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Eleftheriou G, Zandonella Callegher R, Butera R, De Santis M, Cavaliere AF, Vecchio S, Lanzi C, Davanzo R, Mangili G, Bondi E, Somaini L, Gallo M, Balestrieri M, Mannaioni G, Salvatori G, Albert U. Consensus Panel Recommendations for the Pharmacological Management of Breastfeeding Women with Postpartum Depression. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:551. [PMID: 38791766 PMCID: PMC11121006 DOI: 10.3390/ijerph21050551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 04/12/2024] [Accepted: 04/22/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION Our consensus statement aims to clarify the use of antidepressants and anxiolytics during breastfeeding amidst clinical uncertainty. Despite recent studies, potential harm to breastfed newborns from these medications remains a concern, leading to abrupt discontinuation of necessary treatments or exclusive formula feeding, depriving newborns of benefits from mother's milk. METHODS A panel of 16 experts, representing eight scientific societies with a keen interest in postpartum depression, was convened. Utilizing the Nominal Group Technique and following a comprehensive literature review, a consensus statement on the pharmacological treatment of breastfeeding women with depressive disorders was achieved. RESULTS Four key research areas were delineated: (1) The imperative to address depressive and anxiety disorders during lactation, pinpointing the risks linked to untreated maternal depression during this period. (2) The evaluation of the cumulative risk of unfavorable infant outcomes associated with exposure to antidepressants or anxiolytics. (3) The long-term impact on infants' cognitive development or behavior due to exposure to these medications during breastfeeding. (4) The assessment of pharmacological interventions for opioid abuse in lactating women diagnosed with depressive disorders. CONCLUSIONS The ensuing recommendations were as follows: Recommendation 1: Depressive and anxiety disorders, as well as their pharmacological treatment, are not contraindications for breastfeeding. Recommendation 2: The Panel advocates for the continuation of medication that has demonstrated efficacy during pregnancy. If initiating an antidepressant during breastfeeding is necessary, drugs with a superior safety profile and substantial epidemiological data, such as SSRIs, should be favored and prescribed at the lowest effective dose. Recommendation 3: For the short-term alleviation of anxiety symptoms and sleep disturbances, the Panel determined that benzodiazepines can be administered during breastfeeding. Recommendation 4: The Panel advises against discontinuing opioid abuse treatment during breastfeeding. Recommendation 5: The Panel endorses collaboration among specialists (e.g., psychiatrists, pediatricians, toxicologists), promoting multidisciplinary care whenever feasible. Coordination with the general practitioner is also recommended.
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Affiliation(s)
- Georgios Eleftheriou
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Riccardo Zandonella Callegher
- Italian Society of Psychiatry (SIP), Piazza Santa Maria della Pietà 5, 00135 Rome, Italy; (R.Z.C.); (E.B.); (U.A.)
- Psychiatry Unit, Department of Medicine (DAME), University of Udine, 33100 Udine, Italy;
- UCO Clinica Psichiatrica, Azienda Sanitaria Universitaria Giuliano-Isontina, 34148 Trieste, Italy
| | - Raffaella Butera
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Marco De Santis
- Italian Society of Obstetrics and Gynecology (SIGO), Via di Porta Pinciana 6, 00187 Rome, Italy; (M.D.S.); (A.F.C.)
- Department of Obstetrics and Gynecology, Fondazione Policlinico Universitario A. Gemelli, 00168 Rome, Italy
| | - Anna Franca Cavaliere
- Italian Society of Obstetrics and Gynecology (SIGO), Via di Porta Pinciana 6, 00187 Rome, Italy; (M.D.S.); (A.F.C.)
- Department of Gynecology and Obstetrics, Fatebenefratelli Gemelli, Isola Tiberina, 00186 Rome, Italy
| | - Sarah Vecchio
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Addiction Centre, Ser.D, Local Health Unit, 28100 Novara, Italy
| | - Cecilia Lanzi
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Division of Clinic Toxicology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy
| | - Riccardo Davanzo
- Italian Society of Neonatology (SIN), Corso Venezia 8, 20121 Milan, Italy; (R.D.); (G.M.)
- Maternal and Child Health Institute IRCCS “Burlo Garofolo”, 34137 Trieste, Italy
- Task Force on Breastfeeding, Ministry of Health, 00144 Rome, Italy
| | - Giovanna Mangili
- Italian Society of Neonatology (SIN), Corso Venezia 8, 20121 Milan, Italy; (R.D.); (G.M.)
- Department of Neonatology, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Emi Bondi
- Italian Society of Psychiatry (SIP), Piazza Santa Maria della Pietà 5, 00135 Rome, Italy; (R.Z.C.); (E.B.); (U.A.)
- Department of Psychiatry, ASST Papa Giovanni XXIII, 24100 Bergamo, Italy
| | - Lorenzo Somaini
- Ser.D Biella, Drug Addiction Service, 13875 Biella, Italy;
- Italian Society of Addiction Diseases (S.I.Pa.D), Via Tagliamento 31, 00198 Rome, Italy
| | - Mariapina Gallo
- Poison Control Center, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy;
- Italian Society for Drug Addiction (SITD), Via Roma 22, 12100 Cuneo, Italy
| | - Matteo Balestrieri
- Psychiatry Unit, Department of Medicine (DAME), University of Udine, 33100 Udine, Italy;
- Italian Society of Neuropsychopharmacology (SINPF), Via Cernaia 35, 00158 Rome, Italy
| | - Guido Mannaioni
- Italian Society of Toxicology (SITOX), Via Giovanni Pascoli 3, 20129 Milan, Italy; (R.B.); (S.V.); (C.L.); (G.M.)
- Division of Clinic Toxicology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy
- Italian Society of Pharmacology, Via Giovanni Pascoli, 3, 20129 Milan, Italy
| | - Guglielmo Salvatori
- Italian Society of Pediatrics, Via Gioberti 60, 00185 Rome, Italy;
- Department of Medical and Surgical Neonatology Ospedale Pediatrico Bambino Gesù, 00165 Rome, Italy
| | - Umberto Albert
- Italian Society of Psychiatry (SIP), Piazza Santa Maria della Pietà 5, 00135 Rome, Italy; (R.Z.C.); (E.B.); (U.A.)
- UCO Clinica Psichiatrica, Azienda Sanitaria Universitaria Giuliano-Isontina, 34148 Trieste, Italy
- Italian Society of Neuropsychopharmacology (SINPF), Via Cernaia 35, 00158 Rome, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34128 Trieste, Italy
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Zhao W, Alshogran OY, Zhang H, Joshi A, Krans EE, Caritis S, Shaik IH, Venkataramanan R. Simplified processing and rapid quantification of buprenorphine, norbuprenorphine, and their conjugated metabolites in human plasma using UPLC-MS/MS: Assessment of buprenorphine exposure during opioid use disorder treatment. JOURNAL OF MASS SPECTROMETRY : JMS 2024; 59:e5015. [PMID: 38501738 DOI: 10.1002/jms.5015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 01/19/2024] [Accepted: 02/22/2024] [Indexed: 03/20/2024]
Abstract
Opioid use disorder (OUD) is a chronic neurobehavioral ailment and is prevalent in pregnancy. OUD is commonly treated with methadone or buprenorphine (BUP). Pregnancy is known to alter the pharmacokinetics of drugs and may lead to changes in drug exposure and response. A simple, specific, and sensitive analytical method for measuring the parent drug and its metabolites is valuable for assessing the impact of pregnancy on drug exposure. A new liquid chromatography-tandem mass spectrometric method that utilized a simple protein precipitation procedure for sample preparation and four deuterated internal standards for quantification was developed and validated for BUP and its major metabolites (norbuprenorphine [NBUP], buprenorphine-glucuronide [BUP-G], and norbuprenorphine-glucuronide [NBUP-G]) in human plasma. The standard curve was linear over the concentration range of 0.05-100 ng/mL for BUP and NBUP, and 0.1-200 ng/mL for BUP-G and NBUP-G. Intra- and inter-day bias and precision were within ±15% of nominal values for all the analytes. Quality controls assessed at four levels showed high recovery consistently for all the analytes with minimal matrix effect. Adequate analyte stability was observed at various laboratory conditions tested. Overall, the developed method is simple, sensitive, accurate and reproducible, and was successfully applied for the quantification of BUP and its metabolites in plasma samples collected from pregnant women in a clinical study assessing BUP exposure during OUD treatment.
