Affiliation(s)
- Gareth Ryan
- Anishnaabe Bimaadiziwin Research Program, Sioux Lookout, ON
| | - Joe Dooley
- Northern Ontario School of Medicine, Sioux Lookout Meno Ya Win Health Centre, Sioux Lookout, ON
| | - Rory Windrim
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON
| | | | | | - Len Kelly
- Northern Ontario School of Medicine, Sioux Lookout Meno Ya Win Health Centre, Sioux Lookout, ON.
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Abu Jawdeh EG, Westgate PM, Pant A, Stacy AL, Mamilla D, Gabrani A, Patwardhan A, Bada HS, Giannone P. Prenatal Opioid Exposure and Intermittent Hypoxemia in Preterm Infants: A Retrospective Assessment. Front Pediatr 2017; 5:253. [PMID: 29270395 PMCID: PMC5723668 DOI: 10.3389/fped.2017.00253] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 11/10/2017] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Intermittent hypoxemia (IH) is defined as episodic drops in oxygen saturation (SpO2). Preterm infants are at increased risk for IH due to their immature respiratory control/apnea of prematurity. The clinical relevance of IH is a relatively new observation with rising evidence linking IH to neonatal morbidities and long-term impairment. Hence, assessing factors that influence IH in preterm infants is imperative. Given the epidemic of opioid misuse in the USA, there is an urgent need to understand the impact of prenatal opioid exposure on neonatal outcomes. Hence, we wanted to assess the relationship between isolated prenatal opioid exposure and IH in preterm infants. METHODS In order to accurately calculate IH, SpO2 data were prospectively collected using high-resolution pulse oximeters during the first 8 weeks of life in preterm infants less than 30 weeks gestational age. Data related to prenatal opioid misuse were retrospectively collected from medical charts. Infants with tobacco or poly-drug exposure were excluded. The primary outcome measure is percent time spent with SpO2 below 80% (%time-SpO2 < 80). The secondary outcome measure is the number of severe IH events/week with SpO2 less than 80% (IH-SpO2 < 80). RESULTS A total of 82 infants with isolated opioid exposure (n = 14) or who were unexposed (n = 68) were included. There were no significant differences in baseline characteristics between opioid exposed and unexposed groups. There was a statistically significant increase of 0.23 (95% CI: 0.03, 0.43, p = 0.03) in mean of the square root of %time-SpO2 < 80. The number of IH-SpO2 < 80 events was higher in the opioid exposed group (mean difference = 2.95, 95% CI: -0.35, 6.25, p-value = 0.08), although statistical significance was not quite attained. CONCLUSION This study shows that preterm infants prenatally exposed to opioids have increased IH measures compared to unexposed infants. Interestingly, the increased IH in the opioid exposed group persists beyond the immediate postnatal period.
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Affiliation(s)
- Elie G Abu Jawdeh
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, KY, United States
| | - Philip M Westgate
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, United States
| | - Amrita Pant
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, KY, United States
| | - Audra L Stacy
- College of Medicine, University of Kentucky, Lexington, KY, United States
| | - Divya Mamilla
- Children's Hospital of Michigan, Detroit, MI, United States
| | - Aayush Gabrani
- Department of Pediatrics, New Jersey Medical School, Newark, NJ, United States
| | - Abhijit Patwardhan
- Department of Biomedical Engineering, College of Engineering, University of Kentucky, Lexington, KY, United States
| | - Henrietta S Bada
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, KY, United States
| | - Peter Giannone
- Division of Neonatology, Department of Pediatrics, University of Kentucky, Lexington, KY, United States
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Parolin M, Simonelli A. Attachment Theory and Maternal Drug Addiction: The Contribution to Parenting Interventions. Front Psychiatry 2016; 7:152. [PMID: 27625612 PMCID: PMC5004230 DOI: 10.3389/fpsyt.2016.00152] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 08/18/2016] [Indexed: 12/31/2022] Open
Abstract
Children's emotional and relational development can be negatively influenced by maternal substance abuse, particularly through a dysfunctional caregiving environment. Attachment Theory offers a privileged framework to analyze how drug addiction can affect the quality of adult attachment style, parenting attitudes and behaviors toward the child, and how it can have a detrimental effect on the co-construction of the attachment bond by the mother and the infant. Several studies, as a matter of fact, have identified a prevalence of insecure patterns among drug-abusing mothers and their children. Many interventions for mothers with Substance Use Disorders have focused on enhancing parental skills, but they have often overlooked the emotional and relational features of the mother-infant bond. Instead, in recent years, a number of protocols have been developed in order to strengthen the relationship between drug-abusing mothers and their children, drawing lessons from Attachment Theory. The present study reviews the literature on the adult and infant attachment style in the context of drug addiction, describing currently available treatment programs that address parenting and specifically focus on the mother-infant bond, relying on Attachment Theory.
