Group prenatal care for pregnant women with opioid use disorder: Preliminary evidence for acceptability and benefits compared with individual prenatal care

INTRODUCTION

The effectiveness of group prenatal care (G-PNC) compared with individual prenatal care (I-PNC) for women with opioid use disorder (OUD) is unknown. The objectives of this study were to (1) assess the acceptability of co-locating G-PNC at an opioid treatment program and (2) describe the maternal and infant characteristics and outcomes of pregnant women in treatment for OUD who participated in G-PNC and those who did not.

METHODS

This was a retrospective cohort study of 71 women (G-PNC n = 15; I-PNC n = 56) who were receiving treatment for OUD from one center and who delivered in 2019. Acceptability was determined by assessing the representativeness of the G-PNC cohorts, examining attendance at sessions, and using responses to a survey completed by G-PNC participants. The receipt of health services and healthcare use, behaviors, and infant health between those who participated in G-PNC and those who received I-PNC were described.

RESULTS

G-PNC was successfully implemented among women with varying backgrounds (e.g., racial, ethnic, marital status) who self-selected into the group. All G-PNC participants reported that they were satisfied to very satisfied with the program. Increased rates of breastfeeding initiation, breastfeeding at hospital discharge, receipt of the Tdap vaccine, and postpartum visit attendance at 1-2 weeks and 4-8 weeks were observed in the G-PNC group compared with the I-PNC group. Fewer G-PNC reported postpartum depression symptomatology.

CONCLUSION

Findings suggest that co-located G-PNC at an opioid treatment program is an acceptable model for pregnant women in treatment for OUD and may result in improved outcomes.

Implementation of the Eat, Sleep, and Console Model of Care: A Quality Improvement Project

A Southeastern, 741-bed acute care, Magnet designated teaching hospital and level III B NICU identified assessment and treatment concerns for Neonatal Opioid Withdrawal Syndrome (NOWS). In March 2020, a quality improvement project led to a multidisciplinary team formation to determine the effectiveness of the Eat, Sleep, Console (ESC) model of care in reducing the length of treatment (LOT) and length of stay (LOS) for neonates experiencing NOWS rather than use of the Finnegan Neonatal Abstinence Syndrome Scoring tool. The results concluded a decrease in the average LOT from 19.2 to 2.5 days and the average LOS from 23.9 to 9.3 days for those admitted directly into the ESC model of care on postpartum vs previous direct admission to the NICU. A group samples t-test showed there was a statistically significant decrease in LOS for ESC patients (p < .001) and LOT for ESC patients (p <001).

Opportunities to Increase Well-Child Care Engagement for Families Affected by Maternal Opioid Use Disorder: Perceptions of Mothers and Clinicians

OBJECTIVE

Previous research suggests gaps in well-child care (WCC) adherence, quality, and effectiveness for children impacted by parental opioid use disorder (OUD). The objective of this study was to gather in-depth information regarding maternal and clinician-reported factors that enhance ("facilitators") or hinder ("barriers") WCC engagement as well as mothers' experiences during WCC visits.

METHODS

Thirty mothers who were in treatment for OUD and 13 clinicians working at a pediatric primary care clinic participated in this qualitative study. All participants completed one data collection telephone session which involved a brief questionnaire followed by a semi-structured interview. Thematic analyses of the interview transcripts were conducted using an inductive approach.

RESULTS

Three broad themes were identified as facilitators of WCC by mothers and clinicians, including: 1) continuity in care, 2) addressing material needs, and 3) clinician OUD training and knowledge. Themes identified as barriers to WCC included: 1) stigma toward mothers with OUD, 2) gaps in basic parenting knowledge, 3) competing specialized health care needs, and 4) insufficient time to address all concerns.

CONCLUSION

WCC programs or clinical pathways designed for families affected by maternal OUD should consider these barriers and facilitators of WCC engagement and affect experiences of WCC for mothers and clinicians.

Buprenorphine-naloxone, buprenorphine, and methadone throughout pregnancy in maternal opioid use disorder

INTRODUCTION

Current WHO guidelines recommend using methadone or buprenorphine as maintenance treatments for maternal opioid use disorder. However, buprenorphine-naloxone, with a lower abuse risk than buprenorphine monotherapy or methadone, offers a potentially beneficial alternative, but scientific evidence on its effects on pregnancies, fetuses, and newborns is scarce. This paper compares the outcomes of the pregnancies, deliveries, and newborns of women on buprenorphine-naloxone, buprenorphine, or methadone maintenance treatments. According to the hypothesis, as a maintenance treatment, buprenorphine-naloxone does not have more adverse effects than buprenorphine, whereas methadone is more complicated.

MATERIAL AND METHODS

In this population-based study, 172 pregnant women on medical-assisted treatments were followed-up at Helsinki University Women's Hospital (Finland). Women receiving the same opioid maintenance treatment from conception to delivery and their newborns were included. Consequently, 67 mother-child dyads met the final inclusion criteria. They were divided into three groups based on their opioid pharmacotherapy. The outcomes were compared among the groups and, where applicable, with the Finnish population.