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Affiliation(s)
- Wenchen Zhao
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Osama Y Alshogran
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Hongfei Zhang
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Anand Joshi
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Elizabeth E Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, UPMC Magee-Women's Hospital, Pittsburgh, Pennsylvania, USA
- Magee-Women's Research Institute, Pittsburgh, Pennsylvania, USA
| | - Steve Caritis
- Department of Obstetrics, Gynecology and Reproductive Sciences, School of Medicine, UPMC Magee-Women's Hospital, Pittsburgh, Pennsylvania, USA
- Magee-Women's Research Institute, Pittsburgh, Pennsylvania, USA
| | - Imam H Shaik
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Magee-Women's Research Institute, Pittsburgh, Pennsylvania, USA
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Alsmadi MM. Salivary Therapeutic Monitoring of Buprenorphine in Neonates After Maternal Sublingual Dosing Guided by Physiologically Based Pharmacokinetic Modeling. Ther Drug Monit 2024:00007691-990000000-00195. [PMID: 38366333 DOI: 10.1097/ftd.0000000000001172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/08/2023] [Indexed: 02/18/2024]
Abstract
BACKGROUND Opioid use disorder (OUD) during pregnancy is associated with high mortality rates and neonatal opioid withdrawal syndrome (NOWS). Buprenorphine, an opioid, is used to treat OUD and NOWS. Buprenorphine active metabolite (norbuprenorphine) can cross the placenta and cause neonatal respiratory depression (EC50 = 35 ng/mL) at high brain extracellular fluid (bECF) levels. Neonatal therapeutic drug monitoring using saliva decreases the likelihood of distress and infections associated with frequent blood sampling. METHODS An adult physiologically based pharmacokinetic model for buprenorphine and norbuprenorphine after intravenous and sublingual administration was constructed, vetted, and scaled to newborn and pregnant populations. The pregnancy model predicted that buprenorphine and norbuprenorphine doses would be transplacentally transferred to the newborns. The newborn physiologically based pharmacokinetic model was used to estimate the buprenorphine and norbuprenorphine levels in newborn plasma, bECF, and saliva after these doses. RESULTS After maternal sublingual administration of buprenorphine (4 mg/d), the estimated plasma concentrations of buprenorphine and norbuprenorphine in newborns exceeded the toxicity thresholds for 8 and 24 hours, respectively. However, the norbuprenorphine bECF levels were lower than the respiratory depression threshold. Furthermore, the salivary buprenorphine threshold levels in newborns for buprenorphine analgesia, norbuprenorphine analgesia, and norbuprenorphine hypoventilation were observed to be 22, 2, and 162 ng/mL. CONCLUSIONS Using neonatal saliva for buprenorphine therapeutic drug monitoring can facilitate newborn safety during the maternal treatment of OUD using sublingual buprenorphine. Nevertheless, the suitability of using adult values of respiratory depression EC50 for newborns must be confirmed.
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Affiliation(s)
- Mo'tasem M Alsmadi
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan; and
- Nanotechnology Institute, Jordan University of Science and Technology, Irbid, Jordan
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Shelver WL, McGarvey AM, Holthusen JE, Young JM, Byrd CJ, Smith DJ. Comparison of immunoassay and LC-tandem mass spectrometry analyses of ractopamine in hog oral fluid. Food Addit Contam Part A Chem Anal Control Expo Risk Assess 2024; 41:162-174. [PMID: 38190266 DOI: 10.1080/19440049.2023.2300738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 12/26/2023] [Indexed: 01/10/2024]
Abstract
The accurate detection of ractopamine in food animals is crucial for marketing since some entities require animals or animal carcasses to be free of ractopamine residues. Field-based ractopamine screening tests that are rapid, sensitive, and capable of high-throughput are highly desirable to ensure that inadvertent exposure to ractopamine did not occur in animals marketed as animals that have not been fed ractopamine. An immunochemically based lateral flow assay was used to analyze oral fluids from hogs never exposed to ractopamine and from hogs that were presumed positives and results were confirmed using an enhanced sensitivity LC-MSMS method. We found that an immunochemically based lateral flow system having a working range of 2.5 to 15 ng mL-1 worked well as a screening assay with 1.7% false positive results in freshly collected hog oral fluids. Using ractopamine glucuronide standards and LC-MSMS, we determined that the false positive results were not due to the presence of ractopamine glucuronide metabolites in oral fluids.
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Affiliation(s)
- Weilin L Shelver
- Edward T. Schafer Agricultural Research Center, United States Department of Agriculture, Agricultural Research Service, Fargo, North Dakota, USA
| | - Amy M McGarvey
- Edward T. Schafer Agricultural Research Center, United States Department of Agriculture, Agricultural Research Service, Fargo, North Dakota, USA
| | - Jason E Holthusen
- Edward T. Schafer Agricultural Research Center, United States Department of Agriculture, Agricultural Research Service, Fargo, North Dakota, USA
| | - Jennifer M Young
- Department of Animal Sciences, North Dakota State University, Fargo, North Dakota, USA
| | - Christopher J Byrd
- Department of Animal Sciences, North Dakota State University, Fargo, North Dakota, USA
| | - David J Smith
- Edward T. Schafer Agricultural Research Center, United States Department of Agriculture, Agricultural Research Service, Fargo, North Dakota, USA
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Cox J, Morris K, Miller AC, Champion JL, Reisinger AJ, Pandey M, Kraner JC, Arroyo-Mora LE. Oral Cavity Fluid as an Alternative Postmortem Matrix: Comparison to Simultaneously Collected Blood and Urine Specimens. Am J Forensic Med Pathol 2023; 44:258-266. [PMID: 37417473 DOI: 10.1097/paf.0000000000000854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
ABSTRACT In postmortem toxicology analysis, a variety of specimens consisting of fluids and tissues are often collected, each with an intrinsic value. Oral cavity fluid (OCF) is emerging as an alternative matrix in forensic toxicology for contributing to a diagnosis in postmortem cases; especially when blood is limited or not available. The aim of this study was to assess the analytical results obtained from OCF and compare them with blood, urine, and other traditional matrices collected from the same postmortem subjects. Of the 62 decedents studied (including 1 stillborn, 1 charred, and 3 decomposed subjects), 56 had quantifiable drugs and metabolites data in the OCF, blood, and urine. Notable findings were benzoylecgonine (24 cases), ethyl sulfate (23 cases), acetaminophen (21 cases), morphine (21 cases), naloxone (21 cases), gabapentin (20 cases), fentanyl (17 cases), and 6-acetylmorphine (15 cases), which were detected more frequently in OCF than in blood (heart, femoral, or body cavity) or urine. This study suggests that OCF is a suitable matrix for detecting and quantifying analytes in postmortem subjects compared with traditional matrices, particularly when other matrices are limited or difficult to collect because of body condition or putrefaction.
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Affiliation(s)
- Joseph Cox
- From the Department of Forensic and Investigative Science, West Virginia University, Morgantown, WV
| | - Kylea Morris
- From the Department of Forensic and Investigative Science, West Virginia University, Morgantown, WV
| | - Autumn C Miller
- SteelFusion Clinical Toxicology Laboratory, LLC, Monessen, PA
| | - Jana L Champion
- SteelFusion Clinical Toxicology Laboratory, LLC, Monessen, PA
| | - Amy J Reisinger
- SteelFusion Clinical Toxicology Laboratory, LLC, Monessen, PA
| | - Maneesha Pandey
- Forensic Pathologist, The Forensic Pathologists LLC, Holland, OH
| | | | - Luis E Arroyo-Mora
- From the Department of Forensic and Investigative Science, West Virginia University, Morgantown, WV
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Tobacyk J, Parks BJ, Salazar P, Coward LU, Berquist MD, Gorman GS, Brents LK. Interaction between buprenorphine and norbuprenorphine in neonatal opioid withdrawal syndrome. Drug Alcohol Depend 2023; 249:110832. [PMID: 37385117 PMCID: PMC10573081 DOI: 10.1016/j.drugalcdep.2023.110832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 07/01/2023]
Abstract
Buprenorphine (BUP) is the preferred treatment for opioid use disorder during pregnancy but can cause neonatal opioid withdrawal syndrome (NOWS). Norbuprenorphine (NorBUP), an active metabolite of BUP, is implicated in BUP-associated NOWS. We hypothesized that BUP, a low-efficacy agonist of mu opioid receptors, will not antagonize NorBUP, a high-efficacy agonist of mu opioid receptors, in producing NOWS. To test this hypothesis, we treated pregnant Long-Evans rats with BUP (0, 0.01, 0.1 or 1mg/kg/day) ± NorBUP (1mg/kg/day) from gestation day 9 until pup delivery, and tested pups for opioid dependence using our established NOWS model. We used LC-MS-MS to quantify brain concentrations of BUP, NorBUP, and their glucuronide conjugates. BUP had little effect on NorBUP-induced NOWS, with the exception of 1mg/kg/day BUP significantly increasing NorBUP-induced NOWS by 58% in females. BUP and NorBUP brain concentrations predicted NOWS in multiple linear regression models. Interestingly, NorBUP contributed more to NOWS in females (βNorBUP = 51.34, p = 0.0001) than in males (βNorBUP = 19.21, P = 0.093), while BUP was similar for females (βBUP = 10.62, P = 0.0017) and males (βBUP = 11.38, P = 0.009). We are the first to report that NorBUP induces NOWS in the presence of BUP and it is more influential in females than males in the contribution of NorBUP to BUP-associated NOWS. These findings suggest that females are more susceptible to NorBUP-induced NOWS, and that treatment strategies that reduce prenatal NorBUP exposure may be more effective for females than males.
