The Perinatal Outcome of Children Born to Women With Substance Dependence Detoxified in Residential Treatment During Pregnancy

Head Circumference within the Normal Range and Neurodevelopmental Outcomes in Preterm Infants

OBJECTIVE

We sought to determine if variation in head circumference (HC) within the range of normal (5th-10th and 90th-95th percentile) is associated with poor neurodevelopmental outcomes (NDO), which defined as mild or moderate delay by Bayley II psychometrics (BSID-II).

STUDY DESIGN

This is a secondary analysis of a randomized controlled trial assessing the benefits of magnesium for the prevention of cerebral palsy. Fetuses with a normal HC at birth defined as within 5th to 95th percentile were included. NDO were assessed at age 2 with BSID-II. Moderate delay was defined as a score <70 and mild delay as <85. HC was classified as small normal (5th-10th percentile), normal (10th-90th percentile), and large normal (90th-95th percentile). Logistic regression models adjusted for confounding. Linear regression models estimated the impact for every 1 cm of change in HC.

RESULTS

Of 1,236 included infants, 111 (8%) had small normal HC; 1,058 (85%) had normal HC; and 67 (5%) had large normal HC. Baseline characteristics were similar between groups. There was no association with changes in HC within the range of normal and developmental indices. When considered as a continuous variable, every 1 cm increase in HC was also not associated with a significant change in developmental indices.

CONCLUSION

Within the normal range (5th-95th percentile), changes in HC did not correlate with changes in NDO at 2 years as measured by Bayley II scales.

KEY POINTS

· It is unknown if variations in normal HC are associated with poor neurodevelopmental outcomes.. · Alterations in HC within the range of normal (5th-95th percentile) are not associated with adverse NDO.. · When considered as a continuous variable, a 1 cm increase in HC is not associated with adverse NDO.. · Changes in HC within the range of normal do not appear to be a pathologic change altering NDO..

Consequences of Parental Opioid Exposure on Neurophysiology, Behavior, and Health in the Next Generations

Substance abuse and the ongoing opioid epidemic represents a large societal burden. This review will consider the long-term impact of opioid exposure on future generations. Prenatal, perinatal, and preconception exposure are reviewed with discussion of both maternal and paternal influences. Opioid exposure can have long-lasting effects on reproductive function, gametogenesis, and germline epigenetic programming, which can influence embryogenesis and alter the developmental trajectory of progeny. The potential mechanisms by which preconception maternal and paternal opioid exposure produce deleterious consequences on the health, behavior, and physiology of offspring that have been identified by clinical and animal studies will be discussed. The timing, nature, dosing, and duration of prenatal opioid exposure combined with other important environmental considerations influence the extent to which these manipulations affect parents and their progeny. Epigenetic inheritance refers to the transmission of environmental insults across generations via mechanisms independent of the DNA sequence. This topic will be further explored in the context of prenatal, perinatal, and preconception opioid exposure for both the maternal and paternal lineage.

Patientin mit Schwangerschaft, Borderline-Organisation und schwerer Polytoxikomanie

Zielsetzung Ziel dieser Arbeit war es, die Komplexität von Schwangerschaft und Sucht durch ein Fallbeispiel einer Patientin mit schwerer Polytoxikomanie, Borderline-Organisation sowie den Verlauf der Schwangerschaft und die frühe Phase nach der Geburt vorzustellen. Dabei ging es v. a. um die Frage, wie eine langfristige Behandlung mit einem mehrstufigen, multiprofessionellen und multimodalen Setting aussehen könnte. Die Arbeit zeigt zudem Konflikte an Schnittstellen auf und wie wichtig die Kommunikation innerhalb des Teams und fachübergreifend war.

