1
|
Mahnke AH, Roberts MH, Leeman L, Ma X, Bakhireva LN, Miranda RC. Prenatal opioid-exposed infant extracellular miRNA signature obtained at birth predicts severity of neonatal opioid withdrawal syndrome. Sci Rep 2022; 12:5941. [PMID: 35396369 PMCID: PMC8993911 DOI: 10.1038/s41598-022-09793-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 03/29/2022] [Indexed: 11/09/2022] Open
Abstract
Prenatal opioid exposure (POE) is commonly associated with neonatal opioid withdrawal syndrome (NOWS), which is characterized by a broad variability in symptoms and severity. Currently there are no diagnostic tools to reliably predict which infants will develop severe NOWS, while risk stratification would allow for proactive decisions about appropriate clinical monitoring and interventions. The aim of this prospective cohort study was to assess if extracellular microRNAs (miRNAs) in umbilical cord plasma of infants with POE could predict NOWS severity. Participants (n = 58) consisted of pregnant women receiving medications for opioid use disorder and their infants. NOWS severity was operationalized as the need for pharmacologic treatment and prolonged hospitalization (≥ 14 days). Cord blood miRNAs were assessed using semi-quantitative qRT-PCR arrays. Receiver operating characteristic curves and area under the curve (AUC) were estimated. The expression of three miRNAs (miR-128-3p, miR-30c-5p, miR-421) predicted need for pharmacologic treatment (AUC: 0.85) and prolonged hospitalization (AUC: 0.90). Predictive validity improved after two miRNAs (let-7d-5p, miR-584-5p) were added to the need for pharmacologic treatment model (AUC: 0.94) and another two miRNAs (let-7b-5p, miR-10-5p) to the prolonged hospitalization model (AUC: 0.99). Infant cord blood extracellular miRNAs can proactively identify opioid-exposed neonates at high-risk for developing severe NOWS.
Collapse
Affiliation(s)
- Amanda H Mahnke
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, 8447 Riverside Parkway, Bryan, TX, 77807-3260, USA.
| | - Melissa H Roberts
- Department of Pharmacy Practice and Administrative Sciences, Substance Use Research and Education (SURE) Center, University of New Mexico College of Pharmacy, Albuquerque, NM, 87131, USA
| | - Lawrence Leeman
- Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA.,Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA
| | - Xingya Ma
- Department of Pharmacy Practice and Administrative Sciences, Substance Use Research and Education (SURE) Center, University of New Mexico College of Pharmacy, Albuquerque, NM, 87131, USA
| | - Ludmila N Bakhireva
- Department of Pharmacy Practice and Administrative Sciences, Substance Use Research and Education (SURE) Center, University of New Mexico College of Pharmacy, Albuquerque, NM, 87131, USA.,Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA.,Division of Epidemiology, Biostatistics and Preventive Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, 87106, USA
| | - Rajesh C Miranda
- Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, 8447 Riverside Parkway, Bryan, TX, 77807-3260, USA
| |
Collapse
|
2
|
Bakhireva LN, Sparks A, Herman M, Hund L, Ashley M, Salisbury A. Severity of neonatal opioid withdrawal syndrome with prenatal exposure to serotonin reuptake inhibitors. Pediatr Res 2022; 91:867-873. [PMID: 34588611 PMCID: PMC9128601 DOI: 10.1038/s41390-021-01756-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/30/2021] [Accepted: 09/12/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the severity of neonatal opioid withdrawal syndrome (NOWS) in infants prenatally exposed to medications for opioid use disorder (MOUD) and serotonin reuptake inhibitors (SRI). METHODS A prospective cohort included 148 maternal-infant pairs categorized into MOUD (n = 127) and MOUD + SRI (n = 27) groups. NOWS severity was operationalized as the infant's need for pharmacologic treatment with opioids, duration of hospitalization, and duration of treatment. The association between prenatal SRI exposure and the need for pharmacologic treatment (logistic regression), time-to-discharge, and time-to-treatment discontinuation (Cox proportional hazards modeling) was examined after adjusting for the type of maternal MOUD, use of hydroxyzine, other opioids, benzodiazepines/sedatives, alcohol, tobacco, marijuana, gestational age, and