Use of opioids among pregnant women 1997-2016: A Danish drug utilization study

OBJECTIVE

Use of opioids in pregnancy is of concern yet little is known on opioid prescription patterns in Denmark. The aim of this drug utilization study was to describe prescription patterns for opioids during pregnancy in Denmark from 1997 to 2016.

STUDY DESIGN

Using the nationwide health care registers, we obtained information on all women with a registered pregnancy in the period 1 January 1997 to 31 December 2016. Opioids were grouped in four: opioids (N02A except codeines), opioid dependency medications (N07BC), cough medications (R05DA except codeines), and codeines (N02AJ06, N02AJ07, N02BA75, and R05DA04). We used logistic regression analyses to identify factors associated with opioid use in pregnancy and cumulative oral morphine equivalent (OMEQ) to estimate volume of use in pregnancy.

RESULTS

Prescription patterns were similar for women with live births, non-live births, and terminations. Total use of opioids among women with live born deliveries remained stable at 19.8 per 1000 pregnancies from 1997 to 2016. Codeine use declined from 2008 onwards, while use of other opioids increased from 2007 onwards. This was dominated by a threefold increase in tramadol use (2.0-7.6 per 1000 pregnancies with live births). Codeine was the most used opioid, followed by tramadol and codeine combined with paracetamol. The number of women, who used opioids before pregnancy and continued into their pregnancy, was reduced as the pregnancy progressed. The cumulative oral morphine equivalent during pregnancy was stable until 2007, after which, use prior to pregnancy and during the first two trimesters increased. The odds ratios for opioid use were higher in pregnancies of women of lower socioeconomic status or older age. For live births, odds ratios for opioid use in pregnancy were higher among women with obesity or smoking.

CONCLUSIONS

Overall use of opioids was stable from 2007 to 2016. This covers a decline in the use of codeine, but a 3-fold increase in tramadol. The number of pregnant women who continued use throughout pregnancy decreased, while OMEQ among persistent users increased. The real-world data suggest an unmet need of specific focus in local Danish Outpatient Clinics and Multidisciplinary Pain Centers both pre-conceptionally and during pregnancy.

Clinical usefulness of a urine dipstick to detect ethyl glucuronide (EtG): A quantitative clinical study in healthy young female volunteers

The metabolite of ethanol, ethyl glucuronide (EtG), reflects alcohol intake longer than ethanol and is used as a biomarker in clinical settings to detect alcohol use. We aimed to assess the clinical usefulness in a low-to-moderate alcohol intake setting and validate a new urine EtG dipstick. A three-way, open, cross-over trial was conducted. Data were collected from January to June 2019. Among 12 healthy female volunteers, we quantified urine EtG and used a dipstick following intake of either one, two or four units of alcohol. Main outcomes were concentrations of EtG in urine and serum, and creatinine and ethanol in serum. EtG in urine was determined dichotomously by dipsticks at two different thresholds and by mass spectrometry used as gold standard. EtG in urine was quantifiable up to 24 hours after alcohol intake. In some individual cases, EtG was quantifiable up to 72 hours at low concentrations. The dipstick detected EtG in urine up to 24 hours. At thresholds of 1000 and 1500 ng/mL, the dipsticks had a specificity of 100% (both), while sensitivity was 84% and 69%, respectively. The sensitivity of the dipsticks was insufficient to support a screening purpose in this setting of low-to-moderate alcohol intake.

[Tobacco and pregnancy in Denmark]

The risks of smoking during pregnancy are serious and well-documented. It is assumed that we do not identify all pregnant women with tobacco and nicotine consumption. Therefore, a new national Danish guideline presents a new screening and referral model for use from early pregnancy. All tobacco and nicotine consumption must be covered, including previous smoking and exposure to tobacco smoke. All pregnant women should be offered help to stop smoking or use of smokeless tobacco and help to avoid any exposure to tobacco smoke. Reference can be made to the municipality, Stoplinien and/or the hospital.

[A Danish fetal alcohol spectrum disorders definition]

The Danish Paediatric Society presents the first Danish definition of fetal alcohol spectrum disorders (FASD) in a new guideline. FASD is an umbrella term for conditions caused by prenatal alcohol exposure. To varying degrees, fetal alcohol damages manifest as physical defects, characteristic facial features and poor growth, as well as behavioural and cognitive disorders. It requires both somatic and psychological evaluation to identify these damages. Early diagnosis and identification of problems are important for prognosis as professional care has a positive preventive effect on comorbidities.