Intervention Qualifizierte stationäre Entgiftungsbehandlung von Benzodiazepinen, Phenothiazin, Lyrica Venlafaxin und Reduktion von Methadon mit anschließender Umstellung auf Buprenorphin sowie ergänzender kombinierter ärztlicher, psychodynamischer Einzel- und Gruppentherapie und einem pflegerischen DBT-S Einzel- und Gruppensetting. Außerdem wurde schon während der Schwangerschaft zusätzlich zum stationären Behandlungsteam ein fächerübergreifendes Behandlungsteam aus Gynäkologen, Kinderärzten, Kinder- und Jugendpsychiatern sowie der Kinder- und Erwachsenenschutzbehörde (KESB, in Deutschland Jugendamt) zusammengestellt und schon zu Beginn wurde eine langfristige Behandlung mit stationärem, teilstationärem und ambulantem Intervall geplant.

Ergebnis Im Laufe der fast 3-jährigen Behandlung und 5 Jahre späteren katamnestischen Nachuntersuchung konnte zunächst unter 8 mg Buprenorphin eine Abstinenz von illegalen Substanzen erzielt werden. Im Verlauf sogar vollständige Abstinenz ohne Substitution. Dies konnte durch ein erneutes Interview und Drogenscreening im Jahr 2020 bestätigt werden. Außerdem konnte im Rahmen der fächerübergreifenden Arbeit ein stabiles soziales Umfeld und ein Wiedereinstieg ins Berufsleben erreicht werden.

Diskussion Trotz der anfänglich häufigen Rückfälle konnte durch den Erhalt der therapeutischen Beziehung (z. B. mittels Time-out auf die Akutstation, Verlängerung einer Wochenendbeurlaubung oder Neuverhandlung der Behandlungsvereinbarung) unter Fortsetzung der Einzelpsychotherapie und Bezugspflege mit Einbezug der Rückfälle, gegenseitiges Vertrauen und Wertschätzung geschaffen werden. Dafür war allerdings viel supervisorische Arbeit innerhalb des Teams, aber auch fächerübergreifend notwendig, da sich die extreme innerer Welt der Patientin häufig in unterschiedlicher Art und Weise im multiprofessionellen Team zeigte und dadurch zu Konflikten führte, die passager das Verlassen der Neutralität verlangten. Ferner waren für diese Art der Behandlung enorme Ressourcen notwendig sowohl zeitlich als auch personell.

Prevention of Neonatal Abstinence Syndrome in an Outpatient Prenatal Buprenorphine Tapering Program

OBJECTIVES

Many addicted pregnant patients receiving buprenorphine medication-assisted therapy (MAT) wish to discontinue this medication while pregnant. This study was undertaken to determine whether outpatient detoxification from buprenorphine during pregnancy is safe and effective when confirmed with postdetoxification urine drug screens (UDSs).

METHODS

This case series reports the maternal and neonatal outcomes for 21 patients who ended MAT with buprenorphine while pregnant. A retrospective chart review of both maternal and newborn electronic medical records was performed to obtain results. Newborn neonatal abstinence syndrome (NAS) diagnosis, need for morphine, maternal safety and fetal/newborn complications were assessed. Maternal sobriety was documented with UDSs at the time of admission for delivery. Umbilical cord blood also was assessed for substances of abuse. An additional 182 pregnant women who lowered their buprenorphine doses but did not decide to end MAT were assessed via routine quality assurance methods.

RESULTS

None of the women who stopped buprenorphine during their pregnancy as confirmed by UDSs and umbilical cord sampling delivered neonates who had NAS. Eleven patients ended MAT with medical assistance and 10 ended MAT without medical assistance. No overdoses were reported for the 182 additional pregnant patients who indicated an intention to taper buprenorphine dosage while pregnant but who did not decide to end MAT; the neonatal benefits were obtained without any identified maternal harm.

CONCLUSIONS

The neonates of pregnant women enrolled in an outpatient buprenorphine MAT tapering program who are able to completely stop taking buprenorphine (as documented by negative urinary drug screen) are very unlikely to have NAS. Further research will be important.

