1
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Fleser L, Tibbetts E, Hanson A, Chu EC, Gura K, Tom C, Williams K, Levy P. Evaluating Gabapentin Dosing, Efficacy and Safety in Infants. J Pediatr Pharmacol Ther 2024; 29:159-168. [PMID: 38596422 PMCID: PMC11001217 DOI: 10.5863/1551-6776-29.2.159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 08/17/2023] [Indexed: 04/11/2024]
Abstract
OBJECTIVE Gabapentin for management of neuropathic pain, irritability, neonatal abstinence syndrome, rescue sedation, feeding intolerance and visceral hyperalgesia in infants has grown over the past decade. There remains little guidance for indications, initiation, titration and maintenance dosing trends and assessment of outcomes. The primary objective was to describe gabapentin dosing, and the secondary objectives were to identify outcomes to assess efficacy and describe weaning practices. METHODS A retrospective single-center study was performed in infants younger than 1 year who received gabapentin at Boston Children's Hospital between 2015 and 2021. The primary outcome was indication, initiation and maximum gabapentin dose. Secondary outcomes included mortality, adverse reactions and impact on feeding volumes, weight-for-age Z-scores and face, legs, activity, cry, consolability (FLACC) scores. Descriptive statistics were utilized. RESULTS Sixty-six infants received gabapentin at a mean ± SD age of 5.5 ± 2.7 months (range of 0-11 months). The mean ± SD initiation dose of gabapentin was 8.6 ± 5.4 mg/kg/day with a median interval of 24 hours (8-24 hours). The maximum mean dose was 23.2 ± 14.4 mg/kg/day at a median interval of every 8 hours (8 hours). The most common indications for initiation were irritability, rescue sedation, and visceral hyperalgesia. There was a statistical improvement in weight-for-age Z scores from 24 hours prior to gabapentin initiation to 2 weeks after the maximum dose of gabapentin (-2.23 ± 1.78 to -1.66 ± 1.91, p < 0.001) and a reduction in FLACC scores (2.29 ± 1.64 to 1.52 ± 1.76, p = 0.007) from 24 hours prior to gabapentin initiation to 3 days after the maximum dose of gabapentin. Three patients experienced minor adverse events. CONCLUSIONS Gabapentin was well tolerated in infants. Initial gabapentin dosing of 5 mg/kg/dose every 24 hours appears safe and consistent with other published studies in infants. The improvement in outcomes with few adverse events suggests a beneficial role for gabapentin.
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Affiliation(s)
- Lauren Fleser
- Department of Pharmacy (LF, ET, AH, ECC, KG, CT), Boston Children’s Hospital, Boston, MA
| | - Erin Tibbetts
- Department of Pharmacy (LF, ET, AH, ECC, KG, CT), Boston Children’s Hospital, Boston, MA
| | - Alison Hanson
- Department of Pharmacy (LF, ET, AH, ECC, KG, CT), Boston Children’s Hospital, Boston, MA
| | - Esther Chang Chu
- Department of Pharmacy (LF, ET, AH, ECC, KG, CT), Boston Children’s Hospital, Boston, MA
| | - Kathleen Gura
- Department of Pharmacy (LF, ET, AH, ECC, KG, CT), Boston Children’s Hospital, Boston, MA
| | - Crystal Tom
- Department of Pharmacy (LF, ET, AH, ECC, KG, CT), Boston Children’s Hospital, Boston, MA
| | - Kathryn Williams
- Department of Biostatistics and Research Design Center (KW), Boston Children’s Hospital, Boston, MA
| | - Philip Levy
- Division of Newborn Medicine (PL), Boston Children’s Hospital, Boston, MA
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2
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Gabapentin Use During Pregnancy and Lactation With and Without Concurrent Opioid Exposure: Considerations and Future Directions. J Addict Med 2023; 17:123-125. [PMID: 36069804 DOI: 10.1097/adm.0000000000001065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Gabapentin is a γ-aminobutyric acid analog formally indicated for the treatment of epilepsy and neuropathic pain that is gaining increased popularity. Gabapentin has been historically considered a safe medication, including during pregnancy and lactation, with low reported concerns for misuse and use disorders. However, new empirical efforts are revealing concerns regarding the safety of widespread gabapentin use, particularly in pregnancy and for individuals with a propensity toward substance misuse. The Food and Drug Administration's full prescribing information report on gabapentin provides concerning preclinical data and then states that gabapentin is potentially "developmentally toxic" and has an unknown risk of birth impacts. Concerns have also been raised surrounding in utero exposure to gabapentin due to the onset and presentation of atypical and/or difficult to control withdrawal signs and symptoms in neonates, including those dually exposed to opioids, as well as neonatal exposure to gabapentin via breastmilk. Moreover, nonprescribed gabapentin use has become an increasing problem, with opioid use disorder being the greatest risk factor for such misuse. This article summarizes the current literature regarding gabapentin use during pregnancy and related prenatal and neonatal exposure outcomes with special consideration for interactions between gabapentin and opioid use. Taken together, the current literature suggests that gabapentin use should be considered with caution during pregnancy and during the post-partum period. Well-controlled, prospective research studies are needed to determine the extent of the risks and benefits of prescribed and nonprescribed gabapentin exposure to pregnant people and their neonates.