breastfeeding. RESULTS Infants in the MOUD + SRI group were more likely to receive pharmacologic treatment for NOWS (OR = 3.58; 95% CI: 1.31; 9.76) and had a longer hospitalization (median: 11 vs. 6 days; HR = 0.54; 95% CI: 0.33; 0.89) compared to the MOUD group. With respect to time-to-treatment discontinuation, no association was observed in infants who received treatment (HR = 0.59; 95% CI: 0.26, 1.32); however, significant differences were observed in the entire sample (HR = 0.55; 95% CI: 0.34, 0.89). CONCLUSIONS Use of SRIs among pregnant women on MOUD might be associated with more severe NOWS. IMPACT A potential drug-drug interaction between maternal SRIs and opioid medications that inhibit the reuptake of serotonin has been hypothesized but not carefully evaluated in clinical studies. Results of this prospective cohort indicate that the use of SRIs among pregnant women on MOUD is associated with more severe neonatal opioid withdrawal syndrome. This is the first prospective study which carefully examined effect modification between the type of maternal MOUD and SRI use on neonatal outcomes. This report lays the foundation for treatment optimization in pregnant women with co-occurring mental health and substance use disorders.
Collapse
Affiliation(s)
- Ludmila N Bakhireva
- Department of Pharmacy Practice and Administrative Sciences, Substance Use Research and Education (SURE) Center, College of Pharmacy, University of New Mexico, NM, albuquerque, USA.
- Department of Family and Community Medicine, School of Medicine, University of New Mexico, NM, albuquerque, USA.
- Division of Epidemiology, Biostatistics and Preventive Medicine, Department of Internal Medicine, School of Medicine, University of New Mexico, NM, albuquerque, USA.
| | - Aydan Sparks
- Department of Pharmacy Practice and Administrative Sciences, Substance Use Research and Education (SURE) Center, College of Pharmacy, University of New Mexico, NM, albuquerque, USA
| | - Michael Herman
- Department of Pharmacy, University of New Mexico Hospital, NM, albuquerque, USA
| | - Lauren Hund
- School of Law, University of New Mexico, NM, albuquerque, USA
| | - Malia Ashley
- Department of Pharmacy, University of New Mexico Hospital, NM, albuquerque, USA
- Department of Obstetrics and Gynecology, School of Medicine, University of New Mexico, NM, albuquerque, USA
| | - Amy Salisbury
- School of Nursing, Virginia Commonwealth University, Richmond, VA, USA
| |
Collapse
|
3
|
Wang J, Cosci F. Neonatal Withdrawal Syndrome following Late in utero Exposure to Selective Serotonin Reuptake Inhibitors: A Systematic Review and Meta-Analysis of Observational Studies. PSYCHOTHERAPY AND PSYCHOSOMATICS 2021; 90:299-307. [PMID: 33971648 DOI: 10.1159/000516031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/20/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION A clear picture of neonatal withdrawal signs due to in utero selective serotonin reuptake inhibitor (SSRI) exposure and its consequences is still missing. OBJECTIVE A systematic review and a meta-analysis were performed to provide an overview of neonatal withdrawal signs following late in utero exposure to SSRIs and to quantify the corresponding risks. METHODS MEDLINE, Web of Science, and Embase were searched from inception to January 2021. The Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines were followed. English-language observational studies reporting on acute postpartum outcomes following late in utero exposure to SSRIs or SSRIs/venlafaxine were evaluated. RESULTS Of 2,269 citations reviewed, 79 studies were assessed for eligibility; 13 were included in the qualitative analysis of the literature, which allowed us to identify 26 signs. A meta-analysis was run separately for studies on SSRI exposure (n = 3) and those on SSRI/venlafaxine exposure (n = 6). Hypoglycemia was identified as a withdrawal sign based on the SSRI studies. Tremors, hypotonia, tachycardia, rapid breathing, respiratory distress, and hypertonia were identified as withdrawal signs based on the SSRI/venlafaxine studies. CONCLUSIONS The present work provides a framework for the identification of neonatal SSRI withdrawal syndrome. Tapering and discontinuation of antidepressant drugs before and during the early phase of pregnancy are worth attempting to prevent the occurrence of this syndrome.