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Affiliation(s)
- Micol Parolin
- Department of Developmental and Social Psychology, University of Padua, Padua, Italy
| | - Alessandra Simonelli
- Department of Developmental and Social Psychology, University of Padua, Padua, Italy
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Garrison L, Leeman L, Savich RD, Gutierrez H, Rayburn WF, Bakhireva LN. Fetal Growth Outcomes in a Cohort of Polydrug- and Opioid-Dependent Patients. THE JOURNAL OF REPRODUCTIVE MEDICINE 2016; 61:311-319. [PMID: 29075045 PMCID: PMC5654486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To evaluate the effects of prenatal polydrug and exclusive opioid use on fetal growth outcomes. METHODS This analysis relied on the data obtained from two prospective cohorts at the University of New Mexico. For both cohorts, pregnant women were recruited during one of their prenatal care visits and followed up to delivery. The merged sample included 59 polydrug users, 22 exclusive opioid users, and 278 abstinent controls. Continuous growth measures (birth weight, height, occipital frontal circumference [OFC], and corresponding sex-specific percentiles) were compared by ANOVA and ANCOVA in bivariate and multivariable analyses, respectively. Categorical outcomes (prevalence of small-for-gestational age [SGA] for weight, length, and OFC) were compared among groups by Chi-square and multivariable logistic regression analyses.. RESULTS The sample included a large proportion of ethnic minorities (78.8% Hispanic) and patients with low educational attainment (68% ≤ high school). The risk of microcephaly (OFC<10th percentile) was significantly greater in the polydrug (OR=4.7; 95% CI: 2.0; 10.8) and exclusive opioid (OR=2.8; 95% CI: 1.0; 8.1) groups compared to abstinent controls. CONCLUSION Given that microcephaly is often associated with serious neurocognitive and behavioral deficits later in life, our finding of 49.2% incidence of microcephaly among polydrug users is alarming and requires further investigation.
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DiPietro JA, Costigan KA, Voegtline KM. STUDIES IN FETAL BEHAVIOR: REVISITED, RENEWED, AND REIMAGINED. Monogr Soc Res Child Dev 2015; 80:vii;1-94. [PMID: 26303396 DOI: 10.1111/mono.v80.3] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Among the earliest volumes of this monograph series was a report by Lester Sontag and colleagues, of the esteemed Fels Institute, on the heart rate of the human fetus as an expression of the developing nervous system. Here, some 75 years later, we commemorate this work and provide historical and contemporary context on knowledge regarding fetal development, as well as results from our own research. These are based on synchronized monitoring of maternal and fetal parameters assessed between 24 and 36 weeks gestation on 740 maternal-fetal pairs compiled from eight separate longitudinal studies, which commenced in the early 1990s. Data include maternal heart rate, respiratory sinus arrhythmia, and electrodrmal activity and fetal heartrate, motor activity, and their integration. Hierarchical linear modeling of developmental trajectories reveals that the fetus develops in predictable ways consistent with advancing parasympathetic regulation. Findings also include:within-fetus stability (i.e., preservation of rank ordering over time) for heart rate, motor, and coupling measures; a transitional period of decelerating development near 30 weeks gestation; sex differences in fetal heart rate measures but not in most fetal motor activity measures; modest correspondence in fetal neurodevelopment among siblings as compared to unrelated fetuses; and deviations from normative fetal development in fetuses affected