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3
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Boggess T, Williamson JC, Niebergall EB, Sexton H, Mazur A, Egleton RD, Grover LM, Risher WC. Alterations in Excitatory and Inhibitory Synaptic Development Within the Mesolimbic Dopamine Pathway in a Mouse Model of Prenatal Drug Exposure. Front Pediatr 2021; 9:794544. [PMID: 34966707 PMCID: PMC8710665 DOI: 10.3389/fped.2021.794544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/18/2021] [Indexed: 12/19/2022] Open
Abstract
The rise in rates of opioid abuse in recent years in the United States has led to a dramatic increase in the incidence of neonatal abstinence syndrome (NAS). Despite improved understanding of NAS and its acute symptoms, there remains a paucity of information regarding the long-term effects of prenatal exposure to drugs of abuse on neurological development. The primary goal of this study was to investigate the effects of prenatal drug exposure on synaptic connectivity within brain regions associated with the mesolimbic dopamine pathway, the primary reward pathway associated with drug abuse and addiction, in a mouse model. Our secondary goal was to examine the role of the Ca+2 channel subunit α2δ-1, known to be involved in key developmental synaptogenic pathways, in mediating these effects. Pregnant mouse dams were treated orally with either the opioid drug buprenorphine (commonly used in medication-assisted treatment for substance use patients), gabapentin (neuropathic pain drug that binds to α2δ-1 and has been increasingly co-abused with opioids), a combination of both drugs, or vehicle daily from gestational day 6 until postnatal day 11. Confocal fluorescence immunohistochemistry (IHC) imaging of the brains of the resulting wild-type (WT) pups at postnatal day 21 revealed a number of significant alterations in excitatory and inhibitory synaptic populations within the anterior cingulate cortex (ACC), nucleus accumbens (NAC), and medial prefrontal cortex (PFC), particularly in the buprenorphine or combinatorial buprenorphine/gabapentin groups. Furthermore, we observed several drug- and region-specific differences in synaptic connectivity between WT and α2δ-1 haploinsufficient mice, indicating that critical α2δ-1-associated synaptogenic pathways are disrupted with early life drug exposure.
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Affiliation(s)
| | | | | | | | | | | | | | - W. Christopher Risher
- Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, United States
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4
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Evoy KE, Peckham AM, Covvey JR, Tidgewell KJ. Gabapentinoid Pharmacology in the Context of Emerging Misuse Liability. J Clin Pharmacol 2021; 61 Suppl 2:S89-S99. [PMID: 34396549 DOI: 10.1002/jcph.1833] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 02/13/2021] [Indexed: 12/15/2022]
Abstract
This article will review the epidemiology and pharmacology of gabapentinoids (gabapentin and pregabalin) relevant to their emerging misuse potential and provide guidance for clinical and regulatory management. Gabapentinoids are γ-aminobutyric acid analogues that produce their therapeutic effects by inhibiting voltage-gated calcium channels and decreasing neurotransmitter release. Recently gabapentinoid prescribing and use have increased tremendously. Although traditionally thought to possess a favorable safety profile, gabapentinoid misuse has also risen significantly. Gabapentinoid misuse generally occurs in combination with other substances, most notably opioids, and may be for purposes of eliciting euphoric effects, enhancing the effects of other substances, or self-treating conditions such as withdrawal, pain, anxiety, or insomnia. Given its faster onset, increased bioavailability and potency, and nonsaturable absorption, pregabalin's pharmacokinetics theoretically enhance its misuse liability versus gabapentin. However, gabapentin can produce similar euphoric effects, and epidemiologic studies have identified higher rates of gabapentin misuse in the United States, likely because of greater availability and less regulated prescribing. Although adverse events of gabapentinoid-only ingestion are relatively benign, a growing body of evidence indicates that gabapentinoids significantly increase opioid-related morbidity and mortality when used concomitantly. In addition, significant withdrawal effects may occur on abrupt discontinuation. As a result of these trends, several US states have begun to further regulate gabapentinoid prescribing, reclassifying it as a controlled substance or mandating reporting to local prescription drug-monitoring programs. Although increased regulation of gabapentin prescribing may be warranted, harm reduction efforts and increased patient and provider education are necessary to mitigate this concerning gabapentinoid misuse trend.