Collapse
Affiliation(s)
- Jianjun Wang
- Department of Neurology and Psychology, Shenzhen Traditional Chinese Medicine Hospital, The Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Fiammetta Cosci
- Department of Health Sciences, University of Florence, Florence, Italy.,Clinical Pharmacopsychology Laboratory, University of Florence, Florence, Italy.,Department of Psychiatry and Neuropsychology, Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
4
|
Sujan AC, Rickert ME, Quinn PD, Ludema C, Wiggs KK, Larsson H, Lichtenstein P, Almqvist C, Öberg AS, D’Onofrio BM. A population-based study of concurrent prescriptions of opioid analgesic and selective serotonin reuptake inhibitor medications during pregnancy and risk for adverse birth outcomes. Paediatr Perinat Epidemiol 2021; 35:184-193. [PMID: 33350491 PMCID: PMC7878346 DOI: 10.1111/ppe.12721] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/24/2020] [Accepted: 07/31/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Pregnant women with painful conditions often have mental health problems, including depression and anxiety. Co-morbid conditions may cause pregnant women to use multiple medications, although safety of such practice is poorly understood. OBJECTIVES We investigated the influence of combined prescriptions of opioid analgesics and selective serotonin reuptake inhibitors (SSRIs) during pregnancy on two adverse birth outcomes. METHODS We analysed Swedish population-based births (n = 688 914) between 2007 and 2013. Using national registers, we obtained data on filled medication prescriptions, birth outcomes, and a wide range of parental characteristics. We estimated preterm birth and small-for-gestational-age risk following independent or combined prescriptions of the two medications compared with no filled prescriptions for either medication. We adjusted for confounders using inverse probability of treatment weights. RESULTS After adjusting for confounders, preterm birth risk was higher among women with opioid analgesic prescriptions only (5.9%; risk ratio [RR] 1.27, 95% confidence interval [CI] 1.22, 1.33), SSRIs only (6.2%; RR 1.34, 95% CI 1.27, 1.42), and both medications (7.8%; RR 1.70, 95% CI 1.47, 1.96) compared with unexposed women (4.6%). The interaction between the medications on preterm birth was small (risk difference [RD] 0.4%, 95% CI -0.8%, 1.6%); relative excess risk due to interaction [RERI] 0.09, 95% CI -0.17, 0.34; RR 1.00, 95% CI 0.85, 1.17). For small for gestational age, risk was approximately 2% across all groups, and there was no interaction between the medications (RD 0.3%, 95% CI -0.4%, 1.1%); RERI 0.15, 95% CI -0.16, 0.47; RR 1.15, 95% CI 0.87, 1.52). CONCLUSIONS Compared with unexposed pregnancies, those with either medication alone had a small increased risk for preterm birth but no increased risk for small for gestational age. The magnitude of associations with combined exposure to both medications were not greater than the sum of the associations with each medication considered individually.