by intrauterine growth restriction and other conditions. Maternal parameters also change during this period of gestation and there is evidence that fetal sex and individual variation in fetal neurobehavior influence maternal physio-logical processes and the local intrauterine context. Results are discussed within the framework of neuromaturation, the emergence of individual differences, and the bidirectional nature of the maternal-fetal relationship.We pose a number of open questions for future research. Although the human fetus remains just out of reach, new technologies portend an era of accelerated discovery of the earliest period of development
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REFERENCES. Monogr Soc Res Child Dev 2015. [DOI: 10.1111/mono.12184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pharmacogenomic predictors of neonatal abstinence syndrome: correlation with length of stay. Ther Drug Monit 2015; 37:281-2. [PMID: 25970505 DOI: 10.1097/ftd.0000000000000147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Desai RJ, Huybrechts KF, Hernandez-Diaz S, Mogun H, Patorno E, Kaltenbach K, Kerzner LS, Bateman BT. Exposure to prescription opioid analgesics in utero and risk of neonatal abstinence syndrome: population based cohort study. BMJ 2015; 350:h2102. [PMID: 25975601 PMCID: PMC4431352 DOI: 10.1136/bmj.h2102] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2015] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To provide absolute and relative risk estimates of neonatal abstinence syndrome (NAS) based on duration and timing of prescription opioid use during pregnancy in the presence or absence of additional NAS risk factors of history of opioid misuse or dependence, misuse of other substances, non-opioid psychotropic drug use, and smoking. DESIGN Observational cohort study. SETTING Medicaid data from 46 US states. PARTICIPANTS Pregnant women filling at least one prescription for an opioid analgesic at any time during pregnancy for whom opioid exposure characteristics including duration of therapy: short term (<30 days) or long term (≥ 30 days); timing of use: early use (only in the first two trimesters) or late use (extending into the third trimester); and cumulative dose (in morphine equivalent milligrams) were assessed. MAIN OUTCOME MEASURE Diagnosis of NAS in liveborn infants. RESULTS 1705 cases of NAS were identified among 290,605 pregnant women filling opioid prescriptions, corresponding to an absolute risk of 5.9 per 1000 deliveries (95% confidence interval 5.6 to 6.2). Long term opioid use during pregnancy resulted in higher absolute risk of NAS per 1000 deliveries in the presence of additional risk factors of known opioid misuse (220.2 (200.8 to 241.0)), alcohol or other drug misuse (30.8 (26.1 to 36.0)), exposure to other psychotropic medications (13.1 (10.6 to 16.1)), and smoking (6.6 (4.3 to 9.6)) than in the absence of any of these risk factors (4.2 (3.3 to 5.4)). The corresponding risk estimates for short term use were 192.0 (175.8 to 209.3), 7.0 (6.0 to 8.2), 2.0 (1.5 to 2.6), 1.5 (1.0 to 2.0), and 0.7 (0.6 to 0.8) per 1000 deliveries, respectively. In propensity score matched analyses, long term prescription opioid use compared with short term use and late use compared with early use in pregnancy demonstrated greater risk of NAS (risk ratios 2.05 (95% confidence interval 1.81 to 2.33) and 1.24 (1.12 to 1.38), respectively). CONCLUSIONS Use of prescription opioids during pregnancy is associated with a low absolute risk of NAS in the absence of additional risk factors. Long term use compared with short term use and late use compared with early use of prescription opioids are associated with increased NAS risk independent of additional risk factors.