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Affiliation(s)
- Kirk E Evoy
- The University of Texas at Austin College of Pharmacy, Austin, Texas, USA.,University Health System, San Antonio, Texas, USA
| | - Alyssa M Peckham
- School of Pharmacy, Northeastern University, Boston, Massachusetts, USA.,Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jordan R Covvey
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Kevin J Tidgewell
- Duquesne University School of Pharmacy, Pittsburgh, Pennsylvania, USA
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5
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Wright ME, Ginsberg C, Parkison AM, Dubose M, Sherbondy M, Shores E. Outcomes of mothers and newborns to prenatal exposure to kratom: a systematic review. J Perinatol 2021; 41:1236-1243. [PMID: 33589723 PMCID: PMC8225511 DOI: 10.1038/s41372-021-00952-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 11/18/2020] [Accepted: 01/21/2021] [Indexed: 01/06/2023]
Abstract
Kratom is a legal, widely available substance that contains opioid agonist alkaloids. Due to the marketing of kratom as an opioid alternative for treatment of pain, anxiety, depression, or to reduce opioid withdrawal symptoms, the use of kratom has increased among persons in the USA including pregnant women. This systematic review of the peer-reviewed literature regarding kratom in relation to maternal and infant outcomes resulted in analysis of six case reports of prenatal kratom exposure. Maternal and infant withdrawal from kratom exposure was described in each case, resulting in pharmacologic treatment for both mothers and infants.
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Affiliation(s)
| | | | | | - Melissa Dubose
- Clemson University School of Nursing, Greenville, SC, USA
| | | | - Emily Shores
- Clemson University School of Nursing, Greenville, SC, USA
- University of South Carolina, School of Medicine Greenvillle, Greenville, SC, USA
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6
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Okoye NC, McMillin GA. Patterns of Neonatal Co-Exposure to Gabapentin and Commonly Abused Drugs Observed in Umbilical Cord Tissue. J Anal Toxicol 2021; 45:506-512. [PMID: 32860706 DOI: 10.1093/jat/bkaa118] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/18/2020] [Accepted: 08/25/2020] [Indexed: 01/10/2023] Open
Abstract
Gabapentin was thought to have low abuse potential, but it is increasingly being abused by people with substance use disorder in an attempt to potentiate the euphoric effects from opioids and other CNS depressants. Additionally, infants co-exposed to gabapentin and opioids during pregnancy tend to exhibit prolonged and more severe neonatal abstinence syndrome. In this study, we describe positivity rates among commonly abused drugs and rates of co-medication with gabapentin in a large dataset of umbilical cord tissue specimens (n = 25,422) submitted for routine newborn drug testing at a national clinical reference laboratory (ARUP Laboratories, Salt Lake City, UT, USA). Detection of prenatal drug exposure in umbilical cord tissue specimens was accomplished using a semi-quantitative liquid chromatography-tandem mass spectrometry assay designed to detect 47 specific drugs and drug metabolites including opioids, stimulants, sedative-hypnotics and hallucinogens. A positive result for at least one of the measured drugs or drug metabolites was reported in 7,054 (28%) of the umbilical cord tissues analyzed. Gabapentin had a positivity rate of ~2% with 562 positive results. Of the 562 gabapentin-positive samples, 395 (70%) also had a positive result for at least one other drug or drug metabolite, with the highest co-positivity rate observed for norbuprenorphine (32%, n = 182) followed by amphetamine (15%, n = 84), buprenorphine (13%, n = 74), methamphetamine (12%, n = 68), morphine (11%, n = 64), fentanyl (10%, n = 54) and naloxone (10%, n = 54). Notably, the concentration of gabapentin in gabapentin-positive umbilical cord specimens was higher in buprenorphine-containing specimens as compared to specimens containing other opioids, stimulants or benzodiazepines. Identification of neonatal co-exposure to gabapentin and opioids, particularly buprenorphine, may guide clinicians in rapid initiation of monitoring and intervention for neonatal abstinence syndrome.
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Affiliation(s)
- Nkemakonam C Okoye
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Gwendolyn A McMillin
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, Utah, USA.,ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, Utah, USA
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7
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Evoy KE, Sadrameli S, Contreras J, Covvey JR, Peckham AM. Authors' Reply to Bonnet et al. "Abuse and Misuse of Pregabalin and Gabapentin: A Systematic Review Update". Drugs 2021; 81:615-617. [PMID: 33738758 DOI: 10.1007/s40265-021-01495-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Kirk E Evoy
- College of Pharmacy, The University of Texas at Austin, 7703 Floyd Curl Dr., MC 6220, San Antonio, TX, 78229, USA. .,University Health System, San Antonio, TX, USA. .,The University of Texas Health San Antonio School of Medicine, 7703 Floyd Curl Dr., MC 6220, San Antonio, TX, 78229, USA.