Collapse
Affiliation(s)
- Ayesha C. Sujan
- Department of Psychological & Brain Sciences, Indiana University–Bloomington, Bloomington, IN, USA
| | - Martin E. Rickert
- Department of Psychological & Brain Sciences, Indiana University–Bloomington, Bloomington, IN, USA
| | - Patrick D. Quinn
- Department of Applied Health Science, School of Public Health, Indiana University–Bloomington, Bloomington, IN, USA
| | - Christina Ludema
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University–Bloomington, Bloomington, IN, USA
| | - Kelsey K. Wiggs
- Department of Psychological & Brain Sciences, Indiana University–Bloomington, Bloomington, IN, USA
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Paul Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - A. Sara Öberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden,Department of Epidemiology, T.H. Chan School of Public Health, Harvard, Boston, USA
| | - Brian M. D’Onofrio
- Department of Psychological & Brain Sciences, Indiana University–Bloomington, Bloomington, IN, USA,Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
5
|
Coulson CC, Lorencz E, Rittenhouse K, Ramage M, Lorenz K, Galvin SL. Association of Maternal Buprenorphine or Methadone Dose with Fetal Growth Indices and Neonatal Abstinence Syndrome. Am J Perinatol 2021; 38:28-36. [PMID: 31421639 DOI: 10.1055/s-0039-1694729] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Our objective was to compare fetal growth and incidence of neonatal abstinence syndrome requiring treatment across pregnant women with opioid use disorders on two types and two dose categories of medication-assisted treatment. STUDY DESIGN A retrospective cohort study was conducted in a comprehensive, perinatal program in western North Carolina comparing growth percentiles on third-trimester ultrasound and at birth, and diagnosis of neonatal abstinence syndrome requiring treatment. Singletons were exposed in utero to low- to moderate-dose buprenorphine (≤16 mg/day; n = 70), high-dose buprenorphine (≥17 mg/day; n = 36), low- to moderate-dose methadone (≤89 mg/day; n = 41), or high-dose methadone (≥90 mg/day; n = 74). Multivariate analysis of variance with posthoc Bonferroni comparisons (p ≤ 0.01) and multinomial logistic regressions (adjusted odds ratio, 99% confidence interval) were conducted. RESULTS Differences in neonatal outcomes reached statistical significance for larger head circumference for buprenorphine doses (p = 0.01) and for longer length (p < 0.01) and lower odds of neonatal abstinence syndrome requiring treatment (p < 0.01) with low- to moderate-dose buprenorphine versus high-dose methadone. CONCLUSION Among pregnant women using medication-assisted treatment for opioid use disorders, low- to moderate-dose buprenorphine (≤16 mg/day) was associated with the most favorable neonatal outcomes. However, more rigorous control of confounders with a larger sample is necessary to determine if low- to moderate-dose buprenorphine is the better treatment choice.
Collapse
Affiliation(s)
- Carol C Coulson
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina.,Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Erin Lorencz
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Katelyn Rittenhouse
- University of North Carolina School of Medicine-Asheville, Asheville, North Carolina
| | - Melinda Ramage
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Kathleen Lorenz
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina
| | - Shelley L Galvin
- Department of Obstetrics and Gynecology, Mountain Area Health Education Center, Asheville, North Carolina.,Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| |
Collapse
|
6
|
Galvin SL, Ramage M, Mazure E, Coulson CC. The association of cannabis use late in pregnancy with engagement and retention in perinatal substance use disorder care for opioid use disorder: A cohort comparison. J Subst Abuse Treat 2020; 117:108098. [PMID: 32811635 DOI: 10.1016/j.jsat.2020.108098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/07/2020] [Accepted: 07/25/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Prenatal use of cannabis and opioids are increasing and very concerning. Engagement and retention in comprehensive, perinatal substance use disorder (PSUD) care are associated with better outcomes for mothers and babies. We compared the characteristics and engagement in care among women with opioid use disorder who used cannabis late in pregnancy versus those who didn't. METHODS The primary outcome, "overall engagement and retention in PSUD care" included: utilization of substance use treatment prenatally, negative screening/toxicology at delivery (excluding cannabis), and attendance at expected prenatal and postpartum visits. Cannabis use late in pregnancy was objectively assessed at delivery via maternal urine drug screen and/or neonatal meconium/cord toxicology. Between-group comparisons utilized chi square, t-test or Mann-Whitney. Associations were assessed using Spearman Rho and two multivariate, binary logistic regressions for cannabis use and the primary outcome. RESULTS 18.0% (85/472) consumed cannabis late in pregnancy. Women of color, younger women, and those diagnosed with concurrent cannabis use disorder were more likely to consume cannabis. Engagement and retention in PSUD care was not associated with cannabis use, but rather, with prescribed pharmacotherapy for psychiatric disorders. The use of prescribed buprenorphine+naloxone was associated with cannabis avoidance late in pregnancy. CONCLUSIONS Cannabis use late in pregnancy, compared to none, did not impact engagement and retention in our PSUD program. Adjunctive psychotropic medication and/or buprenorphine+naloxone prescription were associated with cannabis avoidance suggesting the use and interactions of pharmacotherapies in an opioid dependent population is complex. A shared decision-making process during PSUD care is warranted.