RESULTS

The buprenorphine-naloxone and buprenorphine groups showed similar outcomes and did not significantly differ from each other in terms of maternal health during pregnancies, deliveries, or newborns. Illicit drug use during the pregnancy was common in all groups, but in the methadone group it was most common (p = 0.001). Most neonates (96%) were born full-term with good Apgar scores. They were of relatively small birth size, with those in the methadone group tending to be the smallest. Of the neonates 63% needed pharmacological treatment for neonatal opioid withdrawal syndrome. The need was lower in the buprenorphine-based groups than in the methadone group (p = 0.029).

CONCLUSIONS

Buprenorphine-naloxone seems to be as safe for pharmacotherapy for maternal opioid use disorder as buprenorphine monotherapy for both mother and newborn. Hence it could be a choice for oral opioid maintenance treatment during pregnancy, but larger studies are needed before changing the official recommendations. Women on methadone treatment carry multifactorial risks and require particularly cautious follow up. Furthermore, illicit drug use is common in all treatment groups and needs to be considered for all patients with opioid use disorder.

Comparison of neonatal outcomes in pregnant women undergoing medication-assisted treatment of opioid use disorder with methadone or buprenorphine/naloxone

INTRODUCTION

The number of pregnant women with opioid use disorder (OUD) has quadrupled from 1999 to 2014. Current first line treatment for OUD in pregnancy is methadone with increasing support for buprenorphine. Limited data exist on use of buprenorphine/naloxone for OUD in pregnancy despite it being standard therapy in the non-pregnant individuals. The aim of this study was to compare neonatal opioid withdrawal syndrome (NOWS) prevalence and characteristics among neonates born to women prescribed methadone and buprenorphine/naloxone.

METHODS

This is a retrospective cohort analysis of mother-neonate dyads treated with either methadone or buprenorphine/naloxone for OUD in pregnancy who received prenatal care in the substance abuse, treatment, education, and prevention program (STEPP) clinic and delivered at OSU. Primary neonatal outcomes included: neonates diagnosed and treated for NOWS, peak scores on Modified Finnegan Neonatal Abstinence Score (FNAS), number of scores ≥9 on FNAS, and duration of treatment for NOWS. Secondary outcomes included: fetal growth restriction, preterm birth (<37 weeks), neonatal head circumference, birth weight, NICU admission, five-minute Apgar score, and length of hospitalization.

RESULTS

From 2013 to 2017, we identified 588 mother-neonate dyads: 149 treated with methadone and 439 treated with buprenorphine/naloxone. Ninety-eight neonates (65.8%) in the methadone group were diagnosed with NOWS requiring pharmacological interventions compared with 170 (38.7%) in the buprenorphine/naloxone group (aOR 3.46, 95% confidence interval (CI) 2.31-5.20, p < .01). Methadone-exposed neonates were six times more likely to be treated with >1 medication for NOWS (aOR 6.32, 95% CI 2.20-18.13, p < .01). Fetal growth restriction was diagnosed more often in the methadone group compared to the buprenorphine/naloxone group (aOR 1.73, 95% CI 1.02-2.93, p < .01). Significant maternal findings were that women using methadone for OUD started PNC earlier (15w vs. 17w, p = .04) and were less likely to be taking selective serotonin-reuptake inhibitors (SSRIs) (15% vs. 25%, p = .02) compared to the buprenorphine/naloxone group.

CONCLUSIONS

Buprenorphine/naloxone treatment for OUD in pregnancy appears safe and has decreased NOWS and pharmacologic intervention for the neonate.

Novel biomarkers to assess in utero effects of maternal opioid use: First steps toward understanding short- and long-term neurodevelopmental sequelae

Maternal opioid use disorder is common, resulting in significant neonatal morbidity and cost. Currently, it is not possible to predict which opioid-exposed newborns will require pharmacotherapy for neonatal abstinence syndrome. Further, little is known regarding the effects of maternal opioid use disorder on the developing human brain. We hypothesized that novel methodologies utilizing fetal central nervous system-derived extracellular vesicles isolated from maternal blood can address these gaps in knowledge. Plasma from opioid users and controls between 9 and 21 weeks was precipitated and extracellular vesicles were isolated. Mu opioid and cannabinoid receptor levels were quantified. Label-free proteomics studies and unbiased small RNA next generation sequencing was performed in paired fetal brain tissue. Maternal opioid use disorder increased mu opioid receptor protein levels in extracellular vesicles independent of opioid equivalent dose. Moreover, cannabinoid receptor levels in extracellular vesicles were upregulated with opioid exposure indicating cross talk with endocannabinoids. Maternal opioid use disorder was associated with significant changes in extracellular vesicle protein cargo and fetal brain micro RNA expression, especially in male fetuses. Many of the altered cargo molecules and micro RNAs identified are associated with adverse clinical neurodevelopmental outcomes. Our data suggest that assays relying on extracellular vesicles isolated from maternal blood extracellular vesicles may provide information regarding fetal response to opioids in the setting of maternal opioid use disorder. Prospective clinical studies are needed to evaluate the association between extracellular vesicle biomarkers, risk of neonatal abstinence syndrome and neurodevelopmental outcomes.