| | - Sarvnaz Sadrameli
- College of Pharmacy, The University of Texas at Austin, 7703 Floyd Curl Dr., MC 6220, San Antonio, TX, 78229, USA.,University Health System, San Antonio, TX, USA.,University of Illinois at Chicago, 833 South Wood St., Chicago, IL, 60612, USA
| | - Jillian Contreras
- College of Pharmacy, The University of Texas at Austin, 7703 Floyd Curl Dr., MC 6220, San Antonio, TX, 78229, USA.,University Health System, San Antonio, TX, USA
| | - Jordan R Covvey
- School of Pharmacy, Duquesne University, 600 Forbes Avenue, 418D Mellon Hall, Pittsburgh, PA, 15282, USA
| | - Alyssa M Peckham
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA.,School of Pharmacy, Northeastern University, 140 The Fenway, Boston, MA, 02115, USA
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8
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Andrews L, Davies TH, Haas J, Loudin S, Heyward A, Werthammer J. Necrotizing enterocolitis and its association with the neonatal abstinence syndrome. J Neonatal Perinatal Med 2021; 13:81-85. [PMID: 32280068 PMCID: PMC7242835 DOI: 10.3233/npm-180154] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE: The purpose of this study was to describe an identified association between necrotizing enterocolitis (NEC) and prenatal opioid exposure with neonatal abstinence syndrome (NAS) in late preterm and full-term neonates. STUDY DESIGN: In this single-center retrospective cohort study, we analyzed inborn neonates with the diagnosis of NEC discharged from 2012 through 2017. We compared infants with NEC > 35 weeks’ gestation to those with NEC<35 weeks’ gestation. We compared gestational age, birth weight, age of onset of symptoms, and incidence of prenatal drug exposure between groups. Significance was determined using Mann-Whitney and Fisher’s exact tests. RESULTS: Over the study period, 23 infants were identified with NEC, 9 (39%) were babies > 35 weeks at birth and 14 (61%) < 35 weeks. Those > 35 weeks had a higher birth weight, earlier onset of symptoms, and a higher percentage of prenatal exposure to opioids compared to those < 35 weeks’ gestation. We further described seven infants with late gestational age onset NEC associated with prenatal opioid exposure. CONCLUSIONS: In this cohort of infants with NEC discharged over a 6 year period we found a higher than expected percentage of infants born at a later gestational age. We speculate that prenatal opioid exposure might be a risk factor for NEC in neonates born at > 35 weeks.
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Affiliation(s)
- L Andrews
- Department of Family and Community Health at Joan C Edwards School of Medicine at Marshall University, Huntington WV, USA
| | - T H Davies
- Department of Family and Community Health at Joan C Edwards School of Medicine at Marshall University, Huntington WV, USA
| | - J Haas
- Hoops Family Children's Hospital at Cabell Huntington Hospital, Huntington, WV, USA
| | - S Loudin
- Department of Pediatrics, Joan C Edwards School of Medicine at Marshall University, Huntington, WV, USA
| | - A Heyward
- Department of Pediatrics, Joan C Edwards School of Medicine at Marshall University, Huntington, WV, USA
| | - J Werthammer
- Department of Pediatrics, Joan C Edwards School of Medicine at Marshall University, Huntington, WV, USA
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9
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Peckham AM, Covvey JR, Evoy KE. Letter to the Editor: Comment on "Gabapentinoid Benefit and Risk Stratification: Mechanisms Over Myth". Pain Ther 2021; 10:751-755. [PMID: 33565039 PMCID: PMC8119553 DOI: 10.1007/s40122-020-00222-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 11/19/2020] [Indexed: 11/01/2022] Open
Affiliation(s)
- Alyssa M Peckham
- Bouvé College of Health Sciences, School of Pharmacy, Northeastern University, Boston, MA, USA. .,Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA.
| | | | - Kirk E Evoy
- The University of Texas at Austin College of Pharmacy, Austin, TX, USA.,University Health System, San Antonio, TX, USA.,The University of Texas Health San Antonio School of Medicine, San Antonio, TX, USA
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10
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Abstract
BACKGROUND A 2017 systematic review (SR) identified 59 studies examining gabapentinoid (pregabalin and gabapentin) misuse/abuse. Evidence of gabapentinoid misuse/abuse has since grown substantially. OBJECTIVE Update previous SR and describe new insights regarding gabapentinoid abuse. METHODS A SR of PubMed was conducted to identify studies published from 7/29/2016-8/31/2020. Four searches were performed using the following terms: "gabapentin [MeSH] OR pregabalin [MeSH] OR gabapentinoid" AND one of the following substance misuse/abuse-related terms: "substance-related disorders [MeSH]", "overdose", "abuse", or "misuse". Clinicaltrials.gov and the Cochrane Library database were searched to identify ongoing studies or similar SRs. Reference lists of included studies were reviewed to identify additional literature. All studies with novel data related to pregabalin and/or gabapentin abuse, misuse, or overdose conducted during the study period were included. Articles not written in English, review articles, and animal studies were excluded. RESULTS Fifty-five studies were included (29 [52.7%] from North America, 17 [30.9%] Europe, 6 [10.9%] Asia, and 3 [5.5%] Australia). Forty-six observational studies and 10 case reports/series were included (one manuscript included both). Twenty (36.4%) studied gabapentin only, 18 (32.7%) pregabalin only, and 17 (30.9%) both pregabalin/gabapentin. These studies corroborate findings from the previous SR that gabapentinoids are increasingly abused or misused to self-medicate, that gabapentinoids can produce desirable effects alone but are often used concomitantly with other drugs, and that opioid use disorder is the greatest risk factor for gabapentinoid abuse. While the original SR identified the largest studies having been published in Europe, this review identified several more generalisable US studies that have subsequently been conducted. The most concerning finding was increased evidence of associated patient harm, including increased hospital utilisation and opioid-related overdose mortality risk. CONCLUSION Evidence suggests that gabapentinoid misuse/abuse represents a growing trend that is causing significant patient harm. Prescribers should exercise appropriate caution with use in high-risk populations and monitor for signs of misuse or abuse.