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Affiliation(s)
- Julia Tobacyk
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Mail Slot 611, Little Rock, AR72205, USA
| | - Brian J Parks
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Mail Slot 611, Little Rock, AR72205, USA
| | - Paloma Salazar
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Mail Slot 611, Little Rock, AR72205, USA
| | - Lori U Coward
- Department of Pharmaceutical Sciences in the McWhorter School of Pharmacy at Samford University, 800 Lakeshore Dr, Birmingham, AL35229, USA
| | - Michael D Berquist
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Mail Slot 611, Little Rock, AR72205, USA
| | - Gregory S Gorman
- Department of Pharmaceutical Sciences in the McWhorter School of Pharmacy at Samford University, 800 Lakeshore Dr, Birmingham, AL35229, USA
| | - Lisa K Brents
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Mail Slot 611, Little Rock, AR72205, USA.
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Vella A, Savona-Ventura C, Mahmood T. Harmful effects of opioid use in pregnancy: A scientific review commissioned by the European Board and College of obstetrics and gynaecology (EBCOG). Eur J Obstet Gynecol Reprod Biol 2023; 286:70-75. [PMID: 37216740 DOI: 10.1016/j.ejogrb.2023.05.019] [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: 05/24/2023]
Abstract
Caring for pregnant women who have a recreational opioid use disorder is a common clinical challenge in modern obstetric care. These are an elusive population who often have multiple social issues that complicate their pregnancy management. Comprehensive and supportive maternal care can motivate these mothers to change her lifestyle. Multidisciplinary non-judgemental approach with appropriate medication and management, can result in good pregnancy outcomes for mother and her baby.
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Affiliation(s)
| | - Charles Savona-Ventura
- Department of Obstetrics and Gynaecology, University of Malta, Member EBCOG Standing Committee on Standards of Care and Position Statements, Malta; Member of the EBCOG Standing Committee on Standards of Care and Position Statements, Malta
| | - Tahir Mahmood
- Victoria Hospital, Kirkcaldy and Spire Murrayfield Hospital, Edinburgh, United Kingdom; Member of the EBCOG Standing Committee on Standards of Care and Position Statements, Malta
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Silva F, Keitt SA, Hobbs GA. Three cases of naloxone interference with an oxycodone immunoassay in oral fluid. Drug Test Anal 2022; 14:1166-1169. [PMID: 35146956 DOI: 10.1002/dta.3228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Fabiola Silva
- Clinical Toxicology, Truetox Laboratories, LLC, Garden City Park, New York, USA
| | - Shawn A Keitt
- Clinical Toxicology, Truetox Laboratories, LLC, Garden City Park, New York, USA
| | - Gregory A Hobbs
- Clinical Toxicology, Truetox Laboratories, LLC, Garden City Park, New York, USA
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Coker JL, Ray-Griffith SL, McLeod C, Han X, Mancino M, Kearns GL, Stowe ZN. Clearance of buprenorphine during pregnancy and neonatal outcomes. Arch Womens Ment Health 2021; 24:933-939. [PMID: 33864131 DOI: 10.1007/s00737-021-01128-1] [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: 08/04/2020] [Accepted: 04/03/2021] [Indexed: 11/28/2022]
Abstract
Buprenorphine is emerging as the preferred pharmacologic treatment for opioid use disorder during pregnancy. We examined the relative plasma clearance of buprenorphine (BUP) across pregnancy. Pregnant women with opioid use disorder participating in a prospective, observational study from 2013 to 2016 on stress in pregnancy who were receiving BUP for opioid use disorder were included. Women with an active eating disorder or suicidal ideation were excluded. Research visits occurred at 4-6-week intervals across pregnancy and the early postpartum period and included medication exposure history and blood samples. All assays for BUP serum concentrations at steady state were completed. Relative weight-adjusted clearance (Cl) was calculated using Cl = (daily dose [mg]/ body weight [kg])/serum concentration [ng/ml]. We collected 112 maternal blood samples from 29 women throughout pregnancy and the postpartum period. Serum concentrations for BUP ranged from < 0.2 to 15.8 ng/ml. Eleven women, with greater than three collected samples, increased their daily dose of BUP during pregnancy; however, there were no significant differences in relative clearance of BUP across this same period. This data suggests that women with opioid use disorder receiving BUP did not demonstrate a significant increase in BUP clearance across pregnancy despite increase in dosages during pregnancy. When selecting an appropriate BUP dosage for management of perinatal opioid use disorder, gestational stage appears not to be an important covariate and should be based on an individualized approach.
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Affiliation(s)
- Jessica L Coker
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR, 72205, USA.
| | - Shona L Ray-Griffith
- Department of Psychiatry and Obstetrics & Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Cody McLeod
- Department of Orthopedics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Xiaotong Han
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR, 72205, USA
| | - Michael Mancino
- Department of Psychiatry, University of Arkansas for Medical Sciences, 4301 W. Markham Street, Little Rock, AR, 72205, USA
| | - Gregory L Kearns
- Departments of Medical Education and Pediatrics, Texas Christian University, UNTHSC School of Medicine, Fort Worth, TX, USA
| | - Zachary N Stowe
- Department of Psychiatry, University of Wisconsin, Madison, WI, USA
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Abstract
BACKGROUND In the United States, drug addiction has become a nationwide health crisis. Recently, buprenorphine (BUP), a maintenance therapy approved by the Food and Drug Administration, has been increasingly used in pregnant women for the treatment of opioid use disorder. Pregnancy is associated with various anatomic and physiological changes, which may result in altered drug pharmacokinetics (PKs). Previously, we reported that dose-adjusted plasma concentrations of BUP are lower during pregnancy than after pregnancy. The mechanism(s) responsible for this difference has not yet been defined. Our study aimed to evaluate alterations in cytochromes P450 (CYP)- and uridine diphosphate glucunosyltransferases (UGT)-mediated metabolism of BUP during pregnancy to determine the mechanism(s) responsible for this observation. METHODS Data from 2 clinical studies were included in the current analysis. Study 1 was a prospective, open-labeled, nonrandomized longitudinal BUP PK study in pregnant women with a singleton gestation, stabilized on twice-daily sublingual BUP opioid substitution therapy. Each subject participated in up to 3 studies during and after pregnancy (the second, third trimester, and postpartum). The design of study 2 was similar to study 1, with patients evaluated at different time points during the pregnancy (first, second-half of pregnancy), as well as during the postpartum period. In addition, the dosing frequency of BUP study 2 participants was not restricted to twice-daily dosing. At each study visit, blood samples were collected before a BUP dose, followed by multiple collection times (10-12) after the dose, for up to 12 hours or till the end of the dosing interval. Plasma concentrations of BUP and 3 metabolites were quantified using validated ultraperformance liquid chromatography-tandem mass spectrometric assays. RESULTS In total, 19, 18, and 14 subjects completed the PK study during 1/2 trimester, third trimester, and postpartum, respectively. The AUC ratios of norbuprenorphine and norbuprenorphine glucuronide to buprenorphine, a measure of CYP3A mediated N-demethylation, were 1.89, 1.84, and 1.33 during the first and second, third trimesters, and postpartum, respectively. The AUC ratios of buprenorphine glucuronide to BUP, indicative of UGT activity, were 0.71, 2.07, and 0.3 at first/second trimesters, third trimester, and postpartum, respectively. Linear mixed-effect modeling analysis indicated that the AUC ratios of CYP- and UGT-mediated metabolism of BUP were significantly higher during pregnancy compared with postpartum. CONCLUSIONS The CYP and UGT activities were significantly increased as determined by the metabolic ratios of BUP during pregnancy compared with the postpartum period. The increased UGT activity appeared to account for a substantial part of the observed change in metabolic activity during pregnancy. This is in agreement with the need for BUP dose increment in pregnant women to reach similar BUP exposure and therapeutic effect as in nonpregnant subjects.