Opioids affect the fetal brain: reframing the detoxification debate

Medication-assisted treatment is recommended for individuals with an opioid use disorder, including pregnant women. Medication-assisted treatment during pregnancy provides benefits to the mother and fetus, including better pregnancy outcomes, reduced illicit drug use, and improved prenatal care. An alternative approach, medically supervised withdrawal (detoxification), has, in recent reports, demonstrated a low risk of fetal death and low rates of relapse and neonatal abstinence syndrome. The rates of relapse and neonatal abstinence syndrome are questioned by many who view medically supervised withdrawal as unacceptable based on the concern for the potential adverse consequences of relapse to mother and baby. The impact of opioids on the fetal brain have not been integrated into this debate. Studies in animals and human brain tissues demonstrate opioid receptors in neurons, astroglia, and oligodendrocytes. Age-specific normative data from infants, children, and adults have facilitated investigation of the impact of opioids on the human brain in vivo. Collectively, these studies in animals, human neural tissue, adult brains, and the brains of children and newborns demonstrate that opioids adversely affect the human brain, primarily the developing oligodendrocyte and the processes of myelinization (white matter microstructure), connectivity between parts of the brain, and the size of multiple brain regions, including the basal ganglia, thalamus, and cerebellar white matter. These in vivo studies across the human lifespan suggest vulnerability of specific fronto-temporal-limbic and frontal-subcortical (basal ganglia and cerebellum) pathways that are also likely vulnerable in the human fetal brain. The long-term impact of these reproducible changes in the fetal brain in vivo is unclear, but the possibility of lasting injury has been suggested. In light of the recent data on medically supervised withdrawal and the emerging evidence suggesting adverse effects of opioids on the developing fetal brain, a new paradigm of care is needed that includes the preferred option of medication-assisted treatment but also the option of medically supervised opioid withdrawal for a select group of women. Both these treatment options should offer mental health and social services support throughout pregnancy. More research on both opioid exposure on the developing human brain and the impact of medically supervised withdrawal is required to identify appropriate candidates, optimal dose reduction regimens, and gestational age timing for initiating medically supervised withdrawal.

Risk Factors Associated with the Occurrence of Neonatal Opioid Withdrawal Syndrome: A Review

In a number of countries, the prevalence of neonatal opioid withdrawal syndrome (NOWS) is increasing. While NOWS is ultimately the result of opioid exposure in utero, a wide range of risk factors have been associated with the prevalence of NOWS, extending beyond just drug exposure. This article reviews the available literature on factors associated with the incidence of NOWS in opioid-exposed neonates. A range of risk factors have been associated with NOWS, including features of neonatal drug exposure, maternal and neonatal characteristics, aspects of labor and delivery, and genetics. Increased length of gestation and higher birth weight were consistently associated with an increased risk of NOWS, while breast feeding and 'rooming-in' were associated with a reduced risk of NOWS. Additionally, several genetic factors have also been associated with NOWS severity. There is conflicting evidence on the association between NOWS and other risk factors including opioid dose, neonate sex, and the use of some medications during pregnancy. This may be in part attributable to differences in how NOWS is diagnosed and the variety of methodologies across studies. While a large number of risk factors associated with NOWS are non-modifiable, encouraging pregnant women to reduce other drug use (including smoking), breast feed their child, and the judicious use of medications during pregnancy may help reduce the prevalence of NOWS. The presence or absence of NOWS in an opioid-exposed neonate is associated with a wide range of factors. Some of these modifiable risk factors may be potential targets for the primary prevention of NOWS.

Mental health in youth prenatally exposed to opioids and poly-drugs and raised in permanent foster/adoptive homes: A prospective longitudinal study

BACKGROUND

Little is known about the mental health of prenatally opioid- and polydrug-exposed youth raised in foster/adoptive families.

AIM

To compare mental health problems among two groups of youth, one prenatally drug-exposed group with participants who were mainly placed in permanent foster or adoptive homes in early infancy and a group without known prenatal risk factors who were raised by their birth parents.