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11
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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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12
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Risher WC, Eroglu C. Emerging roles for α2δ subunits in calcium channel function and synaptic connectivity. Curr Opin Neurobiol 2020; 63:162-169. [PMID: 32521436 DOI: 10.1016/j.conb.2020.04.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/29/2020] [Indexed: 12/17/2022]
Abstract
Central nervous system function requires the proper formation and function of synapses. The α2δ auxiliary subunits of voltage-gated calcium channels have emerged as regulators of a number of critical events associated with regulation of synaptic function, including channel trafficking and localization, as well as the initial establishment of synaptic structures. In this review, we will discuss some of these recent studies which have uncovered novel mechanisms for α2δ function at the synapse, including the regulation of calcium channel α1 subunit specificity and the promotion of dendritic spine growth. Moreover, we will cover recent advances that have been made in understanding the consequences of aberrant α2δ signaling in injury and disease.
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Affiliation(s)
- William Christopher Risher
- Department of Biomedical Sciences, Joan C. Edwards School of Medicine at Marshall University, Huntington, WV 25705, United States.
| | - Cagla Eroglu
- Department of Cell Biology, Duke University Medical Center, Durham, NC 27710, United States; Department of Neurobiology, Duke University Medical Center, Durham, NC 27710, United States; Duke Institute for Brain Sciences (DIBS), Durham, NC 27710, United States; Regeneration Next Initiative, Duke University, Durham, NC 27710, United States
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13
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Boggess T, Risher WC. Clinical and basic research investigations into the long-term effects of prenatal opioid exposure on brain development. J Neurosci Res 2020; 100:396-409. [PMID: 32459039 DOI: 10.1002/jnr.24642] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/01/2020] [Accepted: 04/27/2020] [Indexed: 12/26/2022]
Abstract
Coincident with the opioid epidemic in the United States has been a dramatic increase in the number of children born with neonatal abstinence syndrome (NAS), a form of withdrawal resulting from opioid exposure during pregnancy. Many research efforts on NAS have focused on short-term care, including acute symptom treatment and weaning of the infants off their drug dependency prior to authorizing their release. However, investigations into the long-term effects of prenatal opioid exposure (POE) on brain development, from the cellular to the behavioral level, have not been as frequent. Given the importance of the perinatal period for human brain development, opioid-induced disturbances in the formation and function of nascent synaptic networks and glia have the potential to impact brain connectivity and cognition long after the drug supply is cutoff shortly after birth. In this review, we will summarize the current state of NAS research, bringing together findings from human studies and preclinical animal models to highlight what is known about how POE can induce significant, prolonged deficits in brain structure and function. With rates of NAS continuing to rise, particularly in regions that already face substantial socioeconomic challenges, we speculate as to the most promising avenues for future research to alleviate this growing multigenerational threat.
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Affiliation(s)
- Taylor Boggess
- Department of Biomedical Sciences, Joan C. Edwards School of Medicine at Marshall University, Huntington, WV, USA
| | - W Christopher Risher
- Department of Biomedical Sciences, Joan C. Edwards School of Medicine at Marshall University, Huntington, WV, USA
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14
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Loudin S, Haas J, Payne M, Linz MF, Meaney-Delman D, Honein MA, Saunders A. Identifying Co-Exposure to Opiates and Gabapentin During Pregnancy. J Pediatr 2020; 217:196-198. [PMID: 31668481 PMCID: PMC7503060 DOI: 10.1016/j.jpeds.2019.09.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/15/2019] [Accepted: 09/12/2019] [Indexed: 12/21/2022]
Abstract
Neonatal withdrawal can be difficult to treat in infants with co-exposure to opiates and gabapentin. Because maternal self-report can underestimate exposures, we evaluated the effect of universal toxicology screening for gabapentin. Identification of co-exposure to opiates and gabapentin increased after implementation of toxicology screening, with implications for improved neonatal care.