Collapse
Affiliation(s)
- Shelley L Galvin
- MAHEC, Department of Obstetrics and Gynecology, 119 Hendersonville Road, Asheville 28805, NC, USA.
| | - Melinda Ramage
- MAHEC, Department of Obstetrics and Gynecology, 119 Hendersonville Road, Asheville 28805, NC, USA.
| | - Emily Mazure
- UNC Health Sciences at MAHEC, Department of Library Services, 121 Hendersonville Road, Asheville 28805, NC, USA.
| | - Carol C Coulson
- MAHEC, Department of Obstetrics and Gynecology, 119 Hendersonville Road, Asheville 28805, NC, USA.
| |
Collapse
|
7
|
Black E, Khor KE, Kennedy D, Chutatape A, Sharma S, Vancaillie T, Demirkol A. Medication Use and Pain Management in Pregnancy: A Critical Review. Pain Pract 2019; 19:875-899. [PMID: 31242344 DOI: 10.1111/papr.12814] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/20/2019] [Accepted: 06/21/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pain during pregnancy is common, and its management is complex. Certain analgesics may increase the risk for adverse fetal and pregnancy outcomes, while poorly managed pain can result in adverse maternal outcomes such as depression and hypertension. Guidelines to assist clinicians in assessing risks and benefits of exposure to analgesics for the mother and unborn infant are lacking, necessitating evidence-based recommendations for managing pain in pregnancy. METHODS A comprehensive literature search was conducted to assess pregnancy safety data for pharmacological and nonpharmacological pain management methods. Relevant clinical trials and observational studies were identified using multiple medical databases, and included studies were evaluated for quality and possible biases. RESULTS Paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) are appropriate for mild to moderate pain, but NSAIDs should be avoided in the third trimester due to established risks. Short courses of weaker opioids are generally safe in pregnancy, although neonatal abstinence syndrome must be monitored following third trimester exposure. Limited safety data for pregabalin and gabapentin indicate that these are unlikely to be major teratogens, and tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors have limited but overall reassuring safety data. Many of the included studies were limited by methodological issues. CONCLUSIONS Findings from this review can guide clinicians in their decision to prescribe analgesics for pregnant women. Treatment should be tailored to the lowest therapeutic dose and shortest possible duration, and management should involve a discussion of risks and benefits and monitoring for response. Further research is required to better understand the safety profile of various analgesics in pregnancy.
Collapse
Affiliation(s)
- Eleanor Black
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, NSW, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Kok Eng Khor
- Pain Management Centre, Prince of Wales Hospital, Randwick, NSW, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Debra Kennedy
- MotherSafe, The Royal Hospital for Women, Randwick, NSW, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - Anuntapon Chutatape
- Department of Pain Medicine, Singapore General Hospital, Singapore, Singapore
| | - Swapnil Sharma
- Pain Management Centre, Prince of Wales Hospital, Randwick, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia
| | - Thierry Vancaillie
- School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia.,Women's Health and Research Institute of Australia, Sydney, NSW, Australia
| | - Apo Demirkol
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, NSW, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia.,Pain Management Centre, Prince of Wales Hospital, Randwick, NSW, Australia
| |
Collapse
|
8
|