METHODS

The sample consisted of 45 drug-exposed and 48 nonexposed youth between 17 and 22 years old from an original sample of 136 followed since birth. An extended version of the Mini International Neuropsychiatric Interview was used to assess lifetime psychiatric disorder, and participants completed the Achenbach Adult Self-Report form and Cantril's Ladder of Life Satisfaction Scale.

RESULTS

A higher proportion of the youth in the drug-exposed group had lifetime experiences with major depressive episodes, alcohol abuse and attention deficit, hyperactivity disorder (OR > 3, p ≤ .030). They scored higher on the aggressive behavior scale, had more sexual partners and were younger at their sexual debut (p ≤ .030). There were no group differences in current self-reported satisfaction with life.

CONCLUSION

Youth exposed to drugs prenatally continue to represent a risk group despite early placement in permanent foster and adoptive homes. The factors contributing to this elevated risk may be multifaceted and involve adverse prenatal conditions including but not limited to drug exposure, genetics, and postnatal environmental conditions. The results highlight the need for longitudinal follow-up in the transition to adulthood as well as qualified service provision for these youth and their families.

Opioid Detoxification During Pregnancy: A Systematic Review

OBJECTIVE

To systematically review maternal and neonatal outcomes associated with opioid detoxification during pregnancy.

DATA SOURCES

PubMed, PsycINFO, EMBASE, Cochrane, and ClinicalTrials.gov databases were searched from January 1, 1966, to September 1, 2016.

METHODS OF STUDY SELECTION

English-language studies that reported outcomes associated with opioid detoxification among pregnant women with opioid use disorder were included. Nonoriginal research articles (case reports, editorials, reviews) and studies that failed to report outcomes for detoxification participants were excluded. Bias was assessed using the Cochrane Collaboration's tool for assessing risk of bias and quality was assessed using the U.S. Preventive Service Task Force Quality of Evidence scale.

TABULATION, INTEGRATION, AND RESULTS

Of 1,315 unique abstracts identified, 15 met criteria for inclusion and included 1,997 participants, of whom 1,126 underwent detoxification. Study quality ranged from fair to poor as a result of the lack of a randomized control or comparison arm and high risk of bias across all studies. Only nine studies had a comparison arm. Detoxification completion (9-100%) and illicit drug relapse (0-100%) rates varied widely across studies depending on whether data from participants who did not complete detoxification or who were lost to follow-up were included in analyses. The reported rate of fetal loss was similar among women who did (14 [1.2%]) and did not undergo detoxification (17 [2.0%]).

CONCLUSIONS

Evidence does not support detoxification as a recommended treatment intervention as a result of low detoxification completion rates, high rates of relapse, and limited data regarding the effect of detoxification on maternal and neonatal outcomes beyond delivery.

COGNITIVE AND SOCIOEMOTIONAL FUNCTIONING AT 4½ YEARS IN CHILDREN BORN TO MOTHERS WHO HAVE RECEIVED TREATMENT FOR SUBSTANCE-ABUSE PROBLEMS WHILE PREGNANT

Cognitive and socioemotional functioning at 4½ years of age were examined in children born to mothers with substance-abuse problems (n = 22) recruited from residential treatment institutions while pregnant, and then compared to children born to mothers with mental health problems (n = 18) and children from a low-risk group (n = 26). No significant group differences in cognitive functioning were found, but the children born to mothers with substance-abuse problems showed more caregiver-reported socioemotional problems than did the low-risk children, like the children born to mothers with mental health problems. Birth weight had an effect on internalizing problems at 4½ years and mediated the relation between group and socioemotional problems, although not when controlling for caregiver education, single parenthood, and anxiety and depression. At 4½ years, 7 children born to mothers with substance-abuse problems were placed in foster care. These children had lower birth weight and higher caregiver-rated internalizing problems. In addition to emphasizing the importance of the quality of the prenatal environment, this study suggests that families with previous substance abuse are in need of long-term follow-up to address socioemotional problems and enhance further positive child cognitive development. The foster-placed children may be in particular need of long-term follow-up.