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Affiliation(s)
- Sean Loudin
- Department of Pediatrics, Joan C. Edwards School of Medicine at Marshall University
| | - Jessica Haas
- NICU, Hoops Family Children’s Hospital at Cabell Huntington Hospital
| | - Mary Payne
- Department of Neurology, Joan C. Edwards School of Medicine at Marshall University
| | | | - Dana Meaney-Delman
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Margaret A. Honein
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Amy Saunders
- Marshall University Center of Excellence for Recovery, Huntington, WV.
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Abdi HH, Maitre NL, Benninger KL, Hester ME, Slaughter JL. Gabapentin Use for Hospitalized Neonates. Pediatr Neurol 2019; 97:64-70. [PMID: 30922771 PMCID: PMC6635010 DOI: 10.1016/j.pediatrneurol.2019.02.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 02/11/2019] [Accepted: 02/12/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Despite some clinician advocacy for the use of gabapentin to treat neonatal irritability of presumed neurological origin, the extent of gabapentin administration to hospitalized neonates is unknown. We aimed to identify trends in gabapentin utilization among infants hospitalized in neonatal intensive care units (NICUs) across the United States and to evaluate the associations between clinical diagnoses and gabapentin treatment. METHODS We analyzed neonates admitted to the NICU using the Pediatric Health Information System (2005 to 2016) to measure treatment timing, duration, and frequency. We used modified Poisson regression with a robust between-cluster variance estimator to calculate a probability (adjusted relative risk) for gabapentin administration. RESULTS Of 278,403 neonates, 374 were administered gabapentin (0.13%). The median treatment duration was 16 days (25th to 75th percentile: 8; 40). Gabapentin use increased from 0% in 2005 to 0.39% in 2016. Treatment was prescribed to neonates at 31 of 48 studied hospitals; 73% of total treated infants localized to five neonatal intensive care units. Term (0.16%) and ≤28 weeks' gestation preterm infants (0.22%) were most likely to receive gabapentin. Varying by gestational age, a diagnosis of chromosomal abnormalities, severe bronchopulmonary dysplasia, hemorrhagic stroke, and neonatal abstinence syndrome were associated with higher treatment with gabapentin. The majority (88.8%) of treated infants did not have a seizure diagnosis. CONCLUSION Gabapentin use in NICU in the United States increased in recent years and varies markedly between institutions. Term infants, ≤28 weeks' gestation preterm infants, and neonates with chronic genetic, neurological, and gastrointestinal diagnoses were more likely to receive gabapentin.
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Affiliation(s)
- Hibo H Abdi
- Center for Perinatal Research, Nationwide Children's Hospital, Columbus, Ohio
| | - Nathalie L Maitre
- Center for Perinatal Research, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Kristen L Benninger
- Center for Perinatal Research, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Mark E Hester
- Center for Perinatal Research, Nationwide Children's Hospital, Columbus, Ohio
| | - Jonathan L Slaughter
- Center for Perinatal Research, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, The Ohio State University, Columbus, Ohio.
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Abstract
Tens of thousands of infants are impacted yearly by prenatal opioid exposure. The term neonatal opioid withdrawal syndrome (NOWS) is now replacing the more familiar term neonatal abstinence syndrome (NAS). Ongoing debate continues related to standard regimens for treatment of this oftentimes perplexing condition. Historically, treatment has focused on pharmacologic interventions. However, there is limited research that points to nonpharmacologic methods of treatment as viable options, whether alone or in addition to pharmacologic interventions. This article, utilizing a review of pertinent literature, outlines the physical aspects of NOWS, including its pathophysiology and the resulting physical clinical signs. In addition, we present an overview of how age-appropriate, nonpharmacologic interventions, centered on developmental care, may be a valuable approach to organize and prioritize routine care for these infants, their families, and the health care team facing the challenges of NOWS. Finally, the need for further research to better define evidence-based standards of care for these infants and their families is discussed.
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Abstract
This review examines the continuum of care of opioid-exposed infants, including the assessment of the neonate, diagnosis of neonatal abstinence syndrome, management of the syndrome including nonpharmacologic and pharmacologic care, approach to breastfeeding, pediatric follow-up care, and integration of care of the mother-infant dyad.