Impact of In-utero Exposure to Selective Serotonin Reuptake Inhibitors and Opioids on Neonatal Opioid Withdrawal Syndrome. J Addict Med 2018; 13:227-234. [PMID: 30489344 DOI: 10.1097/adm.0000000000000484] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to compare short-term outcomes of neonatal opioid withdrawal syndrome (NOWS) treatment in infants exposed in-utero to opioids and selective serotonin reuptake inhibitors (SSRIs) or opioids alone. METHODS This was a retrospective cohort study of mother-infant dyads, 34 weeks or greater gestation, receiving opioids and/or SSRIs during pregnancy. Intravenous or oral methadone was administered according to a pre-existing protocol for NOWS treatment guided by withdrawal scores. Primary outcome was length of treatment (LOT). Secondary outcomes included length of stay (LOS), total methadone exposure, time to symptom control, need for a second agent, and NOWS medications at discharge. RESULTS Fifty-five mother-infant dyads were included in the study. LOT was longer in the infants in the SSRI plus opioid group but not significantly different [24 ± 23 days (SSRI plus opioid) vs 20 ± 14 days (opioid alone); P = 0.78]. There was a trend towards shorter LOS (30 ± 22 day vs 27 ± 15 days; P = 0.86), lower total methadone exposure (3.2 ± 4.3 mg/kg vs 2.7 ± 5.1 mg/kg; P = 0.66), less time to control symptoms (1 ± 1.7 days vs 0.5 ± 0.36 days; P = 0.31) and less need for a second agent (OR 2.65, 95% CI 0.69-10.5) in the opioid only group, although these observations also did not reach statistical significance. CONCLUSIONS This study could not demonstrate a statistically significant difference in short-term NOWS outcome of LOT between the 2 groups. However, there was a trend towards longer LOT and LOS in the SSRI plus opioid group which could be clinically significant. A larger cohort may detect a true significant difference in these short-term outcomes.
Collapse
|
9
|
Does Maternal Buprenorphine Dose Affect Severity or Incidence of Neonatal Abstinence Syndrome? J Addict Med 2018; 12:435-441. [DOI: 10.1097/adm.0000000000000427] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
10
|
Klaman SL, Isaacs K, Leopold A, Perpich J, Hayashi S, Vender J, Campopiano M, Jones HE. Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance. J Addict Med 2018; 11:178-190. [PMID: 28406856 PMCID: PMC5457836 DOI: 10.1097/adm.0000000000000308] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 02/12/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The prevalence of opioid use disorder (OUD) during pregnancy is increasing. Practical recommendations will help providers treat pregnant women with OUD and reduce potentially negative health consequences for mother, fetus, and child. This article summarizes the literature review conducted using the RAND/University of California, Los Angeles Appropriateness Method project completed by the US Department of Health and Human Services Substance Abuse and Mental Health Services Administration to obtain current evidence on treatment approaches for pregnant and parenting women with OUD and their infants and children. METHODS Three separate search methods were employed to identify peer-reviewed journal articles providing evidence on treatment methods for women with OUD who are pregnant or parenting, and for their children. Identified articles were reviewed for inclusion per study guidelines and relevant information was abstracted and summarized. RESULTS Of the 1697 articles identified, 75 were included in the literature review. The perinatal use of medication for addiction treatment (MAT, also known as medication-assisted treatment), either methadone or buprenorphine, within comprehensive treatment is the most accepted clinical practice, as withdrawal or detoxification risks relapse and treatment dropout. Medication increases may be needed with advancing pregnancy, and are not associated with more severe neonatal abstinence syndrome (NAS). Switching medication prenatally is usually not recommended as it can destabilize opioid abstinence. Postnatally, breastfeeding is seen as beneficial for the infant for women who are maintained on a stable dose of opioid agonist medication. Less is known about ideal pain management and postpartum dosing regimens. NAS appears generally less severe following prenatal exposure to buprenorphine versus methadone. Frontline NAS medication treatments include protocol-driven methadone and morphine dosing in the context of nonpharmacological supports. CONCLUSIONS Women with OUD can be treated with methadone or buprenorphine during pregnancy. NAS is an expected and manageable condition. Although research has substantially advanced, opportunities to guide future research to improve maternal and infant outcomes are provided.