Neuroanatomical characteristics of youths with prenatal opioid and poly-drug exposure

Neuroanatomical and cognitive differences have been documented during childhood between children with prenatal opioid- and poly-drug exposure and controls in small samples. We investigated whether these differences persisted in larger samples of youth at older ages. Quantitative MRI and cognitive data were compared between 38 youths in the risk group and 44 youths in the non-exposed group (aged 17 to 22 years) who had been followed prospectively since birth. Most drug-exposed youths (84%) moved to permanent foster or adoptive homes before one year of age. The drug-exposed group displayed smaller neuroanatomical volumes (0.70 SD difference in total brain volume, p = 0.001), smaller cortical surface areas and thinner cortices than the comparison group. The birth weight accounted for some of the intergroup differences. Neuroanatomical characteristics partially mediated group differences in cognitive function. The present study cannot differentiate between causal factors but indicates persistent neurocognitive differences associated with prenatal opioid or poly-drug exposure.

Patterns of polydrug use among pregnant substance abusers

Aim

Studies of drug use during pregnancy have generally focused on individual substances or specific combinations of drugs. The aim of this article is to increase our knowledge about polydrug use and pregnancy in a Nordic context by describing the sociodemographic characteristics of a clinical population of pregnant women with severe substance use, examining the scope and type of polydrug use and analysing factors associated with concurrent use of many, as opposed to a few, drugs.

Method

A cross-sectional study of pregnant women on admission to compulsory care for substance abuse in Sweden between 2000 and 2009 (n = 119 women, representing 128 pregnancies). Data were retrieved from administrative registers and client records. Univariate links between demographic, social, obstetrical, treatment history variables and polydrug use were examined. Binary logistic regression was used to analyse the association between explanatory variables and polydrug use.

Results

The average number of drugs being used concurrently was 2.65, and injection drug use was recorded in 73% of the pregnancies. Opiates and amphetamines were the most common primary drugs, followed by alcohol. The likelihood of polydrug use increased with first trimester pregnancy, planned (as opposed to emergency) committals, as well as the combination of partner substance abuse and injection drug use.

Conclusions

Polydrug use was widespread among pregnant substance abusers. Policies, interventions and research often focus on individual drugs separately, but for clinical populations in particular there is a need to address drug use broadly, including a systematic recording of smoking habits. This also entails awarding more attention to those not eligible for established interventions, such as opiate maintenance treatment, and giving more consideration to a variety of life circumstances, such as partner drug use.

Child neuroanatomical, neurocognitive, and visual acuity outcomes with maternal opioid and polysubstance detoxification

BACKGROUND

Maternal opioid and polysubstance use during pregnancy is associated with an increased risk of child neurocognitive and visual problems and neuroanatomical differences. We hypothesized that, in contrast to findings from a previous study of children born to mothers not detoxified, children born to detoxified mothers would not show gross neuroanatomical and neurocognitive differences.

METHODS

Mothers with opioid and polysusbstance abuse problems and their infants (n = 11 + 12) were recruited from residential treatment institutions. Comparison mothers and infants (n = 12 + 12) were recruited from child health centers. The studies were approved by the Regional Committee of Medical Research Ethics. Children had magnetic resonance imaging scanning, neurocognitive, and visual acuity testing at 4.5 years. Neuroanatomical, cognitive, and visual acuity characteristics were compared across groups by analysis of variance and general linear models.

RESULTS

There were no significant differences across groups in neuroanatomical volumes, or cortical thickness, area, or volume. There were no differences in general neurocognitive functioning, but significantly lower left eye visual acuity, and a trend toward lower binocular visual acuity, in the drug-exposed relative to the comparison group.

CONCLUSIONS

The present study does not demonstrate gross differences relative to a comparison group in neuroanatomical and general neurocognitive characteristics of children born to mothers with opioid and polysubstance abuse who were detoxified during pregnancy. However, visual acuity was significantly lower in the drug-exposed group, requiring attention. There is a pressing need for additional and larger studies of long-term and specific child outcomes in this at-risk group.