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Affiliation(s)
- Lauren M Jansson
- The Center for Addiction and Pregnancy, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, D4E, Baltimore, MD 21224, USA.
| | - Stephen W Patrick
- Vanderbilt Center for Child Health Policy, 2525 West End Avenue, Suite 1200, Nashville, TN 37027, USA
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Nellhaus EM, Nieuwenhuizen L, Egleton R, Hansen Z, Chaffin D, Loudin S, Davies TH. History of postpartum depression as a contributor to the severity of NAS. Addict Behav 2019; 89:78-84. [PMID: 30268061 DOI: 10.1016/j.addbeh.2018.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 08/14/2018] [Accepted: 09/08/2018] [Indexed: 11/28/2022]
Abstract
Currently, there are no clinical tools available to accurately predict the severity of neonatal withdrawal. Studies of non-exposed neonates suggest that maternal depression and anxiety are predictive of negative short and long-term neonatal outcomes, but research is lacking in the addicted population. We studied of 109 pregnant women in medication-assisted treatment (MAT) and their neonates to determine if psychiatric conditions co-occurring with Substance Use Disorder (SUD) contributed to the severity of neonatal withdrawal. The need for pharmacological intervention, Finnegan scores, length of methadone treatment, and length of hospital stay were used to assess withdrawal severity. Categorical variables were analyzed in Stata14 using Chi Square and continuous variables were analyzed using Wilcoxon Rank Sum. Among the 110 neonates whose outcomes were reviewed, a maternal history of Postpartum Depression (PPD) was found to be correlated with increased severity of withdrawal. The neonates born to mothers with past diagnoses of PPD had more consecutive days of high Finnegan scores (95% confidence interval [CI], P = 0.003), longer length of treatment (95% CI, P = 0.006), and length of hospital stay (95% CI, P = 0.014). There was no apparent relationship between NAS severity and other psychiatric disorders. In a study of pregnant women with SUD and their neonates, we uncovered a relationship between the severity of NAS and maternal history of PPD. Our findings demonstrate that further research into these deleterious outcomes is warranted. Until then, we suggest collection of maternal history of PPD and careful screening for new cases in the SUD population.
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Affiliation(s)
- Emma M Nellhaus
- Department of Family and Community Health, Joan C Edwards School of Medicine at Marshall University, Huntington, WV, United States
| | - Louis Nieuwenhuizen
- Department of Obstetrics and Gynecology, Cabell-Huntington Hospital, Huntington, WV, United States
| | - Richard Egleton
- Department of Biomedical Sciences, Joan C Edwards School of Medicine at Marshall University, Huntington, WV, United States
| | - Zachary Hansen
- Department of Family Medicine, Valley Health Systems, Huntington, WV, United States
| | - David Chaffin
- Department of Obstetrics and Gynecology, Cabell-Huntington Hospital, Huntington, WV, United States
| | - Sean Loudin
- Department of Pediatrics, Joan C Edwards School of Medicine at Marshall University, Huntington, WV, United States
| | - Todd H Davies
- Department of Family and Community Health, Joan C Edwards School of Medicine at Marshall University, Huntington, WV, United States.
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Davidson L, Rawat M, Stojanovski S, Chandrasekharan P. Natural drugs, not so natural effects: Neonatal abstinence syndrome secondary to 'kratom'. J Neonatal Perinatal Med 2019; 12:109-112. [PMID: 30149482 PMCID: PMC6484255 DOI: 10.3233/npm-1863] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 06/27/2018] [Accepted: 08/02/2018] [Indexed: 06/03/2023]
Abstract
BACKGROUND Mitragyna speciosa, also known as kratom, is obtained from the coffee plant family 'Rubiaceae.' Kratom is available in the form of capsules, whole, processed and powdered leaves, and as liquids. Secondary to its 'natural herb' status and opioid effects, it is misconceived to be a safe alternative for the treatment of chronic pain. The use of kratom has increased by tenfold in the United States since 2010. METHODS AND RESULTS We report a term neonate who was born to a chronic kratom user and required treatment with opiates for neonatal drug withdrawal. CONCLUSION Physicians should be aware of these herbal supplements and its potential withdrawal effects in newborn which cannot be picked up by the standard toxicology screen.