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Hakomäki H, Kokki H, Lehtonen M, Ranta VP, Räsänen J, Voipio HM, Kokki M. Pharmacokinetics of buprenorphine in pregnant sheep after intravenous injection. Pharmacol Res Perspect 2021; 9:e00726. [PMID: 33619904 PMCID: PMC7899927 DOI: 10.1002/prp2.726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 01/15/2021] [Indexed: 01/27/2023] Open
Abstract
Buprenorphine is a semi‐synthetic opioid, widely used in the maintenance treatment for opioid‐dependent pregnant women. Limited data exist on the pharmacokinetics of buprenorphine in pregnancy. We conducted a pharmacokinetic study to determine the pharmacokinetics of intravenous buprenorphine in pregnant sheep. Fourteen pregnant sheep in late gestation received 10 µg/kg of buprenorphine as an intravenous bolus injection. Plasma samples were collected up to 48 h after administration. Buprenorphine and its metabolite, norbuprenorphine, were quantified from plasma using a LC/MS/MS method, with lower limits of quantification of 0.01 µg/L and 0.04 µg/L for buprenorphine and norbuprenorphine, respectively. The pharmacokinetic parameters were calculated using noncompartmental analysis. The pharmacokinetic parameters, median (minimum−maximum), were Cmax 4.31 µg/L (1.93–15.5), AUCinf 2.89 h*µg/L (1.72–40.2), CL 3.39 L/h/kg (0.25–6.02), terminal t½ 1.75 h (1.07–31.0), Vss 8.04 L/kg (1.05–49.3). Norbuprenorphine was undetected in all plasma samples. The median clearance in pregnant sheep was higher than previously reported for nonpregnant sheep and human (male) subjects. Our sensitive analytical method was able to detect long terminal half‐lives for six subjects, and a wide between‐subject variability in the study population. Significance statement: Buprenorphine is widely used for the treatment of opioid use disorder in pregnancy. However, limited data exist on the pharmacokinetics of buprenorphine during pregnancy. As this type of study cannot be done in humans due to ethical reasons, we conducted a study in pregnant sheep. This study provides pharmacokinetic data on buprenorphine in pregnant sheep and helps us to understand the pharmacokinetics of the drug in humans.
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Affiliation(s)
| | - Hannu Kokki
- School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Marko Lehtonen
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Veli-Pekka Ranta
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Juha Räsänen
- Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki, Finland
| | - Hanna-Marja Voipio
- Department of Experimental Surgery, Oulu Laboratory Animal Centre, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Merja Kokki
- Department of Anesthesia and Intensive Care, Kuopio University Hospital, Kuopio, Finland
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12
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Medication-Assisted Treatment for Opioid Use Disorder in Pregnancy: Practical Applications and Clinical Impact. Obstet Gynecol Surv 2020; 75:175-189. [PMID: 32232496 DOI: 10.1097/ogx.0000000000000744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Importance Opioid use disorder is increasingly common in the United States and affects many pregnancies. Given the rise in pregnancies complicated by opioid use, providers should understand the diagnosis and management of opioid use disorder in pregnancy. Objective This article focuses on screening for opioid misuse, selecting appropriate treatment for patients, initiating medication-assisted treatment in the inpatient setting, and providing appropriate peripartum care. Evidence Acquisition A PubMed search was undertaken using the following search terms: "opioid use disorder", "pregnancy," "medication assisted treatment," "buprenorphine," "methadone," "heroin," "addiction," "neonatal abstinence syndrome," and "detoxification." The search was limited to the English language publications, with most being published after 2000. Results All women should be screened for opioid use disorder during pregnancy. Opioid use has profound effects on the mother and infant. Medication-assisted treatment is the standard of care for pregnant women with opioid use disorder. Patients will require a multidisciplinary approach to management in the intrapartum and postpartum period. Conclusions Conclusions Opioid use disorder is a common, chronic condition with significant implications during pregnancy. Recognition and appropriate treatment of this disorder can optimize maternal and fetal outcomes. Conclusions Obstetricians are increasingly being challenged to manage pregnancies complicated by opioid use disorder and should be proficient in providing safe and effective care.
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13
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Martin CE, Shadowen C, Thakkar B, Oakes T, Gal TS, Moeller FG. Buprenorphine dosing for the treatment of opioid use disorder through pregnancy and postpartum. ACTA ACUST UNITED AC 2020; 7:375-399. [PMID: 33585165 DOI: 10.1007/s40501-020-00221-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose of Review Opioid-related deaths are a leading cause of mortality during pregnancy through 12 months postpartum. Buprenorphine use during pregnancy is increasing, yet expert opinion on its dosing through the perinatal period is limited. We provide a review of the current clinical literature on buprenorphine dosing during pregnancy through 12 months postpartum. and present data from a retrospective chart review of patients at our institution describing trends in buprenorphine dosing during pregnancy and postpartum. Utilizing this information, we synthesize findings to provide clinical recommendations for providers. Recent Findings Existing literature during pregnancy reflects how many women increase and split total daily buprenorphine doses as gestational age advances. Summary We present data from a retrospective chart review of patients at our institution describing trends in buprenorphine dosing during pregnancy and postpartum. Utilizing this information, we synthesize findings to provide clinical recommendations for providers. Changes in the total daily dose of buprenorphine used across pregnancy and through 12 months postpartum at the individual level do not follow consistent patterns, highlighting substantial individual variability. Altogether, buprenorphine dosing should be individualized through pregnancy and postpartum with frequent evaluations by providers and solicited input from patients.
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Affiliation(s)
- Caitlin E Martin
- Virginia Commonwealth University, (Department of Obstetrics & Gynecology, Institute for Drug and Alcohol Studies), Richmond, (Virginia), USA
| | - Caroline Shadowen
- Virginia Commonwealth University, (School of Medicine), Richmond, (Virginia), USA
| | - Bhushan Thakkar
- Virginia Commonwealth University, (Department of Obstetrics & Gynecology), Richmond, (Virginia), USA
| | - Travis Oakes
- Virginia Commonwealth University, (Clinical Research Informatics Group, C. Kenneth and Dianne Wright Center for Clinical and Translational Research), Richmond, (Virginia), USA
| | - Tamas S Gal
- Virginia Commonwealth University, (Department of Biostatistics, School of Medicine), Richmond, (Virginia), USA
| | - F Gerard Moeller
- Virginia Commonwealth University, (Department of Psychiatry, Institute for Drug and Alcohol Studies), Richmond, (Virginia), USA
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14
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Abstract
The number of pregnant people affected by the opioid epidemic in the United States continues to rise. The following key aspects of opioid use disorder in pregnancy are explored through the progression of a pregnancy via a patient case: treatment options, treatment decisions, substance use screening, dosing modifications, and other aspects of peripartum care. Many factors affect opioid use disorder treatment choices during pregnancy; however, when a pregnant person is medically eligible for a therapy and multiple options are available locally, the ultimate decision regarding treatment selection should be left up to the patient and strong support services provided. This approach to treatment results in optimal maternal and neonatal outcomes and long-term maternal engagement and retention in care.
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15
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Kongstorp M, Bogen IL, Stiris T, Andersen JM. High Accumulation of Methadone Compared with Buprenorphine in Fetal Rat Brain after Maternal Exposure. J Pharmacol Exp Ther 2019; 371:130-137. [PMID: 31358559 DOI: 10.1124/jpet.119.259531] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/18/2019] [Indexed: 12/12/2022] Open
Abstract
Experimental animal studies are valuable in revealing a causal relationship between prenatal exposure to opioid maintenance treatment (OMT) and subsequent effects; however, previous animal studies of OMT during pregnancy have been criticized for their lack of clinical relevance because of their use of high drug doses and the absence of pharmacokinetic data. Hence, the aim of this study was to determine blood and brain concentrations in rat dams, fetuses, and offspring after continuous maternal exposure to methadone or buprenorphine during gestation and to examine the offspring for neonatal outcomes and withdrawal symptoms. Female rats were implanted with a 28-day osmotic minipump delivering methadone (10 mg/kg per day), buprenorphine (1 mg/kg per day) or vehicle 5 days before mating. Continuous exposure to methadone or buprenorphine induced stable blood concentrations in the dams of 0.25 ± 0.02 µM and 5.65 ± 0.16 nM, respectively. The fetal brain concentration of methadone (1.89 ± 0.35 nmol/g) was twice as high as that in the maternal brain, whereas the fetal brain concentration of buprenorphine (20.02 ± 4.97 pmol/g) was one-third the maternal brain concentration. The opioids remained in the offspring brain several days after the exposure ceased. Offspring prenatally exposed to methadone, but not buprenorphine, displayed reduced body weight and length and increased corticosterone levels. No significant changes in ultrasonic vocalizations were revealed. Our data in rat fetuses and neonates indicate that OMT with buprenorphine may be a better choice than methadone during pregnancy. SIGNIFICANCE STATEMENT: Concern has been raised about the use of opioid maintenance treatment during pregnancy because of the important role of the endogenous opioid system in brain development. Here, we show that the methadone concentration in the fetal rat brain was twice as high as that in the maternal brain, whereas the buprenorphine concentration was one-third the maternal concentration. Furthermore, buprenorphine allowed more favorable birth outcomes, suggesting that buprenorphine may be a better choice during pregnancy.