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Affiliation(s)
- Rishi J Desai
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA
| | | | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA
| | - Karol Kaltenbach
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Leslie S Kerzner
- Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02120, USA Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
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Oral morphine weaning for neonatal abstinence syndrome at home compared with in-hospital: an observational cohort study. Paediatr Drugs 2015; 17:151-7. [PMID: 25342143 DOI: 10.1007/s40272-014-0096-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The objective of this observational study was to evaluate the safety and effectiveness of discharging stabilized neonates to complete their oral morphine weaning at home. STUDY DESIGN This retrospective cohort study evaluated neonates treated with oral morphine at two hospitals in London, Ontario, Canada. Neonates who completed their morphine wean in hospital were compared with neonates who completed their morphine wean following discharge from hospital (at home). RESULTS There were 80 neonates treated with oral morphine at two hospitals from 2006 to 2010. The majority (65%, 52/80) of neonates completed their morphine weaning after hospital discharge and were significantly less likely to return to hospital for further withdrawal treatment (1/52 vs. 4/28, p < 0.05). Neonates who were treated at home remained on morphine for more days (32 vs. 19 days, p < 0.01). CONCLUSIONS We present the first North American cohort of neonates weaned with morphine at home for neonatal abstinence syndrome (NAS). We found that more days on oral morphine resulted in fewer returns to hospital for continued withdrawal management. There was no evidence of increased effectiveness, measured by the number of returns to hospital for further NAS management with in-hospital weaning. The estimated cost savings of continued weaning upon discharge was approximately $11,000 per patient (Canadian dollars). While further prospective research is necessary, in some cases morphine weaning at home may present a safe and cost-effective strategy for NAS management.
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Neonatal withdrawal syndrome after chronic maternal consumption of 4-methylethcathinone. Forensic Sci Int 2014; 245:e33-5. [DOI: 10.1016/j.forsciint.2014.10.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 10/11/2014] [Accepted: 10/14/2014] [Indexed: 12/27/2022]
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DiPietro JA, Davis MF, Costigan KA, Barr DB. Fetal heart rate and motor activity associations with maternal organochlorine levels: results of an exploratory study. JOURNAL OF EXPOSURE SCIENCE & ENVIRONMENTAL EPIDEMIOLOGY 2014; 24:474-481. [PMID: 23591698 PMCID: PMC4513653 DOI: 10.1038/jes.2013.19] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 02/04/2013] [Accepted: 02/12/2013] [Indexed: 06/02/2023]
Abstract
Contemporaneous associations between circulating maternal organochlorines (OCs) and measures of fetal heart rate and motor activity were evaluated. A panel of 47 OCs, including pesticides and polychlorinated biphenyls (PCBs), was analyzed from serum of 50 pregnant women at 36 weeks gestation. Data were empirically reduced into four factors and six individual compounds. All participants had detectable concentrations of at least one-quarter of the assayed OCs and, in general, higher socioeconomic level was associated with higher OC concentrations. Fetal heart rate measures were not consistently associated with maternal OCs. In contrast, one or more indicators of greater fetal motor activity were significantly associated with higher levels of the DDT and low chlorinated OC factors and five of the six individual compounds (heptachlor epoxide, trans nonachlor, oxychlordane, and PCBs 18 and 52). This preliminary demonstration of associations between fetal motor activity and maternal concentrations of persistent and pervasive environmental contaminants suggests that fetal assessment may be useful in ascertaining the potential early effects of these compounds on development.
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Affiliation(s)
- Janet A. DiPietro
- Department of Population, Family & Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Meghan F. Davis
- Department of Environmental Health Sciences, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kathleen A Costigan
- Division of Maternal-Fetal Medicine; Johns Hopkins Medical Institutions, Baltimore, MD
| | - Dana Boyd Barr
- Department of Environmental Health, Rollins School of Public Health, Atlanta, GA
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Wiles JR, Isemann B, Ward LP, Vinks AA, Akinbi H. Current management of neonatal abstinence syndrome secondary to intrauterine opioid exposure. J Pediatr 2014; 165:440-6. [PMID: 24948346 PMCID: PMC4144410 DOI: 10.1016/j.jpeds.2014.05.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Revised: 04/01/2014] [Accepted: 05/01/2014] [Indexed: 11/25/2022]
Affiliation(s)
- Jason R Wiles
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Barbara Isemann
- Department of Pharmacy, University of Cincinnati Medical Center, Cincinnati, OH
| | - Laura P Ward
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alexander A Vinks
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Henry Akinbi
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
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