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Affiliation(s)
- L. Davidson
- Division of Neonatology, Department of Pediatrics, University at Buffalo, Oishei Children’s Hospital, Buffalo, NY, USA
| | - M. Rawat
- Division of Neonatology, Department of Pediatrics, University at Buffalo, Oishei Children’s Hospital, Buffalo, NY, USA
| | - S. Stojanovski
- Department of Pharmacy, Oishei Children’s Hospital, Buffalo, NY, USA
| | - P. Chandrasekharan
- Division of Neonatology, Department of Pediatrics, University at Buffalo, Oishei Children’s Hospital, Buffalo, NY, USA
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21
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Wachman EM, Warden AH, Thomas Z, Thomas-Lewis JA, Shrestha H, Nikita FNU, Shaw D, Saia K, Schiff DM. Impact of psychiatric medication co-exposure on Neonatal Abstinence Syndrome severity. Drug Alcohol Depend 2018; 192:45-50. [PMID: 30205307 DOI: 10.1016/j.drugalcdep.2018.07.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/11/2018] [Accepted: 07/13/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Among opioid-exposed infants, psychiatric medication co-exposure is common. Our objective was to compare Neonatal Abstinence Syndrome (NAS) outcomes based on individual psychiatric medication co-exposures. METHODS A retrospective study of 744 opioid-exposed mother-infant dyads from a single institution was performed. Mothers on pharmacotherapy with methadone or buprenorphine at delivery were included. Data were collected on maternal demographics, psychiatric medication use, and NAS outcomes, including any medication treatment, adjunctive medication treatment, length of hospital stay (LOS), and opioid treatment days. The extent to which individual psychiatric medication and polypharmacy exposure were associated with NAS outcomes was assessed using multivariable regression. RESULTS Fifty-four percent of the mothers were on ≥1 psychiatric medication, with 32% on ≥2 or psychiatric medications (polypharmacy group). In adjusted models, polypharmacy exposure was associated with longer LOS (β = 4.31 days, 95% CI 2.55-6.06) and opioid treatment days (β = 3.98 days, 95% CI 2.24-5.72) and more treatment with adjunctive medication for NAS (aOR = 2.49, 95% CI 1.57-3.95). Benzodiazepines were associated with longer LOS (β = 4.94, 95% CI 2.86-7.03) and opioid treatment days (β = 4.86, 95% CI 2.61-6.75), and more adjunctive medication treatment (aOR = 2.57, 95% CI 1.49-4.42). Gabapentin was associated with longer LOS (β = 2.79, 95% CI 0.54-5.03), more NAS medication treatment (aOR = 2.96, 95% CI 1.18-7.42) including more adjunctive medications (aOR = 1.92, 95% CI 1.05-3.53). CONCLUSION For infants of mothers with OUD who are also on concurrent psychiatric medications, polypharmacy was associated with worse NAS severity. When medically indicated, limiting use of multiple psychiatric medications, particularly benzodiazepines and gabapentin, during pregnancy should be considered to improve NAS outcomes.
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Affiliation(s)
- Elisha M Wachman
- Department of Pediatrics, Boston Medical Center, 771 Albany Street, Boston, MA, 02118, USA.
| | - A Hutcheson Warden
- Department of Obstetrics and Gynecology, Boston Medical Center, 771 Albany Street, Boston, MA, 02118, USA.
| | - Zoe Thomas
- University of Massachusetts, 300 Massachusetts Ave, Amherst, MA, 01003, USA.
| | - Jo Ann Thomas-Lewis
- Boston University School of Medicine, 72 East Concord Street, Boston, MA, 02118, USA.
| | - Hira Shrestha
- Department of Pediatrics, Boston Medical Center, 771 Albany Street, Boston, MA, 02118, USA.
| | - F N U Nikita
- Boston University School of Public Health, 715 Albany Street, Boston, MA, 021178, USA.
| | - Daniel Shaw
- Department of Psychiatry, Boston Medical Center, 771 Albany Street, Boston, MA, 02118, USA.
| | - Kelley Saia
- Department of Obstetrics and Gynecology, Boston Medical Center, 771 Albany Street, Boston, MA, 02118, USA.
| | - Davida M Schiff
- Division of General Academic Pediatrics, Mass General Hospital for Children, 55 Fruit Street, Boston, MA, 02114, USA.
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22
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A management strategy that reduces NICU admissions and decreases charges from the front line of the neonatal abstinence syndrome epidemic. J Perinatol 2017; 37:1108-1111. [PMID: 28682317 PMCID: PMC5633652 DOI: 10.1038/jp.2017.101] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 04/26/2017] [Accepted: 05/22/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The purpose of this study was to test a specialized needs-based management model for a high volume of babies born with neonatal abstinence syndrome (NAS) while controlling costs and reducing neonatal intensive care unit (NICU) bed usage. STUDY DESIGN Data were analyzed from inborn neonates >35 weeks' gestational age with the diagnosis of NAS (ICD9-CM 779.5), requiring pharmacologic treatment and discharged from 2010 through 2015. Significance was determined using Kruskal-Wallis and Mann-Whitney as well as χ2 for trend. RESULTS NAS requiring medication treatment increased from 34.1 per 1000 live births in 2010 to 94.3 per 1000 live births in 2015 (P<0.0001 for trend). Hospital charges were significantly different in the three described locations (P<0.0001). Median per patient hospital charges for medically treated NAS were $90 601 (interquartile range (IQR) $64 489 to $128 135) for NAS patients managed in the NICU, $68 750 (IQR $44 952 to $92 548) for those managed in an in-hospital dedicated unit and $17 688 (IQR $9933 to $20 033) for those cared for in an outpatient neonatal withdrawal center. NICU admission was avoided in 78% of the population once both alternative locations were fully implemented. CONCLUSIONS In this cohort of infants, a 219% increase in the number of infants treated for NAS overwhelmed the capacity of our traditional resources. There was a need to develop new treatment approaches dealing with the NAS crisis and a growing population of prenatally exposed babies. We found that the described model of care significantly reduced charges and stabilized admissions to our NICU despite the marked increase in cases. Without this system, our NICU would be in a critical state of gridlock and diversion; instead, we have efficient management of a large NAS population.
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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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