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Affiliation(s)
- Mette Kongstorp
- Section for Drug Abuse Research, Department of Forensic Sciences (M.K., I.L.B., J.M.A.) and Department of Neonatal Intensive Care (T.S.), Oslo University Hospital, and Institute of Clinical Medicine, Faculty of Medicine (M.K., T.S.), Department of Pharmacy, Faculty of Mathematics and Natural Sciences (J.M.A.), and Institute of Basic Medical Sciences, Faculty of Medicine (I.L.B.), University of Oslo, Oslo, Norway
| | - Inger Lise Bogen
- Section for Drug Abuse Research, Department of Forensic Sciences (M.K., I.L.B., J.M.A.) and Department of Neonatal Intensive Care (T.S.), Oslo University Hospital, and Institute of Clinical Medicine, Faculty of Medicine (M.K., T.S.), Department of Pharmacy, Faculty of Mathematics and Natural Sciences (J.M.A.), and Institute of Basic Medical Sciences, Faculty of Medicine (I.L.B.), University of Oslo, Oslo, Norway
| | - Tom Stiris
- Section for Drug Abuse Research, Department of Forensic Sciences (M.K., I.L.B., J.M.A.) and Department of Neonatal Intensive Care (T.S.), Oslo University Hospital, and Institute of Clinical Medicine, Faculty of Medicine (M.K., T.S.), Department of Pharmacy, Faculty of Mathematics and Natural Sciences (J.M.A.), and Institute of Basic Medical Sciences, Faculty of Medicine (I.L.B.), University of Oslo, Oslo, Norway
| | - Jannike Mørch Andersen
- Section for Drug Abuse Research, Department of Forensic Sciences (M.K., I.L.B., J.M.A.) and Department of Neonatal Intensive Care (T.S.), Oslo University Hospital, and Institute of Clinical Medicine, Faculty of Medicine (M.K., T.S.), Department of Pharmacy, Faculty of Mathematics and Natural Sciences (J.M.A.), and Institute of Basic Medical Sciences, Faculty of Medicine (I.L.B.), University of Oslo, Oslo, Norway
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16
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Desrosiers NA, Huestis MA. Oral Fluid Drug Testing: Analytical Approaches, Issues and Interpretation of Results. J Anal Toxicol 2019; 43:415-443. [DOI: 10.1093/jat/bkz048] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/12/2019] [Accepted: 05/23/2019] [Indexed: 12/19/2022] Open
Abstract
AbstractWith advances in analytical technology and new research informing result interpretation, oral fluid (OF) testing has gained acceptance over the past decades as an alternative biological matrix for detecting drugs in forensic and clinical settings. OF testing offers simple, rapid, non-invasive, observed specimen collection. This article offers a review of the scientific literature covering analytical methods and interpretation published over the past two decades for amphetamines, cannabis, cocaine, opioids, and benzodiazepines. Several analytical methods have been published for individual drug classes and, increasingly, for multiple drug classes. The method of OF collection can have a significant impact on the resultant drug concentration. Drug concentrations for amphetamines, cannabis, cocaine, opioids, and benzodiazepines are reviewed in the context of the dosing condition and the collection method. Time of last detection is evaluated against several agencies' cutoffs, including the proposed Substance Abuse and Mental Health Services Administration, European Workplace Drug Testing Society and Driving Under the Influence of Drugs, Alcohol and Medicines cutoffs. A significant correlation was frequently observed between matrices (i.e., between OF and plasma or blood concentrations); however, high intra-subject and inter-subject variability precludes prediction of blood concentrations from OF concentrations. This article will assist individuals in understanding the relative merits and limitations of various methods of OF collection, analysis and interpretation.
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Affiliation(s)
| | - Marilyn A Huestis
- Lambert Center for the Study of Medicinal Cannabis and Hemp, Institute of Emerging Health Professions, Thomas Jefferson University, Philadelphia, PA, USA
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17
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Ecker J, Abuhamad A, Hill W, Bailit J, Bateman BT, Berghella V, Blake-Lamb T, Guille C, Landau R, Minkoff H, Prabhu M, Rosenthal E, Terplan M, Wright TE, Yonkers KA. Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine. Am J Obstet Gynecol 2019; 221:B5-B28. [PMID: 30928567 DOI: 10.1016/j.ajog.2019.03.022] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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18
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Griffin BA, Caperton CO, Russell LN, Cabanlong CV, Wilson CD, Urquhart KR, Martins BS, Zita MD, Patton AL, Alund AW, Owens SM, Fantegrossi WE, Moran JH, Brents LK. In Utero Exposure to Norbuprenorphine, a Major Metabolite of Buprenorphine, Induces Fetal Opioid Dependence and Leads to Neonatal Opioid Withdrawal Syndrome. J Pharmacol Exp Ther 2019; 370:9-17. [PMID: 31028107 DOI: 10.1124/jpet.118.254219] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 04/25/2019] [Indexed: 11/22/2022] Open
Abstract
Buprenorphine is the preferred treatment of opioid use disorder during pregnancy but can cause fetal opioid dependence and neonatal opioid withdrawal syndrome (NOWS). Notably, withdrawal severity is independent of maternal buprenorphine dose, suggesting that interindividual variance in pharmacokinetics may influence risk and severity of NOWS. Using a rat model of NOWS, we tested the hypothesis that clinically relevant doses of the active metabolite norbuprenorphine (NorBUP) can induce in utero opioid dependence, manifested as naltrexone-precipitated withdrawal signs in the neonate. Pregnant Long-Evans rats were implanted with 14-day osmotic minipumps containing vehicle, morphine (positive control), or NorBUP (0.3-10 mg/kg per day) on gestation day 9. By 12 hours post-delivery, an intraperitoneal injection of the opioid antagonist naltrexone (1 or 10 mg/kg) or saline was administered to pups. Precipitated withdrawal signs were graded by raters blinded to treatment conditions. In a separate group, NorBUP concentrations in maternal and fetal blood and brain on gestation day 20 were determined by liquid chromatography-tandem mass spectrometry. Steady-state maternal blood concentrations of NorBUP in dams infused with 1 or 3 mg/kg per day were comparable to values reported in pregnant humans treated with buprenorphine (1.0 and 9.6 ng/ml, respectively), suggesting a clinically relevant dosing regimen. At these doses, NorBUP increased withdrawal severity in the neonate as shown by an evaluation of 10 withdrawal indicators. These findings support the possibility that NorBUP contributes to fetal opioid dependence and NOWS following maternal buprenorphine treatment during pregnancy.
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Affiliation(s)
- Bryce A Griffin
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Caitlin O Caperton
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Lauren N Russell
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Christian V Cabanlong
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Catheryn D Wilson
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Kyle R Urquhart
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Bradford S Martins
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Marcelle Dina Zita
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Amy L Patton
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Alexander W Alund
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - S Michael Owens
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - William E Fantegrossi
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Jeffery H Moran
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
| | - Lisa K Brents
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, Arkansas (B.A.G.); Departments of Pharmacology and Toxicology (C.O.C., L.N.R., C.V.C., C.D.W., K.R.U., S.M.O., W.E.F., J.H.M., L.K.B.), Psychiatry (B.S.M.), and Microbiology and Immunology (M.D.Z.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; and PinPoint Testing, LLC, Little Rock, Arkansas (A.L.P., A.W.A., J.H.M.)
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19
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Martins F, Oppolzer D, Santos C, Barroso M, Gallardo E. Opioid Use in Pregnant Women and Neonatal Abstinence Syndrome-A Review of the Literature. TOXICS 2019; 7:toxics7010009. [PMID: 30781484 PMCID: PMC6468487 DOI: 10.3390/toxics7010009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/10/2019] [Accepted: 02/13/2019] [Indexed: 02/07/2023]
Abstract
Opiate use during pregnancy has been an increasing problem over the last two decades, making it an important social and health concern. The use of such substances may have serious negative outcomes in the newborn, and clinical and cognitive conditions have been reported, including neonatal abstinence syndrome, developmental problems, and lower cognitive performance. These conditions are common when opiates are used during pregnancy, making the prescription of these kinds of drugs problematic. Moreover, the mother may develop opiate addiction, thus, increasing the likelihood of the infant being born with any of those conditions. This paper reviews the use of opiates during pregnancy and focuses mainly on the neonatal abstinence syndrome. First, the commonly prescribed opiates will be identified, namely those usually involved in cases of addiction and/or neonatal abstinence syndrome. Second, published approaches to deal with those problems will be presented and discussed, including the treatment of both the mother and the infant. Finally, we will outline the treatments that are safest and most efficient, and will define future goals, approaches, and research directions for the scientific community regarding this problem.