Collapse
Affiliation(s)
- Stacey L Klaman
- Department of Maternal and Child Health, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC (SLK); JBS International, Inc., North Bethesda, MD (KI, AL, JP, SH, JV); Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services, Rockville, MD (MC); UNC Horizons, Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC (HEJ); Departments of Psychiatry and Behavioral Sciences and Obstetrics and Gynecology, School of Medicine, Johns Hopkins University, Baltimore, MD (HEJ)
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Kraft WK. Buprenorphine in Neonatal Abstinence Syndrome. Clin Pharmacol Ther 2018; 103:112-119. [PMID: 29105752 PMCID: PMC5739935 DOI: 10.1002/cpt.930] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/01/2017] [Accepted: 11/02/2017] [Indexed: 12/25/2022]
Abstract
Infants exposed in utero to opioids will demonstrate a withdrawal syndrome known as neonatal abstinence syndrome (NAS). Buprenorphine is a long-acting opioid with therapeutic use in medication-assisted treatment of opioid dependency in adults and adolescents. Emerging data from clinical trials and treatment cohorts demonstrate the efficacy and safety of sublingual buprenorphine for those infants with NAS who require pharmacologic treatment. Pharmacometric modeling will assist in defining the exposure-response relationships and facilitate dose optimization.
Collapse
Affiliation(s)
- Walter K Kraft
- Sidney Kimmel Medical College of Thomas Jefferson University, Department of Pharmacology and Experimental Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
12
|
O'Connor AB, Kelly BK, O'Brien LM. Maternal and infant outcomes following third trimester exposure to marijuana in opioid dependent pregnant women maintained on buprenorphine. Drug Alcohol Depend 2017; 180:200-203. [PMID: 28917206 DOI: 10.1016/j.drugalcdep.2017.08.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 08/05/2017] [Accepted: 08/14/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND To determine whether maternal and infant outcomes are associated with exposure to marijuana during the third trimester in a population of opioid dependent pregnant women maintained on buprenorphine. METHODS This retrospective cohort study of 191 maternal-infant dyads exposed to buprenorphine during pregnancy examines a variety of variables including gestational age, birthweight, method of delivery, Apgar scores at one and five minutes, duration of infant hospital stay, peak neonatal abstinence syndrome (NAS) score, duration of NAS and incidence of pharmacologic treatment of NAS in infants exposed to marijuana during the third trimester as compared to infants not exposed to marijuana during the third trimester. RESULTS Analyses failed to support any significant relationship between marijuana use in the third trimester and a variety of maternal and infant outcomes. Two important variables - the likelihood of requiring pharmacologic treatment for NAS (27.6% in marijuana exposed infants vs. 15.7% in non-marijuana exposed infants, p=0.066) and the duration of infant hospital stay (7.7days in marijuana exposed infants vs. 6.6days in non-exposed infants, p=0.053) trended toward significance. CONCLUSIONS Preliminary results indicate that marijuana exposure in the third trimester does not complicate the pregnancy or the delivery process. However, the severity of the infant withdrawal syndrome in the immediate postnatal period may be impacted by marijuana exposure. Because previous study of prenatal marijuana exposure has yielded mixed results, further analysis is needed to determine whether these findings are indeed significant.
Collapse
Affiliation(s)
| | | | - Liam M O'Brien
- Department of Mathematics and Statistics, Colby College, United States; School of Community and Population Health, University of New England, United States
| |
Collapse
|
13
|
Abstract
PURPOSE OF REVIEW Over the last 15 years the prevalence of neonatal abstinence syndrome (NAS) increased almost five-fold. A considerable diversity seems to prevail in the management of NAS. This review provides an overview of factors affecting the expression and course of NAS, and recent developments in NAS assessment and treatment. RECENT FINDINGS Apart from different pharmacological and nonpharmacological treatment modalities, maturity of the infant and genetic variations likely are (co)responsible for interpatient variability in NAS severity, despite similar maternal exposure. Recent efforts concerning the further development of NAS severity scoring systems focus on the development of brief screening measures; in addition, pupil diameter and skin conductance have been proposed as complements to observer-rated scales. The decrease in incidence of NAS begins in the appropriate management of medication assisted treatment of the mother. SUMMARY Mitigating the negative outcomes for infants affected by NAS, their mothers and the healthcare system implies, first and foremost, developing and implementing an organized protocol for the management of NAS, and the homogenous use of a standardized scoring system utilizing interobserver reliability and a guide for medication initiation, maintenance, and weaning which is consistent with traditional methods of treatment for neonates.
Collapse
|