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Affiliation(s)
- Fábio Martins
- Centro de Investigação em Ciências da Saúde, Faculdade de Ciências da Saúde da Universidade da Beira Interior (CICS-UBI), 6200-506 Covilhã, Portugal.
| | - David Oppolzer
- Centro de Investigação em Ciências da Saúde, Faculdade de Ciências da Saúde da Universidade da Beira Interior (CICS-UBI), 6200-506 Covilhã, Portugal.
| | - Catarina Santos
- Centro de Investigação em Ciências da Saúde, Faculdade de Ciências da Saúde da Universidade da Beira Interior (CICS-UBI), 6200-506 Covilhã, Portugal.
| | - Mário Barroso
- Serviço de Química e Toxicologia Forenses, Instituto de Medicina Legal e Ciências Forenses-Delegação do Sul, 1150-334 Lisboa, Portugal.
| | - Eugenia Gallardo
- Centro de Investigação em Ciências da Saúde, Faculdade de Ciências da Saúde da Universidade da Beira Interior (CICS-UBI), 6200-506 Covilhã, Portugal.
- Laboratório de Fármaco-Toxicologia-UBIMedical, Universidade da Beira Interior, 6200-284 Covilhã, Portugal.
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20
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Liao MZ, Gao C, Phillips BR, Neradugomma NK, Han LW, Bhatt DK, Prasad B, Shen DD, Mao Q. Pregnancy Increases Norbuprenorphine Clearance in Mice by Induction of Hepatic Glucuronidation. Drug Metab Dispos 2017; 46:100-108. [PMID: 29158248 DOI: 10.1124/dmd.117.076745] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 11/17/2017] [Indexed: 01/09/2023] Open
Abstract
Norbuprenorphine (NBUP) is the major active metabolite of buprenorphine (BUP) that is commonly used to treat opiate addiction during pregnancy; it possesses 25% of BUP's analgesic activity and 10 times BUP's respiratory depression effect. To optimize BUP's dosing regimen during pregnancy with better efficacy and safety, it is important to understand how pregnancy affects NBUP disposition. In this study, we examined the pharmacokinetics of NBUP in pregnant and nonpregnant mice by administering the same amount of NBUP through retro-orbital injection. We demonstrated that the systemic clearance (CL) of NBUP in pregnant mice increased ∼2.5-fold compared with nonpregnant mice. Intrinsic CL of NBUP by glucuronidation in mouse liver microsomes from pregnant mice was ∼2 times greater than that from nonpregnant mice. Targeted liquid chromatography tandem-mass spectrometry proteomics quantification revealed that hepatic Ugt1a1 and Ugt2b1 protein levels in the same amount of total liver membrane proteins were significantly increased by ∼50% in pregnant mice versus nonpregnant mice. After scaling to the whole liver with consideration of the increase in liver protein content and liver weight, we found that the amounts of Ugt1a1, Ugt1a10, Ugt2b1, and Ugt2b35 protein in the whole liver of pregnant mice were significantly increased ∼2-fold compared with nonpregnant mice. These data suggest that the increased systemic CL of NBUP in pregnant mice is likely caused by an induction of hepatic Ugt expression and activity. The data provide a basis for further mechanistic analysis of pregnancy-induced changes in the disposition of NBUP and drugs that are predominately and extensively metabolized by Ugts.
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Affiliation(s)
- Michael Z Liao
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, Washington
| | - Chunying Gao
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, Washington
| | - Brian R Phillips
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, Washington
| | - Naveen K Neradugomma
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, Washington
| | - Lyrialle W Han
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, Washington
| | - Deepak Kumar Bhatt
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, Washington
| | - Bhagwat Prasad
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, Washington
| | - Danny D Shen
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, Washington
| | - Qingcheng Mao
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, Washington
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21
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Kwong TC, Magnani B, Moore C. Urine and oral fluid drug testing in support of pain management. Crit Rev Clin Lab Sci 2017; 54:433-445. [PMID: 28990451 DOI: 10.1080/10408363.2017.1385053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In recent years, the abuse of opioid drugs has resulted in greater prevalence of addiction, overdose, and deaths attributable to opioid abuse. The epidemic of opioid abuse has prompted professional and government agencies to issue practice guidelines for prescribing opioids to manage chronic pain. An important tool available to providers is the drug test for use in the initial assessment of patients for possible opioid therapy, subsequent monitoring of compliance, and documentation of suspected aberrant drug behaviors. This review discusses the issues that most affect the clinical utility of drug testing in chronic pain management with opioid therapy. It focuses on the two most commonly used specimen matrices in drug testing: urine and oral fluid. The advantages and disadvantages of urine and oral fluid in the entire testing process, from specimen collection and analytical methodologies to result interpretation are reviewed. The analytical sensitivity and specificity limitations of immunoassays used for testing are examined in detail to draw attention to how these shortcomings can affect result interpretation and influence clinical decision-making in pain management. The need for specific identification and quantitative measurement of the drugs and metabolites present to investigate suspected aberrant drug behavior or unexpected positive results is analyzed. Also presented are recent developments in optimization of test menus and testing strategies, such as the modification of the standard screen and reflexed-confirmation testing model by eliminating some of the initial immunoassay-based tests and proceeding directly to definitive testing by mass spectrometry assays.
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Affiliation(s)
- Tai C Kwong
- a Department of Pathology and Laboratory Medicine , University of Rochester Medical Center , Rochester , NY , USA
| | - Barbarajean Magnani
- b Department of Pathology and Laboratory Medicine , Tufts Medical Center , Boston , MA , USA
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An evidence-based recommendation to increase the dosing frequency of buprenorphine during pregnancy. Am J Obstet Gynecol 2017; 217:459.e1-459.e6. [PMID: 28669739 DOI: 10.1016/j.ajog.2017.06.029] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/19/2017] [Accepted: 06/26/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Dose-adjusted plasma concentrations of buprenorphine are significantly decreased during pregnancy compared with the nonpregnant state. This observation suggests that pregnant women may need a higher dose of buprenorphine than nonpregnant individuals to maintain similar drug exposure (plasma concentrations over time after a dose). The current dosing recommendations for buprenorphine during pregnancy address the total daily dose of buprenorphine to be administered, but the frequency of dosing is not clearly addressed. Based on buprenorphine's long terminal half-life, once-daily or twice-daily dosing has generally been suggested. OBJECTIVE The objective of the study was to assess the impact of dosing frequency on buprenorphine plasma concentration time course during pregnancy. STUDY DESIGN We utilized 3 data sources to determine an optimal frequency for dosing of buprenorphine during pregnancy: data from a pharmacokinetic study of 14 pregnant and postpartum women on maintenance buprenorphine in a supervised clinical setting; data from pregnant women attending a buprenorphine clinic; and data from a physiologically based pharmacokinetic modeling of buprenorphine pharmacokinetics in nonpregnant subjects. RESULTS Among the 14 women participating in the pharmacokinetic study during and after pregnancy, plasma concentrations of buprenorphine were <1 ng/mL (the theoretical concentration required to prevent withdrawal symptoms) for 50-80% of the 12 hour dosing interval while at steady state. Among 62 women followed up in a opioid agonist treatment program, in which dosing frequency is determined in part by patient preference, 10 (16%) were on once-daily dosing, 10 (16%) were on twice-daily dosing, 28 (45%) were on thrice-daily dosing, and 14 (23%) were on four-times-daily dosing. A physiologically based pharmacokinetic model in nonpregnant subjects demonstrated that dosing frequency has an impact on the duration over which the plasma concentrations are below a specified plasma concentration threshold. CONCLUSION A more frequent dosing interval (ie, three-times-daily or four-times-daily dosing) may be required in pregnant women to sustain plasma concentrations above the threshold of 1 ng/mL to prevent withdrawal symptoms and to improve adherence.
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Liao MZ, Gao C, Shireman LM, Phillips B, Risler LJ, Neradugomma NK, Choudhari P, Prasad B, Shen DD, Mao Q. P-gp/ABCB1 exerts differential impacts on brain and fetal exposure to norbuprenorphine. Pharmacol Res 2017; 119:61-71. [PMID: 28111265 DOI: 10.1016/j.phrs.2017.01.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/10/2017] [Accepted: 01/16/2017] [Indexed: 01/11/2023]
Abstract
Norbuprenorphine is the major active metabolite of buprenorphine which is commonly used to treat opiate addiction during pregnancy. Norbuprenorphine produces marked respiratory depression and was 10 times more potent than buprenorphine. Therefore, it is important to understand the mechanism that controls fetal exposure to norbuprenorphine, as exposure to this compound may pose a significant risk to the developing fetus. P-gp/ABCB1 and BCRP/ABCG2 are two major efflux transporters regulating tissue distribution of drugs. Previous studies have shown that norbuprenorphine, but not buprenorphine, is a P-gp substrate. In this study, we systematically examined and compared the roles of P-gp and BCRP in determining maternal brain and fetal distribution of norbuprenorphine using transporter knockout mouse models. We administered 1mg/kg norbuprenorphine by retro-orbital injection to pregnant FVB wild-type, Abcb1a-/-/1b-/-, and Abcb1a-/-/1b-/-/Abcg2-/- mice on gestation day 15. The fetal AUC of norbuprenorphine was ∼64% of the maternal plasma AUC in wild-type mice, suggesting substantial fetal exposure to norbuprenorphine. The maternal plasma AUCs of norbuprenorphine in Abcb1a-/-/1b-/- and Abcb1a-/-/1b-/-/Abcg2-/- mice were ∼2 times greater than that in wild-type mice. Fetal AUCs in Abcb1a-/-/1b-/- and Abcb1a-/-/1b-/-/Abcg2-/- mice were also increased compared to wild-type mice; however, the fetal-to-maternal plasma AUC ratio remained relatively unchanged by the knockout of Abcb1a/1b or Abcb1a/1b/Abcg2. In contrast, the maternal brain-to-maternal plasma AUC ratio in Abcb1a-/-/1b-/- or Abcb1a-/-/1b-/-/Abcg2-/- mice was increased ∼30-fold compared to wild-type mice. Protein quantification by LC-MS/MS proteomics revealed significantly higher amounts of P-gp protein in the wild-type mice brain than that in the placenta. These results indicate that fetal exposure to norbuprenorphine is substantial and that P-gp has a minor impact on fetal exposure to norbuprenorphine, but plays a significant role in restricting its brain distribution. The differential impacts of P-gp on norbuprenorphine distribution into the brain and fetus are likely, at least in part, due to the differences in amounts of P-gp protein expressed in the blood-brain and blood-placental barriers. BCRP is not as important as P-gp in determining both the systemic and tissue exposure to norbuprenorphine. Finally, fetal AUCs of the metabolite norbuprenorphine-β-d-glucuronide were 3-7 times greater than maternal plasma AUCs, while the maternal brain AUCs were <50% of maternal plasma AUCs, suggesting that a reversible pool of conjugated metabolite in the fetus may contribute to the high fetal exposure to norbuprenorphine.
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Affiliation(s)
- Michael Z Liao
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, WA 98195, USA
| | - Chunying Gao
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, WA 98195, USA
| | - Laura M Shireman
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, WA 98195, USA
| | - Brian Phillips
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, WA 98195, USA
| | - Linda J Risler
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, WA 98195, USA
| | - Naveen K Neradugomma
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, WA 98195, USA
| | - Prachi Choudhari
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, WA 98195, USA
| | - Bhagwat Prasad
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, WA 98195, USA
| | - Danny D Shen
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, WA 98195, USA
| | - Qingcheng Mao
- Department of Pharmaceutics, School of Pharmacy, University of Washington, Seattle, WA 98195, USA.
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Bastian JR, Chen H, Zhang H, Rothenberger S, Tarter R, English D, Venkataramanan R, Caritis SN. Dose-adjusted plasma concentrations of sublingual buprenorphine are lower during than after pregnancy. Am J Obstet Gynecol 2017; 216:64.e1-64.e7. [PMID: 27687214 PMCID: PMC5245872 DOI: 10.1016/j.ajog.2016.09.095] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 09/12/2016] [Accepted: 09/17/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Buprenorphine is a Food and Drug Administration-approved maintenance therapy for opioid use disorders and is increasingly being used in pregnant women with opioid use disorders as an alternative to methadone. Dosing of buprenorphine in pregnant women is based on the regimen recommended for nonpregnant females and males. Limited data are available defining the pharmacokinetic properties of sublingual buprenorphine administered during pregnancy. OBJECTIVE This study evaluated the impact of physiological changes associated with pregnancy on the pharmacokinetics of sublingual buprenorphine during and after pregnancy. STUDY DESIGN Pregnant women (n = 13), between 180/7 and 376/7 weeks' singleton gestation, receiving sublingual buprenorphine twice daily for opioid use disorders were studied. Pharmacokinetic-2 studies were performed between 18 and 25 weeks (n = 7), pharmacokinetic-3 studies were performed between 31 and 37 weeks (n = 11), and pharmacokinetic-P was performed 4-18 weeks postpartum (n = 10). On the day of the study, blood was withdrawn prior to the daily morning dose of buprenorphine and at 0.25, 0.5, 0.75, 1, 1.5, 2, 4, 8, and 12 hours after the dose. Buprenorphine plasma concentrations were analyzed by liquid chromatography tandem mass spectrometric detection. All pharmacokinetic parameters were observed or estimated using Microsoft Excel. Statistical analyses were performed to identify significant changes in study participants' buprenorphine pharmacokinetic parameter estimates over the duration of the study. Univariate linear and generalized linear mixed models were used to investigate changes in these measures over time, some of which were log transformed for normality. RESULTS Dose-normalized (plasma concentration per dose) buprenorphine plasma concentrations were significantly lower during pregnancy (pharmacokinetic-2 plus pharmacokinetic-3) than during the postpartum period (pharmacokinetic-P). Specific pharmacokinetic parameters (and level of significance) were as follows: the area under the buprenorphine plasma concentration-time curves (P < .003), maximum buprenorphine concentrations (P < .018), buprenorphine concentrations at 0 hour (P < .002), and buprenorphine concentrations at 12 hours (P < .001). None of these parameters differed significantly during pregnancy (ie, pharmacokinetic-2 vs pharmacokinetic-3). The time to maximum buprenorphine concentrations did not differ significantly between groups. CONCLUSION The dose-normalized plasma concentrations during a dosing interval and the overall exposure of buprenorphine (area under the buprenorphine plasma concentration-time curves) are lower throughout pregnancy compared with the postpartum period. This indicates an increase in apparent clearance of buprenorphine during pregnancy. These data suggest that pregnant women may need a higher dose of sublingual buprenorphine compared with postpartum individuals. The dose of buprenorphine should be assessed after delivery to maintain similar buprenorphine exposure during the postpartum period.
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Affiliation(s)
- Jaime R Bastian
- Divisions of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA.
| | - Huijun Chen
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA
| | - Hongfei Zhang
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA
| | - Scott Rothenberger
- Center for Research on Healthcare Data Center, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Ralph Tarter
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA
| | - Dennis English
- Divisions of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Raman Venkataramanan
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA
| | - Steve N Caritis
- Divisions of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA
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Abstract
BACKGROUND Women are commonly prescribed a variety of medications during pregnancy. As most organ systems are affected by the substantial anatomical and physiological changes that occur during pregnancy, it is expected that pharmacokinetics (PK) (absorption, distribution, metabolism, and excretion of drugs) would also be affected in ways that may necessitate changes in dosing schedules. The objective of this study was to systematically identify existing clinically relevant evidence on PK changes during pregnancy. METHODS AND FINDINGS Systematic searches were conducted in MEDLINE (Ovid), Embase (Ovid), Cochrane Central Register of Controlled Trials (Ovid), and Web of Science (Thomson Reuters), from database inception to August 31, 2015. An update of the search from September 1, 2015, to May 20, 2016, was performed, and relevant data were added to the present review. No language or date restrictions were applied. All publications of clinical PK studies involving a group of pregnant women with a comparison to nonpregnant participants or nonpregnant population data were eligible to be included in this review. A total of 198 studies involving 121 different medications fulfilled the inclusion criteria. In these studies, commonly investigated drug classes included antiretrovirals (54 studies), antiepileptic drugs (27 studies), antibiotics (23 studies), antimalarial drugs (22 studies), and cardiovascular drugs (17 studies). Overall, pregnancy-associated changes in PK parameters were often observed as consistent findings among many studies, particularly enhanced drug elimination and decreased exposure to total drugs (bound and unbound to plasma proteins) at a given dose. However, associated alterations in clinical responses and outcomes, or lack thereof, remain largely unknown. CONCLUSION This systematic review of pregnancy-associated PK changes identifies a significant gap between the accumulating knowledge of PK changes in pregnant women and our understanding of their clinical impact for both mother and fetus. It is essential for clinicians to be aware of these unique pregnancy-related changes in PK, and to critically examine their clinical implications.
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Swortwood MJ, Scheidweiler KB, Barnes AJ, Jansson LM, Huestis MA. Simultaneous quantification of buprenorphine, naloxone and phase I and II metabolites in plasma and breastmilk by liquid chromatography–tandem mass spectrometry. J Chromatogr A 2016; 1446:70-7. [DOI: 10.1016/j.chroma.2016.03.076] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 03/08/2016] [Accepted: 03/25/2016] [Indexed: 01/27/2023]
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Ansari J, Carvalho B, Shafer SL, Flood P. Pharmacokinetics and Pharmacodynamics of Drugs Commonly Used in Pregnancy and Parturition. Anesth Analg 2016; 122:786-804. [DOI: 10.1213/ane.0000000000001143] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Srinivas NR. Relationship Between Buprenorphine Dosing and Triglyceride Lowering and creatine kinase [corrected] Elevation in Felines: Possible Human Implications. J Pain Palliat Care Pharmacother 2016; 30:49-52. [PMID: 26861654 DOI: 10.3109/15360288.2015.1134751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Recently published feline data suggest that high doses of buprenorphine can elevate creatine kinase (CK) [corrected] and profoundly influence triglyceride levels in an inverted dose versus effect relationship. This intriguing observation in felines, hitherto not documented for buprenorphine, should be considered in human situations for any trends of translatability. The report evaluates the observed effects in domestic cats and what is known about buprenorphine in human subjects. Based on the objective assessment, the following are deduced: (a) although elevated CK levels is a nonissue in humans, one needs to pay attention especially when buprenorphine is used at the high end of therapeutic dose range in the presence of drugs that can impair the hepatic metabolism of buprenorphine; and (b) the potential for triglyceride lowering can be easily confirmed in human trials, and since it may occur at the relevant therapeutic doses of buprenorphine, it may be beneficial in such patients who may have added cardiovascular risk factors.
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Challenges in managing acute on chronic pain in a pregnant woman at high risk for opioid use disorder in the general hospital setting. Harv Rev Psychiatry 2015; 23:157-66. [PMID: 25747928 DOI: 10.1097/hrp.0000000000000080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
The treatment of opioid dependence during pregnancy has historically consisted of either medication-assisted withdrawal or maintenance treatment with methadone. Buprenorphine maintenance treatment is emerging as a treatment during pregnancy with distinct benefits for the neonate and the pregnant woman. Buprenorphine is effective in decreasing the risk of relapse in pregnant women. In addition, prenatal use of buprenorphine appears to decrease the severity and duration of neonatal abstinence syndrome as compared with methadone maintenance. Management of buprenorphine includes initiation and maintenance treatment as well as careful planning for pain control during and after delivery and prevention of postpartum relapse risk. Only very small amounts of buprenorphine enter breast milk, making it a good option for those who elect to breast-feed. There is evidence that emerging collaborative care models are effective ways to deliver buprenorphine maintenance treatment, although more investigation is needed to generalize this to the obstetric setting.
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Belivanis S, Tzatzarakis MN, Vakonaki E, Kovatsi L, Mantsi M, Alegakis A, Kavvalakis MP, Vynias D, Tsatsakis AM. Buprenorphine and nor-buprenorphine levels in head hair samples from former heroin users under Suboxone® treatment. Drug Test Anal 2014; 6 Suppl 1:93-100. [DOI: 10.1002/dta.1611] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 12/26/2013] [Accepted: 12/28/2013] [Indexed: 12/12/2022]
Affiliation(s)
- Stamatis Belivanis
- Center of Toxicology Science &Research, Medical School; University of Crete; Heraklion Greece
| | - Manolis N. Tzatzarakis
- Center of Toxicology Science &Research, Medical School; University of Crete; Heraklion Greece
| | - Elena Vakonaki
- Center of Toxicology Science &Research, Medical School; University of Crete; Heraklion Greece
| | - Leda Kovatsi
- Laboratory of Forensic Medicine and Toxicology, School of Medicine; Aristotle University of Thessaloniki; Thessaloniki Greece
| | - Mary Mantsi
- Greek National Organization Against Drugs; Athens Greece
| | - Athanasios Alegakis
- Center of Toxicology Science &Research, Medical School; University of Crete; Heraklion Greece
| | - Matthaios P. Kavvalakis
- Center of Toxicology Science &Research, Medical School; University of Crete; Heraklion Greece
| | - Dionisios Vynias
- Center of Toxicology Science &Research, Medical School; University of Crete; Heraklion Greece
| | - Aristidis M. Tsatsakis
- Center of Toxicology Science &Research, Medical School; University of Crete; Heraklion Greece
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Mozurkewich EL, Rayburn WF. Buprenorphine and methadone for opioid addiction during pregnancy. Obstet Gynecol Clin North Am 2014; 41:241-53. [PMID: 24845488 DOI: 10.1016/j.ogc.2014.02.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Buprenorphine and methadone are opioid-receptor agonists used as opioid substitution therapy during pregnancy to limit exposure of the fetus to cycles of opioid withdrawal and reduce the risk of infectious comorbidities of illicit opioid use. As part of a comprehensive care plan, such therapy may result in improved access to prenatal care, reduced illicit drug use, reduced exposure to infections associated with intravenous drug use, and improved maternal nutrition and infant birth weight. This article describes differences in patient selection between the two drugs, their relative safety during pregnancy, and changes in daily doses as a guide for prescribing clinicians.
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Affiliation(s)
- Ellen L Mozurkewich
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, MSC 10 5580, 1 University of New Mexico, Albuquerque, NM 87131, USA.
| | - William F Rayburn
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, MSC 10 5580, 1 University of New Mexico, Albuquerque, NM 87131, USA
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McCormack SA, Best BM. Obstetric Pharmacokinetic Dosing Studies are Urgently Needed. Front Pediatr 2014; 2:9. [PMID: 24575394 PMCID: PMC3920104 DOI: 10.3389/fped.2014.00009] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 01/26/2014] [Indexed: 12/28/2022] Open
Abstract
Use of pharmacotherapy during pregnancy is common and increasing. Physiologic changes during pregnancy may significantly alter the overall systemic drug exposure, necessitating dose changes. A search of PubMed for pharmacokinetic clinical trials showed 494 publications during pregnancy out of 35,921 total pharmacokinetic published studies (1.29%), from the late 1960s through August 31, 2013. Closer examination of pharmacokinetic studies in pregnant women published since 2008 (81 studies) revealed that about a third of the trials were for treatment of acute labor and delivery issues, a third included studies of infectious disease treatment during pregnancy, and the remaining third were for varied ante-partum indications. Approximately, two-thirds of these recent studies were primarily funded by government agencies worldwide, one-quarter were supported by private non-profit foundations or combinations of government and private funding, and slightly <10% were supported by pharmaceutical industry. As highlighted in this review, vast gaps exist in pharmacology information and evidence for appropriate dosing of medications in pregnant women. This lack of knowledge and understanding of drug disposition throughout pregnancy place both the mother and the fetus at risk for avoidable therapeutic misadventures - suboptimal efficacy or excess toxicity - with medication use in pregnancy. Increased efforts to perform and support obstetric dosing and pharmacokinetic studies are greatly needed.
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Affiliation(s)
- Shelley A McCormack
- Pediatrics Department, School of Medicine, Rady Children's Hospital San Diego, University of California San Diego , San Diego, CA , USA
| | - Brookie M Best
- Pediatrics Department, School of Medicine, Rady Children's Hospital San Diego, University of California San Diego , San Diego, CA , USA ; Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego , La Jolla, CA , USA
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Parenteral buprenorphine–naloxone abuse is a major cause of fatal buprenorphine-related poisoning. Forensic Sci Int 2013; 232:11-5. [DOI: 10.1016/j.forsciint.2013.06.017] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 06/18/2013] [Accepted: 06/21/2013] [Indexed: 01/03/2023]
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Abstract
Pregnancy in opioid users poses a number of problems to treating physicians. Most guidelines recommend maintenance treatment to manage opioid addiction in pregnancy, with methadone being the gold standard. More recently, buprenorphine has been discussed as an alternate medication. The use and efficacy of buprenorphine in pregnancy is still controversial. This article reviews the current database on the basis of a detailed and critical literature search performed in MEDLINE (206 counts). Most of the relevant studies (randomised clinical trials and one national cohort sample) were published in the last 2 years and mainly compared buprenorphine with methadone. Some studies are related to maternal outcomes, others to foetal, neonatal or older child outcomes. With respect to maternal outcomes, most studies suggest that buprenorphine has similar effects to methadone. Very few data from small studies discuss an effect of buprenorphine on neurodevelopment of the foetus. Neonatal abstinence syndrome is common in infants of both buprenorphine- and methadone-maintained mothers. As regards neonatal outcomes, buprenorphine has the same clinical outcome as methadone, although some newer studies suggest that it causes fewer withdrawal symptoms. Since hardly any studies have investigated the combination of buprenorphine with naloxone (which has been suggested to possibly have teratogenic effects) in pregnant women, a switch to buprenorphine monotherapy is recommended in women who become pregnant while receiving the combination product. These novel findings indicate that buprenorphine is emerging as a first-line treatment for pregnant opioid users.
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Transdermal buprenorphine—interesting observations on the metabolite norbuprenorphine levels in elderly subjects. Eur J Clin Pharmacol 2013; 69:1607-8. [DOI: 10.1007/s00228-013-1508-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 03/18/2013] [Indexed: 10/27/2022]
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